Effect of an intervention on observed sun protection by vacationers in a randomized controlled trial at North American resorts.

During vacations, many individuals receive high-risk sun exposure that is associated with skin cancer. Vacationers in outdoor recreation venues (pretest n=4347; posttest n=3986) at warm-weather destination resorts in North America (n=41) were enrolled in a pair-matched, group-randomized pretest-posttest controlled quasi-experimental design in 2012-14. Print, audiovisual, and online messages based on Transportation Theory and Diffusion of Innovation Theory and promoting advanced sun protection (e.g., use of clothing, hats, shade and pre-application/reapplication of sunscreen and reliable cues to high UV) were delivered through resort channels. Vacationers' sun protection practices observed by trained research staff (i.e., body coverage and shade use analyzed individually and in combined scores) did not differ by experimental condition (p>0.05) or intervention implementation (p>0.05). However, recreation venue moderated intervention impact. The intervention improved sun protection at waterside recreation venues (z-score composite: intervention pre=-22.74, post=-15.77; control pre=-27.24, post=-23.24) but not non-waterside venues (z-score composite: intervention pre=20.43, post=20.53; control pre=22.94, post=18.03, p<0.01). An additional analysis showed that resorts with greater program implementation showed more improvements in sun protection by vacationers at waterside (z=score composite: high implementation pre=-25.45, post=-14.05; low implementation pre=-24.70, post=-21.40) compared to non-waterside (z-score composite: high implementation pre=14.51, post=19.98; low implementation pre=24.03, post=18.98, p<0.01) recreation venues. The intervention appeared effective with the vacationers in recreation venues with the highest-risk for sun exposure, waterside venues. However, it was not effective throughout all the resort venues, possibly because of the sun-seeking desires of vacationers, information overload at the resorts, and constraints on clothing styles and sun protection by recreation activity.

A Randomized Trial of an Advanced Sun Safety Intervention for Vacationers at 41 North American Resorts.

Taking vacations in sunny locations is associated with the development of skin cancer. This study tested a multi-component sun protection intervention based on diffusion of innovations theory and transportation theory designed to increase vacationers' comprehensive sun protection, i.e., use of clothing, hats, and shade, and use, pre-application, and reapplication of sunscreen. The trial enrolled 41 warm weather resorts in North America in a pair-matched group randomized pretest-posttest design and assessed samples of adult vacationers at resort outdoor recreation venues regarding sun protection at pretest (n = 3,531) and posttest (n = 3,226). While results showed no overall effect of the intervention on comprehensive sun protection across venues, the intervention produced statistically significant improvements in sun protection at waterside venues (pools and beaches). The intervention's overall effects may have been impeded by a lack of uniformly robust implementation, low interest in skin cancer prevention by guests, or shortcomings of the theories used to create prevention messages. The intervention may have worked best with guests in the highest-risk recreation venue, i.e., waterside recreation where they exposed the most skin. Alternative approaches that alter resort organizations, such as through changes in policy, environmental features, or occupational efforts might be more effective than targeting vacationers with behavior-change messages.

Acridine Orange Conjugated Polymersomes for Simultaneous Nuclear Delivery of Gemcitabine and Doxorubicin to Pancreatic Cancer Cells.

Considering the systemic toxicity of chemotherapeutic agents, there is an urgent need to develop new targeted drug delivery systems. Herein, we have developed a new nuclear targeted, redox sensitive, drug delivery vehicle to simultaneously deliver the anticancer drugs gemcitabine and doxorubicin to the nuclei of pancreatic cancer cells. We prepared polymeric bilayer vesicles (polymersomes), and actively encapsulated the drug combination by the pH gradient method. A redox-sensitive polymer (PEG-S-S-PLA) was incorporated to sensitize the formulation to reducing agent concentration. Acridine orange (AO) was conjugated to the surface of the polymersomes imparting nuclear localizing property. The polymersomes' toxicity and efficacy were compared with those of a free drug combination using monolayer and three-dimensional spheroid cultures of pancreatic cancer cells. We observed that the redox sensitive, nuclear-targeted polymersomes released more than 60% of their encapsulated contents in response to 50 mM glutathione. The nanoparticles are nontoxic; however, the drug encapsulated vesicles have significant toxicity. The prepared formulation can increase the drug's therapeutic index by delivering the drugs directly to the cells' nuclei, one of the key organelles in the cells. This study is likely to initiate research in targeted nuclear delivery using other drug formulations in other types of cancers.

