Comparative whole genome analysis of face-derived Streptococcus infantis CX-4 unravels the functions related to skin barrier.

BACKGROUND: The skin microbiome is essential in guarding against harmful pathogens and responding to environmental changes by generating substances useful in the cosmetic and pharmaceutical industries. Among these microorganisms, Streptococcus is a bacterial species identified in various isolation sources. In 2021, a strain of Streptococcus infantis, CX-4, was identified from facial skin and found to be linked to skin structure and elasticity. As the skin-derived strain differs from other S. infantis strains, which are usually of oral origin, it emphasizes the significance of bacterial variation by the environment. OBJECTIVE: This study aims to explore the unique characteristics of the CX-4 compared to seven oral-derived Streptococcus strains based on the Whole-Genome Sequencing data, focusing on its potential role in skin health and its possible application in cosmetic strategies. METHODS: The genome of the CX-4 strain was constructed using PacBio Sequencing, with the assembly performed using the SMRT protocol. Comparative whole-genome analysis was then performed with seven closely related strains, utilizing web-based tools like PATRIC, OrthoVenn3, and EggNOG-mapper, for various analyses, including protein association analysis using STRING. RESULTS: Our analysis unveiled a substantial number of Clusters of Orthologous Groups in diverse functional categories in CX-4, among which sphingosine kinase (SphK) emerged as a unique product, exclusively present in the CX-4 strain. SphK is a critical enzyme in the sphingolipid metabolic pathway, generating sphingosine-1-phosphate. The study also brought potential associations with isoprene formation and retinoic acid synthesis, the latter being a metabolite of vitamin A, renowned for its crucial function in promoting skin cell growth, differentiation, and maintaining of skin barrier integrity. These findings collectively suggest the potential of the CX-4 strain in enhancing of skin barrier functionality. CONCLUSION: Our research underscores the potential of the skin-derived S. infantis CX-4 strain by revealing unique bacterial compounds and their potential roles on human skin.

Sex reporting of cells used in cancer research: A systematic review.

Sex and gender disparities in biomedical research have been emphasized to improve scientific knowledge applied for the health of both men and women. Despite sex differences in cancer incidence, prognosis, and responses to therapeutic agents, mechanistic explanations at molecular levels are far from enough. Recent studies suggested that cell sex is an important biological variable due to differences in sex chromosome gene expression and differences in events associated with developmental biology. The objective of this study was to analyze the reporting of sex of cells used in cancer research using articles published in Cancer Cell, Molecular Cancer, Journal of Hematology & Oncology, Journal for ImmunoTherapy of Cancer, and Cancer Research in 2020, and to examine whether there exists any sex bias. We found that the percentage of cells with sex notation in the article was 36.5%. Primary cells exhibited higher sex notation compared to cell lines. A higher percentage of female cells were used in cell cultures with sex notation. Also, sex-common cells omitted sex description more often compared to sex-specific cells. None of the cells isolated from embryo and esophagus reported the cell sex in the article. Our results indicate cell sex report in cancer research is limited to a small proportion of cells used in the study. These results call for acknowledging the sex of cells to increase the applicability of biomedical research discoveries.

T-Type Ca2+ Channels Mediate a Critical Period of Plasticity in Adult-Born Granule Cells.

