Text message-based Cessation Intervention for People who Smoked or Used Smokeless Tobacco in India: a Feasibility Randomised Controlled Trial

INTRODUCTION

Despite the high burden of tobacco use in India, users do not have access to adequate help. This pilot trial aimed to evaluate the feasibility and acceptability of a text messaging intervention for tobacco cessation, generate preliminary estimates of its impact, and fine-tune procedures for a definitive trial.

METHODS

Parallel two-arm single blind individually randomised controlled pilot trial with nested qualitative study. Participants included adult current tobacco users (smoked and smokeless). Eligible and consenting participants were randomised to receive either (a) text messaging intervention (ToQuit) which covered specific content areas such as psychoeducation about consequences of tobacco use and benefits of quitting and tobacco avoidance strategies or (b) information about tobacco cessation helplines such as the helpline number and the languages in which tobacco cessation support was available (control). Feasibility data included screening and consent rates, treatment dropouts and outcome ascertainment. The primary abstinence outcome was self-reported abstinence from tobacco in the past seven days at three months post-randomisation. In-depth interviews were conducted with a sub-sample of participants primarily to collect acceptability data. The primary abstinence analysis used a chi-squared test and logistic regression (complete-case), and qualitative data analysed using thematic analysis.

RESULTS

Ninety eight participants were randomised into the two trial arms; 77 (79%) completed outcome evaluation. No between-arm differences in abstinence were found though findings favoured the intervention (7-day abstinence: ToQuit 23%, control 19%; adjusted odds ratio 1.23, 95% confidence interval 0.38, 3.97). Participants appreciated the language, comprehensibility, and relevance of the messages; and reported overall satisfaction with and positive impact from the intervention on their lives.

CONCLUSION

The findings indicate the acceptability and feasibility of ToQuit and if found effective, it could be a potentially scalable first-line response to tobacco use in low resource settings.

IMPLICATIONS

Our pilot RCT provides sufficient findings supporting the acceptability and feasibility of an intervention for tobacco cessation which is suitable for a context which has a shortage of healthcare workers and for individuals who use smoked or smokeless tobacco. This is critical on a background of limited contextually relevant interventions for a problem with a high burden in low- and middle- income countries such as India.

Evaluation of Feasibility and Acceptability of a Text-Messaging Intervention for Tobacco Cessation in India

INTRODUCTION

The aim of our study was to assess the feasibility and acceptability of a brief behavioral intervention for tobacco cessation delivered via mobile phone text messaging in India.

AIMS AND METHODS

We conducted an uncontrolled intervention cohort study in adult current users of tobacco. The participants received intervention messages on their mobile phones for eight weeks. We collected qualitative data about participants' perceptions of intervention delivery and receipt, acceptability, and feasibility of the intervention. The outcomes measured at 3 months post-recruitment were self-reported 7- and 28-day point-prevalence abstinence, and Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) risk categories for tobacco-low (0-3), moderate (4-26), and high (≥27).

RESULTS

We recruited 26 eligible participants, and 22 completed the outcome assessments. The participants generally perceived the intervention content to be simple to access and useful in facilitating a change in tobacco use. None of the participants indicated that they wanted to discontinue receiving the intervention messages. Some suggestions for enhancing acceptability included supplementing text messaging with more intensive counseling and the use of multimedia content. Eighteen percent of participants reported abstinence in the past 7 and 28 days. A greater proportion of those who used smokeless tobacco were abstinent at follow-up compared to those who smoked (42.9% vs. 6.7%; p = .04).

CONCLUSIONS

If effective, simple and low-cost mobile phone text messaging can be used to deliver interventions for tobacco use, and has the potential to be scaled up so it can be delivered to populations of smokers interested in receiving cessation support.

IMPLICATIONS

Our study is an important step towards the development of a contextually relevant intervention suited for low- and middle-income countries and which is responsive to the needs of both those who use smoked and smokeless tobacco. If found to be effective, our intervention would be a scalable solution to overcome the human resource related barrier to accessing tobacco cessation services in low resource settings.

Interventions to increase help-seeking for mental health care in low- and middle-income countries: A systematic review

Mental health problems are a significant and growing cause of morbidity worldwide. Despite the availability of evidence-based interventions, most people experiencing mental health problems remain untreated. This treatment gap is particularly large in low- and middle-income countries (LMIC) and is due to both supply-side and demand-side barriers. The aim of this systematic review is to identify and synthesise the evidence on interventions to improve help-seeking for mental health problems in LMICs. The protocol was registered a priori (Registration number: CRD42021255635). We searched eight databases using terms based on three concepts: 'mental health/illness' AND 'help-seeking' AND 'LMICs'; and included all age groups and mental health problems. Forty-two papers were eligible and included in this review. Intervention components were grouped into three categories following the steps in the help-seeking process: (1) raising mental health awareness among the general population (e.g., distribution of printed or audio-visual materials), (2) identification of individuals experiencing mental health problems (e.g., community-level screening or detection), and (3) promoting help-seeking among people in need of mental health care (e.g., sending reminders). The majority of interventions (80%) included components in a combination of the aforementioned categories. Most studies report positive outcomes, yet results on the effectiveness is mixed, with a clear trend in favour of interventions with components from more than one category. Ten out of 42 studies (24%) yielded a statistically significant effect of the intervention on help-seeking; and all targeted a combination of the aforementioned categories (i.e., raising awareness, identification and help-seeking promotion). Only six studies (14%) focused on children and adolescents. Due to the limited number of robust studies done in LMICs and the heterogeneity of study designs, outcomes and components used, no definite conclusions can be drawn with regards to the effects of individual strategies or content of the interventions.

