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BackgroundThe COVID-19 pandemic rapidly changed the landscape of clinical practice in the United States; telehealth became an essential mode of health care delivery, yet many components of telehealth use remain unknown years after the disease’s emergence. ObjectiveWe aim to comprehensively assess telehealth use and its associated factors in the United States. MethodsThis cross-sectional study used a nationally representative survey (Health Information National Trends Survey) administered to US adults (≥18 years) from March 2022 through November 2022. To assess telehealth adoption, perceptions of telehealth, satisfaction with telehealth, and the telehealth care purpose, we conducted weighted descriptive analyses. To identify the subpopulations with low adoption of telehealth, we developed a weighted multivariable logistic regression model. ResultsAmong a total of 6252 survey participants, 39.3% (2517/6252) reported telehealth use in the past 12 months (video: 1110/6252, 17.8%; audio: 876/6252, 11.6%). The most prominent reason for not using telehealth was due to telehealth providers failing to offer this option (2200/3529, 63%). The most common reason for respondents not using offered telehealth services was a preference for in-person care (527/578, 84.4%). Primary motivations to use telehealth were providers’ recommendations (1716/2517, 72.7%) and convenience (1516/2517, 65.6%), mainly for acute minor illness (600/2397, 29.7%) and chronic condition management (583/2397, 21.4%), yet care purposes differed by age, race/ethnicity, and income. The satisfaction rate was predominately high, with no technical problems (1829/2517, 80.5%), comparable care quality to that of in-person care (1779/2517, 75%), and no privacy concerns (1958/2517, 83.7%). Younger individuals (odd ratios [ORs] 1.48-2.23; 18-64 years vs ≥75 years), women (OR 1.33, 95% CI 1.09-1.61), Hispanic individuals (OR 1.37, 95% CI 1.05-1.80; vs non-Hispanic White), those with more education (OR 1.72, 95% CI 1.03-2.87; at least a college graduate vs less than high school), unemployed individuals (OR 1.25, 95% CI 1.02-1.54), insured individuals (OR 1.83, 95% CI 1.25-2.69), or those with poor general health status (OR 1.66, 95% CI 1.30-2.13) had higher odds of using telehealth. ConclusionsTo our best knowledge, this is among the first studies to examine patient factors around telehealth use, including motivations to use, perceptions of, satisfaction with, and care purpose of telehealth, as well as sociodemographic factors associated with telehealth adoption using a nationally representative survey. The wide array of descriptive findings and identified associations will help providers and health systems understand the factors that drive patients toward or away from telehealth visits as the technology becomes more routinely available across the United States, providing future directions for telehealth use and telehealth research.

BackgroundIn-hospital dermatological care has shifted from dedicated dermatology wards to consultation services, and some consulted patients may require postdischarge follow-up in outpatient dermatology. Safe and timely care transitions from inpatient-to-outpatient specialty care are critical for patient health, but communication around these transitions can be disjointed, and workflows can be complex. ObjectiveIn this 3-phase quality improvement effort, we developed and evaluated an intervention that leveraged an electronic health record (EHR) feature, known as SmartPhrase, to enable a new workflow to improve transitions from inpatient care to outpatient dermatology. MethodsPhase 1 (February-March 2021) included interviews with patients and process mapping with key stakeholders to identify gaps and inform an intervention: a SmartPhrase table and associated workflow to promote collection of patient information needed for scheduling follow-up and closed-loop communication between dermatology and scheduling teams. In phase 2 (April-May 2021), semistructured interviews—with dermatologists (n=5), dermatology residents (n=5), and schedulers (n=6)—identified pain points and refinements. In phase 3, the intervention was evaluated by triangulating data from these interviews with measured changes in scheduling efficiency, visit completion, and messaging volume preimplementation (January-February 2021) and postimplementation (April-May 2021). ResultsPreintervention pain points included unclear workflow for care transitions, limited patient input in follow-up planning, multiple messaging channels (eg, EHR based, email, and phone messages), and time-inefficient patient tracking. The intervention addressed most pain points; interviewees reported the intervention was easy to adopt and improved scheduling efficiency, workload, and patient involvement. More visits were completed within the desired timeframe of 14 days after discharge during the postimplementation period (21/47, 45%) than the preimplementation period (28/41, 68%; P=.03). The messaging workload also decreased from 88 scheduling-related messages sent for 25 patients before implementation to 30 messages for 8 patients after implementation. ConclusionsInpatient-to-outpatient specialty care transitions are complex and involve multiple stakeholders, thus requiring multifaceted solutions. With deliberate evaluation, broad stakeholder input, and iteration, we designed and implemented a successful solution using a standard EHR feature, SmartPhrase, integrated into a standardized workflow to improve the timeliness of posthospital specialty care and reduce workload.

