Tigilanol tiglate is an oncolytic small molecule that induces immunogenic cell death and enhances the response of both target and non-injected tumors to immune checkpoint blockade.

BACKGROUND: Tigilanol tiglate (TT) is a protein kinase C (PKC)/C1 domain activator currently being developed as an intralesional agent for the treatment of various (sub)cutaneous malignancies. Previous work has shown that intratumoral (I.T.) injection of TT causes vascular disruption with concomitant tumor ablation in several preclinical models of cancer, in addition to various (sub)cutaneous tumors presenting in the veterinary clinic. TT has completed Phase I dose escalation trials, with some patients showing signs of abscopal effects. However, the exact molecular details underpinning its mechanism of action (MoA), together with its immunotherapeutic potential in oncology remain unclear. METHODS: A combination of microscopy, luciferase assays, immunofluorescence, immunoblotting, subcellular fractionation, intracellular ATP assays, phagocytosis assays and mixed lymphocyte reactions were used to probe the MoA of TT in vitro. In vivo studies with TT used MM649 xenograft, CT-26 and immune checkpoint inhibitor refractory B16-F10-OVA tumor bearing mice, the latter with or without anti-programmed cell death 1 (PD-1)/anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) mAb treatment. The effect of TT at injected and non-injected tumors was also assessed. RESULTS: Here, we show that TT induces the death of endothelial and cancer cells at therapeutically relevant concentrations via a caspase/gasdermin E-dependent pyroptopic pathway. At therapeutic doses, our data demonstrate that TT acts as a lipotoxin, binding to and promoting mitochondrial/endoplasmic reticulum (ER) dysfunction (leading to unfolded protein responsemt/ER upregulation) with subsequent ATP depletion, organelle swelling, caspase activation, gasdermin E cleavage and induction of terminal necrosis. Consistent with binding to ER membranes, we found that TT treatment promoted activation of the integrated stress response together with the release/externalization of damage-associated molecular patterns (HMGB1, ATP, calreticulin) from cancer cells in vitro and in vivo, characteristics indicative of immunogenic cell death (ICD). Confirmation of ICD in vivo was obtained through vaccination and rechallenge experiments using CT-26 colon carcinoma tumor bearing mice. Furthermore, TT also reduced tumor volume, induced immune cell infiltration, as well as improved survival in B16-F10-OVA tumor bearing mice when combined with immune checkpoint blockade. CONCLUSIONS: These data demonstrate that TT is an oncolytic small molecule with multiple targets and confirms that cell death induced by this compound has the potential to augment antitumor responses to immunotherapy.

Comparative Genomics Provides Etiologic and Biological Insight into Melanoma Subtypes.

Melanoma is a cancer of melanocytes, with multiple subtypes based on body site location. Cutaneous melanoma is associated with skin exposed to ultraviolet radiation; uveal melanoma occurs in the eyes; mucosal melanoma occurs in internal mucous membranes; and acral melanoma occurs on the palms, soles, and nail beds. Here, we present the largest whole-genome sequencing study of melanoma to date, with 570 tumors profiled, as well as methylation and RNA sequencing for subsets of tumors. Uveal melanoma is genomically distinct from other melanoma subtypes, harboring the lowest tumor mutation burden and with significantly mutated genes in the G-protein signaling pathway. Most cutaneous, acral, and mucosal melanomas share alterations in components of the MAPK, PI3K, p53, p16, and telomere pathways. However, the mechanism by which these pathways are activated or inactivated varies between melanoma subtypes. Additionally, we identify potential novel germline predisposition genes for some of the less common melanoma subtypes. SIGNIFICANCE: This is the largest whole-genome analysis of melanoma to date, comprehensively comparing the genomics of the four major melanoma subtypes. This study highlights both similarities and differences between the subtypes, providing insights into the etiology and biology of melanoma. This article is highlighted in the In This Issue feature, p. 2711.

Choroidal melanoma with synchronous Fuchs' adenoma and novel ATRX mutation.

