The impact of the pandemic on the presentation and treatment of head and neck squamous cell carcinoma at a county hospital

INTRODUCTION

In March 2020, the World Health Organization declared COVID-19 a pandemic, initiating stay-at-home orders which delayed cancer care and screening. The impact on head and neck cancer care in populations at risk has yet to be elucidated. The objective of this investigation is to evaluate how the presentation, diagnosis, and treatment of head and neck squamous cell carcinoma cancer patients at a county hospital were affected by the pandemic.

METHODS

A retrospective review of patients with head and neck squamous cell carcinoma that were diagnosed at a county hospital 365 days before and after stay-at-home orders were initiated. The primary outcomes were duration between diagnosis from imaging and initiation of treatment. Secondary outcomes included mortality, stage, nodal status, and distant metastasis at presentation.

RESULTS

There was a total of 105 diagnoses. Sixty-five (62 %) head and neck squamous cell carcinoma diagnoses were diagnosed before the stay-at-home orders were initiated, and 40 (38 %) after. Eighty percent (32/40) of diagnoses presenting after had stage IV disease compared to 58 % (38/65) in those before (p < 0.05). A higher percentage of patients who presented later had a >30-day delay to biopsy (43 % v. 20 %, OR: 3.0, p < 0.05). This difference was exacerbated by those with laryngeal, oral cavity, or oropharyngeal cancer (45 % v. 15 %, OR: 4.5, p < 0.05). There was a larger delay from diagnosis to treatment after the orders were initiated (68 v. 53, p < 0.05) however there was no difference in one-year mortality (25 % v. 23 %, p > 0.05). This investigation found a 14 % loss to follow-up.

CONCLUSIONS AND RELEVANCE

In this cohort of head and neck squamous cell carcinoma diagnoses at a county hospital, those diagnosed after the stay-at-home orders were initiated presented with more advanced disease. They also had more delays in diagnosis and initiation of treatment. There was no difference in one-year mortality rates between the two groups however there was a significant loss to follow-up, limiting prognostication. These findings serve to better prepare healthcare providers to implement optimized care during future shutdowns related to public health crises.

LEVEL OF EVIDENCE

III.

Acceptability and continuation of use of the subdermal contraceptive implant among adolescents and young women in Argentina: a retrospective cohort study

A new public policy was instituted in Argentina for free distribution of subdermal contraceptive implants to women aged 15-24 years old in the public healthcare system. The objective of this study is to determine the extent to which this population adhered to the implant, as well as predictors of continuation. The retrospective cohort study was based on a telephone survey of a random sample of 1101 Ministry of Health-registered implant users concerning the continuation of use, satisfaction with the method and side-effects, and reasons for removal. Descriptive statistics and multivariate regression analysis were used to explore the association between adherence and having received contraceptive counselling, satisfaction, and side effects. We found high levels of adherence (87%) and satisfaction (94%). Common reported side effects were amenorrhoea or infrequent bleeding, perceived weight gain, increased menstrual bleeding and headaches. Multivariate regression analysis indicates that, among adolescents, having received contraceptive counselling increased comfort, while frequent bleeding at six months hindered trust. Participants who had a history of a prior delivery or who had themselves primarily chosen the method were less likely to request the removal of the implant. Our results support the public policy of free implant distribution in the public health sector. This is a sustainable public policy that contributes to equity and access to effective contraception. It is appropriate for adolescents and young women and will also reduce unintended pregnancies. Our results suggest that counselling patients is key prior to insertion of the implant, as it improves acceptability and continuation.

