Risk-Stratified Screening for Colorectal Cancer Using Genetic and Environmental Risk Factors: A Cost-Effectiveness Analysis Based on Real-World Data.

BACKGROUND & AIMS: Previous studies on the cost-effectiveness of personalized colorectal cancer (CRC) screening were based on hypothetical performance of CRC risk prediction and did not consider the association with competing causes of death. In this study, we estimated the cost-effectiveness of risk-stratified screening using real-world data for CRC risk and competing causes of death. METHODS: Risk predictions for CRC and competing causes of death from a large community-based cohort were used to stratify individuals into risk groups. A microsimulation model was used to optimize colonoscopy screening for each risk group by varying the start age (40-60 years), end age (70-85 years), and screening interval (5-15 years). The outcomes included personalized screening ages and intervals and cost-effectiveness compared with uniform colonoscopy screening (ages 45-75, every 10 years). Key assumptions were varied in sensitivity analyses. RESULTS: Risk-stratified screening resulted in substantially different screening recommendations, ranging from a one-time colonoscopy at age 60 for low-risk individuals to a colonoscopy every 5 years from ages 40 to 85 for high-risk individuals. Nevertheless, on a population level, risk-stratified screening would increase net quality-adjusted life years gained (QALYG) by only 0.7% at equal costs to uniform screening or reduce average costs by 1.2% for equal QALYG. The benefit of risk-stratified screening improved when it was assumed to increase participation or costs less per genetic test. CONCLUSIONS: Personalized screening for CRC, accounting for competing causes of death risk, could result in highly tailored individual screening programs. However, average improvements across the population in QALYG and cost-effectiveness compared with uniform screening are small.

Epidemiology and Prehospital Care of Pediatric Unintentional Injuries Among Countries with Different Economic Status in Asia: A Cross-National, Multi-Center Observational Study.

OBJECTIVE: Injury is a major cause of morbidity and mortality in children. However, the epidemiology and prehospital care for pediatric unintentional injuries in Asia are still unclear. METHODS: A total of 9,737 pediatric patients aged <18 years with unintentional injuries cared for at participating centers of the Pan-Asian Trauma Outcome Study (PATOS) from October 2015 to December 2020 were reviewed retrospectively. Patients were divided into two groups: those <8 and those ≥8 years of age. Variables such as patient demographics, injury epidemiology, Injury Severity Score (ISS), and prehospital care were collected. Injury severity and administered prehospital care stratified by gross national income were also analyzed. RESULTS: Pediatric unintentional injuries accounted for 9.4% of EMS-transported trauma cases in the participating Asian centers, and the mortality rate was 0.88%. The leading cause of injury was traffic injuries in older children aged ≥8 years (56.5%), while falls at home were common among young children aged <8 years (43.9%). Compared with younger children, older children with similar ISS tended to receive more prehospital interventions. Uneven disease severity was found in that older children in lower-middle and upper-middle-income countries had higher ISS compared with those in high-income countries. The performance of prehospital interventions also differed among countries with different gross national incomes. Immobilizations were the most performed prehospital intervention followed by oxygen administration, airway management, and pain control; only one patient received prehospital thoracentesis. Procedures were performed more frequently in high-income countries than in upper-middle-income and lower-middle-income countries. CONCLUSIONS: The major cause of injury was road traffic injuries in older children, while falls at home were common among young children. Prehospital care in pediatric unintentional injuries in Asian countries was not standardized and might be insufficient, and the economic status of countries may affect the implementation of prehospital care.

A Survey of the Criteria Used for the Selection of Alternative Comparator Products by Participating Regulators and Organizations of the International Pharmaceutical Regulators Programme.