Environmental variables associated with vacationers' sun protection at warm weather resorts in North America.

BACKGROUND: Vacationing at sunny, warm weather locations is a risk factor for excessive solar ultraviolet (UV) radiation exposure and skin cancer. OBJECTIVES: This study examined the association of environmental variables related to UV levels with vacationers' sun protection. METHODS: Vacationers at 41 summer resorts in 17 states and 1 Canadian Province were interviewed (n=3531) and observed (N=4347) during 2012 and 2013. Clothing coverage, sunglasses, and shade use were observed. Use of sunscreen and sunburns were self-reported. Environmental information was recorded by research staff or acquired from ground stations and the weather service. RESULTS: Temperature was positively associated with sun protection behaviors; however clothing coverage was negatively associated with temperature. Cloud cover was negatively associated with sun protection, with the exception of clothing coverage which was positively associated with it. Elevation showed a mixed pattern of associations with vacationer's sun protection. Latitude of a resort was negatively associated with most sun protection behaviors, such that sun protection increased at more southerly resorts. Similarly, the farther south a vacationer traveled to the resort, the less sun protection they employed. The UV index showed a weak, positive relationship with some sun protection behaviors even when controlling for temperature. CONCLUSIONS: Vacationers appeared aware that UV is higher at southern latitudes and may learn UV is intense when living in southern regions. However, many used temperature, an unreliable cue, to judge UV intensity and seemed to adjust clothing for warmth not UV protection. Efforts are needed to help individuals make more accurate sun safety decisions.

Dissemination of go sun smart in outdoor recreation: effect of program exposure on sun protection of guests at high-altitude ski areas.

Go Sun Smart is a theory-based health communication program designed to influence sun-protection behaviors of employees and guests at high-altitude ski areas to reduce skin cancer risk. The effects of Go Sun Smart, in a Phase IV dissemination randomized posttest-only trial, on sun-protection behaviors of ski area guests are reported. Program use was assessed by on-site observation and guest message exposure, and sun protection was measured in intercept surveys at ski areas. Dissemination strategy-enhanced versus basic-was not significantly related to sun safety practices. Additional analyses examined the relation between message exposure and guests' sun safety practices. Ski areas displaying at least 6 Go Sun Smart materials in guest-only areas and 9 Go Sun Smart materials throughout the area increased guests' message exposure. Higher message exposure within the high-use ski areas was associated with improved sun protection by guests but not within the low-use ski areas. The authors underscore the importance of program implementation and message exposure on the success of evidence-based health communication efforts applied industrywide.

Adoption of sun safe workplace practices by local governments.

CONTEXT: Outdoor workers are especially susceptible to skin cancer--the most common, but also one of the most preventable, forms of cancer. Colorado, the location of the study, has the second highest rate of skin cancer deaths in the nation. OBJECTIVE: Local government managers in Colorado-in municipalities, counties, and special districts-were surveyed to ascertain the extent to which they engage in formal (written) and informal practices to protect their outdoor workers against excessive exposure to sun. DESIGN: The survey consisted of 51 questions assessing awareness of formal or informal practices for sun protection of outdoor workers. An index of practices--the study's dependent variable--was created that was composed or practices such as providing employees free or reduced-cost sunscreen, wide-brimmed hats, sunglasses, long-sleeved work shirts, long work pants, and temporary or permanent outdoor shade shelters. Proscriptive policies, such as restricting the use of broad brimmed hats, were subtracted from the index. Surveys were completed by 825 administrators representing 98 jurisdictions. Responses from administrators in the same jurisdiction were averaged. RESULTS: More than 40% of responding jurisdictions indicated that they engaged in informal sun safety practices. Tests conducted to determine what variables might account for the adoption of these sun protection practices found that the degree to which a community could be regarded as cosmopolite and as having an individualistic political culture were significant predictors. Type of government was also significant. Although, higher community income was a significant predictor, neither local government budget nor size was significant. CONCLUSIONS: The adoption of sun safe practices bears low costs with potentially high returns. Findings from this study suggest that awareness campaigns might most effectively target cosmopolite communities, but that the greatest impact might be achieved by targeting localite communities. Government size and budget do not appear to be constraints in the adoption of sun safe practices.

