Evaluating User Feedback for an Artificial Intelligence-Enabled, Cognitive Behavioral Therapy-Based Mental Health App (Wysa): Qualitative Thematic Analysis.

BACKGROUND: Digital mental health apps are rapidly becoming a common source of accessible support across the world, but their effectiveness is often influenced by limited helpfulness and engagement. OBJECTIVE: This study's primary objective was to analyze feedback content to understand users' experiences with engaging with a digital mental health app. As a secondary objective, an exploratory analysis captured the types of mental health app users. METHODS: This study utilized a user-led approach to understanding factors for engagement and helpfulness in digital mental health by analyzing feedback (n=7929) reported on Google Play Store about Wysa, a mental health app (1-year period). The analysis of keywords in the user feedback categorized and evaluated the reported user experience into the core domains of acceptability, usability, usefulness, and integration. The study also captured key deficits and strengths of the app and explored salient characteristics of the types of users who benefit from accessible digital mental health support. RESULTS: The analysis of user feedback found the app to be overwhelmingly positively reviewed (6700/7929, 84.50% 5-star rating). The themes of engaging exercises, interactive interface, and artificial intelligence (AI) conversational ability indicated the acceptability of the app, while the nonjudgmentality and ease of conversation highlighted its usability. The app's usefulness was portrayed by themes such as improvement in mental health, convenient access, and cognitive restructuring exercises. Themes of privacy and confidentiality underscored users' preference for the integrated aspects of the app. Further analysis revealed 4 predominant types of individuals who shared app feedback on the store. CONCLUSIONS: Users reported therapeutic elements of a comfortable, safe, and supportive environment through using the digital mental health app. Digital mental health apps may expand mental health access to those unable to access traditional forms of mental health support and treatments.

Epigenetic Dysregulation of KCNK9 Imprinting and Triple-Negative Breast Cancer.

Genomic imprinting is an inherited form of parent-of-origin specific epigenetic gene regulation that is dysregulated by poor prenatal nutrition and environmental toxins. KCNK9 encodes for TASK3, a pH-regulated potassium channel membrane protein that is overexpressed in 40% of breast cancer. However, KCNK9 gene amplification accounts for increased expression in <10% of these breast cancers. Here, we showed that KCNK9 is imprinted in breast tissue and identified a differentially methylated region (DMR) controlling its imprint status. Hypomethylation at the DMR, coupled with biallelic expression of KCNK9, occurred in 63% of triple-negative breast cancers (TNBC). The association between hypomethylation and TNBC status was highly significant in African-Americans (p = 0.006), but not in Caucasians (p = 0.70). KCNK9 hypomethylation was also found in non-cancerous tissue from 77% of women at high-risk of developing breast cancer. Functional studies demonstrated that the KCNK9 gene product, TASK3, regulates mitochondrial membrane potential and apoptosis-sensitivity. In TNBC cells and non-cancerous mammary epithelial cells from high-risk women, hypomethylation of the KCNK9 DMR predicts for increased TASK3 expression and mitochondrial membrane potential (p < 0.001). This is the first identification of the KCNK9 DMR in mammary epithelial cells and demonstration that its hypomethylation in breast cancer is associated with increases in both mitochondrial membrane potential and apoptosis resistance. The high frequency of hypomethylation of the KCNK9 DMR in TNBC and non-cancerous breast tissue from high-risk women provides evidence that hypomethylation of the KNCK9 DMR/TASK3 overexpression may serve as a marker of risk and a target for prevention of TNBC, particularly in African American women.

Suicide Evaluation in the Pediatric Emergency Setting.

Suicide is 1 of the top 3 leading causes of death in the pediatric population and a serious public health concern. There are evidence-based screening tools for suicide in the pediatric population; however, predicting suicide risks can be a difficult task. The emergency department is an essential source of mental health care for youths and can serve as an important opportunity for suicide screening and subsequent targeted interventions and resource management. More research is needed in emergency department-based screening algorithms and evidence-driven interventions in the pediatric population.

Beyond the Ability to Pay: The Health Status of Native Hawaiians and Other Pacific Islanders in Relationship to Health Insurance.