Biomechanical framework for the inverse dynamic analysis of swimming using hydrodynamic forces from swumsuit

This study aims to integrate an open-source software capable of estimating hydrodynamic forces solely from kinematic data with a full-body biomechanical model of the human body to enable inverse dynamic analyses of swimmers. To demonstrate the methodology, intersegmental forces and joint torques of the lower limbs were computed for a six-beat front crawl swimming motion, acquired at LABIOMEP-UP. The hydrodynamic forces obtained compare well with existing numerical literature. The intersegmental forces and joint torques obtained increase from distal to proximal joints. Overall, the results are consistent with the limited literature on swimming biomechanics, which provides confidence in the presented methodology.

Effects of Cognitive Behavioral Therapy and Cash Transfers on Older Persons Living Alone in India : A Randomized Trial

BACKGROUND

A growing number of older persons in developing countries live entirely alone and are physically, mentally, and financially vulnerable.

OBJECTIVE

To determine whether phone-based cognitive behavioral therapy (CBT) or a cash transfer reduce functional impairment, depression, or food insecurity in this population.

DESIGN

Randomized controlled trial. (ClinicalTrials.gov: NCT04225845; American Economic Association RCT Registry: AEARCTR-0007582).

SETTING

Tamil Nadu, India, 2021.

PARTICIPANTS

1120 people aged 55 years and older and living alone.

INTERVENTIONS

A 6-week, phone-based CBT and a 1-time cash transfer of 1000 rupees (U.S. $12 at market exchange rates) were evaluated in a factorial design.

MEASUREMENTS

The World Health Organization Disability Assessment Schedule (WHODAS), the Geriatric Depression Scale, and food security, all measured 3 weeks after CBT for 977 people and 3 months after for 932. Surveyors were blind to treatment assignment.

RESULTS

The WHODAS score (scale 0 to 48, greater values representing more impairment) decreased between baseline and the 3-week follow-up by 2.92 more (95% CI, -5.60 to -0.23) in the group assigned cash only than in the control group, and the depression score (ranging from 0 to 15, higher score indicating more depressive symptoms) decreased by 1.01 more (CI, -2.07 to 0.06). These effects did not persist to the 3-month follow-up, and CBT alone and the 2 together had no significant effects. There were no effects on food security.

LIMITATIONS

The study cannot say whether more sustained or in-person therapy would have been effective, how results would translate outside of the COVID-19 period, or whether results in the consented sample differ from those in a larger population. Primary outcomes were self-reported.

CONCLUSION

Among older people living alone, a small cash transfer was effective in alleviating short-term (3 weeks) functional impairment, produced a small but not clinically or statistically significant reduction in depression, and had no effect on food security. There were no short-term effects from CBT or the 2 interventions together. None of the interventions showed any effect at 3 months.

PRIMARY FUNDING SOURCE

National Institute on Aging (NIA).

Adaptation and translation of a scalable measure for assessing health worker competence to deliver a brief psychological intervention: A case study from central India of its comparison to a performance-based measure

Efforts to reduce the global burden of common mental disorders have focused on scaling up evidence-based training programs for non-specialist providers to deliver brief psychological interventions. To evaluate these provider training programs, appropriate and scalable assessments of competency need to be developed alongside them. We followed a systematic approach for the cultural adaptation and translation into Hindi of a valid, English, multiple-choice applied knowledge measure to assess non-specialists' competence to deliver a brief psychological intervention for depression in rural India. We then explored the relationship between the performance of 30 non-specialist providers on the same written measure compared with a structured performance-based measure consisting of two role-plays. The results of the multiple-choice assessment had an overall mean score of 37.40 (SD = 11.31) compared to the mean scores of role-play A (the easier role-play) of 43.25 (SD = 14.50) and role-play B (the more difficult role-play) of 43.25 (SD = 13.00). Role-play performance-based measures and written applied knowledge measures represent different approaches with unique strengths and challenges to measuring competence. Scaling up training programs requires the development of scalable methods for competency assessment. Exploring the relationship between these two measures, our team found no apparent differences between the two modes of assessment. Continued comparison of these approaches is needed to determine the consistency of outcomes across the two formats and to link the scores on these measures with clinical performance as reflected by the quality of care and patient outcomes.Trial Registration: ClinicalTrials.gov Identifier: NCT04157816; 8th November 2019.

Adolescent Health Series The status of adolescent mental health research, practice and policy in sub-Saharan Africa: A narrative review

Sub‐Saharan Africa (SSA) has the fastest growing adolescent population in the world. In addition to developmental changes, adolescents in SSA face health and socioeconomic challenges that increase their vulnerability to mental ill‐health. This paper is a narrative review of adolescent mental health (AMH) in SSA with a focus on past achievements, current developments, and future directions in the areas of research, practice and policy in the region. We describe the status of AMH in the region, critical factors that negatively impact AMH, and the ways in which research, practice and policy have responded to this need. Depression, anxiety and post‐traumatic stress disorders are the most common mental health problems among adolescents in SSA. Intervention development has largely been focused on HIV/AIDS service delivery in school or community programs by non‐specialist health workers. There is a severe shortage of specialised AMH services, poor integration of services into primary health care, lack of a coordinated inter‐sectoral collaboration, and the absence of clear referral pathways. Policies for the promotion of AMH have been given less attention by policymakers, due to stigma attached to mental health problems, and an insufficient understanding of the link between mental health and social determinants, such as poverty. Given these gaps, traditional healers are the most accessible care available to help‐seeking adolescents. Sustained AMH research with a focus on the socioeconomic benefits of implementing evidence‐based, contextually adapted psychosocial interventions might prove useful in advocating for much needed policies to improve AMH in SSA.

