BioCanRx Summit for Cancer Immunotherapy 2022 Proceedings.

From 19 to 21 November 2022, BioCanRx held its first post-pandemic in-person Summit for Cancer Immunotherapy in Montreal, Canada. The meeting was well attended by patients, trainees, researchers, clinicians, and industry professionals, who came together to discuss the current state and future of biotherapeutics for cancer in Canada and beyond. Three plenaries, three keynote speakers, a lively debate, and panel discussions, together with poster sessions and a social event, made the event memorable and productive. The current state of cellular therapies, cellular engineering, clinical trials, and the role of the cancer microbiome were discussed in plenary session, and the patient voice was welcomed and present throughout the meeting, in large part due to the Learning Institute, a BioCanRx initiative to include patient partners in research. In this meeting review, we highlight the platform presentations, keynote speakers, debate combatants, panellists, and the patient perspective on the annual meeting.

A Social Media‒Based Public Health Campaign Encouraging COVID-19 Vaccination Across the United States.

Tailored public health messaging encouraging COVID-19 vaccination may help increase vaccination rates and decrease the burden of COVID-19. We conducted a three-part COVID-19 vaccine uptake public health campaign disseminated on Facebook between April and June 2021. Our first campaign focused on reaching Black and Latinx communities; our second campaign focused on addressing vaccine access and scheduling in Latinx communities; and our third campaign focused on religious communities. Overall, we reached 25 million individuals with 171 million views across the United States. (Am J Public Health. 2022;112(9):1253-1256. https://doi.org/10.2105/AJPH.2022.306934).

Optimizing Care Teams by Leveraging Advanced Practice Providers Through Strategic Workforce Planning.

INTRODUCTION: Advanced practice providers (APPs) are integral members of the healthcare delivery team. However, there has been a lack of standardization and uniformity in how they are utilized across inpatient, ambulatory, and procedural settings. METHODS: A multidisciplinary workforce planning committee was formed in March 2021 to evaluate all new and replacement full-time equivalent APP positions at Stanford Health Care (SHC), an academic medical center of more than 600 APPs, to optimize and standardize the role of APPs as per national benchmarks. RESULTS: Six months since the launch of the committee, there has been a 10% increase in the number of visits and procedures performed by APPs providing better access for patients. In addition, there has been a 38.7% improvement in ambulatory APPs meeting their productivity target, 19.4% improvement in ambulatory APPs meeting utilization targets, and 36.8% improvement in ambulatory APPs meeting the 50th percentile and above as per the relative value unit benchmark published by the Medical Group Management Association for Academic Medical Centers. For inpatient APPs, there has been a 38.8% improvement in APPs meeting the average daily census target. DISCUSSION: APP utilization is an important topic that has not been consistently addressed in the literature. Inappropriate utilization and lack of top of licensure practice have been associated with increased turnover, decreased job satisfaction, and professional development. By developing a multidisciplinary workforce planning committee, full-time employee positions are evaluated with a goal of optimizing and standardizing the role of APPs at SHC.

Gearing Up for a Vaccine Requirement: A Mixed Methods Study of COVID-19 Vaccine Confidence Among Workers at an Academic Medical Center.

GOAL: Assessing barriers to vaccination among healthcare workers may be particularly important given their roles in their respective communities. We conducted a mixed methods study to explore healthcare worker perspectives on receiving COVID-19 vaccines at a large multisite academic medical center. METHODS: A total of 5,917 employees completed the COVID-19 vaccine confidence survey (20% response rate). Most participants were vaccinated (93%). Compared to vaccinated participants, unvaccinated participants were younger (60% < 44 years), more likely to be from a non-Asian minority group (48%), and more likely to be nonclinical employees (57% vs. 46%). Among the unvaccinated respondents, 53% indicated they would be influenced by their healthcare provider, while 19% reported that nothing would influence them to get vaccinated. Key perceived barriers to vaccination from the qualitative analysis included the need for more long-term safety and efficacy data, a belief in the right to make an individual choice, mistrust, a desire for greater public health information, personal health concerns, circumstances such as prior COVID-19 infection, and access issues. PRINCIPAL FINDINGS: Strategies endorsed by some participants to address their concerns about safety and access included a communication campaign, personalized medicine approaches (e.g., individual appointments to discuss how the vaccine might interact with personal health conditions), and days off to recover. Mistrust and a belief in the right to make an individual choice may be harder barriers to overcome; further dialogue is needed. APPLICATIONS TO PRACTICE: These findings reflect potential strategies for vaccine requirements that healthcare organizations can implement to enhance vaccine confidence. In addition, organizations can ask respected health professionals to serve as spokespeople, which may help shift the perspectives of unvaccinated healthcare workers.

Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care With Expanded Medical Assistant Support.

PURPOSE: Assess effectiveness of Primary Care 2.0: a team-based model that incorporates increased medical assistant (MA) to primary care physician (PCP) ratio, integration of advanced practice clinicians, expanded MA roles, and extended the interprofessional team. METHODS: Prospective, quasi-experimental evaluation of staff/clinician team development and wellness survey data, comparing Primary Care 2.0 to conventional clinics within our academic health care system. We surveyed before the model launch and every 6-9 months up to 24 months post implementation. Secondary outcomes (cost, quality metrics, patient satisfaction) were assessed via routinely collected operational data. RESULTS: Team development significantly increased in the Primary Care 2.0 clinic, sustained across all 3 post implementation time points (+12.2, +8.5, + 10.1 respectively, vs baseline, on the 100-point Team Development Measure) relative to the comparison clinics. Among wellness domains, only "control of work" approached significant gains (+0.5 on a 5-point Likert scale, P = .05), but was not sustained. Burnout did not have statistically significant relative changes; the Primary Care 2.0 site showed a temporal trend of improvement at 9 and 15 months. Reversal of this trend at 2 years corresponded to contextual changes, specifically, reduced MA to PCP staffing ratio. Adjusted models confirmed an inverse relationship between team development and burnout (P <.0001). Secondary outcomes generally remained stable between intervention and comparison clinics with suggestion of labor cost savings. CONCLUSIONS: The Primary Care 2.0 model of enhanced team-based primary care demonstrates team development is a plausible key to protect against burnout, but is not sufficient alone. The results reinforce that transformation to team-based care cannot be a 1-time effort and institutional commitment is integral.

Implementation outcomes of Humanwide: integrated precision health in team-based family practice primary care.

BACKGROUND: Humanwide was precision health embedded in primary care aiming to leverage high-tech and high-touch medicine to promote wellness, predict and prevent illness, and tailor treatment to individual medical and psychosocial needs. METHODS: We conducted a study assessing implementation outcomes to inform spread and scale, using mixed methods of semi-structured interviews with diverse stakeholders and chart reviews. Humanwide included: 1) health coaching; 2) four digital health tools for blood-pressure, weight, glucose, and activity; 3) pharmacogenomic testing; and 4) genetic screening/testing. We examined implementation science constructs: reach/penetration, acceptability, feasibility, and sustainability. Chart reviews captured preliminary clinical outcomes. RESULTS: Fifty of 69 patients (72%) invited by primary care providers participated in the Humanwide pilot. We performed chart reviews for the 50 participating patients. Participants were diverse overall (50% non-white, 66% female). Over half of the participants were obese and 58% had one or more major cardiovascular risk factor: dyslipidemia, hypertension, diabetes. Reach/penetration of Humanwide components varied: pharmacogenomics testing 94%, health coaching 80%, genetic testing 72%, and digital health 64%. Interview participants (n=27) included patients (n=16), providers (n=9), and the 2 staff who were allocated dedicated time for Humanwide patient intake and orientation. Patients and providers reported Humanwide was acceptable; it engaged patients holistically, supported faster medication titration, and strengthened patient-provider relationships. All patients benefited clinically from at least one Humanwide component. Feasibility challenges included: low provider self-efficacy for interpreting genetics and pharmacogenomics; difficulties with data integration; patient technology challenges; and additional staffing needs. Patient financial burden concerns surfaced with respect to sustainability. CONCLUSION: This is the first report of implementation of a multi-component precision health model embedded in team-based primary care. We found acceptance from both patients and providers; however, feasibility barriers must be overcome to enable broad spread and sustainability. We found that barriers to implementation of precision health in a team-based primary care clinic are mundane and straightforward, though not necessarily easy to overcome. Future implementation endeavors should invest in basics: education, workflow, and reflection/evaluation. Strengthening fundamentals will enable healthcare systems to more nimbly accept the responsibility of meeting patients at the crossroads of innovative science and routinized clinical systems.

