Perspectives on Telemedicine from a National Study of Youth in the United States.

Introduction: Telemedicine is increasingly popular with the recent surge in use due to the COVID-19 pandemic. Despite youth status as "tech natives," limited data are available on their perspectives on telemedicine. Our study seeks to understand youth telemedicine knowledge, prior experiences, preferences for use, and the impact of COVID-19 on these perspectives. Methods: Participants in MyVoice, a national text message cohort of U.S. youth age 14-24, were sent five open-ended questions in October 2019 and October 2020. A codebook was iteratively developed by using inductive analysis. Responses were independently coded by two investigators, with discrepancies resolved by discussion or a third investigator. Results: Sixty-five percent (836/1,283) and 77% (887/1,129) of participants responded to at least 1 question in 2019 and 2020, respectively. Most youth reported awareness of telemedicine and although many have not used it, COVID-19 has increased use. Further, many are willing to try telemedicine services. Most youth noted a preference for video rather than phone visits, but they believe both to be less effective than in person. Youth also reported varied preferences on services best suited for telemedicine, with COVID-19 positively impacting their views. Discussion: Youth are aware of and willing to use telemedicine services, with many reporting use during the COVID-19 pandemic. Youth are willing to accept a wide variety of telemedicine services, though they still desire in-person options. Health systems and clinics should offer a wide range of services via telemedicine to fit the varying needs of youth both during and after the COVID-19 pandemic.

Downregulation of Src-family tyrosine kinases by Srcasm and c-Cbl: A comparative analysis.

AIM: Elevated Src-Family tyrosine kinase (SFK) activity drives carcinogenesis in vivo and elevated SFK activity is found ubiquitously in human cancers. Although human squamous cell carcinomas (SCCs) demonstrate increased SFK activity, in silico analysis of SCCs demonstrates that only 0.4% of lesions contain mutations that could potentially increase SFK activity; similarly, a low frequency of activating SFK mutations is found in other major cancers. These findings indicate that SFK activation in cancers likely is not due to activating mutations but alternative mechanisms. To evaluate potential alternative mechanisms, we evaluated the selectivity of c-Cbl and Srcasm in downregulating native and activated mutant forms of SFKs. MATERIALS AND METHODS: We co-transfected native and activated forms of Src and Fyn with c-Cbl and Srcasm into HaCaT cells and monitored the ability of Srcasm and c-Cbl to downregulate native and activated forms of SFKs by Western blotting. The mechanism of downregulation was probed using mutant forms of Srcasm and c-Cbl and using proteosomal and lysosomal inhibition. RESULTS: The data indicate that Srcasm downregulates native Fyn and Src more effectively than c-Cbl, whereas c-Cbl preferentially downregulates activated SFK mutants, including Fyn Y528F, more effectively than Srcasm. Srcasm downregulates SFKs through a lysosomal-dependent mechanism while c-Cbl utilizes a proteosomal-dependent mechanism. CONCLUSION: Given the rarity of activating SFK mutations in human cancer, these data indicate that decreasing Srcasm level/function may represent a mechanism for increasing SFK activity in SCC and other human tumors.

Implementation of Mobile Teledermatology: Challenges and Opportunities.

Background: While teledermatology is well-established in the Department of Veterans Affairs (VA), its implementation is far from complete. To facilitate consultative teledermatology and extend its reach, VA introduced a mobile teledermatology application (app) at three VA sites. Methods: We evaluated the initial implementation process using a mixed-methods, multiple case study approach to assess organizational readiness for change (ORC), which included examining facilitators, barriers, and contextual factors that affected implementation. We conducted: (1) group interviews and bimonthly reports to understand site processes; (2) semistructured interviews and surveys of individual participants representing a range of implementation roles; and (3) a review of internal organizational documents. We identified themes from interviews using an iterative process, and computed an ORC score based on surveys. Results: Forty-three individuals participated in the study. Qualitative data from all sites, corroborated by survey data available from one site, revealed a high readiness for change with an ORC score of 4.2, where 5 = maximal readiness for change. Facilitators included support from leadership and clinical champions, active telehealth programs, and an understanding and appreciation of the program and the resources needed. At all sites, however, technical issues negatively affected adoption; these included a suboptimal information technology infrastructure, which led to the inoperability of the app at two sites, and technical inefficiencies related to users' unfamiliarity with new devices and inconsistent internet access. Conclusions: Although a strong commitment to change and a confidence to effect change existed, these alone were insufficient to surmount barriers to implementation effectiveness. Clinical Trials Registration: NCT03241589.

Using the RE-AIM framework to assess national teledermatology expansion.