Advanced echocardiographic function analysis in adolescents and young adults with corrected and residual coartation of the aorta

Funding Acknowledgements

Type of funding sources: None.

Introduction

This study aimed to assess systolic and diastolic heart function changes in patients with history of aortic coarctation using advanced echocardiographic imaging. Additionally, we sought to analyse which severity factors influenced these changes.

Methods

We performed a complete echocardiographic evaluation, with advanced functional analysis, including myocardial work analysis, to a random sample of 53 patients (age 12 to 40 years). These had a previous history of coarctation of the aorta (CoAo), which was either corrected (aortic transisthmic Doppler gradient (Dgrad) ≤20mmHg) or presented a significant residual gradient (Dgrad >20mmHg). A control group of healthy individuals, matched for age, sex and BMI, was subjected to the same evaluation. Selected dependent variables were: E/A, E’, E/E’, atrial strain parameters, biplane ejection fraction, ventricular global longitudinal strain, and global myocardial work (GMW). One-way ANOVA with appropriate post-hoc tests was done to compare the distribution of dependent variables among controls (n = 31), patients with corrected coartation (cCOAO) (n = 36), and patients with residual coartation (rCOAO) (n = 17). Multivariable linear regression was used to evaluate the association, in the 53 patients, between the dependent variables and parameters of CoAo severity: systolic blood pressure (SBP), left ventricular indexed mass (LVmass), Dgrad, and the ratio of the narrowest diameter of the aortic arch to the aorta at the diaphragm level (Aoratio). Statistical significance was established as p < 0.05.

Results

Patients with either cCOAO or rCOAO had lower E’ (p < 0.001), higher E/E’ (p < 0.001), lower atrial reservoir (p < 0.001) and conduit (p < 0.001) strain, when compared with controls (table 1). Patients with rCOAO had higher GMW when compared with either cCOAO or controls (p = 0.002). Multivariable regression analysis showed that both lower atrial reservoir and conduit strain were associated with a narrower aortic arch (lower Aoratio (p = 0.002 and p = 0.011, respectively); higher E/E’ with higher LVmass (p = 0.030); higher GMW with higher LVmass (p = 0.027) and Dgrad (p = 0.035). Patients subsequently submitted to an intervention for coartation treatment (n = 8) had lower atrial conduit (p = 0.007) and higher GMW (p = 0.015) when compared to all other patients (n = 45). Conclusion: Myocardial work emerged as a particularly useful tool as it was both significantly different between CoAo groups, and significantly higher in more severe patients, driven by the LV mass and residual gradient. This analysis may have a role in these patients’ clinical decision-making. Abstract Table 1

Problem-Solving Therapy for Older Adults at Risk for Depression: A Qualitative Analysis of the Depression in Later Life Trial

OBJECTIVE

As a sequel to the Depression in Later Life trial of lay counselor-delivered problem-solving therapy for depression prevention among older adults in Goa, India, this qualitative study aimed to explore participant experiences to illuminate the reasons for the trial's positive findings and implications for further efforts at depression prevention in low-resource settings.

METHODS

In-depth interviews were conducted with 19 participants (21% of those randomly assigned to the original intervention). Two independent raters coded the data and organized narratives according to broad themes.

RESULTS

Most participants valued their relationship with the lay counselor, learned self-care strategies to cope with illnesses, and increased engagement in pleasurable social and physical activities. Some participants reported needing assistance with managing financial strain and family conflicts.

CONCLUSIONS

The lay-counselor-delivered intervention was well received. The relationship with the counselor and behavioral activation toward better self-care and more-pleasurable activities may have been keys to the intervention's success.

Adaptation of problem-solving therapy for primary care to prevent late-life depression in Goa, India: the 'DIL' intervention

Background: Depression in late life is a major, yet unrecognized public health problem in low- and middle-income countries (LMICs). The dearth of specialist resources, together with the limited ability of current depression treatments to avert years lived with disability, underscores the need for preventive interventions that can be delivered by lay health workers in primary care settings. We describe the development of an intervention for the indicated prevention of depression in older adults at risk due to subsyndromal symptoms, attending rural and urban public primary care clinics in Goa, India.

Objectives: (1) to describe a mixed-methods approach (qualitative and quantitative)to the development of ‘DIL,’ an intervention for preventing the onset of major depression in older adults living with subsyndromal symptoms in Goa, India; (2) to describe resulting components of the ‘DIL’ intervention; and (3) to present data on the feasibility, acceptability, and benefit of DIL to participants.

Methods: We followed a mixed-methods design, including in-depth interviews, focus group discussions, a theory of change workshop to develop a logic model, and an open-case series.

Results: The mixed-method approach led to the development and adaptation of the DIL (Depression in Later Life) intervention for the indicated prevention of depression in older adults. The intervention was delivered by lay health counselors (LHCs). ‘DIL’ is a hybrid model of simple behavioral strategies grounded in Problem-solving Therapy for Primary Care, improved self-management of common, co-occurring medical disorders such as diabetes mellitus, and pragmatic assistance in navigating to needed social services. The use of ‘DIL’ in an open-case series with 19 participants led to a moderate reduction in symptoms of depression and anxiety on the General Health Questionnaire. A pictorial flipchart was developed to assist in delivering the intervention to participants with low levels of literacy. High rates of participant retention and satisfaction were achieved.

