Evaluation of the Project Echo Tele-Mentoring Model for Knowledge Sharing and Technical Assistance in Cancer Control Planning and Implementation

Background: There is increasing demand for dissemination and implementation of evidence-based guidelines in cancer control. In 2017, the National Cancer Institute's Center for Global Health (NCI-CGH) partnered with University of New Mexico and The University of Texas MD Anderson Cancer Center to provide the Project ECHO (Extension for Community Healthcare Outcomes) model of tele-mentoring as an extension of existing programs that convene relevant stakeholders for knowledge sharing and technical assistance in national cancer control planning. In early 2018, NCI-CGH launched Project ECHO programs in the Caribbean, Asia-Pacific, and sub-Saharan Africa regions, and began plans for implementation in south Asia. As a new approach for the center in program development, NCI-CGH included evaluation measures from the inception of the program to adequately measure its efficacy. Aim: Evaluation of NCI-CGH Project ECHO programs will guide future program development, and assess achievement of the program's goals: (1) to increase individual participant knowledge in specific areas; (2) to improve application of the knowledge learned; and (3) to increase collaboration within and among countries. Methods: Using Project ECHO Evaluation 101, a guide developed by the New York Academy of Medicine, NCI-CGH developed a comprehensive logic model including a concise list of program outcomes prior to the launch of ECHO programs. NCI-CGH used the logic model to develop and pilot-test a Web-based baseline and post-ECHO survey, to be completed by participants in each program, that measures participants' knowledge of cancer control planning principles and strategies. NCI-CGH conducted the baseline survey for all three ECHO programs. The post-ECHO survey will be distributed at the conclusion of each program. Each program is expected to run for approximately six months to one year. Results: Response rates for baseline surveys were: 32% in the Caribbean, 43% in Asia-Pacific, and 78% in sub-Saharan Africa. Respondents (by region) reported high levels of knowledge of the following evidence-based principles and guidelines: the Caribbean - HPV vaccination, Asia-Pacific - cervical cancer early diagnosis, sub-Saharan Africa - raising awareness. Low levels of knowledge were reported for: psychosocial support for cancer patients, family members, and caregivers in the Caribbean; survivorship care for cancer patients in Asia-Pacific; and alcohol consumption control in sub-Saharan Africa. This presentation will highlight baseline and post-ECHO survey analysis findings and the impact of these data on future program development. Conclusion: Inclusion of evaluation measures in the design phase of NCI-CGH Project ECHO tele-mentoring programs enhanced planning efforts by providing a blueprint for developing program curricula, creating an embedded system for gathering data from participants, and informing the pathway to future improvements.

Changes in sexual behaviour between 1986 and 1988 in matched samples of homosexually active men

Matched samples of homosexually active men were obtained using identical sampling methods in a city of one million people in 1986 and 1988. Data indicated that reported sexual behaviours had significantly changed in the direction of safer sex, particularly oral sex without ejaculation, anal sex with a condom (both insertive and receptive), which increased in frequency, and analingual and digitoanal receptive practices, wet kissing, and anal receptive intercourse generally, which decreased. Reported sources of education for both samples were primarily gay media and gay organisations. These data, with some caveats concerning design and comparability of samples, suggest that behavioural change in the appropriate direction has occurred in homosexually active men, and that gay organisations and media have been perceived as the most common source of information on safer sex in this population.

The cellular basis of immune induction at mucosal surfaces by DNA vaccination

The nasal mucosa provides a simple, non-invasive route to deliver DNA encoding the gene of interest to stimulate mucosal and systemic immune responses. However, unlike the intradermal or intramuscular routes for plasmid DNA (pDNA) delivery, immune responsiveness to antigen exposure at the respiratory mucosa is tightly regulated, consistent with the balance between active immunity and non-responsiveness to pathogenic or inert environmental antigens. We have characterised the antigen presenting cell types, their distribution and activation status following nasal vaccination with pDNA-cytofectin complexes encoding model antigens. We demonstrate that nasal immunisation is associated with expression of the encoded protein in a small population of dendritic cells and macrophages at the site of pDNA delivery, in the draining lymph nodes (LN) and in the spleen. Antigen expression by nasal dendritic cells was associated with up-regulation of surface MHC class II and CD86 expression and functional activation of T-lymphocytes. The results highlight the potential of intranasal vaccination with pDNA, provided the activation / costimulatory requirements for an active immune response are achieved.