Adult-born granule cells (abGCs) exhibit a transient period of elevated synaptic plasticity that plays an important role in hippocampal function. Various mechanisms have been implicated in this critical period for enhanced plasticity, including minimal GABAergic inhibition and high intrinsic excitability conferred by T-type Ca2+ channels. Here we assess the contribution of synaptic inhibition and intrinsic excitability to long-term potentiation (LTP) in abGCs of adult male and female mice using perforated patch recordings. We show that the timing of critical period plasticity is unaffected by intact GABAergic inhibition such that 4-6-week-old abGCs exhibit LTP that is absent by 8 weeks. Blocking GABAA receptors, or partial blockade of GABA release from PV and nNos-expressing interneurons by a µ-opioid receptor agonist, strongly enhances LTP in 4-week-old GCs, suggesting that minimal inhibition does not underlie critical period plasticity. Instead, the closure of the critical period coincides with a reduction in the contribution of T-type Ca2+ channels to intrinsic excitability, and a selective T-type Ca2+ channel antagonist prevents LTP in 4-week-old but not mature GCs. Interestingly, whole-cell recordings that facilitate T-type Ca2+ channel activity in mature GCs unmasks LTP (with inhibition intact) that is also sensitive to a T-type Ca2+ channel antagonist, suggesting T-type channel activity in mature GCs is suppressed by native intracellular signaling. Together these results show that abGCs use T-type Ca2+ channels to overcome inhibition, providing new insight into how high intrinsic excitability provides young abGCs a competitive advantage for experience-dependent synaptic plasticity.

Changes in Adolescent Health Behavior and the Exacerbation of Economic Hardship During the COVID-19 Pandemic: A Cross-sectional Study From the Korea Youth Risk Behavior Survey.

OBJECTIVES: This study investigated the association between exacerbated economic hardship during the coronavirus disease 2019 (COVID-19) pandemic and changes in the health behaviors of Korean adolescents. METHODS: We analyzed data from the 2021 Korea Youth Risk Behavior Survey and included 44 908 students (22 823 boys and 22 085 girls) as study subjects. The dependent variables included changes in health behaviors (breakfast habits, physical activity, and alcohol use) that occurred during the COVID-19 pandemic. The aggravation of economic hardship by COVID-19 and the subjective economic status of the family were used as exposure variables. Multiple logistic regression analysis was utilized to calculate the prevalence odds ratios (PORs). RESULTS: Severe exacerbation of a family's economic hardship due to COVID-19 was negatively associated with the health behaviors of adolescents, including increased breakfast skipping (POR, 1.85; 95% confidence interval [CI], 1.55 to 2.21 for boys and POR, 1.56; 95% CI, 1.27 to 1.92 for girls) and decreased physical activity (POR, 1.37; 95% CI, 1.19 to 1.57 for boys and POR, 1.38; 95% CI, 1.19 to 1.60 for girls). These negative changes in health behaviors were further amplified when combined with a low subjective family economic status. CONCLUSIONS: The experience of worsening household hardship can lead to negative changes in health behavior among adolescents. It is crucial to implement measures that address the economic challenges that arise from stressful events such as COVID-19 and to strive to improve the lifestyles of adolescents under such circumstances.

Identification of an Antagonist Targeting G Protein and ß-Arrestin Signaling Pathways of 5-HT7R.

In consideration of the limited number of FDA-approved drugs for autism spectrum disorder (ASD), significant efforts have been devoted to identifying novel drug candidates. Among these, 5-HT7R modulators have garnered considerable attention due to their potential in alleviating autism-like behaviors in ASD animal models. In this study, we designed and synthesized biphenyl-3-ylmethylpyrrolidines 3 and biphenyl-3-yl-dihydroimidazoles 4 as 5-HT7R modulators. Through extensive biological tests of 3 and 4 in G protein and ß-arrestin signaling pathways of 5-HT7R, it was determined that 2-(2'-methoxy-[1,1'-biphenyl]-3-yl)-4,5-dihydro-1H-imidazole 4h acted as a 5-HT7R antagonist in both signaling pathways. In in vivo study with Shank3-/- transgenic (TG) mice, the self-grooming behavior test was performed with 4h, resulting in a significant reduction in the duration of self-grooming. In addition, an immunohistochemical experiment with 4h restored reduced neurogenesis in Shank3-/- TG mice, which is confirmed by the quantification of doublecortin (DCX) positive neurons, suggesting the promising therapeutic potential of 4h.

Sialylated IVIg promotes clinical improvements in a rabbit dry eye model by regulating inflammatory cytokines.