BackgroundBoth clinicians and patients have increasingly turned to telemedicine to improve care access, even in physical examination–dependent specialties such as dermatology. However, little is known about whether teledermatology supports effective and timely transitions from inpatient to outpatient care, which is a common care coordination gap. ObjectiveUsing mixed methods, this study sought to retrospectively evaluate how teledermatology affected clinic capacity, scheduling efficiency, and timeliness of follow-up care for patients transitioning from inpatient to outpatient dermatology care. MethodsPatient-level encounter scheduling data were used to compare the number and proportion of patients who were scheduled and received in-clinic or video dermatology follow-ups within 14 and 90 days after discharge across 3 phases: June to September 2019 (before teledermatology), June to September 2020 (early teledermatology), and February to May 2021 (sustained teledermatology). The time from discharge to scheduling and completion of patient follow-up visits for each care modality was also compared. Dermatology clinicians and schedulers were also interviewed between April and May 2021 to assess their perceptions of teledermatology for postdischarge patients. ResultsMore patients completed follow-up within 90 days after discharge during early (n=101) and sustained (n=100) teledermatology use than at baseline (n=74). Thus, the clinic’s capacity to provide follow-up to patients transitioning from inpatient increased from baseline by 36% in the early (101 from 74) and sustained (100 from 74) teledermatology periods. During early teledermatology use, 61.4% (62/101) of the follow-ups were conducted via video. This decreased significantly to 47% (47/100) in the following year, when COVID-19–related restrictions started to lift (P=.04), indicating more targeted but still substantial use. The proportion of patients who were followed up within the recommended 14 days after discharge did not differ significantly between video and in-clinic visits during the early (33/62, 53% vs 15/39, 38%; P=.15) or sustained (26/53, 60% vs 28/47, 49%; P=.29) teledermatology periods. Interviewees agreed that teledermatology would continue to be offered. Most considered postdischarge follow-up patients to be ideal candidates for teledermatology as they had undergone a recent in-person assessment and might have difficulty attending in-clinic visits because of competing health priorities. Some reported patients needing technological support. Ultimately, most agreed that the choice of follow-up care modality should be the patient’s own. ConclusionsTeledermatology could be an important tool for maintaining accessible, flexible, and convenient care for recently discharged patients needing follow-up care. Teledermatology increased clinic capacity, even during the pandemic, although the timeliness of care transitions did not improve. Ultimately, the care modality should be determined through communication with patients to incorporate their and their caregivers’ preferences.

