Toward resourcefulness: Pathways for community positive health

 

Communities play a central role in strengthening their health, but conventional community health promotion often adopts paternalistic and top-down approaches. Conversely, agentic approaches are critiqued for tasking marginalized communities to create change without opportunities. Taking into consideration these shortcomings, we ask how communities may be most effectively and appropriately supported in their pursuit of health. We review community health literature to articulate how community health is understood, moving from negative to positive conceptions; determined, moving from a risk-factor orientation to social determination; and promoted, moving from conventional to agentic approaches. We develop the concept of resourcefulness as a pathway to strengthen positive health, and explore how this approach may be applied in diverse communities through fieldwork in Kenya, Peru, Trinidad and Tobago, and the US. Through resourcefulness-based approaches to community health, communities cultivate agency to 1) conceptualize what constitutes their health and assets and 2) pursue and sustain health agendas driven by local priorities, needs, and learning, while they also work to 3) change power imbalances that drive inequitable patterns of resource distribution and 4) nurture ecologically sound relationships with their local environment. We discuss how resourcefulness addresses tensions between resource use and sustainability, and how communities leverage partnerships for change. We make practical suggestions to apply resourcefulness as a process-based, place-based, and relational strategy, while recognizing that contexts and scale matter and limit the viability of community-based solutions.

Key messages

Resourcefulness-based strategies can forge new pathways to sustainable and self-sustaining community positive health. Resourcefulness builds on agentic approaches, but it also challenges inequitable power relations and environmental practices that degrade local capacities for health.

Abstract P2-09-22: Use of a functional signal profiling test with high sensitivity and specificity to determine the prevalence of abnormal HER2-driven signaling activity in the HER2-negative breast cancer patient population: New patient group may benefit from HER2 therapy

Background: Biological factors, such as HER2 signaling activity, may be important to measure in addition to expression and amplification of HER2 when identifying patients eligible for HER2 therapies. The CELx HER2 Signaling Function (CELx HSF) Test measures HER2 signaling activity in live tumor cells using a label-free impedance biosensor to identify HER2-negative breast cancer patients likely to be responsive to treatment with anti-HER2 therapies. Previous studies quantified HER2-driven signaling activity in a training set (N=34) of primary tissue samples from HER2-negative breast cancer patients and found 21% of the samples had abnormal HER2 signaling. Other studies confirmed that anti-HER2 therapies, such as trastuzumab, pertuzumab, afatinib, and neratinib, are as effective in inhibiting HER2-driven signaling activity in HER2- tumor cells as they are in HER2+ tumor cells. This study set out to confirm the prevalence of abnormal HER2 signaling amongst HER2-negative breast cancer patients in a larger sample (N=114) and to characterize the sensitivity and specificity of the CELx HSF Test.

Methods: A validation set of de-identified fresh breast tumor specimens were obtained from 114 HER2- breast cancer patients. Real time live cell response to specific HER2 agonists (NRG1b or EGF) with or without an antagonist (HER2 dimerization inhibitor) was measured using an impedance biosensor. From these responses, the net amount of HER2 participation in HER2 signaling initiated by the HER2 agonists was quantified. Samples with HER2 signaling activity levels above a previously determined cut-off value were identified as abnormal.

Results: Of the HER2- breast tumor cell samples tested, 27 of 114 patients (23.7%; 95% CI=17%-32%) had abnormal HER2 signaling activity. Little or no correlation was found between a patient's HER2 signaling activity and their estrogen receptor status or tumor grade. To compare the results obtained from the training set of 34 patients and the current set of 114 patients, the Kolmogorov-Smirnov two-sample test was applied (D=0.17, P-value 0.45) and found no significant difference between the training and validation sets. A normal mixture model was fitted to the new 114 patient data set and found that HER2- breast cancer patients fall into three distinct groups (abnormal, normal, low). Patients falling into the abnormal group had mean HER2 signaling scores 4.5 standard deviations above the mean score of the normal group. A ROC curve constructed with this data projects that both the sensitivity and specificity of the CELx HSF Test would be greater than 90%.