Dry eye disease (DED) is caused by a loss of homeostasis of the tear film, which results in visual disturbance, ocular surface inflammation and damage, and neurosensory abnormalities. Although it is prevalent in 5-50% of the global population, there are limited clinical options for its treatment. This study explored the potential use of human intravenous immunoglobulin (IVIg) and its enriched fractions of sialylation, sialylated IVIg (sIVIg), as a treatment for DED. Fifteen female New Zealand white rabbits were topically instilled with 0.2% benzalkonium chloride (BAC) twice daily for five consecutive days to induce experimental dry eye. Saline, 0.4% IVIg, or 0.04% sIVIg eye drops were instilled twice daily for 20 consecutive days. Clinical evaluations, such as non-invasive tear break-up time (NIBUT) and corneal fluorescein staining (CFS), were conducted. mRNA levels of mucin 4, mucin 16, TNF-α, IL-1ß, MMP9, IL-10, TGF-ß, and CD209 in rabbit conjunctival tissues were examined using reverse transcription polymerase chain reaction (RT-PCR) or quantitative RT-PCR (qRT-PCR). The relationships between CD209 family members in rabbits and various mammalian species were analyzed using a phylogenetic tree. IVIg or sIVIg treatment resulted in clinical improvements in the rabbit DED model. The inflammatory cytokines, TNF-α and IL-1ß, were increased and mucin 4 and mucin 16, cell surface-associated mucins, were decreased in BAC-induced dry eye. Following IVIg or sIVIg treatment, inflammatory cytokines decreased, whereas the anti-inflammatory cytokine, IL-10, increased substantially. Moreover, a 10-fold lower sIVIg treatment dose resulted in prolonged IL-10 production, representing a significantly improved DED compared to IVIg. Furthermore, the expression of rabbit CD209 mRNA in the rabbit conjunctiva and its close relationship with primate homologs suggest that it may interact with IVIg or sIVIg to promote IL-10 expression, as previously described in humans. At a lower dosage, sIVIg showed a more efficient improvement in DED, making it a promising new candidate medication for DED.

Implementation of Healthy Men Healthy Communities: A Health Promotion and Gender-Based Violence Prevention Program for Male South Sudanese Refugees in Uganda.

Men living in refugee settings are often exposed to violence, poverty, and social instability, which impacts physical and mental health and increases the risk of perpetrating sexual and gender-based violence. Healthy Men Healthy Communities was developed as a male-led health promotion program to address men's physical and mental health and their role in creating healthy relationships and families. Three community leaders from the settlements were trained to facilitate the program, which was implemented among six groups consisting of twelve men in each group. Pre/post surveys and feedback were collected among the facilitators and participants. Facilitators suggested culturally appropriate ways to present physical activities as a stress reduction technique and the importance of spacing out births. The small group setting facilitated open conversations on topics such as birth spacing and healthy partner communication. Participants experienced an increase in knowledge and confidence in practicing the program content, such as stress-reduction techniques and healthy communication strategies. Participants recommended additional topics such as fertility and sexually transmitted infections. The Healthy Men Healthy Communities program has the potential for wider implementation among male South Sudanese refugees to promote their health as well as the health of their families.

The use of a mobile obstetric emergency system to improve obstetric referrals in Bong County, Liberia: A pre-post study.

