An improved method for generating human spinal cord neural stem cells

Neural stem cells have exhibited efficacy in pre-clinical models of spinal cord injury (SCI) and are on a translational path to human testing. We recently reported that neural stem cells must be driven to a spinal cord fate to optimize host axonal regeneration into sites of implantation in the injured spinal cord, where they subsequently form neural relays across the lesion that support significant functional improvement. We also reported methods of deriving and culturing human spinal cord neural stem cells derived from embryonic stem cells that can be sustained over serial high passage numbers in vitro, providing a potentially optimized cell source for human clinical trials. We now report further optimization of methods for deriving and sustaining cultures of human spinal cord neural stem cell lines that result in improved karyotypic stability while retaining anatomical efficacy in vivo. This development improves prospects for safe human translation.

Identification of barriers at the primary care provider level to improve inflammatory breast cancer diagnosis and management

The purpose of this study, based in the United States, was to evaluate knowledge gaps and barriers related to diagnosis and care of inflammatory breast cancer (IBC), a rare but lethal breast cancer subtype, amongst Primary Care Providers (PCP) as they are often the first point of contact when patients notice initial symptoms. PCP participants in the Duke University Health System, federally qualified health center, corporate employee health and community practices, nearby academic medical center, Duke physician assistant and advanced practice nurse leadership program alumni were first selected in a convenience sample and for semi-structured interviews (n = 11). Based on these data, an online survey tool was developed and disseminated (n = 78) to assess salient measures of IBC diagnosis, health disparity factors, referral and care coordination practices, COVID-19 impact, and continuing medical education (CME). PCP reported access to care and knowledge gaps in symptom recognition (mean = 3.3, range 1-7) as major barriers. Only 31 % reported ever suspecting IBC in a patient. PCP (n = 49) responded being challenged with referral delays in diagnostic imaging. Additionally, since the COVID-19 pandemic started, 63 % reported breast cancer referral delays, and 33 % reported diagnosing less breast cancer. PCP stated interest in CME in their practice for improved diagnosis and patient care, which included online (53 %), lunch time or other in-service training (33 %), patient and provider-facing websites (32 %). Challenges communicating rare cancer information, gaps in confidence in diagnosing IBC, and timely follow-up with patients and specialists underscores the need for developing PCP educational modules to improve guideline-concordant care.

Docetaxel targets aggressive methylation profiles and serves as a radiosensitizer in high-risk meningiomas

BACKGROUND

Meningioma is the most common primary intracranial tumor in adults. A subset of these tumors recur and invade the brain, even after surgery and radiation, resulting in significant disability. There is currently no standard-of-care chemotherapy for meningiomas. As genomic DNA methylation profiling can prognostically stratify these lesions, we sought to determine whether any existing chemotherapies might be effective against meningiomas with high-risk methylation profiles.

METHODS

A previously published dataset of meningioma methylation profiles was used to screen for clinically significant CpG methylation events and associated cellular pathways. Based on these results, patient-derived meningioma cell lines were used to test candidate drugs in vitro and in vivo, including efficacy in conjunction with radiotherapy.

RESULTS

We identified 981 genes for which methylation of mapped CpG sites was related to progression-free survival in meningiomas. Associated molecular pathways were cross-referenced with FDA-approved cancer drugs, which nominated Docetaxel as a promising candidate for further preclinical analyses. Docetaxel arrested growth in 17 meningioma cell sources, representing all tumor grades, with a clinically favorable IC50 values ranging from 0.3 nM to 10.7 mM. The inhibitory effects of this medication scaled with tumor doubling time, with maximal benefit in fast-growing lesions. The combination of Docetaxel and radiation therapy increased markers of apoptosis and double-stranded DNA breaks, and extended the survival of mice engrafted with meningioma cells relative to either modality alone.

CONCLUSIONS

Global patterns of DNA methylation may be informative for the selection of chemotherapies against meningiomas, and existing drugs may enhance radiation sensitivity in high-risk cases.

α2,6 Sialylation mediated by ST6GAL1 promotes glioblastoma growth

One of the least-investigated areas of brain pathology research is glycosylation, which is a critical regulator of cell surface protein structure and function. β-Galactoside α2,6-sialyltransferase (ST6GAL1) is the primary enzyme that α2,6 sialylates N-glycosylated proteins destined for the plasma membrane or secretion, thereby modulating cell signaling and behavior. We demonstrate a potentially novel, protumorigenic role for α2,6 sialylation and ST6GAL1 in the deadly brain tumor glioblastoma (GBM). GBM cells with high α2,6 sialylation exhibited increased in vitro growth and self-renewal capacity and decreased mouse survival when orthotopically injected. α2,6 Sialylation was regulated by ST6GAL1 in GBM, and ST6GAL1 was elevated in brain tumor-initiating cells (BTICs). Knockdown of ST6GAL1 in BTICs decreased in vitro growth, self-renewal capacity, and tumorigenic potential. ST6GAL1 regulates levels of the known BTIC regulators PDGF Receptor β (PDGFRB), Activated Leukocyte Cell Adhesion Molecule, and Neuropilin, which were confirmed to bind to a lectin-recognizing α2,6 sialic acid. Loss of ST6GAL1 was confirmed to decrease PDGFRB α2,6 sialylation, total protein levels, and the induction of phosphorylation by PDGF-BB. Thus, ST6GAL1-mediated α2,6 sialylation of a select subset of cell surface receptors, including PDGFRB, increases GBM growth.

