Development of a multilevel intervention to increase colorectal cancer screening in Appalachia

BACKGROUND

Colorectal cancer (CRC) screening rates are lower in Appalachian regions of the United States than in non-Appalachian regions. Given the availability of various screening modalities, there is critical need for culturally relevant interventions addressing multiple socioecological levels to reduce the regional CRC burden. In this report, we describe the development and baseline findings from year 1 of "Accelerating Colorectal Cancer Screening through Implementation Science (ACCSIS) in Appalachia," a 5-year, National Cancer Institute Cancer MoonshotSM-funded multilevel intervention (MLI) project to increase screening in Appalachian Kentucky and Ohio primary care clinics.

METHODS

Project development was theory-driven and included the establishment of both an external Scientific Advisory Board and a Community Advisory Board to provide guidance in conducting formative activities in two Appalachian counties: one in Kentucky and one in Ohio. Activities included identifying and describing the study communities and primary care clinics, selecting appropriate evidence-based interventions (EBIs), and conducting a pilot test of MLI strategies addressing patient, provider, clinic, and community needs.

RESULTS

Key informant interviews identified multiple barriers to CRC screening, including fear of screening, test results, and financial concerns (patient level); lack of time and competing priorities (provider level); lack of reminder or tracking systems and staff burden (clinic level); and cultural issues, societal norms, and transportation (community level). With this information, investigators then offered clinics a menu of EBIs and strategies to address barriers at each level. Clinics selected individually tailored MLIs, including improvement of patient education materials, provision of provider education (resulting in increased knowledge, p = .003), enhancement of electronic health record (EHR) systems and development of clinic screening protocols, and implementation of community CRC awareness events, all of which promoted stool-based screening (i.e., FIT or FIT-DNA). Variability among clinics, including differences in EHR systems, was the most salient barrier to EBI implementation, particularly in terms of tracking follow-up of positive screening results, whereas the development of clinic-wide screening protocols was found to promote fidelity to EBI components.

CONCLUSIONS

Lessons learned from year 1 included increased recognition of variability among the clinics and how they function, appreciation for clinic staff and provider workload, and development of strategies to utilize EHR systems. These findings necessitated a modification of study design for subsequent years.

TRIAL REGISTRATION

Trial NCT04427527 is registered at https://clinicaltrials.gov and was registered on June 11, 2020.

Detection and identification of decay fungi in spruce wood by restriction fragment length polymorphism analysis of amplified genes encoding rRNA

We have developed a DNA-based assay to reliably detect brown rot and white rot fungi in wood at different stages of decay. DNA, isolated by a series of CTAB (cetyltrimethylammonium bromide) and organic extractions, was amplified by the PCR using published universal primers and basidiomycete-specific primers derived from ribosomal DNA sequences. We surveyed 14 species of wood-decaying basidiomycetes (brown-rot and white-rot fungi), as well as 25 species of wood-inhabiting ascomycetes (pathogens, endophytes, and saprophytes). DNA was isolated from pure cultures of these fungi and also from spruce wood blocks colonized by individual isolates of wood decay basidiomycetes or wood-inhabiting ascomycetes. The primer pair ITS1-F (specific for higher fungi) and ITS4 (universal primer) amplified the internal transcribed spacer region from both ascomycetes and basidiomycetes from both pure culture and wood, as expected. The primer pair ITS1-F (specific for higher fungi) and ITS4-B (specific for basidiomycetes) was shown to reliably detect the presence of wood decay basidiomycetes in both pure culture and wood; ascomycetes were not detected by this primer pair. We detected the presence of decay fungi in wood by PCR before measurable weight loss had occurred to the wood. Basidiomycetes were identified to the species level by restriction fragment length polymorphisms of the internal transcribed spacer region.

Environmental scanning electron microscopic observation of the hyphal sheath and mycofibrils in Postia placenta

Environmental scanning electron microscopic observations of Postia placenta grown on a defined medium and on red spruce wood allowed for the examination of the hydrated sheath of P. placenta. In the wood environment, mature hyphae that were not adhering to the substrate were observed to have a mycofibrillar morphology whereas hyphal tips and branch points had a smooth sheath morphology. A mycofibrillar adhesive matrix was observed on the hyphae growing on glass slides in the defined medium. These morphologies for hyphal sheaths in P. placenta are similar to those previously described by investigators from other laboratories who have used traditional electron microscopic preparative protocols that include dehydration steps. The potential future usefulness of environmental scanning electron microscopic technology in the study of the fine details of extracellular matrices is briefly discussed.

Iron-Binding Compounds Produced by Wood-Decaying Basidiomycetes

The chrome azurol-S universal siderophore assay and the rapid paper electrophoresis siderophore assay were used to screen 10 wood-decaying basidiomycete isolates for the formation of iron-chelating compounds. All 10 isolates were positive for chrome azurol-S reactivity on solid plating medium and in liquid cultures, and 9 of the 10 isolates produced fluorescent iron-binding compounds in the paper electrophoresis assay.

Monoclonal Antibodies to Glycoprotein Antigens of a Fungal Plant Pathogen, Phytophthora megasperma f. sp. glycinea

Genetic studies of plants and their pathogens indicate that dominant alleles for resistance in hosts are complemented by corresponding dominant alleles for avirulence in pathogens. Products of these genes have not yet been identified. We have produced murine monoclonal antibodies (mAbs) to extracellular antigens of the fungal soybean pathogen Phytophthora megasperma f. sp. glycinea (Pmg, race 1) as part of a larger effort to identify antigenic determinants associated with particular avirulence genes. Thirty-six independent mAbs have been characterized by binding to Western blots of Pmg extracellular glycoproteins and by enzyme-linked immunosorbent assay with glycoproteins modified by treatment with periodate, alpha-mannosidase, and endo-beta-N-acetylglucosaminidase H. The mAbs are predominantly carbohydrate-specific and can be placed in six groups based on interactions with Pmg glycoproteins. Binding patterns of various mAbs to Western blots indicate that Pmg proteins may have single or multiple types of attached carbohydrate antigens. Races of Pmg with differing avirulence genes exhibit more characteristic differences by Western blot analysis than by protein staining of glycoprotein profiles. Several of the mAbs show much higher reaction levels to glycoproteins from race 1 than from two other races. All of the glycoprotein-specific mAbs cross-react with purified mycelial walls.

Exploratory numerical taxonomy based on biochemical and biophysical characters of the tymoviruses

Three different exploratory analytical techniques, principal components analysis, reciprocal averaging and cluster analysis, were used to examine taxonomic relationships among the tymoviruses. The three techniques gave similar but not identical interpretations of the interrelationships within this group. Exploratory numerical analyses were useful in assessing relatedness, and they suggest that andean potato latent virus is misclassified as a strain of eggplant mosaic virus.