OBJECTIVE: Liberia experiences an unmet need for cesarean section with about 5% population coverage, lower than 9%-19% coverage associated with improved maternal and newborn outcomes. Delays in the referral process for comprehensive emergency obstetric and newborn care (CEmONC) services due to ineffective communication between a rural health facility (RHF) and a district hospital contribute to the low CS rate. This study examined the association between mobile obstetric emergency system (MORES) implementation and referral time for obstetric emergencies as well as maternal/newborn outcomes. METHODS: A pre-post descriptive analysis was conducted on data collected from 20 rural health facilities (RHFs) and two hospitals in Bong County. Women with referral data from both RHFs and hospitals were matched and information including transfer time, reasons for referral, and maternal and newborn outcomes were extracted. Descriptive analysis and logistic regression models examined the relationship between the intervention's implementation and mode of delivery, maternal outcome, newborn outcome, and transfer time from RHF to district hospital. Ethics approval was obtained from two study centers. RESULTS: Women had higher odds of undergoing a CS at endline (OR: 1.86 95% CI: 0.99-3.46) compared to baseline. Additionally, newborns had lower odds of showing non-vigorous symptoms (OR: 0.31; 95% CI: 0.14-0.68), defined as a newborn with poor respiratory effort, muscle tone, or heart rate. There was no significant association between the intervention's implementation and transfer time. CONCLUSION: The MORES intervention is a promising means to increase timely care seeking along the referral pathway which may enhance access to cesarean section as well as improved newborn outcome in low- and middle-income countries.

Skin benefits of postbiotics derived from Micrococcus luteus derived from human skin: an untapped potential for dermatological health.

BACKGROUND: The skin microbiome, a diverse community of microorganisms, plays a crucial role in maintaining skin health. Among these microorganisms, the gram-positive bacterium Micrococcus luteus exhibits potential for promoting skin health. This study focuses on postbiotics derived from M. luteus YM-4, a strain isolated from human skin. OBJECTIVE: Our objective is to explore the beneficial effects of YM-4 culture filtrate on dermatological health, including enhancing barrier function, modulating immune response, and aiding recovery from environmental damage. METHODS: The effects of the YM-4 culture filtrate were tested on human keratinocytes and fibroblasts under various conditions using real-time PCR for gene expression analysis and fibroblast migration assays. A dehydration-simulated model was employed to prepare RNA-Seq samples from HaCaT cells treated with the YM-4 culture filtrate. Differentially expressed genes were identified and functionally classified through k-means clustering, gene ontology terms enrichment analyses, and protein-protein interactions mapping. RESULTS: The YM-4 culture filtrate enhanced the expression of genes involved in skin hydration, hyaluronic acid synthesis, barrier function, and cell proliferation. It also reduced inflammation markers in keratinocytes and fibroblasts under stress conditions. It mitigated UVB-induced collagen degradation while promoted collagen synthesis, suggesting anti-aging properties, and accelerated wound healing processes by promoting cell proliferation and migration. RNA sequencing analysis revealed that the YM-4 culture filtrate could reverse dehydration-induced transcriptional changes towards a state similar to untreated cells. CONCLUSION: M. luteus YM-4 culture filtrate exhibits significant therapeutic potential for dermatological applications.

Supervised machine learning model to predict mortality in patients undergoing venovenous extracorporeal membrane oxygenation from a nationwide multicentre registry.

BACKGROUND: Existing models have performed poorly when predicting mortality for patients undergoing venovenous extracorporeal membrane oxygenation (VV-ECMO). This study aimed to develop and validate a machine learning (ML)-based prediction model to predict 90-day mortality in patients undergoing VV-ECMO. METHODS: This study included 368 patients with acute respiratory failure undergoing VV-ECMO from 16 tertiary hospitals across South Korea between 2012 and 2015. The primary outcome was the 90-day mortality after ECMO initiation. The inputs included all available features (n=51) and those from the electronic health record (EHR) systems without preprocessing (n=40). The discriminatory strengths of ML models were evaluated in both internal and external validation sets. The models were compared with conventional models, such as respiratory ECMO survival prediction (RESP) and predicting death for severe acute respiratory distress syndrome on VV-ECMO (PRESERVE). RESULTS: Extreme gradient boosting (XGB) (areas under the receiver operating characteristic curve, AUROC 0.82, 95% CI (0.73 to 0.89)) and light gradient boosting (AUROC 0.81 (95% CI 0.71 to 0.88)) models achieved the highest performance using EHR's and all other available features. The developed models had higher AUROCs (95% CI 0.76 to 0.82) than those of RESP (AUROC 0.66 (95% CI 0.56 to 0.76)) and PRESERVE (AUROC 0.71 (95% CI 0.61 to 0.81)). Additionally, we achieved an AUROC (0.75) for 90-day mortality in external validation in the case of the XGB model, which was higher than that of RESP (0.70) and PRESERVE (0.67) in the same validation dataset. CONCLUSIONS: ML prediction models outperformed previous mortality risk models. This model may be used to identify patients who are unlikely to benefit from VV-ECMO therapy during patient selection.