A Southeast Asian collaborative Delphi consensus on surveying risk factors for head and neck cancer screening and prevention

The objective of this study was to determine high value questions for early detection and prevention of head and neck cancer by querying content experts on patient risk factors relevant to local communities in Southeast Asia (i.e., Vietnam, Laos, China, and Singapore). The Delphi method was employed using three rounds of asynchronous surveying which included participants among five different collaborating medical centers. 60 total survey items were assessed for consensus defined by a priori measures on the relative level of value of these questions for use in head and neck cancer screening. 77% of items reached a consensus and no items were concluded to be of low value despite differences in conclusions regarding relative importance. Survey items focused on patient demographic information and physical examination were examined across variables such as expert department affiliation, academic designation, and years of experience and found to be without statistically significant differences. However, with consensus items related to social risk factors, it was determined that participants who had 15 or more years of experience or identified as otolaryngologists rated these items at a relatively lower value than their peers with less experience (p < 0.0001, p = 0.0017) or outside the field of otolaryngology (p = 0.0101). This study explicitly identifies patient variables to consider in head and neck cancer screening that have not previously been comprehensively or methodically assessed in current literature. Increasing awareness of these risk factors may benefit the design and implementation of future head and neck cancer early detection and prevention programs in Southeast Asia and beyond as well as positively impact head and neck cancer outcomes.

Coping With COVID-19: The Impact of the Pandemic on Latina Immigrant Women's Mental Health and Well-being

INTRODUCTION

We sought to describe how Latina immigrants living in King County coped with the pandemic, including their attitudes and behaviors related to COVID-19, and the impact of the pandemic on their mental health and wellbeing.

METHOD

We conducted surveys by phone with adult Spanish-speaking Latina immigrants (n = 137) in the summer of 2020.

RESULTS

Very few women had been infected with COVID-19, and 23% reported having been tested. Most frequent reasons for not being tested were not knowing where to go (14%), concerns over the cost (15%), and not wanting to know if they were infected (12%). Most participants had concerns about paying for housing (76%) and food (73%). Depression and anxiety symptoms were in the moderate range. Almost all participants were practicing recommended preventive behaviors.

CONCLUSION

Although few participants had COVID-19 infection, the pandemic had significant impacts on their mental health and ability to meet basic needs.

Novel RPL13 Variants and Variable Clinical Expressivity in a Human Ribosomopathy With Spondyloepimetaphyseal Dysplasia

Spondyloepimetaphyseal dysplasias (SEMDs) are a heterogeneous group of disorders with variable growth failure and skeletal impairments affecting the spine and long bone epiphyses and metaphyses. Here we report on four unrelated families with SEMD in which we identified two monoallelic missense variants and one monoallelic splice site variant in RPL13, encoding the ribosomal protein eL13. In two out of four families, we observed autosomal dominant inheritance with incomplete penetrance and variable clinical expressivity; the phenotypes of the mutation-positive subjects ranged from normal height with or without hip dysplasia to severe SEMD with severe short stature and marked skeletal dysplasia. In vitro studies on patient-derived dermal fibroblasts harboring RPL13 missense mutations demonstrated normal eL13 expression, with proper subcellular localization but reduced colocalization with eL28 (p < 0.001). Cellular functional defects in fibroblasts from mutation-positive subjects indicated a significant increase in the ratio of 60S subunits to 80S ribosomes (p = 0.007) and attenuated global translation (p = 0.017). In line with the human phenotype, our rpl13 mutant zebrafish model, generated by CRISPR-Cas9 editing, showed cartilage deformities at embryonic and juvenile stages. These findings extend the genetic spectrum of RPL13 mutations causing this novel human ribosomopathy with variable skeletal features. Our study underscores for the first time incomplete penetrance and broad phenotypic variability in SEMD-RPL13 type and confirms impaired ribosomal function. Furthermore, the newly generated rpl13 mutant zebrafish model corroborates the role of eL13 in skeletogenesis. © 2020 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR)..

Minimally invasive treatment of abdominal lymphocele: A review of contemporary options and how to approach them

Lymphoceles are lymphatic fluid collections resulting from lymphatic vessel disruption after surgery or trauma. They are most often described following retroperitoneal surgeries such as cystectomies, prostatectomies, renal transplants, and gynecologic surgeries. Most lymphoceles are asymptomatic and resolve spontaneously without treatment. If persistent, they can become infected or exert mass effect on adjacent structures causing pain, urinary, or lower limb edema particularly for lymphoceles in the pelvis Symptomatic lymphoceles should be treated to relieve symptoms and prevent functional compromise of vital adjacent structures. Although surgery has been traditionally accepted as the gold standard treatment, advances in imaging and interventional technology allow for less invasive, percutaneous treatment. Available minimally invasive treatment options include percutaneous aspiration, catheter drainage, sclerotherapy, and lymphangiography with lymphatic embolization. A review of these treatment options and a suggested algorithm for managing lymphoceles is presented.

Abstract B034: Improving patient-centered care for inflammatory breast cancer: Strategies for addressing barriers faced by patients, researchers, and providers