Conclusions: These results confirm that a clinically relevant proportion of HER2- breast cancer patients, approximately 20%, have tumors with abnormal HER2-signaling activity and may benefit from HER2 therapy. With high specificity and sensitivity, the CELx HSF test may be suitable as a companion diagnostic to identify new patients eligible to receive HER2 therapies. An interventional trial to evaluate the efficacy of trastuzumab and pertuzumab in HER2- patients selected with the CELx HSF test is underway.

Citation Format: Laing LG, Burns DJ, MacNeil IA, Rich BE, Myhre S, Soltani S, Sullivan BF. Use of a functional signal profiling test with high sensitivity and specificity to determine the prevalence of abnormal HER2-driven signaling activity in the HER2-negative breast cancer patient population: New patient group may benefit from HER2 therapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-09-22.

Abstract P6-07-14: New method to measure functional HER2-driven signaling activity in primary tumor cells identifies HER2-negative breast cancers with abnormal HER2 signaling activity: New group of patients may benefit from anti-HER2 therapy

Background: Clinical trials have indicated a weak correlation between HER2 expression levels and HER2 targeted therapy benefit. Other biological factors, such as HER2 signaling activity, may be important to measure, in addition to expression and amplification of HER2, when identifying patients eligible for HER2 therapies. To measure the HER2-driven signaling activity of a patient's tumor cells, a new assay using an impedance biosensor, the CELx HER2 Signaling Profile (CELx HSP) Test, was developed. This study set out to provide an initial assessment of the CELx HSP Test, specifically to: 1) quantify HER2-driven signaling activity (HER2S) in cell lines and primary epithelial cells; 2) assess the correlation between HER2 expression levels and HER2 signaling activity; 3) define a preliminary cut-point between normal and abnormal HER2 signaling; and 4) estimate the proportion of HER2- primary breast cancer tumors with abnormal HER2 signaling.

Methods: A training set of de-identified fresh breast tissue specimens was obtained from 50 patients, 34 with HER2- breast cancer (IHC 0 or 1+) and 16 healthy patients. Cell samples were comprised of epithelial cells extracted and cultured from each specimen. Reference human breast cancer cell lines (9 HER2+, 10 HER2-) were also tested, including two cell lines used as controls in IHC HER2 tests. Real time live cell response to specific HER2 agonists (NRG1b or EGF) and with or without an antagonist (pertuzumab, an FDA-approved HER2 dimerization inhibitor) was measured and quantified using an xCELLigence RTCA impedance biosensor (ACEA Biosciences, San Diego, CA). From these responses, the net amount of HER2 participation in HER2 signaling initiated by the HER2 agonists (“HER2S”) was determined. Fluorescence cytometry was used to measure HER2 expression levels of each cell sample.

Results: Of the HER2– breast tumor cell samples tested, 7 of 34 patients (20.5%; 95% CI=10%-37%) had net HER2 signaling activity that was greater than the median HER2S of the HER2+ cell lines. There was no categorical correlation between HER2 IHC status (+ or -) and HER2 signaling activity (abnormal or normal) (Pearson's Chi-Square = 3.68; Phi Max = -0.78, Contingency Coefficient 0.28). The median HER2S, or net HER2 signaling activity, was comparable for the HER2- tumor, HER2- cell line, and the healthy patient samples (Md = 100, 117, 77, respectively). The median HER2S in HER2+ cell lines (Md = 248) is approximately 2.5-3.0 fold greater than the median of the other groups. A HER2S above 250 was considered abnormal or test positive, and was defined as the cut-point. The HER2S for the two IHC HER2 test control cell lines, SKBR3 for HER2+ and MDA-MB231 for HER2-, was 544 and 0.

Conclusions: These findings provide strong evidence that measurement of HER2 signaling activity may provide clinically relevant information, particularly for HER2- breast cancer patients. These results suggest a new group of HER2- breast cancer patients with abnormal HER2-driven signaling may benefit from anti-HER2 therapy. Additional studies are underway to confirm these findings and to analytically validate the CELx HSP test.