The safety and efficacy of a generic product are partly based on demonstrating bioequivalence to the innovator product; however, when the innovator product is no longer available as a comparator product, a survey conducted within the Bioequivalence Working Group for Generics (BEWGG) of the International Pharmaceutical Regulators Programme (IPRP) indicated that the criteria for selecting an alternative comparator product varies. For most members of the BEWGG, an existing marketed generic that was approved based on a comparison with the locally registered innovator product can be used, contingent on criteria that ranges from allowing any generic to be used, to allowing only specific criteria-defined generics to be used. Notwithstanding the acceptability of a generic as an alternative comparator, it is not always the preferred comparator for several jurisdictions. Some jurisdictions require the use of a locally sourced alternative innovator comparator (e.g., the same medicinal ingredient manufactured by a different company) or a foreign innovator comparator. Unlike the other members of the BEWGG, the European Union (EU) has no such options available, rather mechanisms are in place to allow manufacturers to develop a new comparator. The criteria described herein regarding the use of an alternative comparator product can also be applied to scenarios where a specific strength of a series of strengths or an innovative fixed dose combination are discontinued. The results of the survey demonstrate that while criteria for selecting alternative comparator products are not harmonized among the BEWGG participants, the common concern for all jurisdictions is to select a comparator product that meets the safety and efficacy standards of the original innovator product.

Investigation of the discriminatory ability of analytes for the bioequivalence assessment of ezetimibe: Parent drug, metabolite, total form, and combination of parent drug and total form.

The analysis of parent drug is usually the design of choice for a bioequivalence (BE) study. However, there is a controversy regarding the choice of analytes between EMA and USFDA for the BE study of ezetimibe (EZE). The EMA recommends measuring the total form alone, that means the sum of the concentration of "parent" EZE and "metabolite" ezetimibe-glucuronide (EZEG), as the BE determination. On the other hand, the USFDA recommends measuring not only total form but also EZE. The aim of this study was to employ a simulation approach to determine which analyte (e.g., EZE alone, EZEG alone, total form alone, or combination of EZE and total form) was more appropriate for use as a BE indicator. The previously published pharmacokinetic model of EZE and EZEG with enterohepatic circulation was used to generate virtual BE studies. Eight different scenarios were performed with changes in the rate of absorption of EZE and EZEG. Five hundred virtual BE studies were generated for each scenario. In addition, the discriminatory ability of selected analytes for detecting differences in the rate of absorption of EZE and EZEG was evaluated based on power curve performance. The results obtained through simulations indicated that none of the single analytes (EZE alone, EZEG alone, and total form alone) could have clear advantages in terms of discriminatory ability. Therefore, it was recommended that a combination of EZE and total form should be used in the BE assessment.

Estimating the excess bed days and economic burden of healthcare-associated infections in Singapore public acute-care hospitals.

We estimated the annual bed days lost and economic burden of healthcare-associated infections to Singapore hospitals using Monte Carlo simulation. The mean (standard deviation) cost of a single healthcare-associated infection was S$1,809 (S$440) [or US$1,362 (US$331)]. This translated to annual lost bed days and economic burden of 55,978 (20,506) days and S$152.0 million (S$37.1 million) [or US$114.4 million (US$27.9 million)], respectively.

Systematic literature review of the disease burden and vaccination of pneumococcal disease among adults in select Asia-Pacific areas.

INTRODUCTION: Pneumococcal diseases are common and cause significant morbidity and mortality, with higher rates especially in developing areas including many in the Asia-Pacific (AP) region. However, current strategies to prevent pneumococcal disease in adults are quite complicated and not well implemented among many AP areas, and vaccination coverage rates among adults are generally low or perceived as low in the region. Thus, this literature review's purpose was to summarize the disease burden and vaccination against pneumococcal diseases among adults in select AP areas (Australia, Hong Kong, India, Indonesia, South Korea, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand, and Vietnam). AREAS COVERED: This systematic review included published articles from January 2010 to August 2020 using MEDLINE/Embase. Grey literature websites were searched for national immunization programs and medical society vaccination recommendations from areas of interest. A total of 69 publications were identified. EXPERT OPINION: In the AP region, pneumococcal disease burden and serotype prevalence are variable among adult populations, particularly among older adults. Data was provided primarily from countries with established national immunization programs (NIPs). Further research on the disease burden and emphasis on the benefits of vaccination in AP areas lacking pneumococcal vaccination programs is warranted.

Requirements for Additional Strength Biowaivers for Modified Release Solid Oral Dosage Forms in International Pharmaceutical Regulators Programme Participating Regulators and Organisations: Differences and Commonalities.