Introduction: Inflammatory breast cancer (IBC) is a rare but the most lethal breast cancer often misdiagnosed as mastitis or dermatitis since majority of cases lack a clinically apparent tumor mass and present with progressive breast erythema and skin edema. Further exacerbating this is its incidence, more often, in premenopausal women who have yet to initiate regular screening, and/or its manifestation in women of color, in whom the signs of disease may be more subtle. Thus, the goal of this research is to understand IBC awareness and knowledge of clinical signs related to diagnosis and treatment amongst the general public, patients, and primary care providers in order to design effective interventions to improve patient care. Methods: Responses (500+ unique) were collected from a facilitated session and representative post meeting interviews including researchers, clinicians, patients, and community stakeholders on open-ended questions related to IBC diagnosis, treatment barriers, and strategies to improve patient care. For thematic analysis, responses were subdivided into patient/community, provider, and organizational level using NVivo 12 Pro qualitative software. Grounded theory shaped both design and analysis. Results: Based on participant responses, barriers at the patient/community level (69.4%) were recognized to be the greatest. The primary factor identified was related to living in a rural community/distance to a treatment center (21.1%). At the organizational level, obstacles included limited or no access to an appropriate treatment center (42.2%), lack of IBC-specific standard of care (20.0%), lack of central source of information about IBC (20.0%) and need for trained patient navigators (8.9%). This analysis highlighted that patients often experience multiple misdiagnoses before finding a physician that correctly recognizes IBC - 79.4% responses indicated a lack of education among primary care providers (79.4%), misdiagnoses due to patients not fitting the typical breast cancer profile (13.1%), and a dearth in communication between physicians and patients (7.5%). This study also identified specific strategies, which included developing culturally tailored IBC media campaign and community-facing patient navigation to address barriers such as social support and care for patients in rural or underserved communities. Conclusions: Taken together, three themes in IBC care were identified- a) barriers to timely diagnosis and treatment, b) strategies for community engagement, and c) the need for provider education. These datasets have led to the development of survey instruments to assess gaps of knowledge during diagnosis and treatment in IBC patients and primary care providers including physicians, physician assistants, and nurse practitioners in the community. Supported by Duke SOM Interdisciplinary Colloquium (GRD); DCI Behavioral and Health Survey Research Core Award (GRD, LF, AT); C-REP 1P20-CA202925-01A12 (GRD, HH, LGS, NB); T32 Surgical Oncology training (WL).

Citation Format: Larisa Gerahart-Serna, Whitney Lane, Laura Fish, Anh N Tran, Gayathri R Devi, Holly Hough, Kearston L Ingraham. Improving patient-centered care for inflammatory breast cancer: Strategies for addressing barriers faced by patients, researchers, and providers [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B034.

A Sub-Clone of RAW264.7-Cells Form Osteoclast-Like Cells Capable of Bone Resorption Faster than Parental RAW264.7 through Increased De Novo Expression and Nuclear Translocation of NFATc1

The murine macrophage cell line RAW264.7 is extensively used as a progenitor to study osteoclast (OC) differentiation. RAW264.7 is a heterogeneous cell line, containing sub-clones with different abilities to form OCs. The aim of this study was to identify characteristics within the heterogeneous RAW264.7 cells that define sub-clones with an augmented ability to form bone-resorbing OCs (H9), as well as sub-clones representing non-OCs (J8). RAW264.7 sub-clones were isolated by single cell cloning. Selection was based on TRAP/cathepsin K expression in sub-clone cultures without added RANKL. Sub-clones before and after differentiation with RANKL were assayed for multiple OC-characteristics. Sub-clone H9 cells presented a higher expression of OC-markers in cultures without added RANKL compared to the parental RAW264.7. After 6 days of RANKL stimulation, sub-clone H9 cells had equal expression levels of OC-markers with RAW264.7 and formed OCs able to demineralize hydroxyapatite. However, sub-clone H9 cells displayed rapid differentiation of OC already at Day 2 compared to Day 4 from parental RAW264.7, and when cultured on plastic and on bone they were more efficient in resorption. This rapid differentiation was likely due to high initial expression/nuclear translocation of OC master transcription factor, NFATc1. In contrast to H9, J8 cells expressed initially very low levels of OC-markers, and they did not respond to RANKL-stimulation by developing OC-characteristics/OC-marker expression. Hence, H9 is an additional clone suitable for experimental setup requiring rapid differentiation of large numbers of OCs.

Identifying core curricular components for behavioral health training in internal medicine residency: Qualitative interviews with residents, faculty, and behavioral health clinicians

OBJECTIVE

Behavioral health services frequently delivered by primary care providers include care for mental health and substance abuse disorders and assistance with behavioral risk factor reduction. Internal medicine residencies in the United States lack formal expectations regarding training in behavioral health for residents. This qualitative study aimed to determine learners' and teachers' perceptions about appropriate behavioral health curricular components for internal medicine residents.

METHOD

Focus groups and interviews were conducted with the following individuals from the Duke Outpatient Clinic: residents with continuity practice (n = 27), advanced practice providers (n = 2), internal medicine attending physicians (n = 4), internal medicine/psychiatry attending physicians (n = 2), and behavioral health clinicians (n = 4). A focus group leader asked regarding residents' successes and challenges in managing behavioral health issues and about specific learning components considered necessary to understand and manage these behavioral health conditions. Transcripts were coded using an editing analysis style to identify central themes and concordance/discordance between groups.

RESULTS

Regarding mental health management (Theme 1), residents emphasized a need for better care coordination with specialty mental health, while attendings and behavioral health clinicians gave priority to residents' skills in primary management of mental health. Residents, attendings, and behavioral health clinicians all emphasized advanced interviewing skills (Theme 2) with subthemes: eliciting the patient's perspective, managing time in encounters, improving patients' understanding, and patient counseling.

CONCLUSIONS

Internal medicine residents, attendings, and behavioral health clinicians may differ significantly in their perceptions of primary care's role in mental health care. Future internal medicine behavioral health curricula should specifically address these attitudinal differences. Curricula should also emphasize interview skills training as an essential component of behavioral health learning.