New realm of precision multiplexing enabled by massively-parallel single molecule UltraPCR.

PCR has been a reliable and inexpensive method for nucleic acid detection in the past several decades. In particular, multiplex PCR is a powerful tool to analyze many biomarkers in the same reaction, thus maximizing detection sensitivity and reducing sample usage. However, balancing the amplification kinetics between amplicons and distinguishing them can be challenging, diminishing the broad adoption of high order multiplex PCR panels. Here, we present a new paradigm in PCR amplification and multiplexed detection using UltraPCR. UltraPCR utilizes a simple centrifugation workflow to split a PCR reaction into ∼34 million partitions, forming an optically clear pellet of spatially separated reaction compartments in a PCR tube. After in situ thermocycling, light sheet scanning is used to produce a 3D reconstruction of the fluorescent positive compartments within the pellet. At typical sample DNA concentrations, the magnitude of partitions offered by UltraPCR dictate that the vast majority of target molecules occupy a compartment uniquely. This single molecule realm allows for isolated amplification events, thereby eliminating competition between different targets and generating unambiguous optical signals for detection. Using a 4-color optical setup, we demonstrate that we can incorporate 10 different fluorescent dyes in the same UltraPCR reaction. We further push multiplexing to an unprecedented level by combinatorial labeling with fluorescent dyes - referred to as "comboplex" technology. Using the same 4-color optical setup, we developed a 22-target comboplex panel that can detect all targets simultaneously at high precision. Collectively, UltraPCR has the potential to push PCR applications beyond what is currently available, enabling a new class of precision genomics assays.

Dermatobacter hominis gen. nov., sp. nov., a new member of the family Iamiaceae, revealed the potential utilisation of skin-derived metabolites.

A non-motile, novel actinobacterial strain, Kera-3T, which is a gram-positive, aerobic, rod-shaped bacterium, was isolated from human keratinocytes on 1/10 diluted R2A agar. Whole-cell hydrolysis of amino acids revealed the presence of meso-DAP, alanine, and glutamic acid. The predominant menaquinone was MK-9 (H8), whereas the primary fatty acids were C16:0 and C18:1 ω9c. The major phospholipids included diphosphatidylglycerol and aminophospholipids, along with an unidentified phosphoglycolipid and an aminophosphoglycolipid. The G+C content of the genomic DNA was 73.2%, based on the complete genome sequence. Phylogenetic analyses of the 16S rRNA gene sequence and phylogenomic analysis of 91 core genes showed that strain Kera-3T formed a new lineage in the family Iamiaceae, with the closest neighbour Rhabdothermincola sediminis SYSU G02662T having 91.19% 16S rRNA gene sequence identity. A comparative genomic study of the predicted general metabolism and carbohydrate-active enzymes supported the phylogenetic and phylogenomic data. Based on the analysis of physiological, biochemical, and genomic characteristics, strain Kera-3T can be distinguished from known genera in the family Iamiaceae and represents a novel genus and species. Therefore, the name Dermatobacter hominis gen. nov., sp. nov. was proposed, with the type strain Kera-3T (= KACC 22415T = LMG 32493T).

Effect of organic acid-soaking and sonication on the formation of volatile compounds and α-dicarbonyl compounds in Robusta coffee.