Native Hawaiians and Other Pacific Islanders (NHOPI) suffer from a number of poor health outcomes, such as high rates of overweight status, obesity, hypertension, and high rates of asthma and cancer mortality. In addition to a disproportionate burden of illness, barriers to health care access and utilization also exist. This study examines the effect of health insurance coverage on the health status of NHOPI in comparison to Asians. To analyze this relationship, the study uses the Behavioral Risk Factor Surveillance System (BRFSS) 2012 data and logistic regression. Findings show insured NHOPI were significantly more likely than insured Asian Americans to report poor or fair health after sequential cumulative adjustments of socioeconomic, lifestyle and behavioral factors, history of diagnosed diseases, and access to care (OR: 1.66, 95% CI:[1.34, 2.05]). Health insurance alone will not eliminate the present disparities experienced by NHOPI. Other barriers prohibit health care access for NHOPI that should be considered in the investigation and development of strategies to increase healthcare access and eliminate health disparities for NHOPI.

Fluoxetine induces cytotoxic endoplasmic reticulum stress and autophagy in triple negative breast cancer.

AIM: To investigate the mechanism of action of lipophilic antidepressant fluoxetine (FLX) in representative molecular subtypes of breast cancer. METHODS: The anti-proliferative effects and mechanistic action of FLX in triple-negative (SUM149PT) and luminal (T47D and Au565) cancer cells and non-transformed MCF10A were investigated. Reverse phase protein microarray (RPPM) was performed with and without 10 µmol/L FLX for 24 and 48 h to determine which proteins are significantly changed. Viability and cell cycle analysis were also performed to determine drug effects on cell growth. Western blotting was used to confirm the change in protein expression examined by RPPM or pursue other signaling proteins. RESULTS: The FLX-induced cell growth inhibition in all cell lines was concentration- and time-dependent but less pronounced in early passage MCF10A. In comparison to the other lines, cell growth reduction in SUM149PT coincided with significant induction of endoplasmic reticulum (ER) stress and autophagy after 24 and 48 h of 10 µmol/L FLX, resulting in decreased translation of proteins along the receptor tyrosine kinase/Akt/mammalian target of rapamycin pathways. The increase in autophagy marker, cleaved microtubule-associated protein 1 light chain 3, in SUM149PT after 24 h of FLX was likely due to increased metabolic demands of rapidly dividing cells and ER stress. Consequently, the unfolded protein response mediated by double-stranded RNA-dependent protein kinase-like ER kinase resulted in inhibition of protein synthesis, growth arrest at the G1 phase, autophagy, and caspase-7-mediated cell death. CONCLUSION: Our study suggests a new role for FLX as an inducer of ER stress and autophagy, resulting in death of aggressive triple negative breast cancer SUM149PT.

Src Inhibition Blocks c-Myc Translation and Glucose Metabolism to Prevent the Development of Breast Cancer.

Preventing breast cancer will require the development of targeted strategies that can effectively block disease progression. Tamoxifen and aromatase inhibitors are effective in addressing estrogen receptor-positive (ER(+)) breast cancer development, but estrogen receptor-negative (ER(-)) breast cancer remains an unmet challenge due to gaps in pathobiologic understanding. In this study, we used reverse-phase protein array to identify activation of Src kinase as an early signaling alteration in premalignant breast lesions of women who did not respond to tamoxifen, a widely used ER antagonist for hormonal therapy of breast cancer. Src kinase blockade with the small-molecule inhibitor saracatinib prevented the disorganized three-dimensional growth of ER(-) mammary epithelial cells in vitro and delayed the development of premalignant lesions and tumors in vivo in mouse models developing HER2(+) and ER(-) mammary tumors, extending tumor-free and overall survival. Mechanistic investigations revealed that Src blockade reduced glucose metabolism as a result of an inhibition in ERK1/2-MNK1-eIF4E-mediated cap-dependent translation of c-Myc and transcription of the glucose transporter GLUT1, thereby limiting energy available for cell growth. Taken together, our results provide a sound rationale to target Src pathways in premalignant breast lesions to limit the development of breast cancers.

Social justice in medical education: strengths and challenges of a student-driven social justice curriculum.

In the current rapidly evolving healthcare environment of the United States, social justice programs in pre-medical and medical education are needed to cultivate socially conscious and health professionals inclined to interdisciplinary collaborations. To address ongoing healthcare inequalities, medical education must help medical students to become physicians skilled not only in the biomedical management of diseases, but also in identifying and addressing social and structural determinants of the patients' daily lives. Using a longitudinal Problem-Based Learning (PBL) methodology, the medical students and faculty advisers at the University of Hawai'i John A. Burns School of Medicine (JABSOM) developed the Social Justice Curriculum Program (SJCP) to supplement the biomedical curriculum. The SJCP consists of three components: (1) active self-directed learning and didactics, (2) implementation and action, and (3) self-reflection and personal growth. The purpose of introducing a student-driven SJ curriculum is to expose the students to various components of SJ in health and medicine, and maximize engagement by using their own inputs for content and design. It is our hope that the SJCP will serve as a logistic and research-oriented model for future student-driven SJ programs that respond to global health inequalities by cultivating skills and interest in leadership and community service.