Recent developments in mucosal delivery of pDNA vaccines

The development of DNA vaccination to mucosal surfaces has continued apace over the last 2 years, with the investigation of several novel delivery vehicles. There have been advances in the understanding of the basic immunological mechanisms behind the induction of immune responses by plasmid DNA. The mechanistic insights are paving the way for the design of a second generation of mucosally delivered DNA vaccines. This article reviews the recent progress in the field of microparticle, cationic lipid and bacterial delivery systems. All these mechanisms afford some protection from environmental degradation and facilitate DNA uptake. These methods have been compared with respect to transfection efficiency, ability to elicit a full range of immune responses and their relative safety for in vivo applications.

Interleukin-8 as an autocrine growth factor for human colon carcinoma cells in vitro

Cell lines derived from human colon carcinomas secrete interleukin 8 (IL-8) in vitro and this chemokine has also been detected immunohistochemically in human colon carcinoma specimens, in which it is tumour cell associated. In these experiments, IL-8 was shown to comprise an important component of the angiogenic activity of colon carcinoma cell line supernatants. The effect of modulating IL-8 activity upon the growth of the colon carcinoma cell lines HCT116A, HT29 and CaCo2 was investigated. Supplementing endogenously produced IL-8 by recombinant chemokine led to stimulation of cell growth. Neutralization of the effect of endogenously produced IL-8, either with the specific antagonist peptide AcRRWWCR or with blocking anti-IL-8 antibody, resulted in around 50% inhibition of cell growth (P<0.05). All of the colon carcinoma cell lines tested expressed mRNA for both IL-8RA and RB when grown at confluence. At the protein level, all cell lines expressed IL-8RA. Expression of IL-8RB was weak, although increased expression was seen in HCT116A cells as they approached confluence. Antibodies to IL-8RA and RB did not affect proliferation at low cell density but were strongly inhibitory when cells were cultured at a higher density. These data suggest that IL-8 acts as an autocrine growth factor for colon carcinoma cell lines and would support the concept that a similar autocrine loop operates in vivo.

Endothelial interactions of hairy cells: the importance of alpha 4 beta 1 in the unusual tissue distribution of the disorder

The tissue-homing of all lymphocytes involves their interactions with endothelial cells (ECs) and with various tissue accessory cells. However, in hairy cell leukemia (HCL), these processes are particularly prominent and result in diagnostic appearances in the spleen, liver, and bone marrow. The present study explores the mechanisms that underlie these tissue reactions. Using a human umbilical vein EC (HUVEC) model, various possible receptor-ligand interactions between hairy cells (HCs) and ECs were examined and a central importance for alpha 4 beta 1/vascular cell adhesion molecule-1 (VCAM-1) was established. This receptor-ligand pair was shown to be important both for strong adhesion and for HC motility/transmigration. A similar importance for alpha 4 beta 1/VCAM-1 was established for the interaction between HCs and relevant tissue accessory cells. The in vitro relevance of these findings was confirmed by the demonstration of VCAM-1 in HCL spleen and by the fact that, in frozen sections, HCs adhered (via VCAM-1) to the red pulp, but not to other areas of normal spleen. These results indicate that alpha 4 beta 1/VCAM-1 is central to the interaction between HCs and endothelium/accessory cells. Such interactions, together with the intrinsic cell activation characteristic of HCL and the HC's consequent ability to interact with matrix, are responsible for many of the characteristic features of the disease.

Detection of interleukin-8 mRNA and protein in human colorectal carcinoma cells

Interleukin-8 (IL-8) is a member of the chemokine family of pro-inflammatory chemotactic cytokines and is secreted by some human colorectal carcinoma cell lines. We have used in situ hybridisation and immunohistochemistry to determine whether IL-8 mRNA and protein, respectively, are produced by human colorectal carcinoma cells in vivo. IL-8 mRNA was detected within the cytoplasm of tumour cells in all nine samples tested, including that of a tumour which had metastasised to a lymph node. Non-involved colonic mucosa within the same tissue blocks showed much weaker labelling. IL-8 protein was detected in 74% (23/31) of tumour samples and was mainly localised to the tumour cell cytoplasm. In 30% of cases, staining was heterogeneous, with between 1 and 30% of cells being positive. In some tumour cells, IL-8 showed a perinuclear distribution resembling that found by in situ hybridisation. Some infiltrating leucocytes, endothelial cells and fibroblast-like cells within the tumour sections were also positive for IL-8 mRNA and protein. The possibilities that colorectal tumours produce IL-8 to aid invasion and/or metastasis or as a tumour growth factor are discussed.