In this study, the effects of organic acid-soaking (malic, citric, tartaric, and succinic acid) and sonication on the formation of flavor and α-dicarbonyl compounds in Robusta (C. canephora syn. Coffea robusta) green beans were investigated. A total of 20 volatile compounds were identified in Robusta coffee. Furfural and 5-methyl furfural, two dominant volatile compounds in Arabica coffee, increased after organic acid pretreatment. In Robusta coffee processed from 3% malic acid-soaked coffee beans, furfural and 5-methyl furfural increased by 90.99% and 24.92%, respectively, compared to the control. In Robusta coffee processed from 3% malic acid-sonicated (280 W, 1 h) coffee beans, furfural and 5-methyl furfural increased by 236.03% and 114.77%, respectively. α-Dicarbonyls (glyoxal, methylglyoxal, and diacetyl) were significantly (p < 0.05) decreased in all Robusta coffees after organic acid pretreatment. In Robusta coffee processed from coffee beans soaked and sonicated in tartaric acid solution, the α-dicarbonyls decreased by up to 44% and 58%, respectively, compared to the control. This study suggested the pretreatment methods to enhance the flavor substances and reduce the α-DCs in Robusta coffee.

Microbiome dataset of bacterial and fungal communities in anthosphere of twelve different wild plants in South Korea.

This dataset provides detailed profiles of bacterial and fungal communities associated with flowers (anthosphere) of 12 different plant species collected from remote and secluded locations characterized by a flourishing and diverse plant ecosystem. In total, 144 flower samples were collected from 12 different wild plants. Bacterial 16S rRNA and fungal ITS genes obtained using the Illumina Miseq approach were used to describe the anthosphere. Metadata and raw sequences obtained in this study are available from the National Center for Biotechnology Information (BioProject ID: PRJNA983070). Amplicon Sequence Variants (ASVs) of bacteria and fungi were analyzed using the DADA2 pipeline. After quality filtering, trimming, and removing the chimeric sequences, 2076 bacterial and 2152 fungal ASVs were identified in the anthosphere. Burkholderiales and Enterobacterales in bacteria, and Pleosporales in fungi were the predominant groups in the anthosphere regardless of the plant species. Among the twelve different plant species, Forsythia koreana exhibited the highest abundance of both bacterial and fungal groups. This dataset represents a detailed exploration of the anthosphere in the most abundant and commonly observed plant species in South Korea, and provides new insights into the microbial communities and interactions of the anthosphere.

The Adverse Effects and Nonmedical Use of Methylphenidate Before and After the Outbreak of COVID-19: Machine Learning Analysis.

BACKGROUND: Methylphenidate is an effective first-line treatment for attention-deficit/hyperactivity disorder (ADHD). However, many adverse effects of methylphenidate have been recorded from randomized clinical trials and patient-reported outcomes, but it is difficult to determine abuse from them. In the context of COVID-19, it is important to determine how drug use evaluation, as well as misuse of drugs, have been affected by the pandemic. As people share their reasons for using medication, patient sentiments, and the effects of medicine on social networking services (SNSs), the application of machine learning and SNS data can be a method to overcome the limitations. Proper machine learning models could be evaluated to validate the effects of the COVID-19 pandemic on drug use. OBJECTIVE: To analyze the effect of the COVID-19 pandemic on the use of methylphenidate, this study analyzed the adverse effects and nonmedical use of methylphenidate and evaluated the change in frequency of nonmedical use based on SNS data before and after the outbreak of COVID-19. Moreover, the performance of 4 machine learning models for classifying methylphenidate use based on SNS data was compared. METHODS: In this cross-sectional study, SNS data on methylphenidate from Twitter, Facebook, and Instagram from January 2019 to December 2020 were collected. The frequency of adverse effects, nonmedical use, and drug use before and after the COVID-19 pandemic were compared and analyzed. Interrupted time series analysis about the frequency and trends of nonmedical use of methylphenidate was conducted for 24 months from January 2019 to December 2020. Using the labeled training data set and features, the following 4 machine learning models were built using the data, and their performance was evaluated using F-1 scores: naïve Bayes classifier, random forest, support vector machine, and long short-term memory. RESULTS: This study collected 146,352 data points and detected that 4.3% (6340/146,352) were firsthand experience data. Psychiatric problems (521/1683, 31%) had the highest frequency among the adverse effects. The highest frequency of nonmedical use was for studies or work (741/2016, 36.8%). While the frequency of nonmedical use before and after the outbreak of COVID-19 has been similar (odds ratio [OR] 1.02 95% CI 0.91-1.15), its trend has changed significantly due to the pandemic (95% CI 2.36-22.20). Among the machine learning models, RF had the highest performance of 0.75. CONCLUSIONS: The trend of nonmedical use of methylphenidate has changed significantly due to the COVID-19 pandemic. Among the machine learning models using SNS data to analyze the adverse effects and nonmedical use of methylphenidate, the random forest model had the highest performance.