Patient and provider perspectives on using telemedicine for chronic disease management among Native Hawaiian and Alaska Native people.

BACKGROUND: Among indigenous populations in remote locations who are at increased risk for chronic diseases such as diabetes, telemedicine has the potential to improve access to health care services and thus may reduce adverse health outcomes. Yet few studies are available on how best to use telemedicine technology in reducing ethnic and racial health care disparities. OBJECTIVE: We examined perspectives of patients and providers in 2 indigenous populations in Alaska and Hawai'i about the use of telemedicine in primary care chronic disease management. DESIGN: Six focus groups with patients and providers at 2 sites (3 in Alaska and 3 in Hawai'i). RESULTS: Three broad themes were common to both sites: (a) benefits and barriers of using telemedicine; (b) building patient-provider relationships; and (c) elements of an acceptable telemedicine primary care encounter. Two key elements were endorsed by both patients and providers as important for an effective telemedicine encounter: (a) the initial patient-provider interaction should be face-to-face; and (b) patients must see the same provider on follow-up visits. CONCLUSION: The use of telemedicine in chronic disease management has potential to improve patient care in remote indigenous populations and may supplement patient-provider relationships.

Cultural competency training requirements in graduate medical education.

BACKGROUND: Cultural competency is an important skill that prepares physicians to care for patients from diverse backgrounds. OBJECTIVE: We reviewed Accreditation Council for Graduate Medical Education (ACGME) program requirements and relevant documents from the ACGME website to evaluate competency requirements across specialties. METHODS: The program requirements for each specialty and its subspecialties were reviewed from December 2011 through February 2012. The review focused on the 3 competency domains relevant to culturally competent care: professionalism, interpersonal and communication skills, and patient care. Specialty and subspecialty requirements were assigned a score between 0 and 3 (from least specific to most specific). Given the lack of a standardized cultural competence rating system, the scoring was based on explicit mention of specific keywords. RESULTS: A majority of program requirements fell into the low- or no-specificity score (1 or 0). This included 21 core specialties (leading to primary board certification) program requirements (78%) and 101 subspecialty program requirements (79%). For all specialties, cultural competency elements did not gravitate toward any particular competency domain. Four of 5 primary care program requirements (pediatrics, obstetrics-gynecology, family medicine, and psychiatry) acquired the high-specificity score of 3, in comparison to only 1 of 22 specialty care program requirements (physical medicine and rehabilitation). CONCLUSIONS: The degree of specificity, as judged by use of keywords in 3 competency domains, in ACGME requirements regarding cultural competency is highly variable across specialties and subspecialties. Greater specificity in requirements is expected to benefit the acquisition of cultural competency in residents, but this has not been empirically tested.

Geographical maldistribution of native Hawaiian and other Pacific Islander physicians in Hawai'i.

BACKGROUND: Native Hawaiians and other Pacific Islanders (NHOPI) have high prevalence of overweight status, obesity, and hypertension, as well as high rates of asthma and cancer mortality. Some barriers to health care delivery for this population are a physician shortage in Hawai'i and a geographical maldistribution of actively practicing physicians. This study examines the distribution of NHOPI physicians compared to the NHOPI population in Hawai'i through Geographical Information System choropleth mapping. METHODS: The maps and results were gathered and constructed from Census Tract data from the US Department of Commerce, the Census Bureau, the Physician Workforce Assessment, and the 'Ahahui o na Kauka reports. RESULTS: With the exception of East Honolulu, all areas of Hawai'i show drastic disparities in the ratio of NHOPI physicians to NHOPI populations as compared to the ratio of total physicians to the total population. DISCUSSION: Given the NHOPI physician shortage and their geographical maldistribution, this study underscores the importance of increasing the number of NHOPI medical school applicants, graduates, residents, and physicians in permanent active practices in rural areas and the neighbor islands. Current institutional and academic programs, such as the John A. Burns School of Medicine, Imi Ho'ola, and the Native Hawaiian Center of Excellence, are contributing to resolving some of the health disparities and should consider expanding their efforts.