Conclusion: The DIL intervention was adapted to the local context for delivery by lay health counselors and was found to be acceptable and feasible among the elderly participants in the study.

Effect of a Lay Counselor Intervention on Prevention of Major Depression in Older Adults Living in Low- and Middle-Income Countries: A Randomized Clinical Trial

IMPORTANCE

Preventing depression in older adults living in low- and middle-income countries is important because of the scarcity of treatment resources and the risk of disability, suicide, and dementia.

OBJECTIVE

To assess whether an intervention for depression prevention provided by lay counselors is effective in older adults from low- and middle-income countries.

DESIGN, SETTING, AND PARTICIPANTS

This parallel-group randomized clinical trial with masked outcome assessment was performed in 181 older adults (≥60 years) with subsyndromal depressive symptoms at rural and urban primary care clinics in Goa, India. The first participant entered the trial on March 31, 2015, and the last exited on June 2, 2017. Data analysis used the intention-to-treat approach.

INTERVENTIONS

Lay counselors provided problem-solving therapy, brief behavioral treatment for insomnia, education in self-care of common medical disorders such as diabetes, and assistance in accessing medical and social programs.

MAIN OUTCOMES AND MEASURES

The main outcome was incidence of major depressive episodes. The study also assessed symptom change during 12 months (12-item General Health Questionnaire [GHQ-12]; score range of 0 to 12, with higher scores indicating greater symptoms of depression and anxiety), functional status (World Health Organization Disability Assessment Schedule 2.0; score range of 12 to 60, with higher scores indicating greater disability), cognition (Hindi Mini-Mental State Examination; score range of 0 to 30, with higher scores indicating better cognitive functioning), blood pressure, and body mass index to provide further clinical context.

RESULTS

The study enrolled 181 participants (mean [SD] age, 69.6 [7.2] years; 114 [63.0%] female): 91 to the intervention arm (depression in later life [DIL] intervention) and 90 to care as usual (CAU). Incident episodes of major depression were lower in the DIL intervention than in the CAU group (4.40% vs 14.44%; log-rank P = .04; number needed to treat, 9.95; 95% CI, 5.12-182.43). The 12-month Kaplan-Meier estimates of percentage of depression-free participants were 95.1% (95% CI, 90.5%-99.9%) in the DIL group vs 87.4% (95% CI, 80.4%-95.1%) in the CAU group. The incidence of depressive symptoms (GHQ-12) was also less (12-month mean difference, -1.18; 95% CI, -2.03 to -0.31; group × time interaction P < .001). There were no changes in measures of disability or cognition. The DIL intervention was associated with a significantly greater lowering of systolic blood pressure (12-month mean difference, -6.98; 95% CI, -11.96 to -2.01; group × time interaction P < .001) and change in body mass index (12-month mean difference, 0.23; 95% CI, -0.97 to 1.43; P = .04).

CONCLUSIONS AND RELEVANCE

The DIL intervention is effective for preventing episodes of major depression in older persons with subsyndromal symptoms. If replicated, the DIL intervention may be effective in older adults living in low- and middle-income countries.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02145429.

Aging and well-being in Goa, India: a qualitative study

OBJECTIVES

The population of India is aging rapidly. This demographic shift brings with it a host of challenges to the health and well-being of older adults, including the increased prevalence of non-communicable diseases, among them depressive disorders. In this paper, we report on qualitative research intended to inform the development of a locally acceptable and appropriate intervention to improve the well-being of older adults in Goa, India and, specifically, to prevent late-life depression.

METHOD

Semi-structured interviews with 20 individuals, aged 60 years and older, attending two primary care clinics in Goa, India. Transcripts were reviewed to identify emerging themes, a coding scheme was developed and thematic analyses were conducted.

RESULTS

Analyses of the interview transcripts revealed the following key themes: (1) notions of old age tended to be negative and there were widespread fears of becoming widowed or incapacitated; (2) the most frequently reported health conditions were joint pain, diabetes and heart disease; (3) emotional distress was described using the terms 'tension', 'stress', 'worry' and 'thinking'; (4) family issues often involved financial matters, difficult relationships with daughters-in-law and conflicted feelings about living with the family or independently; (5) other than a pension scheme, participants did not know of community resources available to older adults.

CONCLUSIONS

Our findings are in general agreement with those of previous research, and with our experiences of working with older adults in Pittsburgh and the Netherlands. This research will inform the development of an intervention to prevent depression in older adults in Goa.

Intervention development for the indicated prevention of depression in later life: the "DIL" protocol in Goa, India

Because depression is a major source of the global burden of illness- related disability, developing effective strategies for reducing its incidence is an important public health priority, especially in low-income countries, where resources for treating depression are scarce. We describe in this report an intervention development project, funded by the US National Institute of Mental Health, to address "indicated" prevention of depression in older adults attending rural and urban primary care clinics in Goa, India. Specifically, participants in the "DIL" ("Depression in Later Life") trial were older adults living with mild, subsyndromal symptoms of depression and anxiety and thus at substantial risk for transitioning to fully syndromal major depression and anxiety disorders. Building upon the MANAS treatment trial ("Promoting Mental Health") led by Patel et al in the same locale, we present here lessons learned in the development and implementation of a protocol utilizing lay health counsellors (LHCs) who deliver a multi-component depression prevention intervention organized conceptually around Problem Solving Therapy for Primary Care (PST), with additional components addressing brief behavioural treatment of sleep disturbances such as insomnia, meeting basic social casework needs, and education in self- management of prevalent comorbid chronic diseases, such as diabetes mellitus. To our knowledge, DIL is the first randomized clinical trial addressing the prevention of depressive disorders ever conducted in a low- or middle-income country.