Abstract 163: Glioblastoma, cancer stem cells, and reactive species balances: A case for GTP cyclohydrolase 1

Glioblastoma (GBM), or grade IV astrocytoma, is a deadly disease due in part to the high degree of intratumoral heterogeneity that contributes to treatment failures. Previous studies have shown the importance of reactive species balances, partially controlled by the coupling of nitric oxide synthases (NOS) with their cofactor, in maintenance of glioma stem cell (GSC) phenotype as well as survival of cancer cells in general. In this study, we investigated the roles of GTP cyclohydrolase 1 (GCH1), which is the first and rate-limiting enzyme of the pathway producing of NOS cofactor producing pathway, in GBM stem cell phenotypes via redox balances. We found that GCH1 RNA and protein expression were increased in GSCs in comparison to non-GSCs, but that GCH1 was not exclusive to the GSC fraction. Indeed, GCH1 was elevated in GBM in comparison to normal brain. Overexpression of GCH1 in GBM cells increased cell growth in vitro and neurosphere-forming capability and decreased survival in an intracranial GBM mouse model. In contrast, GCH1 knockdown with short hairpin RNA in GBM cells led to growth inhibition in vitro as well as increased survival in animal models. GCH1 increased CD44 expression and was upregulated in the detrimental mesenchymal GBM subtype in which CD44 served as a marker. Mechanistically, we found that the expression of GCH1 increased BH4 production, as well as augmented multiple antioxidant pathways, including the expression of PARK7, was critical for controlling reactive species balance, including suppressing reactive oxygen species production. In silico analyses demonstrated that higher GCH1 levels in glioma patients correlate with higher glioma grade, recurrence and worse survival. Together, our data suggest that upregulation of GCH1 in GSCs promotes tumor maintenance and is a key regulator of reactive oxygen species in GBM, and GCH1 pathway is a potential target for therapy.

Citation Format: Anh N. Tran, Kiera Walker, David G. Harrison, Wei Chen, James Mobley, Lauren Hocevar, James R. Hackney, Randee Sedaka, Jennifer Pollock, Matthew S. Goldberg, Dolores Hambardzumyan, Sara J. Cooper, G Yancey Gillespie, Anita B. Hjelmeland. Glioblastoma, cancer stem cells, and reactive species balances: A case for GTP cyclohydrolase 1 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 163.

Abstract 1666: Novel glucose transporter inhibitors decrease glioblastoma growth and glucose uptake

Glioblastoma multiform (GBM) is the most common primary malignant adult brain tumor and one of the deadliest cancers. Patients with GBM typically undergo surgical resection, radiation and chemotherapy with temozolomide. Complete tumor resection is virtually impossible due to tumor location and the highly infiltrative nature of GBM, which leads to disease recurrence near the original tumor site. As such, these patients have a dramatically decreased life expectancy. Therapeutic development to prolong survival has been hampered by a high degree of inter- and intra-tumoral heterogeneity. Contributing to tumor heterogeneity is a subset of highly tumorigenic cells, termed brain tumor initiating cells (BTICs), that are able to self-renew and can be highly invasive and therapy resistant. BTICs are often enriched in perinecrotic regions, a GBM hallmark, where they can survive under nutrient restriction via increased glucose transporter 3 expression (GLUT3). GLUT3 has a 5-fold greater capacity for glucose transport than the other major glucose transporter isoform in the brain, GLUT1, and is typically restricted to neurons, testis, preimplantation embryos, and stem cells. GLUT3 expression is elevated in many solid tumor types, including GBM, and correlates with poor patient prognosis. Previously, we have shown that knockdown of GLUT3 in BTICs significantly inhibits their growth both in vitro and in vivo, indicating GLUT3 is a possible target for therapeutic intervention. Using structure based virtual screening, we have identified novel GLUT inhibitors that preferentially decrease the growth and glucose uptake of BTICs with minimal toxicity to non-malignant cells in vitro. Preliminary in vivo assessment of these compounds has not indicated toxicity. Our goal is to identify a potential new therapeutic option targeting metabolic reprogramming for the treatment of glioblastoma, as well as other tumor types.

Citation Format: Catherine J. Libby, Sixue Zhang, Gloria A. Benavides, Yanjie Li, Matthew Redmann, Anh N. Tran, Arphaxad Otamias, Victor Darley-Usmar, Marek Napierala, Jianhua Zhang, Wei Zhang, Anita Hjelmeland. Novel glucose transporter inhibitors decrease glioblastoma growth and glucose uptake [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1666.

Abstract 5462: GTP cyclohydrolase in brain tumor stem cells is implicated in glioblastoma growth

Glioblastomas (GBMs) are the most common primary brain tumors in adults and one of the most aggressive cancers with high rates of recurrence and therapeutic resistance. In GBMs, subpopulations of highly tumorigenic cells called brain tumor initiating cells (BTICs) have been characterized by their unique capacity to promote tumor maintenance, therapeutic resistance, and angiogenesis. BTIC maintenance is known to be regulated by reactive oxygen and nitrogen species. GTP cyclohydrolase, or GCH1, is a critical molecule regulating reactive species levels. We found that expression of GCH1 RNA and protein were upregulated in BTICs in comparison to non-BTICs. Overexpression of GCH1 in glioma cells increased cell growth in vitro and increased tumor formation and decreased survival in an intracranial GBM mouse model. In contrast, GCH1 depletion with short hairpin RNA in GBM cells led to growth inhibition in vitro as well as increased survival in animal orthotopic models. Furthermore, genetic modulation of GCH1 led to altered ROS levels in GBM xenolines. In silico analyses demonstrate that higher GCH1 levels in glioma patients correlate with higher glioma grade, recurrence and worse survival. Together, our data suggest that upregulation of GCH1 in BTICs promotes tumor maintenance and is a key regulator of reactive oxygen species in glioblastoma.

