Novel prognostic alternative splicing events in colorectal Cancer: Impact on immune infiltration and therapy response.

OBJECTIVE: This study aims to comprehensively analyze alternative splicing (AS) features in colorectal cancer (CRC) using integrative multi-omics and to elucidate their relationship with the CRC immune microenvironment. METHODS: Transcriptomic data, clinical information, and Percent Spliced In (PSI) values of AS events for CRC patients were obtained from The Cancer Genome Atlas (TCGA) and TCGA SpliceSeq databases. Differentially expressed AS events were identified. Univariate Cox analysis was used to pinpoint prognosis-related AS events. A prognostic risk model was developed and validated using multivariate Cox analysis, patient survival analysis, and the area under the receiver operating characteristic (ROC) curve (AUC). Gene Set Enrichment Analysis (GSEA), immune infiltration, immunotherapy, chemotherapy sensitivity analyses, and regulatory relationships between AS events and splicing factors (SFs) were conducted. Single-cell sequencing was used to study the distribution of key factors. siRNA and overexpression vectors were utilized to silence/overexpress BCAS1 in CRC cells and evaluate their effects on cell growth, migration, and invasion. Furthermore, the interaction between BCAS1 and ANO7 pre-mRNA was investigated using RIP-PCR. RESULTS: 82 prognosis-related AS events were identified in CRC patients. A 15-AS prognostic model was constructed, which correlated with immune cell infiltration and showed differences in immunotherapy and chemotherapy sensitivity. BCAS1 was identified as a potential regulator of the ANO7|58341|AT splicing event in CRC. Single-cell sequencing analysis revealed the distribution of BCAS1 and ANO7 in cancer stem cells. In vitro experiments demonstrated that overexpression of BCAS1 and silencing of ANO7 inhibit the proliferation, migration, and invasion of CRC cells. Moreover, BCAS1 suppresses the progression of CRC by modulating ANO7 alternative splicing. CONCLUSION: This study provides new insights into the role of alternative splicing in colorectal cancer, particularly the potential regulatory action of BCAS1 on the ANO7|58341|AT splicing event. It also identifies the impact of alternative splicing on the tumor microenvironment and potential implications for immunotherapy, highlighting its relevance for the in-depth study and treatment of CRC.

Calcite carbonate sinks low-density plastic debris in open oceans.

The vertical settling of plastic debris in oceans is poorly understood. A large share of low-density microplastics (LDMPs) are largely absent from sea surfaces. The present study employs a model that considers the potential of an overlooked microbially induced calcium carbonate precipitation (MICP) process and new motion equations for irregular LDMPs. Here we show that the motion of LDMPs in the present model, exhibiting a damped oscillation pattern, is quite different from that in biofouling models. Furthermore, LDMPs in the size range of 10-200 µm are most likely to gain sufficient density at the biofouling/MICP stage to independently sink to the ocean floor with relatively small drag coefficients, potentially explaining the selective enrichment of LDMPs in the oceanic sediment. The size and shape exhibit strong non-linear effects on the settling patterns of LDMPs. Overall, the present study highlights the importance of calcite-mediated sinking of LDMPs in open oceans.

Factors Influencing the Implementation of Infant Warming Devices Among Healthcare Workers in Malawian Hospitals.

Objectives. Preterm infants are at risk of hypothermia. This study described the available infant warming devices (IWDs) and explored the barriers and facilitators to their implementation in neonates in Malawi. Methods. A qualitative descriptive study was conducted among 19 health care workers in Malawi from January to March 2020. All interviews were digitally recorded, transcribed, and managed using NVivo and analyzed using a thematic approach. Results. The warming devices included radiant warmers, Blantyre hot-cots, wall-mounted heaters, portable warmers, and incubators. Inadequate equipment and infrastructure and gaps in staff knowledge and capacity were reported as the main challenges to optimal IWD implementation. Caregiver acceptance was described as the main facilitator. Strategies to optimize implementation of IWD included continuous practical training and adequate availability of equipment and spare parts. Conclusion. Implementation of warming devices for the management of neonatal hypothermia is effective when there are adequate human and material resources.