A Virtual COVID-19 Youth Ambassador Program: The UI Health CHAMPIONS Experience

The COVID-19 pandemic continues to exacerbate socioeconomic and educational hardships rooted in systemic inequities for youth across the United States. (Virtual) youth resilience and health promotion efforts are viable mechanisms to address these hardships in the context of a double pandemic: COVID-19 and structural racism. Health professions training programs hold a unique opportunity to incorporate COVID-19 health education to train and empower youth to become community health ambassadors. Grounded on a Grow-Your-Own (GYO) approach, UI Health CHAMPIONS spearheaded the development of the COVID-19 Youth Ambassador Program (COVID-19 YAP), a virtual multistage and multipartner effort. Its mission is to equip youth with knowledge, perspective, and tools to have empathetic, informative conversations within their networks about COVID-19. Via e-learning, modules cover viruses and the immune system; vaccine development; health disparities/equity; and health advocacy. Participants are introduced to Human-Centered Design Thinking to guide the development of advocacy projects. COVID-19 YAP's uniqueness lies in the team of program coordinators consisting of (pre-)health professional student workers with a desire to engage in health equity efforts and community health ambassadorship. Freirean principles are applied across program design and delivery; Dialogical Education encourages the educator to become the student and the student to become an educator. This co-learning process empowers students and educators to become agents of social change. COVID-19 YAP can serve as a collaborative effort addressing a public health priority, contributing toward digital health equity, and creating community resilience while encouraging youth to pursue a health profession and become community health advocates.

Engaging Youth Through Digital Badges to Promote Health in Underserved Communities

The CHAMPIONS NETWork program trains Chicago high school students as health advocates while preparing them to become future health professionals. We added digital badging to the curriculum in its third year of programming (2018). This article describes methods and student feedback about digital badging, allowing others to implement similar technology-driven opportunities to engage youth and promote healthy living. Program staff created seven online experiences (XPs) on health advocacy that made up a playlist. Students adopted three adults as clients and completed four XPs themselves and three with clients. Completion of all XPs resulted in a digital badge-an electronic portfolio of health advocacy experiences to be shared with employers and colleges. Following the 2019 cohort's completion of the digital badge, we conducted two focus groups with students about their feedback on the digital badge. Results showed that students most liked the healthy eating and cardiopulmonary resuscitation XPs. They had more positive reactions to the experience than negative, and especially appreciated aspects of active learning, as well as the badge's long-term benefits. This technology can potentially help any student with access to an electronic device become a health advocate, and could become a new tool for career development while improving population health.

Mo or W catalysts promoted with Ni or Co supported on modified bentonite for decane hydroconversion

A clay mineral-type modified bentonite, produced via delamination and subsequent incorporation of AlZr and AlCe species to modulate their acid properties, was used to obtain bifunctional catalysts with the incorporation of NiMo, CoMo, NiW and CoW.

Exploring Latinidad, Migration Processes, and Immigrant Experiences: Experiences Influencing Latino Health

Introduction Over the last few decades, Latino migration to the U.S.has re-shaped the ethnic composition of the country, and influencedthe meaning of “ethnic” and “racial” identity. The purpose of thisqualitative study was to explore the definition and meaning of beingLatino and how this may guide the development of interventions topromote their health. Methods Twenty-six Latino immigrants living in Kansas completeda socio-demographic survey and semi-structured interviews to assessand explore personal immigration experiences and perspectives onthe meaning of being Latino in the U.S. Results Participant reports were grouped into eight themes on Latinoidentity that were organized by geographic origin, family roots/ties,and acculturation. Immigration experiences were described as bothpositive and negative with most participants experiencing discriminationand loneliness, but also reports of improved quality of life.Further, most participants reported a strong sense of Latinidad; thatLatino immigrant communities in the U.S. are interdependent andsupportive of each other. Conclusions The experience of being a member of a minority groupmight contribute to the development of a cohesive sense of Latinoidentity as participants acculturate to the U.S. while preserving asense of attachment to their culture of origin. Future interventionsshould be sensitive to migration experiences as they might influencechanges in health behaviors.