Qualitative Assessment of Rapid System Transformation to Primary Care Video Visits at an Academic Medical Center.

BACKGROUND: The coronavirus disease 2019 pandemic spurred health systems across the world to quickly shift from in-person visits to safer video visits. OBJECTIVE: To seek stakeholder perspectives on video visits' acceptability and effect 3 weeks after near-total transition to video visits. DESIGN: Semistructured qualitative interviews. SETTING: 6 Stanford general primary care and express care clinics at 6 northern California sites, with 81 providers, 123 staff, and 97 614 patient visits in 2019. PARTICIPANTS: 53 program participants (overlapping roles as medical providers [n = 20], medical assistants [n = 16], nurses [n = 4], technologists [n = 4], and administrators [n = 13]) were interviewed about video visit transition and challenges. INTERVENTION: In 3 weeks, express care and primary care video visits increased from less than 10% to greater than 80% and from less than 10% to greater than 75%, respectively. New video visit providers received video visit training and care quality feedback. New system workflows were created to accommodate the new visit method. MEASUREMENTS: 9 faculty, trained in qualitative research methods, conducted 53 stakeholder interviews in 4 days using purposeful (administrators and technologists) and convenience (medical assistant, nurses, and providers) sampling. A rapid qualitative analytic approach for thematic analysis was used. RESULTS: The analysis revealed 12 themes, including Pandemic as Catalyst; Joy in Medicine; Safety in Medicine; Slipping Through the Cracks; My Role, Redefined; and The New Normal. Themes were analyzed using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to identify critical issues for continued program utilization. LIMITATIONS: Evaluation was done immediately after deployment. Although viewpoints may have evolved later, immediate evaluation allowed for prompt program changes and identified broader issues to address for program sustainability. CONCLUSION: After pandemic-related systems transformation at Stanford, critical issues to sustain video visit long-term viability were identified. Specifically, technology ease of use must improve and support multiparty videoconferencing. Providers should be able to care for their patients, regardless of geography. Providers need decision-making support with virtual examination training and home-based patient diagnostics. Finally, ongoing video visit reimbursement should be commensurate with value to the patients' health and well-being. PRIMARY FUNDING SOURCE: Stanford Department of Medicine and Stanford Health Care.

An App-Based Intervention to Support First Responders and Essential Workers During the COVID-19 Pandemic: Needs Assessment and Mixed Methods Implementation Study.

BACKGROUND: The COVID-19 pandemic has created unprecedented challenges for first responders (eg, police, fire, and emergency medical services) and nonmedical essential workers (eg, workers in food, transportation, and other industries). Health systems may be uniquely suited to support these workers given their medical expertise, and mobile apps can reach local communities despite social distancing requirements. Formal evaluation of real-world mobile app-based interventions is lacking. OBJECTIVE: We aimed to evaluate the adoption, acceptability, and appropriateness of an academic medical center-sponsored app-based intervention (COVID-19 Guide App) designed to support access of first responders and essential workers to COVID-19 information and testing services. We also sought to better understand the COVID-19-related needs of these workers early in the pandemic. METHODS: To understand overall community adoption, views and download data of the COVID-19 Guide App were described. To understand the adoption, appropriateness, and acceptability of the app and the unmet needs of workers, semistructured qualitative interviews were conducted by telephone, by video, and in person with first responders and essential workers in the San Francisco Bay Area who were recruited through purposive, convenience, and snowball sampling. Interview transcripts and field notes were qualitatively analyzed and presented using an implementation outcomes framework. RESULTS: From its launch in April 2020 to September 2020, the app received 8262 views from unique devices and 6640 downloads (80.4% conversion rate, 0.61% adoption rate across the Bay Area). App acceptability was mixed among the 17 first responders interviewed and high among the 10 essential workers interviewed. Select themes included the need for personalized and accurate information, access to testing, and securing personal safety. First responders faced additional challenges related to interprofessional coordination and a "culture of heroism" that could both protect against and exacerbate health vulnerability. CONCLUSIONS: First responders and essential workers both reported challenges related to obtaining accurate information, testing services, and other resources. A mobile app intervention has the potential to combat these challenges through the provision of disease-specific information and access to testing services but may be most effective if delivered as part of a larger ecosystem of support. Differentiated interventions that acknowledge and address the divergent needs between first responders and non-first responder essential workers may optimize acceptance and adoption.