Introduction: Teledermatology has proven to be an effective means of providing dermatologic care. The existing research has primarily evaluated its usefulness in a consultative model. Few academic centers have evaluated a patient-initiated model, and direct-to-consumer services remain the subject of controversy. Stanford Health Care recently launched a direct-care, patient-initiated teledermatology pilot program. This article evaluates the viability and patient satisfaction with this service. Materials and Methods: During the pilot period, patients were able to seek remote dermatologic care using an eVisit tool in their MyHealth account. Patients initiated the consultation, answered questions regarding their complaint, and uploaded a picture if relevant. A Stanford dermatologist reviewed each eVisit and responded with an assessment and plan. The dermatologist noted whether they were able to make a diagnosis and their level of confidence in it. After the study, 10 patients participated in a focus group to provide feedback on the service. Results: In all, 38 patients sought care during the pilot period. A dermatologist was able to make a diagnosis in 36 of 38 (95%) cases, with an average confidence level of 7.9 of 10. The average time to consultation was 0.8 days. Patients indicated high levels of satisfaction with the service although they had suggestions for improvement. Discussion: Patients provided clinically useful images and information in a direct-care teledermatology model. Such services allow dermatology providers to increase access while maintaining high-quality care in an academic medical center. Further research is needed on standalone services that cannot integrate encounters with the patient’s existing medical record.

Attachment to the intestinal epithelium is critical to the lifestyle of the ubiquitous parasite Giardia lamblia. The ventrolateral flange is a sheet-like membrane protrusion at the interface between parasites and attached surfaces. This structure has been implicated in attachment, but its role has been poorly defined. Here, we identified a novel actin associated protein with putative WH2-like actin binding domains we named Flangin. Flangin complexes with Giardia actin (GlActin) and is enriched in the ventrolateral flange making it a valuable marker for studying the flanges' role in Giardia biology. Live imaging revealed that the flange grows to around 1 μm in width after cytokinesis, then remains uniform in size during interphase, grows in mitosis, and is resorbed during cytokinesis. A flangin truncation mutant stabilizes the flange and blocks cytokinesis, indicating that flange disassembly is necessary for rapid myosin-independent cytokinesis in Giardia. Rho family GTPases are important regulators of membrane protrusions and GlRac, the sole Rho family GTPase in Giardia, was localized to the flange. Knockdown of Flangin, GlActin, and GlRac result in flange formation defects. This indicates a conserved role for GlRac and GlActin in forming membrane protrusions, despite the absence of canonical actin binding proteins that link Rho GTPase signaling to lamellipodia formation. Flangin-depleted parasites had reduced surface contact and when challenged with fluid shear force in flow chambers they had a reduced ability to remain attached, confirming a role for the flange in attachment. This secondary attachment mechanism complements the microtubule based adhesive ventral disc, a feature that may be particularly important during mitosis when the parental ventral disc disassembles in preparation for cytokinesis. This work supports the emerging view that Giardia's unconventional actin cytoskeleton has an important role in supporting parasite attachment.

Many metabolic enzymes self-assemble into micron-scale filaments to organize and regulate metabolism. The appearance of these assemblies often coincides with large metabolic changes as in development, cancer, and stress. Yeast undergo cytoplasmic acidification upon starvation, triggering the assembly of many metabolic enzymes into filaments. However, it is unclear how these filaments assemble at the molecular level and what their role is in the yeast starvation response. CTP Synthase (CTPS) assembles into metabolic filaments across many species. Here, we characterize in vitro polymerization and investigate in vivo consequences of CTPS assembly in yeast. Cryo-EM structures reveal a pH-sensitive assembly mechanism and highly ordered filament bundles that stabilize an inactive state of the enzyme, features unique to yeast CTPS. Disruption of filaments in cells with non-assembly or pH-insensitive mutations decreases growth rate, reflecting the importance of regulated CTPS filament assembly in homeotstasis.

Inosine monophosphate dehydrogenase (IMPDH) mediates the first committed step in guanine nucleotide biosynthesis and plays important roles in cellular proliferation and the immune response. IMPDH reversibly polymerizes in cells and tissues in response to changes in metabolic demand. Self-assembly of metabolic enzymes is increasingly recognized as a general mechanism for regulating activity, typically by stabilizing specific conformations of an enzyme, but the regulatory role of IMPDH filaments has remained unclear. Here, we report a series of human IMPDH2 cryo-EM structures in both active and inactive conformations. The structures define the mechanism of filament assembly, and reveal how filament-dependent allosteric regulation of IMPDH2 makes the enzyme less sensitive to feedback inhibition, explaining why assembly occurs under physiological conditions that require expansion of guanine nucleotide pools. Tuning sensitivity to an allosteric inhibitor distinguishes IMPDH from other metabolic filaments, and highlights the diversity of regulatory outcomes that can emerge from self-assembly.