Per- and polyfluoroalkyl substances (PFAS) exposure in plasma and their blood-brain barrier transmission efficiency-A pilot study.

Per- and polyfluoroalkyl substances (PFAS) have been shown to penetrate the blood-brain barrier (BBB) and accumulate in human brain. The BBB transmission and accumulation efficiency of PFAS, as well as the potential health risks from human co-exposure to legacy and emerging PFAS due to differences in transport efficiency, need to be further elucidated. In the present pilot study, 23 plasma samples from glioma patients were analyzed for 17 PFAS. The concentrations of PFAS in six paired brain tissue and plasma samples were used to calculate the BBB transmission efficiency of PFAS (RPFAS). This RPFAS analysis was conducted with utmost care and consideration amid the limited availability of valuable paired samples. The results indicated that low molecular weight PFAS, including short-chain and emerging PFAS, may have a greater potential for accumulation in brain tissue than long-chain PFAS. As an alternative to perfluorooctane sulfonic acid (PFOS), 6:2 chlorinated polyfluorinated ether sulfonate (6:2 Cl-PFESA) exhibited brain accumulation potential similar to that of PFOS, suggesting it may not be a suitable substitute concerning health risk in brain. The BBB transmission efficiencies of perfluorooctanoic acid, PFOS, and 6:2 Cl-PFESA showed similar trends with age, which may be an important factor influencing the entry of exogenous compounds into the brain. A favorable link between perfluorooctane sulfonamide (FOSA) and the development and/or progression of glioma may be implicated by a strong positive correlation (r2 = 0.94; p < 0.01) between RFOSA and Ki-67 (a molecular marker of glioma). However, a causal relationship between RFOSA and glioma incidence were not established in the present study. The present pilot study conducted the first examination of BBB transmission efficiency of PFAS from plasma to brain tissue and highlighted the importance of reducing and/or controlling exposure to PFAS.

Risk factors for pre-eclampsia in clinical practice guidelines: Comparison with the evidence.

OBJECTIVE: To compare pre-eclampsia risk factors identified by clinical practice guidelines (CPGs) with risk factors from hierarchical evidence review, to guide pre-eclampsia prevention. DESIGN: Our search strategy provided hierarchical evidence of relationships between risk factors and pre-eclampsia using Medline (Ovid), searched from January 2010 to January 2021. SETTING: Published studies and CPGs. POPULATION: Pregnant women. METHODS: We evaluated the strength of association and quality of evidence (GRADE). CPGs (n = 15) were taken from a previous systematic review. MAIN OUTCOME MEASURE: Pre-eclampsia. RESULTS: Of 78 pre-eclampsia risk factors, 13 (16.5%) arise only during pregnancy. Strength of association was usually 'probable' (n = 40, 51.3%) and the quality of evidence was low (n = 35, 44.9%). The 'major' and 'moderate' risk factors proposed by 8/15 CPGs were not well aligned with the evidence; of the ten 'major' risk factors (alone warranting aspirin prophylaxis), associations with pre-eclampsia were definite (n = 4), probable (n = 5) or possible (n = 1), based on moderate (n = 4), low (n = 5) or very low (n = 1) quality evidence. Obesity ('moderate' risk factor) was definitely associated with pre-eclampsia (high-quality evidence). The other ten 'moderate' risk factors had probable (n = 8), possible (n = 1) or no (n = 1) association with pre-eclampsia, based on evidence of moderate (n = 1), low (n = 5) or very low (n = 4) quality. Three risk factors not identified by the CPGs had probable associations (high quality): being overweight; 'prehypertension' at booking; and blood pressure of 130-139/80-89 mmHg in early pregnancy. CONCLUSIONS: Pre-eclampsia risk factors in CPGs are poorly aligned with evidence, particularly for the strongest risk factor of obesity. There is a lack of distinction between risk factors identifiable in early pregnancy and those arising later. A refresh of the strategies advocated by CPGs is needed.

Transitioning from the "Three Delays" to a focus on continuity of care: a qualitative analysis of maternal deaths in rural Pakistan and Mozambique.