Exploring Latinidad, Migration Processes, and Immigrant Experiences: Experiences Influencing Latino Health

INTRODUCTION

Over the last few decades, Latino migration to the U.S. has re-shaped the ethnic composition of the country, and influenced the meaning of "ethnic" and "racial" identity. The purpose of this qualitative study was to explore the definition and meaning of being Latino and how this may guide the development of interventions to promote their health.

METHODS

Twenty-six Latino immigrants living in Kansas completed a socio-demographic survey and semi-structured interviews to assess and explore personal immigration experiences and perspectives on the meaning of being Latino in the U.S.

RESULTS

Participant reports were grouped into eight themes on Latino identity that were organized by geographic origin, family roots/ties, and acculturation. Immigration experiences were described as both positive and negative with most participants experiencing discrimination and loneliness, but also reports of improved quality of life. Further, most participants reported a strong sense of Latinidad; that Latino immigrant communities in the U.S. are interdependent and supportive of each other.

CONCLUSIONS

The experience of being a member of a minority group might contribute to the development of a cohesive sense of Latino identity as participants acculturate to the U.S. while preserving a sense of attachment to their culture of origin. Future interventions should be sensitive to migration experiences as they might influence changes in health behaviors.

Empowering Chicago's Youths as the Next Generation of Health Advocates

The CHAMPIONS NETWork summer program trains high school students to become health advocates in underserved Chicago, Illinois, communities. It provides a more innovative approach to traditional pipeline programs through the added responsibility of active health promotion. To determine whether student empowerment changed during the program, participants completed pre- and postassessments on health knowledge and self-efficacy. We found significant increases in student empowerment after the program compared with before, especially regarding the students' abilities and experiences.

The CHAMPIONS NETWork: Training Chicago High School Students as Health Advocates to Improve Health Equity

In Chicago, major disparities exist across ethnic groups, income levels, and education levels for common chronic conditions and access to care. Concurrently, many of Chicago's youth are unemployed, and the number of minorities pursuing health professions is low. In an effort to eliminate this health equity gap, the University of Illinois at Chicago convened a community-university-hospital partnership to implement the CHAMPIONS NETWork (Community Health And eMPowerment through Integration Of Neighborhood-specific Strategies using a Novel Education & Technology-leveraged Workforce). This innovative workforce training program is a "High School to Career Training Academy" to empower underserved youth to improve population health in their communities, expose them to careers in the health sciences, and provide resources for them to become community and school advocates for healthy lifestyles. This program differs from other traditional pipeline programs because it gives its students a paid experience, extends beyond the summer, and broadens the focus to population health with patient contact. The CHAMPIONS NETWork creates a new type of health workforce that is both sustainable and replicable throughout the United States.

Role of NOD1 in Heart Failure Progression via Regulation of Ca2+ Handling

BACKGROUND

Heart failure (HF) is a complex syndrome associated with a maladaptive innate immune system response that leads to deleterious cardiac remodeling. However, the underlying mechanisms of this syndrome are poorly understood. Nucleotide-binding oligomerization domain-containing protein 1 (NOD1) is a newly recognized innate immune sensor involved in cardiovascular diseases.

OBJECTIVES

This study evaluated the role of NOD1 in HF progression.

METHODS

NOD1 was examined in human failing myocardium and in a post-myocardial infarction (PMI) HF model evaluated in wild-type (wt-PMI) and Nod1^-/- mice (Nod1^-/--PMI).

RESULTS

The NOD1 pathway was up-regulated in human and murine failing myocardia. Compared with wt-PMI, hearts from Nod1^-/--PMI mice had better cardiac function and attenuated structural remodeling. Ameliorated cardiac function in Nod1^-/--PMI mice was associated with prevention of Ca²⁺ dynamic impairment linked to HF, including smaller and longer intracellular Ca²⁺ concentration transients and a lesser sarcoplasmic reticulum Ca²⁺ load due to a down-regulation of the sarcoplasmic reticulum Ca²⁺-adenosine triphosphatase pump and by augmented levels of the Na⁺/Ca²⁺ exchanger. Increased diastolic Ca²⁺ release in wt-PMI cardiomyocytes was related to hyperphosphorylation of ryanodine receptors, which was blunted in Nod1^-/--PMI cardiomyocytes. Pharmacological blockade of NOD1 also prevented Ca²⁺ mishandling in wt-PMI mice. Nod1^-/--PMI mice showed significantly fewer ventricular arrhythmias and lower mortality after isoproterenol administration. These effects were associated with lower aberrant systolic Ca²⁺ release and with a prevention of the hyperphosphorylation of ryanodine receptors under isoproterenol administration in Nod1^-/--PMI mice.

