An Evaluation of Kiosks for Direct-to-Consumer Telemedicine Using the National Quality Forum Assessment Framework.

Background: Evaluation of direct-to-consumer (DTC) telemedicine programs has focused on care delivery via personal electronic devices. Telemedicine kiosks for the delivery of virtual urgent care services have not been systematically described. Introduction: Our institution has placed kiosks for DTC urgent care in pharmacies. These kiosks can be used without a personal electronic device. Materials and Methods: Retrospective review of adult patients using pharmacy-based kiosks (kiosk) or personal electronic devices (app) for DTC evaluation. Data for patient characteristics, wait time, technical quality, visit duration diagnosis codes, follow-up recommendations, and whether the patient was traveling were compared. Results were interpreted using the National Quality Forum framework for telemedicine service evaluation, focused on access, experience, and effectiveness. Comparisons were made using chi-square test, Student's t-test, and Wilcoxon rank-sum tests. Results: Over 1 year there were 1,996 DTC visits; 238 (12%) initiated from kiosks. Kiosk patients were slightly older (mean age 38 ± 13 vs. 35 ± 11; p < 0.001), more likely to be male (52% vs. 39%; p < 0.001), more likely to be remote from home (25% vs. 3%; p < 0.001), and had less technical difficulty (10% vs. 19%; p = 0.003). Referral for urgent in-person evaluation was low in both groups (10% kiosk vs. 16%; app p = 0.017). Discussion: Kiosks may increase access to care and improve technical experience. Low urgent referral rates suggest effective care for both types of visit. Conclusions: Despite their potential advantages, kiosk visits accounted for a minority of overall visits for our DTC telemedicine service line, and daily use of each kiosk location was low.

Use of Physician-Guided Patient Self-Examination to Diagnose Appendicitis: A Telemedicine Case Report.

Background: Direct-to-consumer (DTC) telemedicine platforms have been increasingly implemented by large hospital systems. This care delivery mechanism shares similarities with bedside medical care, but also differs in key attributes such as the inability to perform a "hands-on" physical examination. Methods: We present a case of DTC telehealth evaluation that resulted in the diagnosis of acute appendicitis. The case of one female patient presenting to our urgent care mobile application and subsequently to the emergency department (ED) is discussed. Results: Physician-guided patient self-examination of the abdomen demonstrated concordance with findings on bedside physical examination in the ED, leading to the correct diagnosis of acute appendicitis. Conclusions: For the patient presented here, physician-guided patient self-examination resulted in appropriate referral to the ED and diagnosis of appendicitis. Additional research on the reproducibility of virtual physical examination findings and potential cost savings of telemedicine visits is warranted.

Elucidating Human Mitosis Using an Anaphase-Like Cell-Free System.

A balanced progression through mitosis and cell division is largely dependent on orderly phosphorylation and ubiquitin-mediated proteolysis of regulatory and structural proteins. These series of events ultimately secure genome stability and time-invariant cellular properties during cell proliferation. Two of the core enzymes regulating mitotic milestones in all eukaryotes are cyclin dependent kinase 1 (CDK1) with its coactivator cyclin B, and the E3 ubiquitin ligase anaphase promoting complex/cyclosome (APC/C). Discovering mechanisms and substrates for these enzymes is vital to understanding how cells move through mitosis and segregate chromosomes with high fidelity. However, the study of these enzymes has significant challenges. Purely in vitro studies discount the contributions of yet to be described regulators and misses the physiological context of cellular environment. In vivo studies are complicated by the fact that each of these enzymes, as well as many of their regulators and downstream targets, are essential. Moreover, long-term in vivo manipulations can result in cascading, indirect effects that can distort data analysis and interpretation. Many of these challenges can be circumvented using cell-free systems, which have historically played a critical role in identifying these enzymes and their contributions under quasicellular environments. Here, we describe the preparation of a newly developed human cell-free system that recapitulates an anaphase-like state of human cells. This new toolkit complements traditional cell-free systems from human cells and frog eggs and can be easily implemented in cell biology labs for direct and quantitative studies of mitotic signaling regulated by phosphorylation, APC/C-mediated proteolysis, and beyond.

Complex Cartography: Regulation of E2F Transcription Factors by Cyclin F and Ubiquitin.

The E2F family of transcriptional regulators sits at the center of cell cycle gene expression and plays vital roles in normal and cancer cell cycles. Whereas control of E2Fs by the retinoblastoma family of proteins is well established, much less is known about their regulation by ubiquitin pathways. Recent studies placed the Skp1-Cul1-F-box-protein (SCF) family of E3 ubiquitin ligases with the F-box protein Cyclin F at the center of E2F regulation, demonstrating temporal proteolysis of both activator and atypical repressor E2Fs. Importantly, these E2F members, in particular activator E2F1 and repressors E2F7 and E2F8, form a feedback circuit at the crossroads of cell cycle and cell death. Moreover, Cyclin F functions in a reciprocal circuit with the cell cycle E3 ligase anaphase-promoting complex/cyclosome (APC/C), which also controls E2F7 and E2F8. This review focuses on the complex contours of feedback within this circuit, highlighting the deep crosstalk between E2F, SCF-Cyclin F, and APC/C in regulating the oscillator underlying human cell cycles.

Cell cycle oscillators underlying orderly proteolysis of E2F8.

E2F8 is a transcriptional repressor that antagonizes E2F1 at the crossroads of the cell cycle, apoptosis, and cancer. Previously, we discovered that E2F8 is a direct target of the APC/C ubiquitin ligase. Nevertheless, it remains unknown how E2F8 is dynamically controlled throughout the entirety of the cell cycle. Here, using newly developed human cell-free systems that recapitulate distinct inter-mitotic and G1 phases and a continuous transition from prometaphase to G1, we reveal an interlocking dephosphorylation switch coordinating E2F8 degradation with mitotic exit and the activation of APC/CCdh1. Further, we uncover differential proteolysis rates for E2F8 at different points within G1 phase, accounting for its accumulation in late G1 while APC/CCdh1 is still active. Finally, we demonstrate that the F-box protein Cyclin F regulates E2F8 in G2-phase. Altogether, our data define E2F8 regulation throughout the cell cycle, illuminating an extensive coordination between phosphorylation, ubiquitination and transcription in mammalian cell cycle.

It's not just FaceTime: core competencies for the Medical Virtualist.

New applications for virtual healthcare have resulted in an expansion of medical care beyond traditional healthcare settings. However, the rapid development of telemedicine as a field has resulted in poor standardization of the care provided through this new medium. The authors outline core competencies to be used in developing training programs for practicing physicians, medical students, and other clinicians using telemedicine as a medium for providing patient care. These competencies aim to provide a framework for defining a standard of care in telemedicine and the ultimate development of a certification in the field.