BACKGROUND: The Three Delays Framework was instrumental in the reduction of maternal mortality leading up to, and during the Millennium Development Goals. However, this paper suggests the original framework might be reconsidered, now that most mothers give birth in facilities, the quality and continuity of the clinical care is of growing importance. METHODS: The paper explores the factors that contributed to maternal deaths in rural Pakistan and Mozambique, using 76 verbal autopsy narratives from the Community Level Interventions for Pre-eclampsia (CLIP) Trial. RESULTS: Qualitative analysis of these maternal death narratives in both countries reveals an interplay of various influences, such as, underlying risks and comorbidities, temporary improvements after seeking care, gaps in quality care in emergencies, convoluted referral systems, and arrival at the final facility in critical condition. Evaluation of these narratives helps to reframe the pathways of maternal mortality beyond a single journey of care-seeking, to update the categories of seeking, reaching and receiving care. CONCLUSIONS: There is a need to supplement the pioneering "Three Delays Framework" to include focusing on continuity of care and the "Four Critical Connection Points": (1) between the stages of pregnancy, (2) between families and health care workers, (3) between health care facilities and (4) between multiple care-seeking journeys. TRIAL REGISTRATION: NCT01911494, Date Registered 30/07/2013.

Expression of ACE2, TMPRSS2, and SARS-CoV-2 nucleocapsid protein in gastrointestinal tissues from COVID-19 patients and association with gastrointestinal symptoms.

BACKGROUND: Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can infect the gastrointestinal (GI) tract in coronavirus disease 2019 (COVID-19) patients, the mechanism of GI tract injury is largely unknown. We aimed to study the potential factors that cause COVID-19 GI symptoms. METHODS: We investigated the expression and co-localization of angiotensin converting enzyme 2 (ACE2), transmembrane serine protease 2 (TMPRSS2), SARS-CoV-2 nucleocapsid protein (NP), and the severity of inflammation in GI tissues from COVID-19 patients (n = 19) by immunofluorescence and histopathologic staining, and then studied their associations with GI symptoms. RESULTS: Infected stomach tissues showed significantly higher ACE2 expression than uninfected ones, while infected duodenum tissues showed significantly higher TMPRSS2 expression than uninfected ones. The expression of TMPRSS2 exhibited a moderate correlation with viral NP across different GI tissues, while no significant association was observed between ACE2 and viral NP. Some GI symptoms such as diarrhea and nausea, were related to the expression level of ACE2, TMPRSS2 or the severity of inflammation. Furthermore, age and elevated aspartate transaminase were major risk factors for disease progression. CONCLUSIONS: ACE2 and TMPRSS2 were essential proteins in the SARS-CoV-2 infection of GI tract, while TMPRSS2 rather than ACE2 may play a more important role. GI symptoms may derive from the host receptor expression level and pro-inflammatory response in COVID-19 patients after viral infection of GI tissues, and further exacerbate the disease. So targeting TMPRSS2 and inflammation may represent an effective strategy for treating COVID-19 patients with GI symptoms.

Hydrophobic organic contaminants affiliated with polymer-specific microplastics in urban river tributaries and estuaries.

Exposure to microplastics (MPs) and hydrophobic organic contaminants (HOCs) combined at high concentrations may induce adverse effects to aquatic organisms in laboratory-scale studies. To determine environmentally relevant concentrations of HOCs in MPs, it is essential to understand the occurrence of MP-affiliated HOCs in the aquatic environment. Here we report the occurrences of HOCs affiliated with polymer-specific floating MPs from 12 tributaries and three estuaries in the Pearl River Delta, South China. Target HOCs include nine synthetic musks (SMs), 14 ultraviolet adsorbents (UVAs), 15 polycyclic aromatic hydrocarbons (PAHs), eight polybrominated diphenyl ethers (PBDEs), and 14 polychlorinated biphenyls (PCBs). Average concentrations of MP-affiliated ∑9SM, ∑14UVA, ∑15PAH, ∑8PBDE, and ∑14PCB were 1790, 5550, 1090, 412, and 107 ng g-1, respectively. The average concentrations of HOCs affiliated with MPs of different polymer types were 9790, 7220, 72,500, and 55,800 ng g-1 for polyethylene (PE), polypropylene, polystyrene, and other MPs, respectively. As the concentration of PE was the highest among all MPs at the average concentration of 0.77 mg m-3, the monthly outflow of PE-affiliated HOCs accounted for the largest proportion (46 %) in the outflow of MP-affiliated HOCs (2.8 g) to the coastal ocean via three estuaries. These results suggest that HOCs were highly concentrated in MPs and varied among different chemicals and polymer types. Due to the differences of polymer characteristics and half-life of affiliated chemicals, future toxicology studies concerning exposure to these combined pollutants may need to specify polymer types and their affiliated chemicals.