Prodrug-activated gene therapy: involvement of an immunological component in the "bystander effect"

The integration and expression of the herpes simplex virus type 1 thymidine kinase (HSV1-TK) gene in localized tumors results in tumor regression after the administration of the specific nucleoside analogue ganciclovir (GCV). Although only 10% to 20% of the tumor cells take up the HSV1-TK gene, the neighboring cells also die, a phenomenon termed "bystander effect.". In the present study, coinjection of the MC26 mouse colon carcinoma cell line and the HSV1-TK expressing retroviral packaging cell line followed after 7 days by the intraperitoneal administration of GCV resulted in almost total tumor regression in the immunocompetent BALB/c mice but not in immunocompromised athymic BALB/c mice. This suggested a strong cell-mediated immune component to the bystander effect.

Extensive TCR junctional diversity of V gamma 9/V delta 2 clones from human female reproductive tissues

Panels of gamma delta T cell clones bearing the V gamma 9/V delta 2 form of TCR were derived from human first trimester decidualized endometrium and cervix. Seventy-three percent of these clones expressed the human mucosal lymphocyte Ag HML-1 compared with only 14% of PBL V gamma 9/V delta 2 clones, indicating that most clones were derived from the tissue itself rather than contaminating peripheral blood. All 13 clones isolated expressed V gamma 9JPC gamma 1- and V delta 2(D)J delta 1-encoded receptors; TCR gamma and delta junctional regions from most of these were sequenced and analyzed, together with the TCR-delta junctional region of a sequence obtained from bulk CD3+ decidual leukocytes. There was considerable junctional diversity of both gamma- and delta-chains with a similar extent of germline V and J gene trimming and N-region nucleotide addition to that found in PBL V gamma 9/V delta 2 cells. Eight of eleven TCR-delta junctional sequences contained a strongly hydrophobic amino acid in position 97, as has been found in > 90% o V gamma 9/V delta 2 clones. Thymic V gamma 9/V delta 2 cells show much less junctional diversity and less pronounced selection at residue 97 of the delta-chain. Thus, unlike the mouse, gamma delta T cells from human female reproductive tissues exhibit extensive TCR junctional as well as combinatorial diversity. This suggests that V gamma 9/V delta 2 cells in these human tissues have undergone selective but diverse peripheral expansion in response to antigenic stimuli in a similar manner to those in peripheral blood.

Extensive TCR junctional diversity of V gamma 9/V delta 2 clones from human female reproductive tissues

Panels of gamma delta T cell clones bearing the V gamma 9/V delta 2 form of TCR were derived from human first trimester decidualized endometrium and cervix. Seventy-three percent of these clones expressed the human mucosal lymphocyte Ag HML-1 compared with only 14% of PBL V gamma 9/V delta 2 clones, indicating that most clones were derived from the tissue itself rather than contaminating peripheral blood. All 13 clones isolated expressed V gamma 9JPC gamma 1- and V delta 2(D)J delta 1-encoded receptors; TCR gamma and delta junctional regions from most of these were sequenced and analyzed, together with the TCR-delta junctional region of a sequence obtained from bulk CD3+ decidual leukocytes. There was considerable junctional diversity of both gamma- and delta-chains with a similar extent of germline V and J gene trimming and N-region nucleotide addition to that found in PBL V gamma 9/V delta 2 cells. Eight of eleven TCR-delta junctional sequences contained a strongly hydrophobic amino acid in position 97, as has been found in &gt; 90% o V gamma 9/V delta 2 clones. Thymic V gamma 9/V delta 2 cells show much less junctional diversity and less pronounced selection at residue 97 of the delta-chain. Thus, unlike the mouse, gamma delta T cells from human female reproductive tissues exhibit extensive TCR junctional as well as combinatorial diversity. This suggests that V gamma 9/V delta 2 cells in these human tissues have undergone selective but diverse peripheral expansion in response to antigenic stimuli in a similar manner to those in peripheral blood.