Citation Format: Anh N. Tran, Kiera Walker, David Harisson, Wei Chen, James Mobley, Lauren Hocevar, James R. Hackney, Randee S. Sedaka, Jennifer S. Pollock, Sara J. Cooper, George Y. Gillespie, Anita B. Hjelmeland. GTP cyclohydrolase in brain tumor stem cells is implicated in glioblastoma growth [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5462. doi:10.1158/1538-7445.AM2017-5462

NOS Expression and NO Function in Glioma and Implications for Patient Therapies

SIGNIFICANCE

Gliomas are central nervous system tumors that primarily occur in the brain and arise from glial cells. Gliomas include the most common malignant brain tumor in adults known as grade IV astrocytoma, or glioblastoma (GBM). GBM is a deadly disease for which the most significant advances in treatment offer an improvement in survival of only ∼2 months.

CRITICAL ISSUES

To develop novel treatments and improve patient outcomes, we and others have sought to determine the role of molecular signals in gliomas. Recent Advances: One signaling molecule that mediates important biologies in glioma is the free radical nitric oxide (NO). In glioma cells and the tumor microenvironment, NO is produced by three isoforms of nitric oxide synthase (NOS), NOS1, NOS2, and NOS3. NO and NOS affect glioma growth, invasion, angiogenesis, immunosuppression, differentiation state, and therapeutic resistance.

FUTURE DIRECTIONS

These multifaceted effects of NO and NOS on gliomas both in vitro and in vivo suggest the potential of modulating the pathway for antiglioma patient therapies. Antioxid. Redox Signal. 26, 986-999.

A Community-Engaged Research Approach to Improve Mental Health Among Latina Immigrants: ALMA Photovoice

Recent Latina immigrants are at increased risk of poor mental health due to stressors associated with adapting to life in the United States. Existing social and health care policies often do not adequately address the mental health concerns of new Latino populations. Amigas Latinas Motivando el Alma, a community-partnered research project, seeks to improve immigrant Latinas' mental health outcomes. Using Photovoice methodology, promotoras (lay health advisors) reflected on community factors affecting mental health through photography and guided discussion. Discussions were audio-recorded, transcribed, and coded using content analysis to identify salient themes. Promotoras reviewed codes to develop themes that they presented in community forums to reach local policy makers and to increase community awareness. These forums included an exhibit of the promotoras' photographs and discussion of action steps to address community concerns. Themes included transitioning to life in the United States, parenting, education, and combating racism. Nearly 150 stakeholders attended the community forums and proposed responses to promotoras' photographic themes. Our findings suggest that Photovoice provides an opportunity for Latinas and the larger community to identify issues that they find most important and to explore avenues for action and change by creating sustainable partnerships between the community and forum attendees.

Hypervascular tumor volume estimated by comparison to a large-scale cerebral blood volume radiographic atlas predicts survival in recurrent glioblastoma treated with bevacizumab

Background

Dynamic susceptibility contrast (DSC)-MRI is a well-established perfusion MR imaging technique for estimating relative cerebral blood volume (CBV) in primary brain tumors; however, tumors localized to regions with naturally elevated perfusion, including cortical tissue and common vascular territories, make evaluation of tumor vascularity difficult to assess. In the current study, we have constructed a large-scale radiographic atlas of CBV to assess treatment response to bevacizumab in individual patients with recurrent glioblastoma.

Methods

Z-score normalized CBV maps were registered to stereotactic atlas space in 450 patients with brain tumors. A CBV atlas was created by calculating the voxel-wise mean and variability in CBV. MRI and CBV maps from 32 recurrent glioblastoma patients were then obtained prior to and following treatment with bevacizumab, registered to and compared with the CBV atlas. The volume of tumor tissue with elevated CBV, percentage of enhancing tumor with elevated CBV, and the mean and maximum change in normalized CBV intensity relative to the atlas were computed.

Results

Voxel-wise comparison of individual patient CBV maps to the atlas allowed delineation of elevated tumor perfusion from artery and normal cortical tissue. An atlas-defined hypervascular tumor blood volume greater than 2.35 cc prior to treatment, 0.14 cc after treatment, and a decrease in atlas-defined hypervascular tumor volume less than 80% following treatment were characteristic of a shorter PFS and OS. Traditional measures of CBV were not predictive of PFS or OS.

Conclusions

This study highlights the advantages of large-scale population maps to identify abnormal biological tissues.

The Primary Care Leadership Track at the Duke University School of Medicine: creating change agents to improve population health

PROBLEM

Physicians need training in community engagement, leadership, and population health to prepare them to work with partners within the community and to adapt medical care to address population health needs.

APPROACH

With an overall goal of training primary care practitioners to be change agents for improving population health, the Duke University School of Medicine launched the Primary Care Leadership Track (PCLT) in 2011. The four-year PCLT curriculum requires students to contribute to existing community health initiatives, perform community-engaged research, and participate in leadership training. The clinical curriculum incorporates a longitudinal approach to allow students to follow patient outcomes. In addition, students regularly interact with faculty to explore population health issues, review patient cases, and adjust individual learning opportunities as needed.

OUTCOMES

The first cohort of PCLT students will graduate in 2015. Prospective comparisons with traditional track students are planned on performance on standardized tests and career choices.

NEXT STEPS

The authors created the PCLT as a laboratory in which students can engage with the community and explore solutions to address the health of the public and the future delivery of health care. To meet the goal of training change agents, PCLT leaders need to expand opportunities for students to learn from providers and organizations that are successfully bridging the gap between medical care and public health.