Caregiver perceptions of nutrition interventions in infants and children under 24 months of age: a systematic review.

OBJECTIVE: Efficacy studies show early nutrition interventions improving infant nutrition status, but understanding caregiver acceptability is required for implementation of such interventions. This systematic review examines caregivers' perceptions of nutrition interventions in young children. DESIGN: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL and PsychINFO from date of online journal inception through December 2020. Interventions included oral (powder/liquid/tablet) and/or intravenous supplementation, food fortification and nutrition counselling. Inclusion criteria included primary research, data presented on caregiver perception and studies published in English. Quality assessment was performed using the Critical Appraisal Skills Programme tool. Studies underwent narrative synthesis using inductive thematic analysis. SETTING: No restriction. PARTICIPANTS: Caregivers of children under 24 months of age. RESULTS: Of 11 798 records identified, thirty-seven publications were included. Interventions included oral supplementation, food fortification and nutrition counselling. Caregivers included mothers (83 %), fathers, grandparents and aunts. Perceptions were gathered through individual interviews, focus group discussions, questionnaires, surveys and ratings. Totally, 89 % of studies noted high acceptability (n 33 most notably increased appetite (n 17). In total, 57 % of studies (n 21) cited low acceptability, commonly from side effects (n 13) such as gastrointestinal issues, appetite loss and stained teeth. CONCLUSIONS: Positive perceptions and enthusiasm for interventions were frequently reported. Key to implementation was the increased appetite noted by caregivers. A substantial proportion of studies reported negative perceptions, mainly due to side effects. In future interventions, mitigation and education around common side effects are crucial for acceptability. Understanding both positive and negative caregiver perceptions is important for informing future nutrition interventions and strengthening sustainability and implementation.

The influence of complex matrices on method performance in extracting and monitoring for microplastics.

Previous studies have evaluated method performance for quantifying and characterizing microplastics in clean water, but little is known about the efficacy of procedures used to extract microplastics from complex matrices. Here we provided 15 laboratories with samples representing four matrices (i.e., drinking water, fish tissue, sediment, and surface water) each spiked with a known number of microplastic particles spanning a variety of polymers, morphologies, colors, and sizes. Percent recovery (i.e., accuracy) in complex matrices was particle size dependent, with ∼60-70% recovery for particles >212 µm, but as little as 2% recovery for particles <20 µm. Extraction from sediment was most problematic, with recoveries reduced by at least one-third relative to drinking water. Though accuracy was low, the extraction procedures had no observed effect on precision or chemical identification using spectroscopy. Extraction procedures greatly increased sample processing times for all matrices with the extraction of sediment, tissue, and surface water taking approximately 16, 9, and 4 times longer than drinking water, respectively. Overall, our findings indicate that increasing accuracy and reducing sample processing times present the greatest opportunities for method improvement rather than particle identification and characterization.

Plastic waste discharge to the global ocean constrained by seawater observations.