BACKGROUND: To report a case of Fuchs' adenoma occurring in an eye with a large choroidal melanoma. We have reviewed the literature to describe the clinical presentation, ultrasound characteristics and pathological features of these entities. CASE PRESENTATION: A 69-year-old Caucasian man presented with vision loss from a large choroidal melanoma. Enucleation showed an incidental Fuchs' adenoma in the same eye. Whole-exome sequence analysis was also performed on the patient's blood and melanoma, which showed a rarely-reported ATRX mutation. CONCLUSIONS: Fuchs' adenoma is an under-diagnosed benign age-related hyperplasia of the non-pigmented ciliary epithelium (NPCE). Given its location and characteristics, it can be mistaken for choroidal melanoma and clinicians are reminded how to differentiate between these pathologies and that they may co-exist.

Characterization of Efficacy and Animal Safety across Four Caprine Disbudding Methodologies.

There is a strong industry demand for technically simple and highly efficacious alternatives to heat cautery disbudding in goat kids that can be performed as a stand-alone procedure without adjunct anesthesia, and that result in improved overall welfare through reduced acute pain, reduced tissues healing interval, and a consistent safety record. The objective of this study was to consider the net effect of disbudding techniques on goat welfare by examining vocalization frequency, long-term efficacy and animal safety associated with four alternative caprine disbudding methods against sham-disbudded and heat-cautery controls. Sixty-five commercial male dairy kids were disbudded at 3-10 days of age with one of six disbudding treatments (clove oil injection, caustic paste, two cryosurgical methods, heat-cautery, and sham procedure). Heat cautery was 91% effective, caustic paste was 55% effective, and the other treatments were ineffective. Heat cautery and sham procedures resulted in similar vocalization efforts; freezing with a liquid-nitrogen cooled iron resulted in significantly greater vocalization numbers. No unintended paste transfer injuries were observed with short-term application of the caustic paste. Heat cautery resulted in numerous superficial infections but no permanent injury. Clove oil injection was associated with several unexpected and severe complications including unintended tissue necrosis, temporary paresis, skull defects, meningitis, and death. Collectively, we did not find that any of the alternative methods of disbudding provided a feasible option over heat cautery to improve welfare.

Germline variants in oculocutaneous albinism genes and predisposition to familial cutaneous melanoma.

Approximately 1%-2% of cutaneous melanoma (CM) is classified as strongly familial. We sought to investigate unexplained CM predisposition in families negative for the known susceptibility genes using next-generation sequencing of affected individuals. Segregation of germline variants of interest within families was assessed by Sanger sequencing. Several heterozygous variants in oculocutaneous albinism (OCA) genes: TYR, OCA2, TYRP1 and SLC45A2, were present in our CM cohort. OCA is a group of autosomal recessive genetic disorders, resulting in pigmentation defects of the eyes, hair and skin. Missense variants classified as pathogenic for OCA were present in multiple families and some fully segregated with CM. The functionally compromised TYR p.T373K variant was present in three unrelated families. In OCA2, known pathogenic variants: p.V443I and p.N489D, were present in three families and one family, respectively. We identified a likely pathogenic SLC45A2 frameshift variant that fully segregated with CM in a family of four cases. Another four-case family harboured cosegregating variants (p.A24T and p.R153C) of uncertain functional significance in TYRP1. We conclude that rare, heterozygous variants in OCA genes confer moderate risk for CM.

Barriers and facilitators to self-care communication during medical appointments in the United States for adults with type 2 diabetes.

OBJECTIVE: Diabetes self-care is challenging and requires effective patient-provider communication to achieve optimal treatment outcomes. This study explored perceptions of barriers and facilitators to diabetes self-care communication during medical appointments. DESIGN: Qualitative study using in-depth interviews with a semistructured interview guide. PARTICIPANTS: Thirty-four patients with type 2 diabetes and 19 physicians who treat type 2 diabetes. RESULTS: Physicians described some patients as reluctant to discuss their self-care behaviors primarily because of fear of being judged, guilt, and shame. Similarly, patients described reluctant communication resulting from fear of being judged and shame, particularly shame surrounding food intake and weight. Physicians and patients recommended trust, nonjudgmental acceptance, open/honest communication, and providing patients hope for living with diabetes as important factors for improving self-care communication. Further, patients stressed the clinical benefits of physicians directly addressing poor self-care behaviors while physicians described having few strategies to address these difficulties. CONCLUSIONS: Physician-patient self-care communication barriers included patients' reluctance to discuss self-care behaviors and physicians' perceptions of few options to address this reluctance. Treatment recommendations stressed the importance of establishing trusting, nonjudgmental and open patient-provider communication for optimal diabetes treatment. Medical education is needed to improve physicians' strategies for addressing self-care communication during medical appointments.