Growth Increase in the Herbaceous Plant Centella asiatica by the Plant Growth-Promoting Rhizobacteria Priestia megaterium HyangYak-01.

Centella asiatica is a traditional herbaceous plant with numerous beneficial effects, widely known for its medicinal and cosmetic applications. Maximizing its growth can lead to beneficial effects, by focusing on the use of its active compounds. The use of plant growth-promoting rhizobacteria (PGPR) is known to be an alternative to chemical fertilizers. In this study, we used the PGPR Priestia megaterium HY-01 to increase the yield of C. asiatica. In vitro assays showed that HY-01 exhibited plant growth-promoting activities (IAA production, denitrification, phosphate solubilization, and urease activity). Genomic analyses also showed that the strain has plant growth-promoting-related genes that corroborate with the different PGP activities found in the assays. This strain was subsequently used in field experiments to test its effectiveness on the growth of C. asiatica. After four months of application, leaf and root samples were collected to measure the plant growth rate. Moreover, we checked the rhizosphere microbiome between the treated and non-treated plots. Our results suggest that treatment with Hyang-yak-01 not only improved the growth of C. asiatica (leaf length, leaf weight, leaf width, root length, root width, and chlorophyll content) but also influenced the rhizosphere microbiome. Biodiversity was higher in the treated group, and the bacterial composition was also different from the control group.

Acceptability of a Whatsapp Triage, Referral, and Transfer System for Obstetric Patients in Rural Liberia.

Background: Maternal mortality continues to disproportionately affect low- and middle-income countries, including Liberia. Though the relationship between obstetric triage systems and improved maternal outcomes is well documented, standardized triage protocols are lacking in rural Liberia. Mobile health interventions are a promising method to triage obstetric patients. Objectives: This study explores the acceptability of a WhatsApp Triage, Referral, and Transfer (WAT-RT) system among Liberian midwives and community health assistants. Methods: Individual interviews and focus group discussions were conducted among midwives (n = 18) and community health assistants (n = 112). Interviews were designed to understand the current referral system in rural Liberia, how a WAT-RT System can address referral limitations, and the acceptability of the WAT-RT System. Data were audio recorded, transcribed, and translated into English. Data analysis was conducted via NVivo12 with independent and cooperative techniques among multiple researchers. Findings: The current referral system is not standardized with limitations including a lack of triage protocols, transportation difficulties, and inconsistent communication of patient information, which could be addressed by a WAT-RT System. The acceptability for the WAT-RT System was high. Facilitators to implementation included utilizing a pre-existing communication and referral infrastructure, access and competency surrounding mobile phones, and increased opportunities for training and inter-provider collaboration. Barriers included disproportionate phone access between midwives and community health assistants, network reliability, and a lack of data standards. Recommendations for successful implementation included centralizing phone financing and standardizing triage protocols. Conclusions: The WAT-RT System demonstrated high acceptability among frontline health care providers in rural Liberia. Barriers to program success could be reasonably addressed with simple interventions and planning. Multiple benefits included addressing care delays for obstetric patients, promoting bidirectional provider communication, and increasing the quality of obstetric triage. Future studies should focus on piloting the WAT-RT System among this population and recruiting other key stakeholders to determine intervention feasibility.