Citation Format: Laing L, Burns D, MacNeil I, Rich B, Huang Y, Myhre S, Soltani S, Sullivan B. New method to measure functional HER2-driven signaling activity in primary tumor cells identifies HER2-negative breast cancers with abnormal HER2 signaling activity: New group of patients may benefit from anti-HER2 therapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-07-14.

Abstract P4-12-06: Quantification of HER2-driven signaling (HER2S) inhibition of four different anti-HER2 drugs tested ex vivo in live primary HER2-negative breast cancer cell samples with abnormal HER2 signaling activity

Background: A new functional cellular analysis platform, the CELx HER2 Signaling Profile (CELx HSP) Test, uses a label-free impedance biosensor to measure HER2 signaling activity in live tumor cells. A recently completed study quantified HER2-driven signaling activity in epithelial cell samples extracted and cultured from fresh breast tissue specimens obtained from 34 patients with HER2-negative breast cancer (DAKO 0 or 1+). Of the cell samples tested, 7 of 34 HER2-negative breast tumor patients (20.5%; 95% CI=10%-37%) were found to have abnormal HER2 signaling activity (HER2S+). The current study set out to: 1) evaluate the primary cells with abnormal HER2-driven signaling with four HER2 signal inhibitors - pertuzumab, lapatinib, neratinib, afatinib; and 2) evaluate the same four HER2 signal inhibitors with 9 HER2-positive cell lines. The objective was to quantify the percentage of HER2-driven signaling activity each drug could inhibit ex vivo in the primary cell samples and cell lines. Comparing the results between the HER2-negative primary cells and the HER2-positive cell lines was also of interest. The anti-HER2 drug, trastuzumab, was not studied because its primary mechanism of action does not appear to be direct mediation of HER2-driven signaling.

Methods: Epithelial cells from the 7 HER2-negative tumor specimens with abnormal HER2-driven signaling (HER2S+) and the 9 HER2-positive cell lines were obtained. Real time live cell response to NRG1, a specific HER2/HER3 agonist, with or without a HER2 targeted drug (pertuzumab, lapatinib, neratinib, afatinib) was measured and quantified using an xCELLigence RTCA impedance biosensor (ACEA Biosciences, San Diego, CA). Clinically relevant concentrations of the HER2 drugs were used. From these responses, the percentage inhibition of the HER2-driven signaling initiated by NRG1 by the HER2 drugs was determined.

Results: Each of the HER2 drugs inhibited an average of at least 69% of the HER2-driven signaling activated by NRG1 stimulation in the HER2-negative primary cell samples; the highest level of inhibition was found with the two irreversible covalent dual RTKi's, afatinib and neratinib. All of the HER2 drugs inhibited a greater percentage of HER2-driven signaling in the HER2-negative primary tumor cells than in the HER2-positive cell lines.

table 1  Avg. % NRG1 Inhibition  Cell LinesPrimariesHER2 DrugsMechanism of Action(HER2+)(HER2-)PertuzumabHER2 dimerization inhibitor46%78%LapatinibReversible Dual RTKi (HER2, EGF)15%69%AfatinibIrreversible Covalent Dual RTKi (HER2, EGF)47%93%NeratinibIrreversible Covalent Dual RTKi (HER2, EGF)95%100%

Conclusions: These findings provide strong evidence that HER2 signal inhibitors are effective in blocking abnormal levels of HER2-driven signaling (HER2S+) ex vivo in live primary cells from breast cancer patients with normal expression levels of HER2. These results suggest a new group of breast cancer patients, HER2-negative with abnormal HER2 signaling (HER2-/HER2S+), may benefit from the addition of HER2 signal inhibitors to current combination therapeutic regimens. Additional studies to confirm these findings are underway.

Citation Format: Laing L, Burns D, Huang Y, MacNeil I, Rich B, Myhre S, Soltani S, Sullivan B. Quantification of HER2-driven signaling (HER2S) inhibition of four different anti-HER2 drugs tested ex vivo in live primary HER2-negative breast cancer cell samples with abnormal HER2 signaling activity [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-12-06.