This article describes an overview of waivers of in vivo bioequivalence studies for additional strengths in the context of the registration of modified release generic products and is a follow-up to the recent publication for the immediate release solid oral dosage forms. The current paper is based on a survey among the participating members of the Bioequivalence Working Group for Generics (BEWGG) of the International Pharmaceutical Regulators Program (IPRP) regarding this topic. Most jurisdictions consider the extrapolation of bioequivalence results obtained with one (most sensitive) strength of a product series as less straightforward for modified release products than for immediate release products. There is consensus that modified release products should demonstrate bioequivalence not only in the fasted state but also in the fed state, but differences exist regarding the necessity of additional multiple dose studies. Fundamental differences between jurisdictions are revealed regarding requirements on the quantitative composition of different strengths and the differentiation of single and multiple unit dosage forms. Differences in terms of in vitro dissolution requirements are obvious, though these are mostly related to possible additional comparative investigations rather than regarding the need for product-specific methods. As with the requirements for immediate release products, harmonization of the various regulations for modified release products is highly desirable to conduct the appropriate studies from a scientific point of view, thus ensuring therapeutic equivalence.

Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis.

BACKGROUND: Thirty countries with the highest tuberculosis (TB) burden bear 87% of the world's TB cases. Delayed diagnosis and treatment are detrimental to TB prognosis and sustain TB transmission in the community, making TB elimination a great challenge, especially in these countries. Our objective was to elucidate the duration and determinants of delayed diagnosis and treatment of pulmonary TB in high TB-burden countries. METHODS: We conducted a systematic review and meta-analysis of quantitative and qualitative studies by searching four databases for literature published between 2008 and 2018 following PRISMA guidelines. We performed a narrative synthesis of the covariates significantly associated with patient, health system, treatment, and total delays. The pooled median duration of delay and effect sizes of covariates were estimated using random-effects meta-analyses. We identified key qualitative themes using thematic analysis. RESULTS: This review included 124 articles from 14 low- and lower-middle-income countries (LIC and LMIC) and five upper-middle-income countries (UMIC). The pooled median duration of delays (in days) were-patient delay (LIC/LMIC: 28 (95% CI 20-30); UMIC: 10 (95% CI 10-20), health system delay (LIC/LMIC: 14 (95% CI 2-28); UMIC: 4 (95% CI 2-4), and treatment delay (LIC/LMIC: 14 (95% CI 3-84); UMIC: 0 (95% CI 0-1). There was consistent evidence that being female and rural residence was associated with longer patient delay. Patient delay was also associated with other individual, interpersonal, and community risk factors such as poor TB knowledge, long chains of care-seeking through private/multiple providers, perceived stigma, financial insecurities, and poor access to healthcare. Organizational and policy factors mediated health system and treatment delays. These factors included the lack of resources and complex administrative procedures and systems at the health facilities. We identified data gaps in 11 high-burden countries. CONCLUSIONS: This review presented the duration of delays and detailed the determinants of delayed TB diagnosis and treatment in high-burden countries. The gaps identified could be addressed through tailored approaches, education, and at a higher level, through health system strengthening and provision of universal health coverage to reduce delays and improve access to TB diagnosis and care. PROSPERO registration: CRD42018107237.

An analysis of national action plans on antimicrobial resistance in Southeast Asia using a governance framework approach.

The complex problem of antimicrobial resistance (AMR) is spread across human health, animal health, and the environment. The Global Action Plan (GAP) on AMR and context-specific national action plans (NAPs) were developed to combat this problem. To date, there is no systematic content analysis of NAPs from countries of the Association of Southeast Asia Nations (ASEAN). As the validity periods of most NAPs are ending, an analysis now will provide an opportunity to improve subsequent iterations of these NAPs. We analysed the current NAPs of ten ASEAN countries. We explored their objective alignment with GAP and performed content analysis using an AMR governance framework. Themes were broadly classified under five governance areas: policy design, implementation tools, monitoring and evaluation, sustainability, and One Health engagement. We identified policy priorities, useful features of NAPs, and specific areas that should be strengthened, including accountability, sustained engagement, equity, behavioural economics, sustainability plans and transparency, international collaboration, as well as integration of the environmental sector. Enhancement of these areas and adoption of best practices will drive improved policy formulation and its translation into effective implementation.

A Survey of the Regulatory Requirements for the Waiver of In Vivo Bioequivalence Studies of Generic Products in Certain Dosage Forms by Participating Regulators and Organisations of the International Pharmaceutical Regulators Programme.