The outer membrane (OM) of Gram-negative bacteria serves as a selective permeability barrier that allows entry of essential nutrients while excluding toxic compounds, including antibiotics. The OM is asymmetric and contains an outer leaflet of lipopolysaccharides (LPS) or lipooligosaccharides (LOS) and an inner leaflet of glycerophospholipids (GPL). We screened Acinetobacter baumannii transposon mutants and identified a number of mutants with OM defects, including an ABC transporter system homologous to the Mla system in E. coli. We further show that this opportunistic, antibiotic-resistant pathogen uses this multicomponent protein complex and ATP hydrolysis at the inner membrane to promote GPL export to the OM. The broad conservation of the Mla system in Gram-negative bacteria suggests the system may play a conserved role in OM biogenesis. The importance of the Mla system to Acinetobacter baumannii OM integrity and antibiotic sensitivity suggests that its components may serve as new antimicrobial therapeutic targets.

Abstract Biopsy-based histology has been the foundation of disease diagnosis and management for over a century. A long-sought goal in dermatology is the development of an imaging modality with sufficient resolution and compositional detail to noninvasively interrogate skin histology in vivo. Here, we describe a system that achieves this goal using cross-sectionally scanned, multimodal microscopy (cross-modal). Cross-modal combines multiphoton and reflectance confocal microscopy into one compact system with coordinated three-axis scanning that preserves optical resolution in cross-section. A custom pinhole-free mechanism employing finite-infinite conjugates further simplifies and stabilizes confocal alignment. Evaluated in participants ages 9–81 and Fitzpatrick skin types (FST) 1–5, cross-modal images revealed histological details analogous to those obtained from traditional biopsied tissue. We observed dermal elastosis in sun-damaged skin, elevated melanin in pigmented skin, basaloid nests in basal cell carcinoma, and elongated rete ridges in seborrheic keratosis, supporting cross-modal’s potential to deliver histological insights noninvasively.

Artificial intelligence (AI)-enabled technology has the potential to expand access to high-quality health information and health care services. Learning how diverse users interact with technology enables improvements to the AI model and the user interface, maximizing its potential benefit for a greater number of people. This narrative describes how technology developers, academic researchers, and representatives from a community-based organization collaborated to conduct a community-centered project on emerging health technologies. Our project team comprised representatives from Stanford Medicine, Google, and Santa Clara Family Health Plan’s Blanca Alvarado Community Resource Center. We aimed to understand the usability and acceptability of an AI-driven dermatology tool among East San Jose, California, community members. Specifically, our objectives were as follows: to test a model for cross-sector research of AI-based health technology; to determine the utility of the tool in an ethnically and age-diverse population; to obtain in-depth user experience feedback from participants recruited during community events; to offer free skin health consultations; and to provide resources for receiving follow-up care. We describe a collaborative approach in which each party contributed expertise: knowledge of the community from the community health partner, clinical expertise from the academic research institution, and software and AI expertise from the technology company. Through an iterative process, we identified important community needs, including technological, language, and privacy support. Our approach allowed us to recruit and engage a diverse cohort of participants, over 70% of whom preferred a language other than English. We distill learnings from planning and executing this case study that may help other collaborators bridge the gap between academia, industry, and community in AI health care innovation.