Marine plastic pollution poses a potential threat to the ecosystem, but the sources and their magnitudes remain largely unclear. Existing bottom-up emission inventories vary among studies for two to three orders of magnitudes (OMs). Here, we adopt a top-down approach that uses observed dataset of sea surface plastic concentrations and an ensemble of ocean transport models to reduce the uncertainty of global plastic discharge. The optimal estimation of plastic emissions in this study varies about 1.5 OMs: 0.70 (0.13-3.8 as a 95% confidence interval) million metric tons yr-1 at the present day. We find that the variability of surface plastic abundance caused by different emission inventories is higher than that caused by model parameters. We suggest that more accurate emission inventories, more data for the abundance in the seawater and other compartments, and more accurate model parameters are required to further reduce the uncertainty of our estimate.

Country-specific riverine contributions to marine plastic pollution.

Marine plastic debris are mainly derived from land-based sources, and the transport of plastics via global rivers is of great concern. Ample efforts have been made in estimating the land-based contributions of plastic to the global oceans, but quantifying country-specific (and per capita) riverine outflows is an important step toward the development of a globally integrated framework to mitigate marine plastic pollution. To estimate the country-specific riverine contributions to global marine plastic pollution, we built a River-to-Ocean model framework. In 2016, the median annual country-specific riverine plastic outflows and related per capita values for 161 countries varied between 0.76 and 103,000 metric tons (MT) and 0.83-248 g, respectively. India, China, and Indonesia were the top three contributors to riverine plastic outflows, whereas Guatemala, Philippines, and Colombia had the highest per capita riverine plastic outflows. The total riverine plastic outflow from 161 countries was in the range of 0.15-0.53 million MT annually, accounting for 0.4 %-1.3 % of the 40 million MT plastic waste generated yearly by more than seven billion humans. Population, plastic waste generation, and Human Development Index are the dominant factors influencing riverine plastic outflows to global oceans from individual countries. Our findings provide an important basis for launching effective plastic pollution management and control measures in global countries.

The development and implementation of a community engagement strategy to improve maternal health in southern Mozambique.

Delays to seek medical help can contribute to maternal deaths particularly in community settings at home or on the road to a health facility. Community engagement (CE) can improve care-seeking behaviours and complements community-based interventions strengthening maternal health. The purpose of this paper is to describe the process undertaken to develop and implement a large-scale community engagement strategy in rural southern Mozambique. The CE strategy was developed within the context of the "Community-Level Interventions for Pre-eclampsia" (NCT01911494) conducted between 2015-2017 in southern Mozambique. Key CE messages included pregnancy complications and their warning signs, including pre-eclampsia and eclampsia, as well as emergency readiness, birth preparedness, decision-making mechanisms, transport options and information about the trial. CE meeting logs were used to record quantitative and qualitative information on demographic data and feedback. Quantitative data was analyzed using RStudio (RStudio Inc, Boston, United States) and community feedback was qualitatively analyzed on NVivo12 (QSR International, Melbourne, Australia). CE activities reached 19,169 participants during 4,239 meetings. CE activities were reported to be well received by community members though there was a relatively lower participation of men (3565 /18.6%). The use of recognized local leaders and personnel, such as community leaders, nurses and community health workers, allowed for greater acceptance of CE activities and maximized coverage of health messages in the community setting. Our CE strategy was effective in integrating maternal health promoting activities in routine care of community health workers and nurses in the area. Understanding district differences, engaging husbands, partners, mothers-in-law and community-level decision-makers to build local support for maternal health and flexibility to tailor messages to local needs were important in developing sustainable forms of CE. Better strategies are needed to effectively engage men in maternal health promotion who were less available due to working outside of the home or neighbourhoods.

Environmental fate of microplastics in an urban river: Spatial distribution and seasonal variation.