Gestation-related gene expression and protein localization in endometrial tissue of Suffolk and Cheviot ewes at gestation Day 19, after transfer of Suffolk or Cheviot embryos

The objective of this study was to investigate the gene expression of progesterone and estrogen receptor α (PR, ERα), insulin-like growth factor (IGF) 1, IGF-2, their receptor (IGFR1), IGF-binding proteins (BP) 1 to 6, insulin receptor, adiponectin receptors (AdipoR1/2), cyclooxygenase 2 (PTGS2), mucin 1 and to localize PR, ERα, IGF-1, IGFR1, PTGS2, and proliferating cellular nuclear antigen (PCNA) in the endometrium of pregnant (Day 19) Suffolk and Cheviot ewes carrying Suffolk and Cheviot embryos transferred within and reciprocally between breeds. Gene expression was determined by real-time quantitative polymerase chain reaction (RT-qPCR), and antigen determination was measured by immunohistochemistry in the luminal epithelium (LE), superficial and deep glands (SG, DG, respectively) and superficial and deep stroma. Gene expression of PR, IGF-1, IGFBP2, and IGFBP5 was higher in Suffolk than that in Cheviot ewes (P < 0.05). Greater abundance of IGF-2 and IGBP3 expression was found in Cheviot ewes carrying Cheviot embryos than Cheviot ewes carrying Suffolk embryos (P < 0.05). No staining for PR and ERα was observed in the LE, very scarce staining in SG and DG, whereas positive staining was observed in both superficial and deep stroma. No differences were found for PR staining, but Cheviot ewes had higher ERα staining intensity than Suffolk ewes (P < 0.05). Positive staining for IGF-1 was observed in all cell types except DG, and staining of IGFR1 was observed in all cell types. No differences among groups in staining were found for IGF-1 or IGFR1 in any cell type. Positive staining of PTGS2 was observed in LE and SG in all groups. An interaction between ewe and embryo breed affected PTGS2 staining (P < 0.05), whereby Cheviot ewes carrying Suffolk embryos had a lower PTGS2 staining than Suffolk ewes carrying Suffolk embryos. Positive staining of PCNA was found in LE and SG. Suffolk ewes carrying Suffolk embryos showed lower PCNA immunostaining than Cheviot ewes carrying Suffolk embryos (P < 0.05), whereas no differences were observed in ewes carrying Cheviot embryos. This study showed that gestation-related protein expression in the endometrium of Suffolk and Cheviot ewes is affected by both ewe and embryo breed at Day 19 of pregnancy.

Resistance to HSP90 inhibition involving loss of MCL1 addiction

Inhibition of the chaperone heat-shock protein 90 (HSP90) induces apoptosis, and it is a promising anti-cancer strategy. The mechanisms underpinning apoptosis activation following HSP90 inhibition and how they are modified during acquired drug resistance are unknown. We show for the first time that, to induce apoptosis, HSP90 inhibition requires the cooperation of multi BH3-only proteins (BID, BIK, PUMA) and the reciprocal suppression of the pro-survival BCL-2 family member MCL1, which occurs via inhibition of STAT5A. A subset of tumour cell lines exhibit dependence on MCL1 expression for survival and this dependence is also associated with tumour response to HSP90 inhibition. In the acquired resistance setting, MCL1 suppression in response to HSP90 inhibitors is maintained; however, a switch in MCL1 dependence occurs. This can be exploited by the BH3 peptidomimetic ABT737, through non-BCL-2-dependent synthetic lethality.

Abstract PD5-3: Anti-metastatic activity, chemotherapeutic enhancement and therapeutic potential of targeting Hsp90 with ganetespib in triple negative breast cancer

Background: While the incidence of triple negative breast cancer (TNBC) is only 10-20%, these tumors show a disproportionate mortality for breast cancer patients. Due to a lack of effective molecular targets in this disease, therapeutic options are largely limited to systemic chemotherapeutic approaches which have shown disappointing efficacy in the metastatic setting. Here we undertook a comprehensive evaluation of the activity of the drug candidate, ganetespib, a potent inhibitor of heat shock protein 90 (Hsp90), in this malignancy.

Methods: The sensitivity of TNBC cells to ganetespib was determined in viability assays using a panel of tumor lines. The effects of ganetespib exposure on client proteins and their effector pathways were examined by Western blot and reverse phase protein array analysis. The anti-metastatic activity of ganetespib was evaluated using a 4T1 metastasis model. Combinatorial drug analyses were performed with chemotherapeutic agents. DNA damage and cell cycle disruption were assessed using the comet assay, Western blotting and fluorescence microscopy. The in vivo efficacy of the compound, both as a single agent and in combination, was established using MDA-MB-231 xenograft models. Computed tomography scans were obtained for a metastatic TNBC patient undergoing ganetespib treatment.