Background: Teledermatology has been utilized in the United States Department of Veterans Affairs (VA) for decades but continues to have incomplete penetration. VA has funded an initiative to enhance access to dermatology services since 2017 to support asynchronous teledermatology for Veterans living in rural areas. As part of an ongoing evaluation of this program, we assessed the teledermatology activity between the fiscal years 2020 and 2022. We focused on the second cohort of the initiative, comprising six VA facilities and their 54 referral clinics. Methods: We studied teledermatology programs at cohort facilities using the reach, effectiveness, adoption, implementation, and maintenance framework. We used a mixed-methods design including annual online reports completed by participating facilities and VA administrative data. When possible, we compared the data from the 3 years of teledermatology funding with the baseline year prior to the start of funding. Findings: Reach: Compared with the baseline year, there was a 100% increase in encounters and a 62% increase in patients seen at the funded facilities. Over 500 clinicians and support staff members were trained. Effectiveness: In FY 2022, primary or specialty care clinics affiliated with the funded facilities had more dermatology programs than primary or specialty care clinics across the VA (83% vs. 71% of sites). Adoption: By the end of the funding period, teledermatology constituted 16% of dermatology encounters at the funded facilities compared with 12% nationally. This reflected an increase from 9.2% at the funded facilities and 10.3% nationally prior to the funding period. Implementation: The continued funding for staff and equipment facilitated the expansion to rural areas. Maintenance: By the end of the funding period, all facilities indicated that they had fully implemented their program for patients of targeted primary care providers. The Program Sustainability Index scores generally increased during the funding period. Conclusions: Targeted funding to support asynchronous teledermatology implementation for rural Veterans increased its reach, adoption, and implementation, ultimately improving access. Providing program guidance with staffing and training resources can increase the impact of these programs. Ongoing efforts to maintain and increase communication between primary care and dermatology will be needed to sustain success.

Protein kinase structure and function analysis with chemical tools.

Protein kinases are the largest enzyme superfamily involved in cell signal transduction and represent therapeutic targets for a range of diseases. There have been intensive efforts from many labs to understand their catalytic mechanisms, discover inhibitors and discern their cellular functions. In this review, we will describe two approaches developed to analyze protein kinases: bisubstrate analog inhibition and phosphonate analog utilization. Both of these methods have been used in combination with the protein semisynthesis method expressed protein ligation to advance our understanding of kinase-substrate interactions and functional elucidation of phosphorylation. Previous work on the nature of the protein kinase mechanism suggests it follows a dissociative transition state. A bisubstrate analog was designed against the insulin receptor kinase to mimic the geometry of a dissociative transition state reaction coordinate distance. This bisubstrate compound proved to be a potent inhibitor against the insulin receptor kinase and occupied both peptide and nucleotide binding sites. Bisubstrate compounds with altered hydrogen bonding potential as well as varying spacers between the adenine and the peptide demonstrate the importance of the original design features. We have also shown that related bisubstrate analogs can be used to potently block serine/threonine kinases including protein kinase A. Since many protein kinases recognize folded protein substrates for efficient phosphorylation, it was advantageous to incorporate the peptide-ATP conjugates into protein structures. Using expressed protein ligation, a Src-ATP conjugate was produced and shown to be a high affinity ligand for the Csk tyrosine kinase. Nonhydrolyzable mimics of phosphoSer/phosphoTyr can be useful in examining the functionality of phosphorylation events. Using expressed protein ligation, we have employed phosphonomethylene phenylalanine and phosphonomethylene alanine to probe the phosphorylation of Tyr and Ser, respectively. These tools have permitted an analysis of the SH2-phosphatases (SHP1 and SHP2), revealing a novel intramolecular stimulation of catalytic activity mediated by the corresponding phosphorylation events. They have also been used to characterize the cellular regulation of the melatonin rhythm enzyme by phosphorylation.

Bisubstrate analog probes for the insulin receptor protein tyrosine kinase: molecular yardsticks for analyzing catalytic mechanism and inhibitor design.

Bisubstrate analogs have the potential to provide enhanced specificity for protein kinase inhibition and tools to understand catalytic mechanism. Previous efforts led to the design of a peptide-ATP conjugate bisubstrate analog utilizing aminophenylalanine in place of tyrosine and a thioacetyl linker to the gamma-phosphate of ATP which was a potent inhibitor of the insulin receptor kinase (IRK). In this study, we have examined the contributions of various electrostatic and structural elements in the bisubstrate analog to IRK binding affinity. Three types of changes (seven specific analogs in all) were introduced: a Tyr isostere of the previous aminophenylalanine moiety, modifications of the spacer between the adenine and the peptide, and deletions and substitutions within the peptide moiety. These studies allowed a direct evaluation of the hydrogen bond strength between the anilino nitrogen of the bisubstrate analog and the enzyme catalytic base Asp and showed that it contributes 2.5 kcal/mol of binding energy, in good agreement with previous predictions. Modifications of the linker length resulted in weakened inhibitory affinity, consistent with the geometric requirements of an enzyme-catalyzed dissociative transition state. Alterations in the peptide motif generally led to diminished inhibitory potency, and only some of these effects could be rationalized based on prior kinetic and structural studies. Taken together, these results suggest that a combination of mechanism-based design and empirical synthetic manipulation will be necessary in producing optimized protein kinase bisubstrate analog inhibitors.

Design, synthesis, and characterization of an ATP-peptide conjugate inhibitor of protein kinase A.

An ATP-peptide conjugate was synthesized as a bisubstrate analogue inhibitor of the serine/threonine kinase protein kinase A. The compound was found to be a linear, competitive inhibitor with respect to ATP substrate, exhibiting a Ki of 3.8 microM. The compound was noncompetitive with respect to peptide substrate. The inhibitor was shown to be selective for protein kinase A versus the closely related protein kinase C as well as tyrosine kinase Csk. This analysis provides new evidence for the dissociative transition state of protein serine/threonine kinases and illustrates a simple method to convert a low affinity peptide substrate to a selective and moderately potent inhibitor for these enzymes.