Rivers are recognized as an important pathway for transport of microplastics (MPs) from land to sea, but limited information is available on the spatial distribution and seasonal variation of riverine MPs from upper reaches to estuaries. Such information is critical for source apportionment and development of effective management measures for riverine MPs. To fill the knowledge gap, we investigated the occurrence of MPs in surface water along an urban river in Guangzhou, southern China in wet and dry seasons. The abundances of MPs from 16 sampling sites in the wet and dry seasons varied from 0.123 to 1.84 particles m-3 and from 0.046 to 4.21 particles m-3, respectively. The spatial distribution of MP abundances showed an increasing trend from upstream to midstream and a decreasing trend from midstream to downstream and estuaries. The abundances of MPs peaked at the midstream, which is surrounded by a highly urbanized region with high population density (∼2530 persons per km2). The large surface water runoff during the wet season elevated the MP abundance in riverine water, except for that flowing through the central urban area where the abundance of MPs collected in the dry season was higher than that in the wet season. This was mainly ascribed to the large input from extensive anthropogenic activities and slow water flow rate in urban areas. The estimated monthly riverine MP fluxes from Humen, Hongqili, and Jiaomen were 7.42, 2.38, and 2.3 billion particles, respectively, in the wet season, and 0.86, 0.71, and 0.19 billion particles, respectively, in the dry season. An increase of riverine MP fluxes from Humen, Hongqili, and Jiaomen in the past three years was evident. The results from the present study provide valuable information for source apportionment of riverine MPs and support the initialization of possible MPs controlling measures.

Neonatal Intensive Care Unit Interventions to Improve Breastfeeding Rates at Discharge Among Preterm and Low Birth Weight Infants: A Systematic Review and Meta-Analysis.

Background: While breast milk is widely accepted as the best source of nutrients for almost all newborns, breastfeeding can be especially challenging for preterm and low birth weight (LBW) infants. With increased risk of admission to neonatal intensive care units (NICUs) and separation from parents, this population experiences significant barriers to successful breastfeeding. Thus, it is crucial to identify interventions that can optimize breastfeeding for preterm and LBW infants that is continued from birth and admission, through to hospital discharge and beyond. Objectives: To identify and analyze evidence-based interventions that promote any and exclusive breastfeeding among preterm and LBW neonates at discharge and/or postdischarge from hospital. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. Searches were performed in the following databases: MEDLINE Ovid, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health (CINAHL). Results: From the 42 studies included, 6 groups of intervention types were identified: educational and breastfeeding support programs, early discharge, oral stimulation, artificial teats and cups, kangaroo mother care (KMC), and supportive policies within NICUs. All groupings of interventions were associated with significantly increased rates of any breastfeeding at discharge. All types of interventions except artificial teats/cups and oral stimulation showed statistically significant increases in exclusive breastfeeding at discharge. KMC demonstrated the highest increased odds of breastfeeding at discharge among preterm and LBW infants. Conclusions: A variety of effective interventions exist to promote breastfeeding among hospitalized preterm and LBW infants. Hospital settings hold unique opportunities for successful breastfeeding promotion. PROSPERO registration: CRD42021252610.

An evidence review and nutritional conceptual framework for pre-eclampsia prevention.

Pre-eclampsia is a serious complication of pregnancy, and maternal nutritional factors may play protective roles or exacerbate risk. The tendency to focus on single nutrients as a risk factor obscures the complexity of possible interactions, which may be important given the complex nature of pre-eclampsia. An evidence review was conducted to compile definite, probable, possible and indirect nutritional determinants of pre-eclampsia to map a nutritional conceptual framework for pre-eclampsia prevention. Determinants of pre-eclampsia were first compiled through an initial consultation with experts. Second, an expanded literature review was conducted to confirm associations, elicit additional indicators and evaluate evidence. The strength of association was evaluated as definite relative risk (RR) < 0·40 or ≥3·00, probable RR 0·40-0·69 or 1·50-2·99, possible RR 0·70-0·89 or 1·10-1·49 or not discernible RR 0·90-1·09. The quality of evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluation. Twenty-five nutritional factors were reported in two umbrella reviews and twenty-two meta-analyses. Of these, fourteen were significantly associated with pre-eclampsia incidence. Higher serum Fe emerged as a definite nutritional risk factors for pre-eclampsia incidence across populations, while low serum Zn was a risk factor in Asia and Africa. Maternal vitamin D deficiency was a probable risk factor and Ca and/or vitamin D supplementation were probable protective nutritional factors. Healthy maternal dietary patterns were possibly associated with lower risk of developing pre-eclampsia. Potential indirect pathways of maternal nutritional factors and pre-eclampsia may exist through obesity, maternal anaemia and gestational diabetes mellitus. Research gaps remain on the influence of household capacities and socio-cultural, economic and political contexts, as well as interactions with medical conditions.