Differentiation of prostate cancer cells using flexible fluorescent polymers.

Using water-soluble, fluorescent, flexible polymers, we have devised a novel methodology for identification and differentiation of prostate cancer cells. Using a stepwise linear discriminant analysis, we demonstrate that the differential modulations of the polymer emission intensities in the presence of conditioned cell culture media can be used to distinguish between prostate cancer subtypes and between cancerous and noncancer cells. The differences in the compositions of the conditioned cell culture media are likely contributing to different fluorescence spectral patterns of the polymers. This in vitro approach may provide a novel platform for the development of an alternative prostate cancer diagnostic and subtyping technique.

Ultrasound enhanced matrix metalloproteinase-9 triggered release of contents from echogenic liposomes.

The extracellular enzyme matrix metalloproteinase-9 (MMP-9) is overexpressed in atherosclerotic plaques and in metastatic cancers. The enzyme is responsible for rupture of the plaques and for the invasion and metastasis of a large number of cancers. The ability of ultrasonic excitation to induce thermal and mechanical effects has been used to release drugs from different carriers. However, the majority of these studies were performed with low frequency ultrasound (LFUS) at kilohertz frequencies. Clinical usage of LFUS excitations will be limited due to harmful biological effects. Herein, we report our results on the release of encapsulated contents from substrate lipopeptide incorporated echogenic liposomes triggered by recombinant human MMP-9. The contents release was further enhanced by the application of diagnostic frequency (3 MHz) ultrasound. The echogenic liposomes were successfully imaged employing a medical ultrasound transducer (4-15 MHz). The conditioned cell culture media from cancer cells (secreting MMP-9) released the encapsulated dye from the liposomes (30-50%), and this release is also increased (50-80%) by applying diagnostic frequency ultrasound (3 MHz) for 3 min. With further developments, these liposomes have the potential to serve as multimodal carriers for triggered release and simultaneous ultrasound imaging.

Fluorescent polymer-based post-translational differentiation and subtyping of breast cancer cells.

Herein, we report the application of synthesized fluorescent, water soluble polymers for post-translational subtyping and differentiation of breast cancer cells in vitro. The fluorescence emission spectra from these polymers were modulated differently in the presence of conditioned cell culture media from various breast cancer cells. These polymers differentiate at a post-translation level possibly due to their ability to interact with extracellular enzymes that are over-expressed in cancerous conditions.

Compliance with sunscreen advice in a survey of adults engaged in outdoor winter recreation at high-elevation ski areas.

BACKGROUND: Adults are advised to wear sunscreen with a sun protection factor (SPF) of 15 or higher, apply it up to 30 minutes before sun exposure, and reapply it after 2 hours to reduce exposure to ultraviolet radiation in sunlight for the prevention of skin cancer. OBJECTIVE: This study investigated the extent to which adults comply with sunscreen advice. METHODS: A survey was conducted with 4837 adult skiers and snowboarders at 28 high-altitude ski areas in western North America in January through April 2001 through 2002. Respondents self-reported use of sunscreen, its SPF, time of first application, and reapplication. RESULTS: Only 4.4% (95% confidence interval [CI] = ±0.6) of adults were in full compliance with all sunscreen advice. Half (49.8% [95% CI = ±1.4]) complied with SPF 15 or higher advice. Of those wearing sunscreen, 73.2% (95% CI = ±1.8) applied the sunscreen 30 minutes before beginning skiing/snowboarding, but only 20.4% (95% CI = ±2.0) complied with advice to reapply it after 2 hours. Total compliance was lowest during inclement weather, on low-ultraviolet days, by men, and among respondents who believed skin cancer was unimportant and with low sun-sensitive skin. It was positively associated with wearing lip balm and hats with a brim. LIMITATIONS: The sample was predominantly male and of high socioeconomic status; the results apply most to winter recreation when ultraviolet radiation levels are low, and sunscreen use was assessed by self-report. CONCLUSION: Although the recommendation to use SPF 15 or higher sunscreen has reached many adults, the reapplication advice is heeded by few adults and needs to be highlighted in future sun safety promotions.