CONCLUSIONS

NOD1 modulated intracellular Ca²⁺ mishandling in HF, emerging as a new target for HF therapy.

Empowering Promotores de Salud to engage in Community-Based Participatory Research

BACKGROUND

Latino immigrants are less likely to be involved in addressing health-related issues affecting their own community. Community health workers have played a significant role in addressing the health of underserved communities in several countries.

OBJECTIVE

The objective of this article is to describe the development, implementation and evaluation of a community-based training program that empowers promotores to identify the health needs of recent Latino immigrants. Promotores were able to develop interventions based on the needs of recent Latino immigrants.

METHODS

Latino community members participated in a 30-hour training program. Training was provided in 15 two-hour sessions over 3 months. Training included field work accompanied by skills development in leadership, organization, interpersonal communication, and survey implementation. Upon completion of the training, promotores conducted household surveys designed to identify community health needs. The evaluation employed quantitative measures to track promotores' canvassing activities and assessment of health behaviors.

RESULTS

Out of the 22 promotores enrolled in the training program, 15 (68.18%) completed the training program. Within 3 months, promotores administered 105 household surveys and identified poor access to health care, lack of insurance (78.6%), low daily consumption of fruits (73%) and vegetables (37.5%) and frequent exposure to tobacco smoke (31.7%).

CONCLUSION

Our study demonstrated the feasibility of recruiting and engaging promotores to identify health priorities within the Latino community. This initial step will inform the development of future community-based interventions.

Dendritic cells take up and present antigens from viable and apoptotic polymorphonuclear leukocytes

Dendritic cells (DC) are endowed with the ability to cross-present antigens from other cell types to cognate T cells. DC are poised to meet polymorphonuclear leukocytes (PMNs) as a result of being co-attracted by interleukin-8 (IL-8), for instance as produced by tumor cells or infected tissue. Human monocyte-derived and mouse bone marrow-derived DC can readily internalize viable or UV-irradiated PMNs. Such internalization was abrogated at 4°C and partly inhibited by anti-CD18 mAb. In mice, DC which had internalized PMNs containing electroporated ovalbumin (OVA) protein, were able to cross-present the antigen to CD8 (OT-1) and CD4 (OT-2) TCR-transgenic T cells. Moreover, in humans, tumor cell debris is internalized by PMNs and the tumor-cell material can be subsequently taken up from the immunomagnetically re-isolated PMNs by DC. Importantly, if human neutrophils had endocytosed bacteria, they were able to trigger the maturation program of the DC. Moreover, when mouse PMNs with E. coli in their interior are co-injected in the foot pad with DC, many DC loaded with fluorescent material from the PMNs reach draining lymph nodes. Using CT26 (H-2(d)) mouse tumor cells, it was observed that if tumor cells are intracellularly loaded with OVA protein and UV-irradiated, they become phagocytic prey of H-2(d) PMNs. If such PMNs, that cannot present antigens to OT-1 T cells, are immunomagnetically re-isolated and phagocytosed by H-2(b) DC, such DC productively cross-present OVA antigen determinants to OT-1 T cells. Cross-presentation to adoptively transferred OT-1 lymphocytes at draining lymph nodes also take place when OVA-loaded PMNs (H-2(d)) are coinjected in the footpad of mice with autologous DC (H-2(b)). In summary, our results indicate that antigens phagocytosed by short-lived PMNs can be in turn internalized and productively cross-presented by DC.