Risk of systemic toxicity with topical lidocaine/prilocaine: a review

The eutectic mixture of lidocaine and prilocaine (EMLA, APP Pharmaceuticals, LLC.) is an anesthetic cream frequently used by dermatologists. Although side effects of EMLA are usually mild local skin reactions (ie, edema, pallor, erythema), more severe complications can be encountered including methemoglobinemia, central nervous system toxicity, and cardiotoxicity. This article reviewed the literature regarding risk of systemic toxicity associated with use of EMLA in the pediatric and adult population. All 12 clinical trials evaluating the safety of EMLA in either the pediatric or adult population generally followed dosing and administration guidelines set by the manufacturer and reported clinically insignificant plasma levels of methemoglobin, lidocaine, prilocaine, and their respective metabolites. To date, nine pediatric cases and three adult cases of systemic toxicity associated with EMLA have been published. Possible factors that contributed to the development of systemic toxicity include excessive amount of EMLA, large application area, prolonged application time, diseased and/or inflamed skin (eg, vascular malformations, molluscum contagiosum, eczema, previously abraded skin), age less than 3 months, prematurity, and concomitant use of a methemoglobin-inducing agent. Recommendations are provided on how to safely use EMLA to minimize the risk of systemic toxicity.

Results from a pilot promotora program to reduce depression and stress among immigrant Latinas

The stressful experiences that Latino immigrants face throughout the migration process to the United States put them at increased risk for poor mental health. Latinas are at heightened risk due to stigma, limited access to mental health resources, domestic violence, and gender role expectations. In addition, for those who live in new immigrant settlement areas, such as the Southeast, these disparities are magnified by even fewer culturally appropriate services and limited social support. This study evaluates the impact of ALMA (Amigas Latinas Motivando el Alma/Latina Friends Motivating the Soul), a pilot promotora intervention offered in three North Carolina counties to improve mental health among Latinas by offering coping skills training. The intervention trained community-based promotoras to conduct outreach to Latina women in their social network (compañeras). Using a pre-post test design, we assessed the mental health outcomes of compañeras. Compañeras improved on the following outcomes: depressive symptoms, attitudes of depression treatment, perceived and acculturative stress, perceived social support, and positive coping responses. Our findings suggest that promotora interventions, such as ALMA, that focus on building self-care strategies can be valuable to reducing preclinical symptoms and addressing health care disparities that are exacerbated by unavailable or underused mental health services.

Evaluation of Amigas Latinas Motivando el Alma (ALMA): a pilot promotora intervention focused on stress and coping among immigrant Latinas

Recent immigrant Latinas are at increased risk of poor mental health due to stressors associated with adapting to life in the United States. This study evaluated Amigas Latinas Motivando el Alma, a promotora intervention to reduce stress and promote health and coping among recent immigrant Latinas. Using a pre- and post-test design, we evaluated mental health outcomes, specifically, in promotoras. Promotoras' knowledge levels related to role of promotora and stress management increased, depressive symptoms and stress levels decreased, and coping responses and perceived social support increased as well. Results suggest that promotora programs may be an effective way to improve mental health in recent immigrant Latinas.

Increased sensitivity to radiochemotherapy in IDH1 mutant glioblastoma as demonstrated by serial quantitative MR volumetry

BACKGROUND

Isocitrate dehydrogenase 1 (IDH1) mutations have been linked to favorable outcomes in patients with glioblastoma multiforme (GBM). Recent in vitro experiments suggest that IDH1 mutation sensitizes tumors to radiation damage. We hypothesized that radiographic treatment response would be significantly different between IDH1 mutant versus wild-type GBMs after radiotherapy (RT) and concurrent temozolomide (TMZ).

METHODS

A total of 39 newly diagnosed GBM patients with known IDH1 mutational status (10 IDH1 mutants), who followed standard therapy and had regular post-contrast T1W (T1+C) and T2W/ fluid-attenuated inversion recovery (FLAIR) images in the 6-month period after starting RT, were enrolled. The volume of contrast-enhancing and FLAIR hyperintensity were calculated from each scan. Linear and polynomial regression techniques were used to estimate the rate of change and temporal patterns in tumor volumes.

RESULTS

IDH1 mutant GBMs demonstrated a favorable response to RT/TMZ in the study period, as demonstrated by 10 of 10 mutants showing radiographic response (decreasing V(T1+C)), compared with 13 of 29 wild-types (P < .001). During the study period, V(T1+C) and V(FLAIR) changed at -3.6% per week and +0.6% per week in IDH1 mutant tumors, respectively, as compared with +0.8% per week and +5.2% per week in IDH1 wild-type tumors (P = .0076 and P = .0118, respectively). Amongst the radiographic responders, IDH1 mutant GBMs still demonstrated significant progression-free and overall survival benefit. Aggregated tumor kinetics by group showed significant lower rate in IDH1 mutant GBMs in specific periods: >105 days for V(FLAIR) and 95-120 and >150 days for V(T1+C) from starting RT/TMZ.

CONCLUSIONS

The current study supports the hypothesis that IDH1 mutant GBMs are more sensitive to radiochemotherapy than IDH1 wild-type GBMs.

Amigas Latinas Motivando el ALMA (ALMA)

Use of mental health care services for psychological distress is limited among Latino immigrants. In geographic areas where migration has been rapid, mental health systems possess limited capacity to provide bilingual and bicultural assistance. The development of a bilingual and bicultural workforce is a necessary yet long-term solution. More immediate strategies, however, are needed to meet the needs of immigrant Latinos. This paper describes the development of a stress-reduction focused, lay health advisor training that targets individual behavior change among Latina immigrants. The theoretical foundation, curriculum components, and pilot implementation of the training are discussed. As natural leaders, Latina promotoras disseminated learned strategies and resources within their communities. The lay health advisor model is a salient method for disseminating information regarding mental health and stress reduction among Latinas.