Fluorescent water soluble polymers for isozyme-selective interactions with matrix metalloproteinase-9.

Matrix metalloproteinases (MMPs) are overexpressed in various pathological conditions, including cancers. Although these isozymes have similar active sites, the patterns of exposed amino acids on their surfaces are different. Herein, we report the synthesis and molecular interactions of two water soluble, fluorescent polymers which demonstrate selective interactions with MMP-9 compared to MMP-7 and -10.

Qualitative study of principles pertaining to lifestyle and pressure ulcer risk in adults with spinal cord injury.

PURPOSE: The aim of this article is to identify overarching principles that explain how daily lifestyle considerations affect pressure ulcer development as perceived by adults with spinal cord injury (SCI). METHOD: Qualitative in-depth interviews over an 18-month period with 20 adults with spinal injury and a history of pressure ulcers were conducted using narrative and thematic analyses. RESULTS: Eight complexly interrelated daily lifestyle principles that explain pressure ulcer development were identified: perpetual danger; change/disruption of routine; decay of prevention behaviors; lifestyle risk ratio; individualization; simultaneous presence of prevention awareness and motivation; lifestyle trade-off; and access to needed care, services and supports. CONCLUSIONS: Principles pertaining to the relationship between in-context lifestyle and pressure ulcer risk underscore previous quantitative findings, but also lead to new understandings of how risk unfolds in everyday life situations. Pressure ulcer prevention for community-dwelling adults with SCI can potentially be enhanced by incorporating principles, such as the decay of prevention behaviors or lifestyle trade-off, that highlight special patterns indicative of elevated risk. The identified principles can be used to theoretically drive future research or to guide innovative lifestyle-focused intervention approaches. Public policies that promote short-term preventive interventions at critical junctures throughout a person's life should be considered.

Teaching Health Advocacy: A Systematic Review of Educational Interventions for Postgraduate Medical Trainees.

PURPOSE: A systematic review was undertaken to characterize the training approaches that are currently being implemented in postgraduate medical education to teach residents advocacy skills. METHOD: An initial search was conducted in MEDLINE, PubMed, Embase, ERIC, and PsycINFO in November 2016 (updated in December 2017) for articles discussing postgraduate medical education interventions covering advocacy. Articles published between 1995 and 2017 were included. Two authors independently reviewed titles and abstracts (and, if needed, the full text) for inclusion; disagreements were resolved by consensus. Data were extracted from studies to characterize the content and pedagogy of the interventions by mapping them to the CanMEDS health advocate core competencies and key concepts. RESULTS: A total of 3,027 unique abstracts were retrieved; 2,864 were excluded upon title and abstract review, and another 85 were excluded upon full-text review. Seventy-eight total articles were included. More studies involved residents from pediatrics, psychiatry, primary care or preventative medicine, or internal medicine than from emergency medicine, surgery, obstetrics and gynecology, or neurology. Published interventions varied widely by pedagogical approach and assessment method. CONCLUSIONS: Using the CanMEDS framework, this review maps the breadth and nature of postgraduate medical education interventions in health advocacy, with applicability to community organizations, program directors, educators, and administrators working to develop advocacy training interventions. Areas of focus included adapting practice to respond to the needs of or advocacy in partnership with patients, communities, or populations served; determinants of health; health promotion; mobilizing resources as needed; and social accountability.

Implementation of Occupational Sun Safety at a 2-Year Follow-Up in a Randomized Trial: Comparison of Sun Safe Workplaces Policy Intervention to Attention Control.