The requirements to waive in vivo bioequivalence studies for immediate release solid oral dosage forms based on the Biopharmaceutics Classifications System (BCS) are well known, and biowaivers[1] for other types of oral dosage forms based on pre-defined criteria may also be acceptable. Similarly, biowaivers for dosage forms such as injectable products may also be allowed if certain criteria are met. The current paper summarises the biowaiver requirements for oral solutions and suspensions, soft gelatin capsules and injectable products (intravenous injections, subcutaneous and intramuscular injections, emulsions for injection and micellar solutions for injection) among the participants of the Bioequivalence Working Group for Generics (BEWGG) of the International Pharmaceutical Regulators Programme (IPRP). A review of the requirements indicated that there was a trend towards convergence when the dosage form became less complex; however, the most common approach used by each of the jurisdictions was a case-by-case approach given that most jurisdictions do not have well defined guidelines to support all possible scenarios. Even in the simplest case of intravenous solutions, the acceptability of qualitative changes in excipients differ between the IPRP members.  Notwithstanding the differences, the dissemination of the information is a first step towards regulatory convergence regarding biowaivers for certain dosage forms and should be useful for pharmaceutical companies currently developing generic medicinal products for IPRP jurisdictions.

Assessment of green tea reductive degradation of halogenated solvents.

Green tea (GT) leaves can be brewed into a solution rich in polyphenols that serve as effective reducing agents, and the complexes formed by combining green tea with ferrous ion (GT/Fe(II)) can provide an elevated reduction potential. The dissociated GT polyphenols at alkaline pH can dramatically increase the formation of GT/Fe(II) complexes. This experimental work evaluated the reductive reactivity of alkaline GT solution and GT/Fe(II) complexes (at pH 10) on 14 halogenated volatile organic compounds (VOCs). Carbon tetrachloride (CT), with a highest carbon oxidation state (COS) of IV, was observed to be degradable by the alkaline GT solution, while all others proved ineffective. The GT/Fe(II) complexes are very reactive and capable of degrading halogenated methanes, ethanes, and ethenes, in which chemical structures exhibit zero or positive COS values, and the chlorine or bromine atom is bonded at the saturated carbon atom, such as CT, chloroform, bromoform, dibromomethane, 1,1,1-trichloroethane, and 1,1,1,2-tetrachloroethane. The linear free energy relationship (LFER) approach was used to determine the overall reduction potentials (EH0) of the alkaline GT solution and GT/Fe(II) complexes, which were found to be -0.131 V and -0.368 V, respectively. These findings demonstrated that GT/Fe(II) complexes exhibit the potential to remediate halogenated contaminants and the EH0 information obtained in this study may serve as a reference in determining probable reactivity that contributes to degradation of environmental contaminants.

Gaussian process regression for survival time prediction with genome-wide gene expression.

Predicting the survival time of a cancer patient based on his/her genome-wide gene expression remains a challenging problem. For certain types of cancer, the effects of gene expression on survival are both weak and abundant, so identifying non-zero effects with reasonable accuracy is difficult. As an alternative to methods that use variable selection, we propose a Gaussian process accelerated failure time model to predict survival time using genome-wide or pathway-wide gene expression data. Using a Monte Carlo expectation-maximization algorithm, we jointly impute censored log-survival time and estimate model parameters. We demonstrate the performance of our method and its advantage over existing methods in both simulations and real data analysis. The real data that we analyze were collected from 513 patients with kidney renal clear cell carcinoma and include survival time, demographic/clinical variables, and expression of more than 20 000 genes. In addition to the right-censored survival time, our method can also accommodate left-censored or interval-censored outcomes; and it provides a natural way to combine multiple types of high-dimensional -omics data. An R package implementing our method is available in the Supplementary material available at Biostatistics online.

Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe.

The COVID-19 pandemic is an unprecedented global crisis. Many countries have implemented restrictions on population movement to slow the spread of severe acute respiratory syndrome coronavirus 2 and prevent health systems from becoming overwhelmed; some have instituted full or partial lockdowns. However, lockdowns and other extreme restrictions cannot be sustained for the long term in the hope that there will be an effective vaccine or treatment for COVID-19. Governments worldwide now face the common challenge of easing lockdowns and restrictions while balancing various health, social, and economic concerns. To facilitate cross-country learning, this Health Policy paper uses an adapted framework to examine the approaches taken by nine high-income countries and regions that have started to ease COVID-19 restrictions: five in the Asia Pacific region (ie, Hong Kong [Special Administrative Region], Japan, New Zealand, Singapore, and South Korea) and four in Europe (ie, Germany, Norway, Spain, and the UK). This comparative analysis presents important lessons to be learnt from the experiences of these countries and regions. Although the future of the virus is unknown at present, countries should continue to share their experiences, shield populations who are at risk, and suppress transmission to save lives.