Impact of reinforcement of diabetes self-care on poorly controlled diabetes: a randomized controlled trial.

PURPOSE: The purpose of the study was to assess the value of reinforcing diabetes self-management for improving glycemia and self-care among adults with type 2 diabetes who had at least 3 hours of prior diabetes education. METHODS: In this randomized controlled trial, 134 participants (75% white, 51% female, 59 ± 9 years old, 13 ± 8 years with diabetes, A1C = 8.4% ± 1.2%) were randomized to either a group map-based program (intervention) or group education on cholesterol and blood pressure (control). Participants were assessed for A1C levels, diabetes self-care behaviors (3-day pedometer readings, 6-minute walk test, blood glucose checks, frequency of self-care), and psychosocial factors (distress, frustration, quality of life) at baseline, 3, 6, and 12 months post intervention and health literacy at baseline. RESULTS: Groups did not differ on baseline characteristics including A1C levels, health literacy, or self-care; however, the intervention group had more years of education than controls. Intervention arm participants modestly improved A1C levels at 3 months post intervention but did not maintain that improvement at 6 and 12 months while control patients did not improve A1C levels at any time during follow-up. Importantly, frequency of self-reported self-care, diabetes quality of life, diabetes-related distress, and frustration with diabetes self-care improved in both groups over time. CONCLUSIONS: Reinforcing self-care with diabetes education for patients who have not met glycemic targets helps improve A1C and could be considered a necessary component of ongoing diabetes care. The best method to accomplish reinforcement needs to be established.

A qualitative study of perceived responsibility and self-blame in type 2 diabetes: reflections of physicians and patients.

BACKGROUND: Despite new treatment therapies and the emphasis on patient activation, nearly 50 % of diabetes patients have hemoglobin A(1c) levels above target. Understanding the impact of unmet treatment goals on the physician-patient relationship is important for maintaining quality care in clinical practice. OBJECTIVE: To explore physicians' and type 2 diabetes patients' views of patients' difficulty achieving diabetes treatment goals. DESIGN: Qualitative study using in-depth interviews with a semi-structured interview guide. PARTICIPANTS: Nineteen endocrinologists and primary care physicians and 34 patients diagnosed with type 2 diabetes at least two years prior. MAIN MEASURES: In-depth interviews with physicians and patients. A multidisciplinary research team performed content and thematic analyses. KEY RESULTS: Qualitative analysis revealed two main findings, organized by physician and patient perspectives. Physician Perspective: Physicians' Perceived Responsibility for Patients' Difficulty Achieving Treatment Goals: Physicians assumed responsibility for their patients not achieving goals and expressed concern that they may not be doing enough to help their patients achieve treatment goals. Physicians' Perceptions of Patients' Reactions: Most speculated that their patients may feel guilt, frustration, or disappointment when not reaching goals. Physicians also felt that many patients did not fully understand the consequences of diabetes. Patient Perspective: Patients' Self-Blame for Difficulty Achieving Treatment Goals: Patients attributed unmet treatment goals to their inability to carry out self-care recommendations. Most patients blamed themselves for their lack of progress and directed their frustration and disappointment inwardly through self-depreciating comments. Patients' Perceptions of Physicians' Reactions: Several patients did not know how their physician felt, while others speculated that their physicians might feel disappointed or frustrated. CONCLUSIONS: Physicians' perceived responsibility and patients' self-blame for difficulty achieving treatment goals may serve as barriers to an effective relationship. Physicians and patients may benefit from a greater understanding of each other's frustrations and challenges in diabetes management.

Look who's (not) talking: diabetic patients' willingness to discuss self-care with physicians.