Modulation of circadian rhythms through estrogen receptor signaling.

Circadian rhythms are physiological and behavioral processes that exhibit a 24-hr cycle. These daily rhythms are essential for living organisms to align their behavior and physiology with the environment to increase the likelihood of survival. In mammals, circadian rhythms synchronize with the environment primarily by the suprachiasmatic nucleus, a hypothalamic brain region that integrates exogenous and endogenous timing cues. Sex steroid hormones, including estrogens, are thought to modulate sexually dimorphic behaviors through developmental programming of the brain (i.e., organization), as well as acute receptor signaling during adulthood (i.e., activation). Importantly, there are known sex differences in the expression of circadian locomotor activity and molecular organization of the suprachiasmatic nucleus, likely due, in part, to the actions of circulating estrogens. Circadian locomotor rhythms, which are coordinated by the suprachiasmatic nucleus, have been shown to be regulated by developmental and adult levels of circulating estrogens. Further, increasing evidence suggests that estrogens can modulate expression of circadian clock genes that are essential for orchestration of circadian rhythms by the suprachiasmatic nucleus. In this review, we will discuss the organizational and activational modulation of the circadian timekeeping system by estrogens through estrogen receptor signaling.

Ten Ways Artificial Intelligence Will Transform Primary Care.

Artificial intelligence (AI) is poised as a transformational force in healthcare. This paper presents a current environmental scan, through the eyes of primary care physicians, of the top ten ways AI will impact primary care and its key stakeholders. We discuss ten distinct problem spaces and the most promising AI innovations in each, estimating potential market sizes and the Quadruple Aims that are most likely to be affected. Primary care is where the power, opportunity, and future of AI are most likely to be realized in the broadest and most ambitious scale. We propose how these AI-powered innovations must augment, not subvert, the patient-physician relationship for physicians and patients to accept them. AI implemented poorly risks pushing humanity to the margins; done wisely, AI can free up physicians' cognitive and emotional space for patients, and shift the focus away from transactional tasks to personalized care. The challenge will be for humans to have the wisdom and willingness to discern AI's optimal role in twenty-first century healthcare, and to determine when it strengthens and when it undermines human healing. Ongoing research will determine the impact of AI technologies in achieving better care, better health, lower costs, and improved well-being of the workforce.

Breast Cancer knowledge, perceptions and practices in a rural Community in Coastal Kenya.

BACKGROUND: Data on breast healthcare knowledge, perceptions and practice among women in rural Kenya is limited. Furthermore, the role of the male head of household in influencing a woman's breast health seeking behavior is also not known. The aim of this study was to assess the knowledge, perceptions and practice of breast cancer among women, male heads of households, opinion leaders and healthcare providers within a rural community in Kenya. Our secondary objective was to explore the role of male heads of households in influencing a woman's breast health seeking behavior. METHODS: This was a mixed method cross-sectional study, conducted between Sept 1st 2015 Sept 30th 2016. We administered surveys to women and male heads of households. Outcomes of interest were analysed in Stata ver 13 and tabulated against gender. We conducted six focus group discussions (FGDs) and 22 key informant interviews (KIIs) with opinion leaders and health care providers, respectively. Elements of the Rapid Assessment Process (RAP) were used to guide analysis of the FGDs and the KIIs. RESULTS: A total of 442 women and 237 male heads of households participated in the survey. Although more than 80% of respondents had heard of breast cancer, fewer than 10% of women and male heads of households had knowledge of 2 or more of its risk factors. More than 85% of both men and women perceived breast cancer as a very serious illness. Over 90% of respondents would visit a health facility for a breast lump. Variable recognition of signs of breast cancer, limited decision- autonomy for women, a preference for traditional healers, lack of trust in the health care system, inadequate access to services, limited early-detection services were the six themes that emerged from the FGDs and the KIIs. There were discrepancies between the qualitative and quantitative data for the perceived role of the male head of household as a barrier to seeking breast health care. CONCLUSIONS: Determining level of breast cancer knowledge, the characteristics of breast health seeking behavior and the perceived barriers to accessing breast health are the first steps in establishing locally relevant intervention programs.