The Perfect Moral Storm: Diverse Ethical Considerations in the COVID-19 Pandemic.

The COVID-19 pandemic has both exposed and created deep rifts in society. It has thrust us into deep ethical thinking to help justify the difficult decisions many will be called upon to make and to protect from decisions that lack ethical underpinnings. This paper aims to highlight ethical issues in six different areas of life highlighting the enormity of the task we are faced with globally. In the context of COVID-19, we consider health inequity, dilemmas in triage and allocation of scarce resources, ethical issues associated with research, ethical considerations relating to tracing apps, and exit strategies such as immunity passports and COVID-19 vaccines. Finally, we consider environmental issues in light of COVID-19. The paper also offers some ethical reflection on these areas as many parts of the world contemplate the recovery phase.

Assessment of polygenic architecture and risk prediction based on common variants across fourteen cancers.

Genome-wide association studies (GWAS) have led to the identification of hundreds of susceptibility loci across cancers, but the impact of further studies remains uncertain. Here we analyse summary-level data from GWAS of European ancestry across fourteen cancer sites to estimate the number of common susceptibility variants (polygenicity) and underlying effect-size distribution. All cancers show a high degree of polygenicity, involving at a minimum of thousands of loci. We project that sample sizes required to explain 80% of GWAS heritability vary from 60,000 cases for testicular to over 1,000,000 cases for lung cancer. The maximum relative risk achievable for subjects at the 99th risk percentile of underlying polygenic risk scores (PRS), compared to average risk, ranges from 12 for testicular to 2.5 for ovarian cancer. We show that PRS have potential for risk stratification for cancers of breast, colon and prostate, but less so for others because of modest heritability and lower incidence.

Effect of community active case-finding strategies for detection of tuberculosis in Cambodia: study protocol for a pragmatic cluster randomized controlled trial.

BACKGROUND: Cambodia has made notable progress in the fight against tuberculosis (TB). However, these gains are impeded by a significant proportion of undiagnosed cases. To effectively reach people with TB, active case-finding (ACF) strategies have been adopted by countries affected by the epidemic, including Cambodia, alongside passive case finding (PCF). Despite increased efforts to improve case detection, approximately 40% of TB cases in Cambodia remained undiagnosed in 2018. In Cambodia, several community-based TB ACF modalities have been implemented, but their effectiveness has yet to be systematically assessed. METHODS: This pragmatic cluster randomized controlled trial will be conducted between December 2019 and June 2021. We will randomize eight operational districts (clusters) in seven provinces (Kampong Cham, Kampong Thom, Prey Veng, Thbong Khmum, Kampong Chhnang, Kandal, and Kampong Speu) to either the control group (PCF) or the intervention groups (ACF using a seed-and-recruit model, ACF targeting household and neighborhood contacts, and ACF targeting persons aged ≥ 55 years using mobile screening units). The primary endpoints will be TB case notification rates, additionality, and cumulative yield of TB cases. The secondary endpoints include treatment outcomes, the number needed to screen to find one TB case, and cost-effectiveness outcome measures. We will analyze the primary and secondary endpoints by intention to treat. We will compare cluster and individual-level characteristics using Student's t test and hierarchical or mixed-effect models to estimate the ratio of these means. The incremental cost-effectiveness ratio per disability-adjusted life year averted will also be considered as a benchmark to determine whether the interventions are cost-effective. DISCUSSION: This study will build an evidence base to inform future scale-up, implementation, and sustainability of ACF strategies in Cambodia and other similar settings. Implementation of this study will also complement TB control strategies in Cambodia by conducting ACF in operational districts without active interventions to find TB cases currently. Those who are ill and might have TB will be promptly screened, diagnosed, and linked to care. Early diagnosis and treatment initiation will also benefit their community by interrupting transmission and prevent further infections. The experience gained from this project will inform future attempts in conducting pragmatic trials in low-resource settings. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04094350. Registered on 18 September 2019.