Results: Ganetespib reduced cell viability in TNBC cell lines with low nanomolar potency. Ganetespib treatment induced robust destabilization of multiple client proteins and oncogenic signaling pathways and suppressed lung metastasis in the experimental model. Ganetespib potentiated the cytotoxic activity of doxorubicin via enhanced DNA damage and mitotic arrest, conferring superior efficacy to the doxorubicin + cyclophosphamide (AC) regimen in MDA-MB-231 xenograft models. Ganetespib also promoted mitotic catastrophe and apoptosis in combination with taxanes in vitro, and these effects translated to significantly improved combinatorial activity in vivo. Marked tumor shrinkage of metastatic lung lesions was seen in the patient while on ganetespib monotherapy.

Conclusion: The preclinical activity profile and clinical evidence of tumor regression suggest that ganetespib offers considerable promise as a new therapeutic candidate to target TNBC. In particular, the capacity of ganetespib to potentiate the activity of standard of care chemotherapeutics provides a rationale for the exploration of this agent in novel combinatorial treatment strategies for this disease.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr PD5-3.

Content and distribution of arsenic in soils, sediments and groundwater environments of the southern Pampa region, Argentina

The health of a large rural population in the southern Pampa (Argentina) is at risk owing to newly detected areas where As-groundwater exceeds 0.01 mg/L standard (WHO (1995) Guidelines for drinking water quality, 2nd edition. pp 43-45). Currently, devitrification of volcanic glass is invoked to interpret the origin of arsenic in the aquifers hosted in a sequence of pampean loess (Plio-Pleistocene) juxtaposed with postpampean loess (Holocene). Our data suggest that arsenic is not specifically associated with volcanic glass and that other minerals contribute to As-release into groundwater. The goals were (1) to understand As-groundwater spatial variability, (2) to explore soils/sediments/water relationships and to identify the probable As-provenance. Comparable As concentrations of the light and the heavy sand fractions suggest that though detrital glass is a major light constituent, other existing primary minerals are As-bearers that contribute to As-release into groundwater. Grouping of materials according to their As-content indicated spatial variability in the sedimentary distribution pattern leading to differences in the frequencies of occurrence of As-bearing minerals. Phreatic waters were Ca + Mg bicarbonate and devoid of As in the intake areas (Ventania System) and Na-carbonate but As-rich towards the discharge (Atlantic coast and local depressions). As-groundwater reflects a patchy distribution within the pampean landscape. A correspondence between As-high groundwater, EC >1 dSm, CO(3)H(-), alkaline pH and a longer water residence time do exist triggering As extraction from the loess sand fraction and desorption from charged fine particles which lead to As-toxicity towards groundwater discharge.

Organochlorine compounds and stable isotopes indicate bottlenose dolphin subpopulation structure around the Iberian Peninsula

Isotopic signatures and organochlorine pollutant loads of organisms reflect the characteristics of the waters in which they live and feed. To investigate population structure of bottlenose dolphins around the Iberian Peninsula we determined delta(13)C and delta(15)N in the skin and organochlorine (OC) levels in the blubber of stranded bottlenose dolphins inhabiting the Mediterranean (Catalonia, Valencia and Balearic Islands) and adjacent Atlantic waters (Huelva and Portugal). OC levels were high in all regions, reflecting the predatory habits of the species, its coastal distribution and the existence of intense agricultural and industrial activity throughout the region. PCB congeners showed a gradient from the relatively more chlorinated forms to those that are less so, and followed a northeast to northwest direction across the Iberian Peninsula. This suggests that PCB inputs are more recent in the temperate latitudes of the eastern Atlantic Ocean than in the western Mediterranean Sea. Comparatively, OC ratios and isotopic signatures proved to be more efficient ways of discriminating groups than did raw OC concentrations. Significant differences in delta(13)C and in PCB congener profiles indicate that dolphins from the Atlantic and the Mediterranean do not intermingle. In addition, the two Atlantic groups differed in delta(15)N signature, tDDT concentration, DDT/PCB ratio and the PCB congener profile, which also suggests some degree of isolation between them. In the Mediterranean, dolphins from Catalonia and Valencia were indistinguishable, suggesting a common distribution area. However, dolphins from the Balearic Islands differed from those of the Peninsula in their DDT/PCB ratio and from all the other sample groups in their PCB congener profiles, which supports the hypothesis that the deep waters between the Islands and the Peninsula represent an effective barrier for the species.

Demonstration of reduced in vivo surface expression of activating mutant thyrotrophin receptors in thyroid sections

OBJECTIVE

Thyroid function and growth are controlled by TSH. Hyperthyroidism can be due to Graves' Disease (GD), in which thyroid-stimulating antibodies mimic TSH, or gain-of-function mutations in the TSH receptor (TSHR). These activating mutations have poor surface expression when assessed in non-thyroidal cells in vitro but nothing is known of their in vivo behaviour. Several TSHR antibodies have been produced but none has been applied to thyroid paraffin sections. This study aimed to develop a technique suitable for use on paraffin sections and apply it to investigate TSHR expression in thyroids harbouring activating TSHR germline mutations compared with normal and GD thyroids.

DESIGN AND METHODS

Immunocytochemistry coupled with antigen retrieval, using a spectrum of antibodies to the TSHR, was applied to paraffin sections of GD thyroid tissue. Subsequently, TSHR immunoreactivity was examined in three normal thyroids, three patients with GD and three patients with familial hyperthyroidism, due to different gain-of-function TSHR germline mutations, using the optimised protocol.