PURPOSE: Implementation of employer sun safety actions was assessed in a 2-year follow-up to an occupational sun protection policy intervention. DESIGN: Two-year follow-up assessment in a randomized pretest-posttest controlled design. SETTING: Local government organizations with workers in public safety, public works, and parks and recreation. PARTICIPANTS: Sixty-three local government organizations (participation = 64%) and 330 frontline supervisors and 1454 workers. INTERVENTION: Sun Safe Workplaces (SSW) intervention promoting occupational sun safety policy and education. MEASURES: Observations of SSW messages and sun safety items and surveys on organizations' communication and actions on sun safety. ANALYSIS: Comparison between SSW and control groups was conducted using regression models and adjusted for clustering where appropriate, with α criterion set at P = .05 (2-tailed). RESULTS: At intervention worksites, more SSW messages ( P < .001) and sun safety items ( P = .025) were observed; more frontline supervisors reported organizations provided free/reduced price sunscreen ( P = .005) and communicated about sun safety ( P < .001); and more workers recalled receiving sun safety messages ( P < .001) and sun safety training ( P <.001) compared to control organizations. Implementation was greater at larger than smaller intervention organizations for wide-brimmed hats ( P = .009), long work pants ( P = .017), and shade structures ( P = .036). Older workers received the most written messages ( P = .015). CONCLUSIONS: Sun Safe Workplaces appeared to produce actions by organizations to support employee sun safety. Large organizations may have processes, communication channels, and slack resources to achieve more implementation.

Increasing sun protection in winter outdoor recreation a theory-based health communication program.

BACKGROUND: Unprotected and excessive exposure to ultraviolet radiation (UVR) is the primary risk factor for skin cancer. DESIGN: A pair-matched, group-randomized, pre-test/post-test, quasi-experimental design, with ski resorts as the unit of randomization, tested the effectiveness of Go Sun Smart, a multi-channel skin cancer prevention program. Independent samples of guests were taken at baseline (2001) and follow-up (2002); data were analyzed in 2006. SETTING AND PARTICIPANTS: A total of 6516 adult guests at 26 ski areas in the western U.S. and Canada were recruited, consented, and interviewed on chairlifts. This study was nested within an occupational intervention for ski area workers. INTERVENTION: Ski areas were pair-matched and randomized to receive Go Sun Smart, which consisted of print, electronic, visual, and interpersonal skin cancer prevention messages. MAIN OUTCOME MEASURES: Sun-protection behaviors, sunburning, recall of sun-protection messages, and the association of message exposure to sun protection. RESULTS: The difference in recall of all sun-protection messages, messages on signs and posters, and the Go Sun Smart logo was significant between the intervention and control resorts. Reported use of sun-protection practices was higher by guests at intervention ski areas using more (a higher dose of) Go Sun Smart materials. Intervention-group guests who recalled a sun-safety message were more likely to practice sun safety than intervention-group guests who did not recall a message and control-group guests. CONCLUSIONS: While the mere implementation of Go Sun Smart did not produce sun-safety improvements, Go Sun Smart appeared to be effective for guests who encountered and remembered it. Many factors can work against message exposure. Signage seemed to produce the greatest increase in exposure to sun-safety messages.

Synthesis of barbiturate-based methionine aminopeptidase-1 inhibitors.

The syntheses of a new class of barbiturate-based inhibitors for human and Escherichia Coli methionine aminopeptidase-1 (MetAP-1) are described. Some of the synthesized inhibitors show selective inhibition of the human enzyme with high potency.

Go Sun Smart.

This is the story of Go Sun Smart, a worksite wellness program endorsed by the North American Ski Area Association and funded by the National Cancer Institute. Between 2000 and 2002 we designed and implemented a large-scale worksite intervention at over 300 ski resorts in North America with the objective of reducing ski area employees and guests risk for skin cancer by adopting sun safe practices. The following narrative describes the intervention in toto from its design and implementation through assessment. Our theory driven, experimentally tested intervention was successful in reducing employees' risks for skin cancer during and after the ski season. We also succeeded in making ski area guests more aware of the need to take sun safe precautions with both themselves and their children.

Results of a Randomized Trial on an Intervention Promoting Adoption of Occupational Sun Protection Policies.