Amigas Latinas Motivando el ALMA (ALMA): Development and Pilot Implementation of a Stress Reduction Promotora Intervention

Use of mental health care services for psychological distress is limited among Latino immigrants. In geographic areas where migration has been rapid, mental health systems possess limited capacity to provide bilingual and bicultural assistance. The development of a bilingual and bicultural workforce is a necessary yet long-term solution. More immediate strategies, however, are needed to meet the needs of immigrant Latinos. This paper describes the development of a stress-reduction focused, lay health advisor training that targets individual behavior change among Latina immigrants. The theoretical foundation, curriculum components, and pilot implementation of the training are discussed. As natural leaders, Latina promotoras disseminated learned strategies and resources within their communities. The lay health advisor model is a salient method for disseminating information regarding mental health and stress reduction among Latinas.

Understanding African American men's perceptions of racism, male gender socialization, and social capital through photovoice

In this study we used a participatory qualitative research approach--photovoice--to collect information about African American men's perceptions of the factors that influenced their own health and the health of their communities. Photovoice was conducted as part of the "Men as Navigators (MAN) for Health" project, an evaluation of a male lay health advisor (LHA) intervention in central North Carolina. Twelve African American men living in both urban and rural communities took photographs and discussed the photos in six photo discussion sessions. Analysis involved identifying recurring themes from the photos and transcriptions of photo discussions. The results suggest that race and racism, male gender socialization, and social networks and social capital all have important influences on African American men's health. The implications for further research and public health practice are discussed.

Towards a more comprehensive understanding of cancer burden in North Carolina: priorities for intervention

OBJECTIVE

To apply 4 measures of population burden in examining cancer burden in North Carolina and to identify priorities for intervention.

METHODS

Four measures were used: incidence, mortality, prevalence, and years of potential life lost (YPLL). The North Carolina Central Cancer Registry provided summary data on incidence and mortality and record-level data that were examined using SEER*Stat software to calculate prevalence. North Carolina vital statistics (mortality) data and life expectancy estimates stratified by age, race, and sex were used to calculate YPLL. Each cancer site was ranked according to burden for each of the 4 individual burden measures and summarized into an overall rank. Burden was examined overall and by sex and race.

PRINCIPAL FINDINGS

Four cancers--lung/bronchus, female breast, prostate, and colon/rectum--accounted for approximately 57% of the total cancer incidence, prevalence, mortality, and YPLL in North Carolina. Patterns of burden in gender and race subgroups were similar, although non-whites often had higher mortality rates than did whites despite similar incidence rates. An estimated 207,583 people were living with cancer in 2004 Breast and prostate cancer accounted for 42% of these survivors. Lung/bronchus cancer was the most severe cancer, accounting for more deaths and years of life lost than any other 5 cancers combined.

CONCLUSIONS

Each of the 4 measures provides unique insight and guidance for cancer coordination and control efforts. Lung/bronchus, female breast, prostate, and colon/rectum cancers accounted for the majority of North Carolina's cancer burden and should be priorities for intervention.

Immunity against breast cancer by TERT DNA vaccine primed with chemokine CCL21

Human telomerase reverse transcriptase (TERT) has been considered a potential tumor-associated antigen for active-specific immunotherapy. However, effective specific tumor antigen-specific immunity has been difficult to induce consistently by various TERT vaccine formulations. New adjuvant strategies have been employed, such as utilizing chemokines to attract T cells and antigen-presenting cells. Chemokine adjuvant strategies may enhance tumor antigen-specific immunity induced by vaccines. Therefore, we utilized chemokine ligand 21 (CCL21) as an adjuvant with a xenogeneic TERT DNA vaccine to induce tumor antigen-specific immunity against TERT-expressing breast cancer. The TERT DNA vaccine consisted of a plasmid containing the COOH terminal end of the TERT (cTERT) gene, encapsulated in multilayered liposomes with hemagglutinating virus of Japan coating. We demonstrated that CCL21 treatment before cTERT DNA vaccine, given intramuscularly, induced significantly higher anti-TERT specific cell-mediated immunity compared to cTERT DNA vaccine alone. Effective tumor antigen-specific immunity was shown both in prophylactic and therapeutic regimens against TS/A murine breast cancer. The study demonstrated that CCL21 administration before cTERT DNA vaccination significantly augmented tumor antigen-specific immunity against breast cancer.

Associations between the impact of terrorism and health perceptions of patients

OBJECTIVE

Previous studies have demonstrated the effects of the September 11th 2001 terrorist attacks on anxiety and anxiety-related conditions in Americans. However, data regarding associations between the attacks and patients' health perceptions are lacking. The objective of this study was to explore associations between the personal impact of the September 11th attacks and patients' perceptions of health and illness.

METHOD

We performed a cross-sectional survey of 303 adult African-American, Caucasian, and Hispanic patients at primary care clinics in Houston, Texas. Data were collected between October 15, 2001 and March 1, 2002. We developed items to measure the impact of the September 11th attacks and patients' quality of life. Previously validated scales were used to measure health status, health locus of control, preferences regarding the patient-physician relationship, and patients' explanatory models of illness.

RESULTS

Twenty-two percent of patients reported no impact from the attacks, 41% reported mildly negative impact, 22% reported moderately negative impact, and 15% reported extremely negative impact in their lives. In multivariate analysis, demographic characteristics were not associated with impact from the attacks. However, patients who perceived a more external locus of control with respect to health and patients who reported greater meaning of illness in their lives also reported more negative impact from the September 11th attacks.