Abstract P3-04-03: A seven-gene profile predicting benefit of postmastectomy radiotherapy independently of nodal status in high risk breast cancer

Background: Recommendations for postmastectomy radiotherapy (PMRT) are well established in patients estimated to have a high risk of loco-regional recurrence (LR) (e.g. tumor size > 5 cm or ≥ 4 positive lymph nodes). International recommendations for patients with 1–3 positive lymph nodes suggest that PMRT should be restricted to younger patients and patients with other poor prognostic features. However, large randomized trials, including the DBCG82 trials (Danish Breast Cancer Cooperative Group), have previously shown a substantial overall survival benefit after PMRT in patients with low risk of LR, and shown that the largest translation of LR reduction into breast cancer mortality reduction occurs within the most favorable prognosis group. Our hypothesis is that a more refined partitioning of patients likely to benefit from PMRT can be established through identification of genes whose transcription interacts with PMRT to modify the hazard of LR.

Material and methods: The DBCG82bc cohort constitutes high risk patients (tumor size > 5 cm and/or positive nodes and/or invasion in skin or pectoral fascia) diagnosed between 1983–89, treated with mastectomy and partial axillary lymph nodes dissection and randomized to +/− PMRT. From 267 DBCG82bc patients, frozen tumor samples were available. Whole genome arrays (Applied Biosystem Human Genome Survey Microarray v2.0®, Applied Biosystem, Foster City, USA) were successful in 195 samples. Genes, whose expression levels interacted with PMRT on the association with LR, were identified through a two step Cox Proportional Hazard model with lasso penalty. 11 node negative patients were excluded from the subsequent analysis of 184 node positive patients (1–3 pos. nodes: 102 pts, ≥ 4 pos. nodes: 82 pts).

Results: Seven genes were identified whose expression interact with the effect of PMRT, and a specialized index was generated based on the expression levels of these genes. Patients were ranked according to the size of the index, and divided into quartiles with 25% of the patients designated as having a “high index” and 75% a “low index”. Among patients not receiving PMRT, a low index was in both nodal groups (1–3 vs. ≥ 4 positive nodes) associated with a significantly higher risk of LR compared to patients with a high index. In both nodal groups, PMRT significantly reduced the risk of LR in patients with a low index; equalizing the risk to patients with a high index, who showed no additional LR reduction by PMRT. In the group of 1–3 positive nodes, PMRT raised the local control rate (LCR) after 10 years from 47.5 % to 91.8% in the low index group (p = 0.0001), whereas the change in the high index group was non-significant (92.3% vs. 100.0%). In the group of patients with ≥ 4 positive nodes, PMRT raised LCR from 16.6% to 80.0% in the low index group (p = 0.0001), and no effect on LCR was seen in the high index group (83.3% vs. 87.5%, n.s.).

Conclusion: A seven gene-profile attaining prognostic and predictive impact, irrespective of number of positive nodes, was identified. The profile allowed the identification of 25% of the patients not showing any additional benefit from PMRT in terms of LR. The gene-profile may provide a method to identify patients expected to benefit from PMRT.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-04-03.

Retracted: 147 reduced syntaxin-5 in skeletal muscle of patients with type 2 diabetes. A link between lipid storage and insulin resistance

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This abstract has been retracted at the request of Jan Borén, co-author, because of conscious fabrication, corruption or suppression of basic material and conscious preparation and presentation of falsified results in the abstract by one of the authors.