OBJECTIVE: Nearly one-half of diabetic patients have glycated hemoglobin A(1c) (HbA(1c)) levels above recommended targets. Effective physician-patient communication improves glycemia and diabetes self-care; however, communication gaps may exist that prevent patients from discussing self-care problems with treatment providers. RESEARCH DESIGN AND METHODS: We assessed diabetic patients' (n = 316, 85% white, 51% female, 71% type 2 diabetes, 59 ± 11 years old, 16 ± 3 years education, 19 ± 13 years diabetes duration, and HbA(1c) = 7.9 ± 1.4%) HbA(1c), frequency of self-care, diabetes-related distress, depressive and anxiety symptoms, coping styles, diabetes quality of life, and self-care communication in the treatment relationship. Multivariate logistic regression models examined the main and interaction effects of health and psychosocial factors associated with patients' reluctance to discuss self-care. RESULTS: Patients reported positive relationships with their doctors and valued honest communication; however, 30% of patients were reluctant to discuss self-care. Reluctant patients reported less frequent self-care (P = 0.05), lower diabetes quality of life (P = 0.002), and more diabetes-related distress (P = 0.001), depressive symptoms (P < 0.001), and anxiety symptoms (P = 0.001). Patients who reported elevated depressive symptoms, although not necessarily major depression, were more likely to be reluctant to discuss self-care (odds ratio [OR] 1.66 for 10-point change in t score; P < 0.001), whereas patients who were older (OR 0.78 for 10-year change; P = 0.05) and those who used more self-controlled coping styles (OR 0.78 for 10-point change; P = 0.007) were less likely to be reluctant. CONCLUSIONS: Awareness of elevated depressive symptoms is important in clinical practice given that these patients may be more reluctant to discuss self-care. Interventions and evidence-based approaches are needed to improve both depressive symptoms and physician-patient communication about self-care.

Physicians' perceptions of the type 2 diabetes multi-disciplinary treatment team: a qualitative study.

PURPOSE: The purpose of this study was to explore physicians' perceptions of the multidisciplinary type 2 diabetes treatment team. METHODS: Nineteen physicians (74% endocrinologists; 26% primary care) participated in semistructured interviews. Audiorecorded data were transcribed, coded, and analyzed using thematic analysis and NVivo 8 software. RESULTS: Physicians considered the multidisciplinary team, including a physician and diabetes educator, as very important to diabetes treatment. Participants described how diabetes, with its many comorbidities and challenging lifestyle recommendations, is difficult for any single physician to treat. They further described how the team's diverse staff offers complementary skills and more contact time for assessment and treatment of patients, developing treatment relationships, and supporting patients in learning diabetes self-care. Physicians stressed the necessity of regular and ongoing communication among team members to ensure patients receive consistent information, and some reported that institutional factors interfere with intra-team communication. They also expressed concerns about the team approach in relation to individualized treatment and patients' reluctance to see multiple providers. CONCLUSIONS: This study highlights physicians' positive perceptions of and concerns about the type 2 diabetes multidisciplinary team. Further study of diabetes educators' and patients' perceptions of the team approach is needed.

Understanding physicians' challenges when treating type 2 diabetic patients' social and emotional difficulties: a qualitative study.

OBJECTIVE: To explore physicians' awareness of and responses to type 2 diabetic patients' social and emotional difficulties. RESEARCH DESIGN AND METHODS: We conducted semistructured interviews with 19 physicians. Interviews were transcribed, coded, and analyzed using thematic analysis. RESULTS: Three themes emerged: 1) physicians' awareness of patients' social and emotional difficulties: physicians recognized the frequency and seriousness of patients' social and emotional difficulties; 2) physicians' responses to patients' social and emotional difficulties: many reported that intervening with these difficulties was challenging with few treatment options beyond making referrals, individualizing care, and recommending more frequent follow-up visits; and 3) the impact of patients' social and emotional difficulties on physicians: few available patient treatment options, time constraints, and a perceived lack of psychological expertise contributed to physicians' feeling frustrated, inadequate, and overwhelmed. CONCLUSIONS: Recognition and understanding of physicians' challenges when treating diabetes patients' social and emotional difficulties are important for developing programmatic interventions.

Targeted disruption of Brca1 in restricted compartments of the mouse mammary epithelia.

Tumours arising in BRCA1 mutation carriers have a characteristic phenotype, the molecular and cellular basis of which is unknown. To address the hypothesis that this phenotype reflects a role for BRCA1 in either in the basal or the stem cell compartments of the mammary epithelia, we have targeted its disruption to K14 and K6a expressing cells of the mouse. Unlike MMTV and WAP driven conditional knockout models of Brca1, these two models did not result in any observable changes in the mammary gland. Our results suggest that BRCA1-associated tumours arise either in K14 and K6a negative basal cells of the mammary gland, or possibly from transdifferentiation of luminal epithelia.