CONCLUSIONS

The September 11th terrorist attacks had at least a somewhat negative impact for a majority of patients far from the site of the nearest attack, and regardless of their demographic backgrounds. The amount of negative impact that patients perceived as a result of the terrorist attacks correlates with certain illness perceptions, including an external health locus of control and a perception of greater meaning of illness in one's life. Such correlations may indicate an effect of terrorism on patients' illness behaviors. Further research is needed to better understand effects of the threat of terrorism on the general health and illness behaviors of patients.

Empowering communication: a community-based intervention for patients

The "How to Talk to Your Doctor" community education forums operate under the assumption that information exchange and consumer involvement in healthcare can empower communities in need. We report on the development and preliminary evaluation of this community-based intervention designed to activate and enhance patients' communicative abilities in the medical encounter. We review evidence supporting the feasibility of and benefits that can be expected from improving patients' communication competency. Our intervention is simple and flexible so, therefore, can be portable to a large number of communities. Our preliminary evaluation suggests that the intervention is well-received and produces improved self-perceptions of communication competence across diverse settings and participants. We describe our intervention and its development and dissemination as a model for improving patients' communicative abilities through a community-based, active learner approach. By sharing our experiences, the barriers we encountered, and our ongoing efforts to improve patient communication in the medical encounter, we hope to empower patients to communicate better with their physicians.

Gene survey of the pathogenic protozoan Trypanosoma cruzi

We have performed a survey of the active genes in the important human pathogen Trypanosoma cruzi by analyzing 5013 expressed sequence tags (ESTs) generated from a normalized epimastigote cDNA library. Clustering of all sequences resulted in 771 clusters, comprising 54% of the ESTs. In total, the ESTs corresponded to 3054 transcripts that might represent one-fourth of the total gene repertoire in T. cruzi. About 33% of the T. cruzi transcripts showed similarity to sequences in the public databases, and a large number of hitherto undiscovered genes predicted to be involved in transcription, cell cycle control, cell division, signal transduction, secretion, and metabolism were identified. More than 140 full-length gene sequences were derived from the ESTs. Comparisons with all open reading frames in yeast and in Caenorhabditis elegans showed that only 12% of the T. cruzi transcripts were shared among diverse eukaryotic organisms. Comparison with other kinetoplastid sequences identified 237 orthologous genes that are shared between these evolutionarily divergent organisms. The generated data are a useful resource for further studies of the biology of the parasite and for development of new means to combat Chagas' disease.

Complete sequence of a 93.4-kb contig from chromosome 3 of Trypanosoma cruzi containing a strand-switch region

We have initiated large-scale sequencing of the third smallest chromosome of the CL Brener strain of Trypanosoma cruzi and we report here the complete sequence of a contig consisting of three cosmids. This contig covers 93.4 kb and has been found to contain 20-30 novel genes and several repeat elements, including a novel chromosome 3-specific 400-bp repeat sequence. The intergenic sequences were found to be rich in di- and trinucleotide repeats of varying lengths and also contained several known T. cruzi repeat elements. The sequence contains 29 open reading frames (ORFs) longer than 700 bp, the longest being 5157 bp, and a large number of shorter ORFs. Of the long ORFs, seven show homology to known genes in parasites and other organisms, whereas four ORFs were confirmed by sequencing of cDNA clones. Two shorter ORFs were confirmed by a database homology and a cDNA clone, respectively, and one RNA gene was identified. The identified genes include two copies of the gene for alanine-aminotransferase as well as genes for glucose-6-phosphate isomerase, protein kinases and phosphatases, and an ATP synthase subunit. An interesting feature of the sequence was that the genes appear to be organized in two long clusters containing multiple genes on the same strand. The two clusters are transcribed in opposite directions and they are separated by an approximately 20-kb long, relatively GC-rich sequence, that contains two large repetitive elements as well as a pseudogene for cruzipain and a gene for U2snRNA. It is likely that this strand switch region contains one or more regulatory and promoter regions. The reported sequence provides the first insight into the genome organization of T. cruzi and shows the potential of this approach for rapid identification of novel genes. [The sequence data described in this paper have been submitted to the GenBank data library under accession nos. AF052831-AF052833.]

Laparoscopic para-aortic lymphadenectomy in gynecologic malignancies

OBJECTIVE

To determine the feasibility, safety, limiting factors, and advantages of laparoscopic para-aortic lymphadenectomy in a series of patients with gynecologic malignancies.

METHODS

During a 2-year period, 61 women underwent laparoscopic para-aortic lymph node dissection as part of their management for invasive gynecologic malignancies. A transperitoneal incision directly over the aorta was used. Initially, only the right-side infra-inferior mesenteric artery nodes were removed. The technique of removal of left-side low para-aortic nodes was then developed, followed by the technique for removal of right- and left-side nodes above the transverse duodenum. A total of 52 right para-aortic lymphadenectomies were performed, 12 of which were combined with left-side lymphadenectomies. A total of 17 left-side lymphadenectomies were performed, 12 of which were bilateral. Four patients had nodes removed above the inferior mesenteric artery.

RESULTS

The procedure could not be performed in four instances because of obesity or adhesions. Twenty-four patients had their laparoscopic surgery combined with another procedure, which increased their hospital stays: radical hysterectomy (five), laparoscopy-assisted vaginal hysterectomy (17), transperineal interstitial irradiation (one), and anterior-posterior colporrhaphy (one). The remaining 33 patients had laparoscopic surgical staging only. One patient required laparotomy to control bleeding from the vena cava; however, the others had no short- or long-term complications, and the average hospital stay was 1.3 days.

CONCLUSION

Laparoscopic para-aortic lymphadenectomy is a safe, effective procedure that allows a shorter hospitalization than traditional laparotomy.