Acceptability and Feasibility of a Low-Cost Device for Gestational Age Assessment in a Low-Resource Setting: Qualitative Study.

BACKGROUND: Ultrasound for gestational age (GA) assessment is not routinely available in resource-constrained settings, particularly in rural and remote locations. The TraCer device combines a handheld wireless ultrasound probe and a tablet with artificial intelligence (AI)-enabled software that obtains GA from videos of the fetal head by automated measurements of the fetal transcerebellar diameter and head circumference. OBJECTIVE: The aim of this study was to assess the perceptions of pregnant women, their families, and health care workers regarding the feasibility and acceptability of the TraCer device in an appropriate setting. METHODS: A descriptive study using qualitative methods was conducted in two public health facilities in Kilifi county in coastal Kenya prior to introduction of the new technology. Study participants were shown a video role-play of the use of TraCer at a typical antenatal clinic visit. Data were collected through 6 focus group discussions (N=52) and 18 in-depth interviews. RESULTS: Overall, TraCer was found to be highly acceptable to women, their families, and health care workers, and its implementation at health care facilities was considered to be feasible. Its introduction was predicted to reduce anxiety regarding fetal well-being, increase antenatal care attendance, increase confidence by women in their care providers, as well as save time and cost by reducing unnecessary referrals. TraCer was felt to increase the self-image of health care workers and reduce time spent providing antenatal care. Some participants expressed hesitancy toward the new technology, indicating the need to test its performance over time before full acceptance by some users. The preferred cadre of health care professionals to use the device were antenatal clinic nurses. Important implementation considerations included adequate staff training and the need to ensure sustainability and consistency of the service. Misconceptions were common, with a tendency to overestimate the diagnostic capability, and expectations that it would provide complete reassurance of fetal and maternal well-being and not primarily the GA. CONCLUSIONS: This study shows a positive attitude toward TraCer and highlights the potential role of this innovation that uses AI-enabled automation to assess GA. Clarity of messaging about the tool and its role in pregnancy is essential to address misconceptions and prevent misuse. Further research on clinical validation and related usability and safety evaluations are recommended.

Health worker perspectives of Smart Triage, a digital triaging platform for quality improvement at a referral hospital in Uganda: a qualitative analysis.

BACKGROUND: Effective triage at hospitals can improve outcomes for children globally by helping identify and prioritize care for those most at-risk of death. Paper-based pediatric triage guidelines have been developed to support frontline health workers in low-resource settings, but these guidelines can be challenging to implement. Smart Triage is a digital triaging platform for quality improvement (QI) that aims to address this challenge. Smart Triage represents a major cultural and behavioural shift in terms of managing patients at health facilities in low-and middle-income countries. The purpose of this study is to understand user perspectives on the usability, feasibility, and acceptability of Smart Triage to inform ongoing and future implementation. METHODS: This was a descriptive qualitative study comprising of face-to-face interviews with health workers (n = 15) at a regional referral hospital in Eastern Uganda, conducted as a sub-study of a larger clinical trial to evaluate Smart Triage (NCT04304235). Thematic analysis was used to assess the usability, feasibility, and acceptability of the platform, focusing on its use in stratifying and prioritizing patients according to their risk and informing QI initiatives implemented by health workers. RESULTS: With appropriate training and experience, health workers found most features of Smart Triage usable and feasible to implement, and reported the platform was acceptable due to its positive impact on reducing the time to treatment for emergency pediatric cases and its use in informing QI initiatives within the pediatric ward. Several factors that reduced the feasibility and acceptability were identified, including high staff turnover, a lack of medical supplies at the hospital, and challenges with staff attitudes. CONCLUSION: Health workers can use the Smart Triage digital triaging platform to identify and prioritize care for severely ill children and improve quality of care at health facilities in low-resource settings. Future innovation is needed to address identified feasibility and acceptability challenges; however, this platform could potentially address some of the challenges to implementing current paper-based systems.