RESULTS

Two antibodies, A10 and T3-495, to the extracellular domain (ECD) and membrane spanning region (MSR) of the TSHR respectively, produced specific basolateral staining of thyroid follicular cells. In normal and GD thyroids, basolateral staining with T3-495 was generally more intense than with A10, suggesting a possible surfeit of MSR over ECD. Graves' Disease thyroids have more abundant TSHR than normal glands. In contrast, thyroids harbouring gain-of-function mutations have the lowest expression in vivo, mirroring in vitro findings.

CONCLUSIONS

The development of an immunocytochemical method applicable to paraffin sections has demonstrated that different molecular mechanisms causing hyperthyroidism result in the lowest (mutation) and highest (autoimmunity) levels of receptor at the thyrocyte surface.

Efficacy and mechanisms of action of rmB7.2-Ig as an antitumor agent in combination with Adriamycin and Cytoxan chemotherapy

The efficacy of chemotherapy for cancer is often limited by toxicity. Immune approaches to cancer immunotherapy, while promising for specificity and long-term protection, have not typically proven potent enough to generate significant therapeutic responses. We have shown therapeutic benefit using recombinant murine B7.2-Ig (rmB7.2-Ig) in murine tumor models. Efficacy was dependent on immune activity and was not associated with toxicity. Recently, the efficacy of rmB7.2-Ig was demonstrated in leukemia tumor models in combination with chemotherapeutic agents. To further explore the potential of this approach, we evaluated the efficacy in solid tumor models of rmB7.2-Ig given in combination with chemotherapeutics commonly used in clinical practice, testing the effects of dose and schedule. RmB7.2-Ig in combination with some chemotherapeutics enhances the activity and efficacy of reduced chemotherapeutic doses. However, the relative timing of chemotherapy and rmB7.2-Ig dosing can be important. Investigation of mechanisms of action based on histological studies suggests that inflammatory as well as T cell mechanisms comprise the response. Additional studies of mice deleted of B7.1, B7.2, and CTLA-4 suggest that the enhanced response induced by rmB7.2-Ig may not be mediated through CD28 ligation alone. The efficacy suggests potential for recombinant human B7.2-Ig as an adjuvant to chemotherapy in promoting immune-mediated mechanisms to augment the activity of chemotherapy.

Heavy metals in the tissues of common dolphins (Delphinus delphis) stranded on the Portuguese coast

The concentrations of Hg, Sn, Cr, Zn, Ni, Co, Cd, Mn, Fe and Cu were determined in the liver, kidney and muscle of 24 common dolphins stranded on the Portuguese coast between 1995 and 1998. Nitric acid was used to extract the metals from the tissues for analysis by inductively-coupled plasma/atomic emission spectroscopy (ICP/AES). Those metals with relatively higher concentrations included Fe, Zn and Hg, particularly in liver. Other metals including Cr, Ni and Cd tended to show much lower levels, or were even undetected (e.g. Co). Different metals seemed to show different temporal trends, although due to substantial variations of the mean concentrations for each year obtained, such temporal pattern has to be studied further. Total Hg concentration in the kidney, muscle and particularly liver, were higher in females than in males. Total Hg concentrations in all the organs increased with body length of dolphins, whilst those of Zn and Cu in muscle decreased with dolphin length. A strong correlation was found between essential metals Zn and Cu in muscle, possibly resulting from sequestration of these metals by metallothionein. In addition, significant co-associations existed between the same metal (e.g. Hg, Sn and Zn) in different organs.

Sebaceous carcinoma of the eyelid treated with Mohs micrographic surgery

BACKGROUND

Sebaceous carcinoma is an aggressive neoplasm that commonly arises from the meibomian glands of the eyelids and other sebaceous glands of the ocular adnexa. Historic data indicate a nearly 30% local recurrence rate with standard surgical excision. Excision by means of Mohs micrographic surgery may be more efficacious. However, reports documenting the effectiveness of this technique for the treatment of eyelid sebaceous carcinoma have been limited to a few cases.

OBJECTIVE

We report our experience in the treatment of ocular sebaceous carcinoma with the Mohs fresh tissue technique.

METHODS

Eighteen patients with a diagnosis of sebaceous carcinoma of the eyelid who underwent resection by means of the Mohs fresh tissue technique during the years 1988-1998 were reviewed.

RESULTS

Sixteen of the 18 patients were free of disease after an average follow-up of 37 months (11.1% recurrence rate). One patient who experienced local recurrence also had metastatic disease of the parotid lymph nodes (5.6% metastatic rate). The recurrence and metastasis were noted 9 months after excision. The other patient experienced a local recurrence 19 months postoperatively. Both patients exhibited pagetoid spread and involvement of both the upper and lower eyelid at the time of Mohs excision.

CONCLUSION

Mohs surgery offers excellent results when used as the primary treatment modality for sebaceous carcinoma of the eyelid. When compared with historic series of standard surgical excision, Mohs micrographic surgery has a significantly lower recurrence rate and metastatic rate.

