Patient accounts for nonadherence: A critical window into the patient experience.

OBJECTIVES: This paper explores patient use of excuses to better understand the patient experience during clinical interactions. METHODS: A content analysis of 32 residents treating 99 different patients was used to reveal accounts of nonadherence. Using grounded theory, these accounts were coded into types and then reduced using a Q-sort. RESULTS: Analysis revealed 163 accounts of nonadherence. When questioned about their adherence to treatment, 68% of patients offered at least one account for nonadherence during the visit. These accounts were coded into fourteen types and then the Q-sort identified four types of accounts: healthcare system failures, treatment failure, situational exigencies, and self-directed. Of the accounts offered, 7% of the patients provided 6 or more accounts and 25% provided between 3 and 5 accounts. CONCLUSIONS: The examination of excuses provides a unique way to gain insight into how patients communicate with their physicians. Patient accounts ranged from those where patients indicated adherence was within their control (self-directed) and accounts outside their control (healthcare system failure, treatment failure, and situational exigency). PRACTICE IMPLICATIONS: The types of accounts of nonadherence patients could provide doctors insight into the patient experience. Recognizing these types could allow opportunities for doctors to develop communication strategies for encouraging patient adherence.

Differential transactivation of sphingosine-1-phosphate receptors modulates NGF-induced neurite extension.

The process of neurite extension after activation of the TrkA tyrosine kinase receptor by nerve growth factor (NGF) involves complex signaling pathways. Stimulation of sphingosine kinase 1 (SphK1), the enzyme that phosphorylates sphingosine to form sphingosine-1-phosphate (S1P), is part of the functional TrkA signaling repertoire. In this paper, we report that in PC12 cells and dorsal root ganglion neurons, NGF translocates SphK1 to the plasma membrane and differentially activates the S1P receptors S1P1 and S1P2 in a SphK1-dependent manner, as determined with specific inhibitors and small interfering RNA targeted to SphK1. NGF-induced neurite extension was suppressed by down-regulation of S1P1 expression with antisense RNA. Conversely, when overexpressed in PC12 cells, transactivation of S1P1 by NGF markedly enhanced neurite extension and stimulation of the small GTPase Rac, important for the cytoskeletal changes required for neurite extension. Concomitantly, differentiation down-regulated expression of S1P2 whose activation would stimulate Rho and inhibit neurite extension. Thus, differential transactivation of S1P receptors by NGF regulates antagonistic signaling pathways that modulate neurite extension.

Sphingosine kinase type 2 is a putative BH3-only protein that induces apoptosis.

There are two isoforms of sphingosine kinase (SphK) that catalyze the formation of sphingosine 1-phosphate, a potent sphingolipid mediator. Whereas SphK1 stimulates growth and survival, here we show that SphK2 enhanced apoptosis in diverse cell types and also suppressed cellular proliferation. Apoptosis was preceded by cytochrome c release and activation of caspase-3. SphK2-induced apoptosis was independent of activation of sphingosine 1-phosphate receptors. Sequence analysis revealed that SphK2 contains a 9-amino acid motif similar to that present in BH3-only proteins, a pro-apoptotic subgroup of the Bcl-2 family. As with other BH3-only proteins, co-immunoprecipitation demonstrated that SphK2 interacted with Bcl-xL. Moreover, site-directed mutation of Leu-219, the conserved leucine residue present in all BH3 domains, markedly suppressed SphK2-induced apoptosis. Hence, the apoptotic effect of SphK2 might be because of its putative BH3 domain.

Lysophospholipid receptors in the nervous system.

The lysophospholipid mediators, lysophosphatidic acid (LPA) and sphingosine-1-phosphate (S1P), are responsible for cell signaling in diverse pathways including survival, proliferation, motility, and differentiation. Most of this signaling occurs through an eight-member family of G-protein coupled receptors once known as the endothelial differentiation gene (EDG) family. More recently, the EDG receptors have been divided into two subfamilies: the lysophosphatidic acid subfamily, which includes LPA1, (EDG-2/VZG-1), LPA2 (EDG-4), and LPA3 (EDG-7), and the sphingosine-1-phosphate receptor subfamily, which includes S1P1 (EDG-1), S1P2 (EDG-5/H218/AGR16), S1P3 (EDG-3), S1P4 (EDG-6), and S1P5 (EDG-8/NRG-1). The ubiquitous expression of these receptors across species, coupled with their diverse cellular functions, has made lysophospholipid receptors an important focus of signal transduction research. Neuroscientists have recently begun to explore the role of lysophospholipid receptors in a number of cell types; this research has implicated these receptors in the survival, migration, and differentiation of cells in the mammalian nervous system.

Ceramide-induced cell death in primary neuronal cultures: upregulation of ceramide levels during neuronal apoptosis.

Ceramide is a sphingolipid that has been implicated both in apoptosis and protection from cell death. We show that in both rat cerebellar granule cells and cortical neuronal cultures application of C(2)-ceramide causes cell death in a dose- and time-dependent manner. Similar effects were observed with the exogenous application of bacterial sphingomyelinase, which hydrolyzes sphingomyelin located on the outer leaflet of the plasma membrane and leads to endogenous ceramide accumulation. Furthermore, endogenous ceramide levels were increased during apoptosis induced by nutrient deprivation or etoposide treatment. These findings suggest that upregulation of ceramide levels, which may be generated through activation of sphingomyelinase, contributes to neuronal apoptosis.