Pilot clinical trial of type 1 dendritic cells loaded with autologous tumor lysates combined with GM-CSF, pegylated IFN, and cyclophosphamide for metastatic cancer patients

Twenty-four patients with metastatic cancer received two cycles of four daily immunizations with monocyte-derived dendritic cells (DC). DC were incubated with preheated autologous tumor lysate and subsequently with IFN-α, TNF-α, and polyinosinic:polycytidylic acid to attain type 1 maturation. One DC dose was delivered intranodally, under ultrasound control, and the rest intradermally in the opposite thigh. Cyclophosphamide (day -7), GM-CSF (days 1-4), and pegIFN alpha-2a (days 1 and 8) completed each treatment cycle. Pretreatment with cyclophosphamide decreased regulatory T cells to levels observed in healthy subjects both in terms of percentage and in absolute counts in peripheral blood. Treatment induced sustained elevations of IL-12 in serum that correlated with the output of IL-12p70 from cultured DC from each individual. NK activity in peripheral blood was increased and also correlated with the serum concentration of IL-12p70 in each patient. Circulating endothelial cells decreased in 17 of 18 patients, and circulating tumor cells markedly dropped in 6 of 19 cases. IFN-γ-ELISPOT responses to DC plus tumor lysate were observed in 4 of 11 evaluated cases. Tracing DC migration with [(111)In] scintigraphy showed that intranodal injections reached deeper lymphatic chains in 61% of patients, whereas with intradermal injections a small fraction of injected DC was almost constantly shown to reach draining inguinal lymph nodes. Five patients experienced disease stabilization, but no objective responses were documented. This combinatorial immunotherapy strategy is safe and feasible, and its immunobiological effects suggest potential activity in patients with minimal residual disease. A randomized trial exploring this hypothesis is currently ongoing.

Tobacco use and interest in smoking cessation among Latinos attending community health fairs

Health fairs are vital for reaching underserved Latinos providing access to health services including smoking cessation. The purpose of this study is to describe tobacco use and interest in smoking cessation among Latino smokers attending community health fairs. We surveyed 262 self-identified Latinos attending health fairs; we assessed smoking behavior and attitudes of 53 (20.2%) current smokers. Smokers were mostly uninsured (98.1%), male (54.7%), recent immigrants (96.2%) with limited English proficiency (60.4% spoke Spanish at home), and were mainly light (86.3%) and nondaily (58.7%) smokers. Although most participants attempted to quit smoking at least once in the past year, only 5.0% of current smokers reported ever using cessation medication and 94.3% were unaware of free-telephone counseling. The majority of smokers were ready to quit within 30 days and were interested in participating in cessation programs. Health fairs provide a unique opportunity to address smoking cessation among underserved Latinos with limited knowledge of access to, and use of effective cessation services.

Clinical development of combination strategies in immunotherapy: are we ready for more than one investigational product in an early clinical trial?

Stimulating the innate and adaptive immunity against cancer necessitates the tricking of a system evolved to fight microbial pathogens and directing its activity towards transformed self-tissue. Efficacious interventions to start and sustain the response will probably require a number of agents to tamper simultaneously or sequentially with several immune mechanisms. Although master switches controlling various functions may exist, the goal of a curative immune response will probably demand the combined actions of several therapeutic components. Synergy occurs when drugs interact in ways that enhance or magnify one or more effects or side effects. In cancer immunotherapy, two agents that have minor or no therapeutic effects as single agents can be powerful when combined. Mouse experimentation provides multiple examples of synergistic combinations. Elements to be combined include chiefly: tumor vaccines, adoptive T-cell therapies, cytokines, costimulatory molecules, molecular deactivation of immunosuppressive or tolerogenic pathways and immunostimulatory monoclonal antibodies. These novel therapies, even as single agents, are extremely complex products to be developed owing to the associated biomolecules, cell therapies or gene therapies. At present, drug-development programs are run individually for each immunotherapeutic agent and combinations are considered only at a later stage in clinical development, even in the absence of formal compulsory regulations to prevent clinical trials with combinations. As a result, instead of the search for maximal efficacy, ease of combination with standard treatments, intellectual property management, regulations and business-based decisions often guide the way. Even though the maximal effort must be made in order to prevent adverse effects in patients, it seems reasonable that combination pilot trials should be performed at an early stage, following safe completion of Phase I trials. These trials should be performed based on evidence for synergy in animal models and be simplified in terms of regulatory requirements. Such 'short-cut' combination immunotherapy trials can bring much needed efficacy earlier to the bedside.