Interplay of the physical microenvironment, contact guidance, and intracellular signaling in cell decision making.

The peritumoral physical microenvironment consists of complex topographies that influence cell migration. Cell decision making, upon encountering anisotropic, physiologically relevant physical cues, has yet to be elucidated. By integrating microfabrication with cell and molecular biology techniques, we provide a quantitative and mechanistic analysis of cell decision making in a variety of well-defined physical microenvironments. We used MDA-MB-231 breast carcinoma and HT1080 fibrosarcoma as cell models. Cell decision making after lateral confinement in 2-dimensional microcontact printed lines is governed by branch width at bifurcations. Cells confined in narrow feeder microchannels prefer to enter wider branches at bifurcations. In contrast, in feeder channels that are wider than the cell body, cells elongate along one side wall of the channel and are guided by contact with the wall to the contiguous branch channel independent of its width. Knockdown of ß1-integrins or inhibition of cellular contractility suppresses contact guidance. Concurrent, but not individual, knockdown of nonmuscle myosin isoforms IIA and IIB also decreases contact guidance, which suggests the existence of a compensatory mechanism between myosin IIA and myosin IIB. Conversely, knockdown or inhibition of cell division control protein 42 homolog promotes contact guidance-mediated decision making. Taken together, the dimensionality, length scales of the physical microenvironment, and intrinsic cell signaling regulate cell decision making at intersections.-Paul, C. D., Shea, D. J., Mahoney, M. R., Chai, A., Laney, V., Hung, W.-C., Konstantopoulos, K. Interplay of the physical microenvironment, contact guidance, and intracellular signaling in cell decision making.

Impact of Scribes on Physician Satisfaction, Patient Satisfaction, and Charting Efficiency: A Randomized Controlled Trial.

PURPOSE: Scribes are increasingly being used in clinical practice despite a lack of high-quality evidence regarding their effects. Our objective was to evaluate the effect of medical scribes on physician satisfaction, patient satisfaction, and charting efficiency. METHODS: We conducted a randomized controlled trial in which physicians in an academic family medicine clinic were randomized to 1 week with a scribe then 1 week without a scribe for the course of 1 year. Scribes drafted all relevant documentation, which was reviewed by the physician before attestation and signing. In encounters without a scribe, the physician performed all charting duties. Our outcomes were physician satisfaction, measured by a 5-item instrument that included physicians' perceptions of chart quality and chart accuracy; patient satisfaction, measured by a 6-item instrument; and charting efficiency, measured by time to chart close. RESULTS: Scribes improved all aspects of physician satisfaction, including overall satisfaction with clinic (OR = 10.75), having enough face time with patients (OR = 3.71), time spent charting (OR = 86.09), chart quality (OR = 7.25), and chart accuracy (OR = 4.61) (all P values <.001). Scribes had no effect on patient satisfaction. Scribes increased the proportion of charts that were closed within 48 hours (OR =1.18, P =.028). CONCLUSIONS: To our knowledge, we have conducted the first randomized controlled trial of scribes. We found that scribes produced significant improvements in overall physician satisfaction, satisfaction with chart quality and accuracy, and charting efficiency without detracting from patient satisfaction. Scribes appear to be a promising strategy to improve health care efficiency and reduce physician burnout.

Pharmacological investigations of a yohimbine-impulsivity interaction in rats.