Expression of the human mucosal lymphocyte antigen, HML-1, by T cells activated with mitogen or specific antigen in vitro

Expression of the human mucosal lymphocyte antigen, HML-1 (CD103), recently identified as a novel alpha E beta 7 integrin, was studied on peripheral blood lymphocytes activated with mitogen or specific antigen. HML-1 was up-regulated on PHA activated T-lymphoblasts cultured in 100IU/ml interleukin-2 (IL-2), reaching a peak of > 50% positive cells at day 7, and expression was maintained at this level throughout the 28-day culture period. Following a transient decrease in the percentage of L-selectin cells, expression of this molecule was maintained on most PHA T-lymphoblasts. Cells activated by purified protein derivative of M. tuberculosis (PPD) or in mixed lymphocyte culture also up-regulated and maintained HML-1 expression for 14 days. In contrast, in all cases the percentage of CD25+ cells rose initially but subsequently declined over the same time periods. When freshly isolated cells from tonsil, spleen, mesenteric lymph node and lung were analysed, only lung contained significant numbers (39 +/- 6%) of HML-1+ cells. In both freshly isolated and activated cell populations the great majority of HML-1+ cells co-expressed CD8 although some HML-1+ CD8- cells were also present. Production of TGF-beta 1 peaked early during T-lymphoblast and MLR cultures and was not related to induction of HML-1 expression. Immunoprecipitation studies showed that the HML-1 molecule expressed on 10-day PHA T-lymphoblasts was indistinguishable from that found on intestinal intraepithelial lymphocytes and that no alpha 4 beta 7 integrin was expressed by these cells. Although HML-1 expression is essentially restricted to mucosal leucocytes in vivo, these experiments show that it is readily induced and maintained along with co-expression of L-selectin following CD8+ T-lymphocyte activation in vitro.

Phenotypic and functional cellular differences between human CD3- decidual and peripheral blood leukocytes

CD3- leukocyte clones derived from human decidualized endometrial tissue of first trimester pregnancy have been compared with CD3- PBL clones. Most CD3- decidual granulated leukocyte (DGL) clones were CD16- CD56+, whereas most CD3- PBL clones were CD16+ CD56+. CD3- DGL and PBL clones, whether CD16+ or not, showed MHC-nonrestricted NK cell activity. However, CD3- CD16- DGL clones had low cytotoxic activity against the NK-resistant cell line BSM, whereas CD3- CD16+ DGL and CD3- PBL clones were strongly cytotoxic. Cytolytic activity has also been investigated in respect of target cell HLA-G expression, because this nonpolymorphic class I MHC molecule is expressed selectively by invasive fetal cytotrophoblast. Class I HLA Ag loss cell mutants were killed efficiently by CD3- DGL clones. Expression of transfected HLA-B8 increased their sensitivity to lysis by most CD3- DGL clones, whereas expression of transfected HLA-G commonly led to decreased target cell killing. In addition, the effects of uncloned CD3- DGL on the one-way MLR have been examined. These cells were very poor responders and, unless cultured to induce expression of class II MHC molecules, were also very poor stimulators. When fresh CD3- DGLs were added as third-party cells, either autologous or allogeneic to responder cells, [3H]TdR incorporation was decreased in the MLR. Thus, CD3- DGL clones express MHC-nonrestricted cytolytic activity, notably against HLA-negative cells, but expression of HLA-G offers protection to target cells. In addition, CD3- DGL may function to suppress allogeneic responses.

Phenotypic and functional cellular differences between human CD3- decidual and peripheral blood leukocytes