CTP Synthetase (CtpS) is a universally conserved and essential metabolic enzyme. While many enzymes form small oligomers, CtpS forms large-scale filamentous structures of unknown function in prokaryotes and eukaryotes. By simultaneously monitoring CtpS polymerization and enzymatic activity, we show that polymerization inhibits activity, and CtpS's product, CTP, induces assembly. To understand how assembly inhibits activity, we used electron microscopy to define the structure of CtpS polymers. This structure suggests that polymerization sterically hinders a conformational change necessary for CtpS activity. Structure-guided mutagenesis and mathematical modeling further indicate that coupling activity to polymerization promotes cooperative catalytic regulation. This previously uncharacterized regulatory mechanism is important for cellular function since a mutant that disrupts CtpS polymerization disrupts E. coli growth and metabolic regulation without reducing CTP levels. We propose that regulation by large-scale polymerization enables ultrasensitive control of enzymatic activity while storing an enzyme subpopulation in a conformationally restricted form that is readily activatable.

Abstract Background Elderly patients in senior communities faced high barriers to care during the COVID‐19 pandemic, including increased vulnerability to COVID‐19, long quarantines for clinic visits, and difficulties with telemedicine adoption. Objective To pilot a new model of dermatologic care to overcome barriers for senior living communities during the COVID‐19 pandemic and assess patient satisfaction. Methods From 16 November 2020 to 9 July 2021, this quality improvement programme combined in‐residence full body imaging with real‐time outlier lesion identification and virtual teledermatology. Residents from the Sequoias Portola Valley Senior Living Retirement Community (Portola Valley, California) voluntarily enroled in the Stanford Skin Scan Programme. Non‐physician clinical staff with a recent negative COVID‐19 test travelled on‐site to obtain in‐residence full body photographs using a mobile app‐based system on an iPad called SkinIO that leverages deep learning to analyse patient images and suggest suspicious, outlier lesions for dermoscopic photos. A single dermatologist reviewed photographs with the patient and provided recommendations via a video visit. Objective measures included follow‐up course and number of skin cancers detected. Subjective findings were obtained through patient experience surveys. Results Twenty‐seven individuals participated, three skin cancers were identified, with 11 individuals scheduled for a follow up in‐person visit and four individuals starting home treatment. Overall, 88% of patients were satisfied with the Skin Scan programme, with 77% likely to recommend the programme to others. 92% of patients agreed that the Skin Scan photographs were representative of their skin. In the context of the COVID‐19 pandemic, 100% of patients felt the process was safer or comparable to an in‐person visit. Despite overall appreciation for the programme, 31% of patients reported that they would prefer to see dermatologist in‐person after the pandemic. Conclusions This programme offers a framework for how a hybrid skin scan programme may provide high utility for individuals with barriers to accessing in‐person clinics.

Abstract Background Alopecia areata (AA) is characterized by hair loss that can affect the scalp and body. This study describes the psychosocial burden of AA. Methods Participants diagnosed with AA who had experienced ≥50% scalp hair loss according to the Severity of Alopecia Tool (SALT) were identified by clinicians. A semi-structured interview guide, developed with expert clinician input, included open-ended questions to explore patients’ experiences of living with AA. Data were thematically analyzed to identify concepts and relationships. Results Participants (n = 45, 58% female, mean age 33.3 years [range 15–72], mean SALT 67.2 [range 0–100]) described the AA diagnosis as “devastating”. Both males and females reported emotional and psychological impacts of AA including feeling sad/depressed (n = 21), embarrassed/ashamed (n = 10) and angry/frustrated (n = 3). Patients felt helpless (n = 5) due to the unpredictability of disease recurrence, and anxious (n = 19) about judgement from others. Many patients avoided social situations (n = 18), which impaired relationships and increased isolation. Coping strategies included concealment of hair loss through wigs or make-up, although fear of the displacement of these coverings also caused anxiety and the avoidance of activities that could result in scalp exposure (n = 22). Some patients became more accepting of AA over time, which lessened the emotional impact, though efficacious treatment was still desired. A conceptual framework was developed, and a conceptual model was created to depict the relationship between the physical signs/symptoms and the associated psychosocial effects of AA. Conclusion AA impairs patients’ emotional and psychological wellbeing, relationships and lifestyles. Greater disease awareness and effective treatments are needed.