Both impulsivity and stress are risk factors for substance abuse, but it is not clear how these two processes interact to alter susceptibility for the disorder. The aim of this project was to examine the pharmacology of a stress-impulsivity interaction in rats. To do so, we tested the effects of yohimbine on impulsive action and then assessed whether behavioural changes could be reduced by antagonists at different receptor subtypes. Male Long-Evans rats were injected with various doses of yohimbine (0-5.0 mg/kg) before testing in the response-inhibition task. In subsequent experiments, yohimbine (2.5 mg/kg) was injected following pretreatment with the following receptor antagonists: corticotropin-releasing factor receptor 1, antalarmin (0-20 mg/kg); glucocorticoid, mifepristone (0-30 mg/kg); noradrenergic (NA) α1, prazosin (0-2 mg/kg); NA α2, guanfacine (0-0.5 mg/kg); NA ß2, propranolol (0.5-2.0 mg/kg); dopamine D1/5, SCH 39166 (0-0.0625 mg/kg); µ opioid, naloxone (0-2 mg/kg); or 5-HT2A, M100907 (0.005-0.05 mg/kg). In all experiments, impulsive action was measured as increased premature responding. Yohimbine dose dependently increased impulsive action, but the effect was not reversed by antagonist pretreatment. None of the drugs altered any other behavioural measure. We conclude that stress-impulsivity interactions are likely mediated by a synergy of multiple neurotransmitter systems.

"I have it just like you do": voices of HIV-negative partners in serodifferent relationships receiving primary care at a public clinic in San Francisco.

HIV transmission among serodifferent couples has a significant impact on incidence of HIV worldwide. Antiretroviral interventions (i.e., preexposure prophylaxis, post-exposure prophylaxis, and treatment as prevention) are important aspects of comprehensive prevention and care for serodifferent couples. In this study, HIV-negative members of serodifferent couples were interviewed using open-ended questions to explore their health-care needs, perceptions of clinic-based prevention services, and experience of having an HIV-infected partner. Analysis of interviews with 10 HIV-negative partners revealed the following themes: (1) health needs during joint medical visits; (2) sexual risk reduction strategies; (3) relationship dynamics; and (4) strategies for coping. This study elucidated relationship, health and health care factors that might affect development and implementation of clinic-based prevention interventions for HIV serodifferent couples. The findings point to possible relationship-centered recommendations for health-care providers who serve HIV-affected couples in clinical settings.

Medicine plus mindset: A mixed-methods evaluation of a novel mindset-focused training for primary care teams.

OBJECTIVES: Patient mindsets influence health outcomes; yet trainings focused on care teams' understanding, recognizing, and shaping patient mindsets do not exist. This paper aims to describe and evaluate initial reception of the "Medicine Plus Mindset" training program. METHODS: Clinicians and staff at five primary care clinics (N = 186) in the San Francisco Bay Area received the Medicine Plus Mindset Training. The Medicine Plus Mindset training consists of a two-hour training program plus a one-hour follow-up session including: (a) evidence to help care teams understand patients' mindsets' influence on treatment; (b) a framework to support care teams in identifying specific patient mindsets; and (c) strategies to shape patient mindsets. RESULTS: We used a common model (Kirkpatrick) to evaluate the training based on participants' reaction, learnings, and behavior. Reaction: Participants rated the training as highly useful and enjoyable. Learnings: The training increased the perceived importance of mindsets in healthcare and improved self-reported efficacy of using mindsets in practice. Behavior: The training increased reported frequency of shaping patient mindsets. CONCLUSIONS: Development of this training and the study's results introduce a promising and feasible approach for integrating mindset into clinical practice. Practice Implications Mindset training can add a valuable dimension to clinical care and should be integrated into training and clinical practice.

Storylines of family medicine VIII: clinical approaches.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VIII: clinical approaches', authors address the following themes: 'Evaluation, diagnosis and management I-toward a working diagnosis', 'Evaluation, diagnosis and management II-process steps', 'Interweaving integrative medicine and family medicine', 'Halfway-the art of clinical judgment', 'Seamless integration in family medicine-team-based care', 'Technology-uncovering stories from noise' and 'Caring for patients with multiple long-term conditions'. May readers recognise in these essays the uniqueness of a family medicine approach to care.