Adenovirus 5 vector genetically re-targeted by an Affibody molecule with specificity for tumor antigen HER2/neu

In order to use adenovirus (Ad) type 5 (Ad5) for cancer gene therapy, Ad needs to be de-targeted from its native receptors and re-targeted to a tumor antigen. A limiting factor for this has been to find a ligand that (i) binds a relevant target, (ii) is able to fold correctly in the reducing environment of the cytoplasm and (iii) when incorporated at an optimal position on the virion results in a virus with a low physical particle to plaque-forming units ratio to diminish the viral load to be administered to a future patient. Here, we present a solution to these problems by producing a genetically re-targeted Ad with a tandem repeat of the HER2/neu reactive Affibody molecule (ZH) in the HI-loop of a Coxsackie B virus and Ad receptor (CAR) binding ablated fiber genetically modified to contain sequences for flexible linkers between the ZH and the knob sequences. ZH is an Affibody molecule specific for the extracellular domain of human epidermal growth factor receptor 2 (HER2/neu) that is overexpressed in inter alia breast and ovarian carcinomas. The virus presented here exhibits near wild-type growth characteristics, infects cells via HER2/neu instead of CAR and represents an important step toward the development of genetically re-targeted adenoviruses with clinical relevance.

Decreased immune reactivity towards a knobless, affibody-targeted adenovirus type 5 vector

In this study, a prototype Adenovirus type 5 (Ad5) vector deleted of the fiber knob domain and carrying an Affibody molecule as the targeting ligand showed decreased susceptibility to human pre-existing antibodies. This vector, Ad5/R7-Z(taq)Z(taq), has short fibers carrying seven shaft repeats, a non-native trimerization signal and an affibody molecule (Z(taq)) reactive to Taq polymerase. Ad5/R7-Z(taq)Z(taq) could be specifically targeted to 293 cells stably expressing membrane-bound anti-Z(taq) idiotypic affibody called Z(ztaq) (293Z(ztaq)). Sera from 50 blood donors were analyzed for neutralization activity (NA) against the parental Ad5/Fiwt vector and knobless Ad5/R7-Z(taq)Z(taq) on 293Z(ztaq) cells. Twenty-three sera had NA titers (> or =1:64) against Ad5/Fiwt (46%) and only two against Ad5/R7-Z(taq)Z(taq) (4%). Characterization of sera with NA titers showed that the knob domain is one of the targets of the antibodies. Neutralization assays using sera pre-adsorbed on knob and hexon proteins showed that the NA of the sera was carried mainly by anti-knob and anti-hexon antibodies, but in certain sera the anti-hexon antibodies represent the major population of the neutralizing antibodies (NAbs). Our results suggested that a combination of knob deletion and hexon switching could be an effective strategy for Ad vectors to better evade the anti-Ad NAbs.

Developing health education materials for inner-city low literacy parents

The question of identifying and treating childhood illness confronts all new parents. Misconceptions often lead parents to manage illnesses in their young children inappropriately through overly aggressive treatment or insufficient attention. This responsibility is especially challenging for low-income new parents who lack the literacy levels needed to understand and use much of the existing health education literature and who are without access to health facilities and providers. In response to a perceived need for health information directed at low-income, low-literacy parents, students from the University of California at Los Angeles School of Public Health created an easy-to-use reference booklet called "A Parent's Guide: When Your Child Is Sick." The booklet's aim is to assist parents in treating common childhood illness and identifying more serious diseases requiring medical attention. A comprehensive and manageable amount of information is provided in the booklet. Behaviors and issues covered include (a) recognition of symptoms, (b) actions that could be taken in the home, (c) medicines that could be administered, and (d) recommendations on how persistent problems might be handled.

New multiple congenital anomalies syndrome in a stillborn infant of consanguinous parents and a prediabetic pregnancy

We report on a term stillborn female infant with multiple congenital anomalies (MCA) which have not previously been reported as occurring together. The malformations include a first and second branchial arch sequence, ectopia cordis with congenital heart defect, caudal "regression" sequence with absent sacrum and hypoplastic right femur, ectrodactyly, left radial abnormality, islet cell hyperplasia, and skin lesions. The pregnancy was complicated by abdominal cramping with exercise, heavy vaginal bleeding, maternal obesity, and a normal screening glucose tolerance test at 6 months gestation. The infant was born to 20-year-old G3P1SAB2 Mexican-American parents who are first cousins. There was strong maternal family history of adult-onset diabetes. The malformations have some findings in common with those seen in infants of diabetic mothers. Structural defects similar to, but not inclusive of, those in our infant have been reported in 2 sibs born to a prediabetic mother with a first cousin marriage as well as in focal dermal hypoplasia. Parental consanguinity is suggestive of an autosomal recessive disorder. Alternatively, it may represent a combined multifactorial effect making the conceptus more sensitive to metabolic teratogens and thus placing it at increased risk for disruption of normal development.