Novel TSHR germline mutation (Met463Val) masquerading as Graves' disease in a large Welsh kindred with hyperthyroidism

Hereditary nonautoimmune hyperthyroidism is caused by activating germline mutations in the thyrotropin (TSH) receptor (TSHR) gene. We describe an extended Welsh kindred with toxic thyroid hyperplasia affecting 8 family members in three generations and a history consistent with thyrotoxicosis in a further three generations now deceased. A novel heterozygous germline mutation (ATG --> GTG; Met463Val) was identified in the second membrane spanning TSHR region in 6 relatives with thyrotoxicosis and goiter and absence of TSHR antibodies. Screening of 5 additional family members led to the identification of 2 siblings with the mutation, who were asymptomatic at the time, although subsequent thyroid function tests in these children showed suppressed serum TSH and increased serum free triiodothyronine (FT3) and free thyroxine (FT4) concentrations. Functional studies of the novel TSHR germline mutation demonstrated a constitutive activation of the cAMP pathway, which in the thyroid controls both thyroid hormone production and stimulation of thyroid growth. The molecular diagnosis in this family has clinical implications: genetic counseling is required, and primary thyroid ablation should be advocated as the preferred treatment in the patients with the constitutively activating TSHR germline mutation.

The use of conscious sedation for outpatient dermatologic surgical procedures

BACKGROUND

Dermatologic surgery has undergone increasing levels of sophistication over the past few decades. Commensurate with this demand, an established anesthesia technique called conscious sedation has been employed.

OBJECTIVES

Methods for performing office-based conscious sedation are described. Recommendations are made regarding prerequisites for conscious sedation in an office setting, patient selection, complications management, and postoperative discharge requirements.

CONCLUSION

The goals of anesthesia are to provide for patient safety and comfort, to increase patient acceptance of the procedure, and to enhance the surgeon's efficiency and satisfaction.

The combined use of propofol and fentanyl for outpatient intravenous conscious sedation

BACKGROUND

Intravenous conscious sedation is currently being widely utilized for outpatient surgery including dermatologic surgery. Even though this type of anesthesia is typically administered by a trained, licensed anesthetist, it is important for dermatologists who either intend to or are currently utilizing this type of anesthesia to be familiar with some of the methods and agents that are commonly employed.

OBJECTIVE

Propofol and fentanyl are two anesthetic agents that are in prevalent use for skin and soft tissue surgery of brief or limited duration. With the goal of familiarizing dermatologic surgeons with this form of anesthesia, a study was conducted to evaluate the safety and effectiveness of the combination of propofol and fentanyl when used for conscious sedation in an outpatient dermatology center.

METHODS

Twenty patients, ages 25-65 years, who required conscious sedation were enrolled. Each patient received a standard dosage of fentanyl and propofol, as determined on a kilogram basis. Sedation time, total procedure time, recovery time, and total propofol dose, along with side effects, were determined.

RESULTS

The mean onset to sedation was 52.5 seconds, the mean procedure time was 40 minutes 37 seconds, and the mean interval to recovery was 3 minutes 43 seconds, with a mean total dose of propofol of 5.83 mg/kg. Minimal side effects occurred.

CONCLUSION

Propofol when used in conjunction with fentanyl appears to be a safe, quick, and effective method of providing conscious sedation.

Surgical intervention for the aging face. Combination of mini-face-lifting and superficial carbon dioxide laser resurfacing

BACKGROUND

Patients seeking facial rejuvenation often would benefit from a combination of face-lifting and laser resurfacing. Fear of skin slough has prevented the study of this issue.

OBJECTIVE

We report our experience utilizing a combination of simultaneous cervicofacial rhytidectomy and carbon dioxide (CO2) laser resurfacing, and summarize the results of a survey completed by each patient.

METHODS

Forty patients underwent the combination treatment. Patients were followed and asked to respond to a questionnaire 12 months postprocedure regarding their surgical experience.

RESULTS

Our survey revealed an overall degree of satisfaction. Reported complications included transient swelling, redness, pigmentary alteration, and numbness. One patient experienced minimal slough in a nonresurfaced site.

CONCLUSIONS

The control of depth of thermal damage with the CO2 UltraPulse laser allows for precision in its combined application along with face-lifting. In the area of the flap, one pass at low power settings is safe in our experience and results in an improved cosmetic result.

[Characterization of fatty acids and mycolic acid degradation products in mycobacterial species of major incidence in Argentina]

The human immunodeficiency virus (HIV) epidemic has altered the epidemiological profile of tuberculosis in both industrialized and developing countries. Serious diseases caused by mycobacteria other that M. tuberculosis, mostly belonging to the M. avium-intracellulare complex (MAC), have become very common in association with severe immunosuppression. The increase in mycobacterial disease complexity has stimulated the development of more rapid and efficient methods of diagnosis. In the present study we characterized the cellular fatty acids and the mycolic acid cleavage product from most frequent mycobacteria species in Argentina using gas chromatography in order to develop a rapid technique for their identification. Fatty acids and mycolic acids extracted from saponified mycobacterial cells were examined as methyl esters by capillary has chromatography. The major constituent fatty acids in all species, with the exception of M. smegmatis, were octadecenoic (18:1) and hexadecanoic (16:1) acids. The fatty acids and mycolic acid cleavage product profiles from the studied species were quantitatively but not qualitatively different. Tuberculostearic acid was found in all species. Significantly different amounts of some fatty acids (p < 0.01) were observed among clinical isolates of M. tuberculosis, M. bovis and MAC. Traces of 2-eicosanol were detected in the M. tuberculosis H37Rv strain. Although a limited number of strains and species were tested, preliminary results indicate that this method could be used to characterize mycobacterial cultures.

Dermatologic uses of interferons

Interferons are members of the cytokine family, with diverse antiviral, antiproliferative, antifibrotic, and immunomodulatory activities. Over the past 10 years, interferon use in clinical dermatology has extended beyond its historical antiviral efficacy. In this article, FDA-approved indications and non-FDA-approved dermatologic uses of interferons are reviewed.