CD3- leukocyte clones derived from human decidualized endometrial tissue of first trimester pregnancy have been compared with CD3- PBL clones. Most CD3- decidual granulated leukocyte (DGL) clones were CD16- CD56+, whereas most CD3- PBL clones were CD16+ CD56+. CD3- DGL and PBL clones, whether CD16+ or not, showed MHC-nonrestricted NK cell activity. However, CD3- CD16- DGL clones had low cytotoxic activity against the NK-resistant cell line BSM, whereas CD3- CD16+ DGL and CD3- PBL clones were strongly cytotoxic. Cytolytic activity has also been investigated in respect of target cell HLA-G expression, because this nonpolymorphic class I MHC molecule is expressed selectively by invasive fetal cytotrophoblast. Class I HLA Ag loss cell mutants were killed efficiently by CD3- DGL clones. Expression of transfected HLA-B8 increased their sensitivity to lysis by most CD3- DGL clones, whereas expression of transfected HLA-G commonly led to decreased target cell killing. In addition, the effects of uncloned CD3- DGL on the one-way MLR have been examined. These cells were very poor responders and, unless cultured to induce expression of class II MHC molecules, were also very poor stimulators. When fresh CD3- DGLs were added as third-party cells, either autologous or allogeneic to responder cells, [3H]TdR incorporation was decreased in the MLR. Thus, CD3- DGL clones express MHC-nonrestricted cytolytic activity, notably against HLA-negative cells, but expression of HLA-G offers protection to target cells. In addition, CD3- DGL may function to suppress allogeneic responses.

T-cell receptor heterogeneity of gamma delta T-cell clones from human female reproductive tissues

gamma delta T cells were isolated from human decidua parietalis, decidua basalis and cervix and cloned in the presence of interleukin-2 (IL-2). T-cell receptor (TcR) expression was then analysed and compared with that of a panel of gamma delta T-cell clones from peripheral blood. Only 17/40 (42.5%) clones from decidua parietalis were V gamma 9+/V delta 2+ as compared to 68/94 (72%) of peripheral blood clones (P < 0.005). Conversely, 50% of clones from decidua parietalis but only 15% of clones from peripheral blood were V delta 1+ (P < 0.001). At least seven distinct TcR types were identified among the panel of clones from decidua parietalis and at least six different types were expressed by the panel of 17 clones from cervix. This receptor heterogeneity was not a result of interdonor variation as in all instances where more than one clone was obtained from a single sample, individual clones having between two and five receptor types were identified. However, 23/24 (95.8%) of clones from decidua basalis were V gamma 9+/V delta 2+. Most clones from decidua parietalis and cervix, whether V gamma 9+/V delta 2+ or V delta 1+, were positive for the mucosal lymphocyte marker, HML-1, but expression was often heterogeneous within a single clone. In contrast, almost all gamma delta T-cell clones from peripheral blood were HML-1-. Thus, unlike the mouse, gamma delta T cells within these human female reproductive tissues have a diverse TcR repertoire which, in decidua parietalis, is distinct from that of peripheral blood.

Human T cells expressing V beta 8 do not predominantly recognize DR2 alloantigen

A panel of seven monoclonal antibodies recognizing human T-cell antigen receptor (TcR) V alpha or V beta subsets has been used to measure TcR gene expression in peripheral blood lymphocytes and mixed lymphocyte culture responses (MLR) between DR2- and DR2+ (DRw15+) donors. There were no significant differences between DR2- and DR2+ donors in per cent T cells in fresh peripheral blood labelled with any of these antibodies, which included an antibody recognizing V beta 8. This indicates strongly that increased negative selection of V beta 8+ T cells does not occur in DR2+ compared with DR2- individuals. In MLR between DR2- and DR2+ donors the only significant change compared with fresh peripheral lymphocytes was that T cells expressing V beta 5.1 were decreased in DR2- lymphocyte populations responding to DR2 alloantigen. No changes in levels of V beta 8+ T cells were detected in MLR between DR2- and DR2+ donors. This suggests that V beta 8+ T cells are not predominantly reactive against DR2 (DRw15). The data support the concept that alloreactivity against a single class II major histocompatibility complex (MHC) mismatch is mediated by T cells expressing a range of different TcR V beta molecules.

T-cell receptor Vbeta gene usage by lymphocytes infiltrating human renal allografts

T cell lines have been derived from human kidney allograft biopsies using mitogenic stimulation. Southern blotting using a T-cell receptor (TCR) Cbeta probe revealed an oligoclonal pattern of rearranged bands in all 12 samples analysed. In some cases, differences in band patterns were noted between independent cultures from the same biopsy. Most T-cell clones derived from 2 biopsies showed different patterns of rearranged bands. The polymerase chain reaction (PCR) was used to study TCR Vbeta gene usage in allograft-derived T-cell cultures. This was more sensitive and more informative than Southern blotting and revealed that most TCR Vbeta genes were expressed in T cells from biopsies showing cellular rejection. The potential usefulness of this technique to quantify TCR V gene usage in allospecific T-cell populations is discussed.