PURPOSE: To evaluate an intervention promoting adoption of occupational sun protection policies by employers in a randomized trial. DESIGN: A randomized pretest-posttest controlled design with 2-year follow-up was conducted in 2010 to 2013. SETTING: Local government organizations in Colorado who had outdoor workers in public works, public safety, and/or parks and recreation. PARTICIPANTS: Ninety-eight local government organizations (n = 51 municipalities, 10 counties, and 37 special districts). INTERVENTION: Organizations were randomly assigned to receive a policy and education intervention comprised of personal contacts and theory-based training and materials or to an attention control group. MEASURES: Occupational policy documents were coded for sun safety content by a trained research assistant blind to condition. ANALYSIS: Policy scores were analyzed with logistic and Poisson regression models using imputation. RESULTS: At posttest, more organizations in the intervention group had a sun protection policy than in the control group (odds ratio [OR] = 4.91, P < .05; intent to treat: OR = 5.95, P < .05) and policies were more extensive (χ2 = 31.29, P < .01; intent to treat: χ2 =73.79, P < .01) and stronger (χ2 = 24.50, P < .01; intent to treat: χ2 = 51.95, P < .01). Policy adoption was higher when the number of contacts and trainings increased ( P < .05). CONCLUSION: The intervention had a large effect on adoption of formal sun protection policies, perhaps because of its fit with legal requirements to maintain safe workplaces. Personal contacts with managers were influential on adoption of occupational policy even in this age of communication technology and social media.

Prevalence of Sun Protection at Outdoor Recreation and Leisure Venues at Resorts in North America.

BACKGROUND: Exposure to solar ultra violet radiation (UVR) is a primary risk factor for skin cancer. Vacationers often fail to protect themselves from harmful UVR. PURPOSE: The study assessed the sun protection practices of resort guests in various outdoor leisure and recreation venues during warm-weather seasons. METHOD: 41 North American resorts were enrolled in a quasi-experimental randomized controlled trial. Adult guests were observed (n=4091) and surveyed (n=3694) in a cross sectional sample. Data collection was conducted in recreation and leisure venues with outdoors commons/reception areas acting as the comparison condition. RESULTS: The mean percent of vacationers at pools and beaches were more likely (p < 0.001) to wear sunscreen than in commons areas but less likely (p < 0.001) to wear cover-up clothing or use shade. In both samples, the combined sun protection scores were higher in commons areas compared to all venues except for outdoor dining (p < 0.001). DISCUSSION: Sun safety was suboptimal in all venues and was potentially mitigated by venue type. TRANSLATION TO HEALTH EDUCATION PRACTICE: Approaches are needed to encourage vacationers to practice comprehensive sun protection and to work with resorts to construct built environments that facilitate rather than act as barriers to sun safety.

Rationale, design, samples, and baseline sun protection in a randomized trial on a skin cancer prevention intervention in resort environments.

INTRODUCTION: Exposure to solar ultraviolet radiation during recreation is a risk factor for skin cancer. A trial evaluated an intervention to promote advanced sun protection (sunscreen pre-application/reapplication; protective hats and clothing; use of shade) during vacations. MATERIALS AND METHODS: Adult visitors to hotels/resorts with outdoor recreation (i.e., vacationers) participated in a group-randomized pretest-posttest controlled quasi-experimental design in 2012-14. Hotels/resorts were pair-matched and randomly assigned to the intervention or untreated control group. Sun. protection (e.g., clothing, hats, shade and sunscreen) was measured in cross-sectional samples by observation and a face-to-face intercept survey during two-day visits. RESULTS: Initially, 41 hotel/resorts (11%) participated but 4 dropped out before posttest. Hotel/resorts were diverse (employees=30 to 900; latitude=24° 78' N to 50° 52' N; elevation=2ft. to 9726ft. above sea level), and had a variety of outdoor venues (beaches/pools, court/lawn games, golf courses, common areas, and chairlifts). At pretest, 4347 vacationers were observed and 3531 surveyed. More females were surveyed (61%) than observed (50%). Vacationers were mostly 35-60years old, highly educated (college education=68%) and non-Hispanic white (93%), with high-risk skin types (22%). Vacationers reported covering 60% of their skin with clothing. Also, 40% of vacationers used shade; 60% applied sunscreen; and 42% had been sunburned. CONCLUSIONS: The trial faced challenges recruiting resorts but result showed that the large, multi-state sample of vacationers were at high risk for solar UV exposure.