Dendritic cells adhere to and transmigrate across lymphatic endothelium in response to IFN-α

Migration of DC into lymphatic vessels ferries antigenic cargo and pro-inflammatory stimuli into the draining LN. Given that tissues under the influence of viral infections produce type I IFN, it is conceivable that these cytokines enhance DC migration in order to facilitate an antiviral immune response. Cultured lymphatic endothelium monolayers pretreated with TNF-α were used to model this phenomenon under inflammatory conditions. DC differentiated in the presence of either IFN-α2b or IFN-α5 showed enhanced adhesion to cultured lymphatic endothelial cells. These pro-adhesive effects were mediated by DC, not the lymphatic endothelium, and correlated with increased DC transmigration across lymphatic endothelial cell monolayers. Transmigration was guided by chemokines acting on DC, and blocking experiments with mAb indicated a role for LFA-1. Furthermore, incubation of DC with IFN-α led to the appearance of active conformation epitopes on the CD11a integrin chains expressed by DC. Differentiation of mouse DC in the presence of IFN-α also increased DC migration from inflammed footpads toward popliteal LN. Collectively, these results indicate a role for type I IFN in directing DC toward LN under inflammatory conditions.

Palettes of vaccines and immunostimulatory monoclonal antibodies for combination

Various monoclonal antibodies (mAb) target immune system molecules to enhance immunity by costimulating T cells (i.e., CD137, OX40, CD40, GITR) or interfering in coinhibitory signals (i.e., CTLA-4, PD-1). These powerful agents can be guided by cancer vaccines to enhance immunity against tumor but not self tissues. Clinically powerful therapeutic synergies are at hand.

Effects of aspirin or basic amino acids on collagen cross-links and complications in NIDDM

OBJECTIVE

To determine if long-term therapy with aspirin or basic amino acids for subjects with NIDDM reduces the severity of clinical complications and/or reduces tissue levels of markers of glycooxidative damage.

RESEARCH DESIGN AND METHODS

Subjects with NIDDM were administered either aspirin (100 mg/day) or a combination of basic amino acids consisting of L-arginine (2 g/day) plus L-lysine (0.5 g/day) for 1 year. The study was double-blind and placebo-controlled. The presence and severity of retinopathy, nephropathy, and neuropathy were assessed in all subjects at 4-month intervals, as were serum blood glucose, glycohemoglobin levels, and presence of albuminuria. Collagen cross-linking and collagen glycation were measured in skin collagen obtained by biopsy at the beginning and the end of the study. Skin biopsies were also obtained from age-matched control subjects.

RESULTS

Skin samples obtained from NIDDM subjects at the beginning of the study had significantly increased levels of glucitolyllysine, pentosidine, and hydroxypyridinium, as compared with age-matched control subjects. Pentosidine levels were significantly correlated with severity of retinopathy and neuropathy, but not nephropathy. Subjects receiving aspirin, but not amino acids or placebo, had significantly decreased levels of skin pentosidine after 1 year of therapy.

CONCLUSIONS

It is concluded that 1) low-dose aspirin may reduce glycooxidative damage in people with NIDDM, and 2) treatment may need to continue for more than 1 year before clinical status improves.