Patients' and healthcare providers' perspectives of diabetes management in Cambodia: a qualitative study.

OBJECTIVE: This study aimed to explore the challenges encountered by patients and healthcare providers and opportunities for improvement in managing diabetes mellitus (DM) in a low- and middle-income country (LMIC) facing a rise in DM prevalence. DESIGN: Qualitative cross-sectional study. SETTING: Urban, semiurban, and rural areas in Cambodia. PARTICIPANTS: Thirty health service providers and fifty-nine adult DM patients. RESULTS: Most of the 59 DM patients reported having developed DM complications when they first sought treatment. The biggest challenges for the patients were geographical barriers, diet control, and shortage of medication supply. The healthcare staff expressed concerns about their limited knowledge and lack of confidence to treat diabetes, limited availability of diabetes care services, inadequate laboratory services, shortage of staff, poor patients' compliance, and insufficient medication supplies. Both healthcare staff and patients urged an expansion of diabetes services in Cambodia and prioritisation of diabetes care in a manner similar to communicable disease control programmes of the recent past. CONCLUSIONS: Currently, the Cambodian healthcare system has very limited capacity to provide quality care for chronic diseases. As a consequence, many patients are either left untreated or have interrupted care due to several barriers including financial, geographical, and lack of knowledge and skills. A more comprehensive and multipronged approach is urgently needed to improve DM care, which would require a collaborative effort from government, external funding agencies, private sector, and communities.

Delayed diagnosis and treatment of pulmonary tuberculosis in high-burden countries: a systematic review protocol.

INTRODUCTION: Countries identified to bear the highest tuberculosis (TB) incidence account for approximately 85% of the global TB burden. TB is curable, yet nearly 40% of TB cases remained undiagnosed hence delaying treatment and perpetuating transmission. This systematic review aimed to review current evidence on factors associated with delayed diagnosis and treatment of TB in the high TB-burden countries. METHODS AND ANALYSIS: This systematic review will incorporate qualitative and observational study designs published between 2008 and 2018. Articles will be retrieved from major databases including PubMed, EMBASE, CINAHL and PsycINFO. Reference lists of key articles, including relevant systematic reviews and meta-analysis, will be screened for additional studies. Two independent reviewers will screen and select studies, extract data and assess the quality and risk of bias of each study. Study-specific estimates will be pooled by meta-analysis, and effect sizes will be presented as OR and their 95% CI. Levels of heterogeneity will be evaluated using chi-square statistic Q and I2. Publication bias will be assessed using forest plots and Egger's tests. Qualitative findings and sample quotes will be extracted. Textual references to the topics of interest will be retrieved and categorised using qualitative thematic analysis. We will triangulate quantitative and qualitative findings for a complete understanding of the reasons for delayed TB diagnosis and treatment. Results will be presented by geographical region. ETHICS AND DISSEMINATION: This study will be conducted based on published data. This systematic review may provide insights into the reasons for delayed TB diagnosis in high-burden countries. These findings will also inform future research and key stakeholders in developing interventions to reach these undiagnosed cases effectively. Findings from this review will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42018107237.

Nursing students' experiences of using a smart phone application for a physical assessment course: A qualitative study.

AIM: It is important that nurses possess adequate clinical skills so that the patient receives safe and competent care. Smart phone applications (apps) can promote active learning and the long-term retention of knowledge of undergraduate students. Therefore, the aim of this study was to explore the thoughts and experiences of nursing students who received a smart phone, app-based physical assessment educational intervention. METHODS: A qualitative descriptive approach with in-depth interviews was considered as suitable to obtain a comprehensive understanding of students' experiences of a smart phone-enabled physical assessment course. RESULTS: Based on interviews with 16 nursing students following the intervention, five themes were derived from the analysis of the interview transcripts: "the APP's physical assessment scenarios are very close to real-life clinical situations," "watching physical assessment videos over the APP is a quick way to learn what to do," "the APP is a new way of learning that enhances thinking and reflection," "some nursing students felt that it was out of their depth to analyze the scenarios in the APP," and "the APP needs enhancements in stability and interactivity." CONCLUSION: The findings of this study showed the mobile app as an effective learning aid that promoted transferability of the nursing students' knowledge and past experience. With the help of the APP, the teachers could offer timely guidance to the students.