Amniotic fluid embolus. A report of two cases resulting in maternal survival

Two cases of amniotic fluid embolus resulted in patient survival. Both were manifested by fetal bradycardia, respiratory distress and disseminated intravascular coagulopathy. Rapid diagnosis and treatment and anticipation of subsequent events, especially coagulopathy, appear to offer the best chance of a successful outcome.

Plant protoplasts immobilized in calcium alginate: a simple method of preparing fragile cells for transmission electron microscopy

A simple method for electron microscopic preparation of plant protoplasts is described. The main problems in preparing these fragile protoplasts for electron microscopy have been cell collapse due to steep gradients between protoplasts and fixatives and unacceptable loss of material during the many steps of the procedure. These problems may be solved by immobilization of the protoplasts in calcium alginate beads. The free diffusion properties of this gel prevent steep gradients. The beads also simplify handling and prevent loss of material. Protoplasts isolated from hypocotyls of rape, Brassica napus (var. Niklas), have been used as a model system. Transmission electron microscopy of the immobilized protoplasts osmotically stabilized with glucose demonstrated adequate structural and ultrastructural preservation.

Ectopia cordis thoracalis with craniofacial defects resulting from early amnion rupture

A 33-week-gestation fetus was evaluated as having ectopia cordis thoracalis, midline sternal cleft, frontonasal dysgenesis, a midfacial cleft, and amniotic bands. Fibrous bands were attached to the apex of the heart, face, and the brain. There were no associated limb defects or scoliosis. The findings in this fetus and those in the literature suggest that acute amnion rupture in the third week of gestation may be the cause of these defects. Mechanical teratogenesis by tissue bands adherent to the heart may lead to ectopia cordis. The changes seen in the thorax, face, and brain suggest pressure necrosis, incomplete morphogenesis, tearing and tethering by amnion, and compression as a cause for these defects. A spectrum of defects is found following amnion rupture with the abnormalities being dependent upon the timing of the event. Ectopia cordis with amniotic bands appears to have an etiology distinct from isolated ectopia cordis. This suggests several different etiologies for ectopia cordis.

Demonstration of extracellular chymotrypsin-like activity from various Legionella species

Concentrated extracellular supernatants from Legionella pneumophila, L. bozemanii, L. dumoffi, L. gormanii, but not L. micdadei, exhibited a strong chymotrypsin-like activity upon synthetic chromogenic tri- and tetrapeptides. Bacterial cell sonic extracts showed low protease activities, different from those of the extracellular concentrates. Extracellular concentrates were also tested in the API ZYM system, where weak protease activity only was recorded. Protease inhibitors decreased the activity of the extracellular Legionella proteases upon the chromogenic peptides.

Detection of staphylococcal enterotoxin A, B, and C in milk by an ELISA procedure

Enterotoxigenic reference strains of Staphylococcus aureus were cultivated in sterile whole and skim milk for 18 h at 37°G. Staphylococcal enterotoxin A, B, and C were detected directly in the milk by an enzyme linked immunosorbent assay (ELISA), sensitive down to 1 ng/ml. Enterotoxins in the range of 1 ng–20 µg/ml milk were detected without any concentration or extraction. Skim and whole milk were almost identical as medium for enterotoxin production.

Sotos syndrome with intestinal polyposis and pigmentary changes of the genitalia

We report two adult males with the Sotos syndrome, who also presented intestinal polyposis and pigmentary spotting of the shaft and glans penis. We propose that patients with the Sotos syndrome may develop hamartoneoplastic disease and we urge clinicians to consider this possibility in those patients.