To ensure uncertainty in match outcomes, professional sporting leagues have used various competitive balance policies, including player salary caps, revenue sharing among teams and player drafts. The Australian Football League (AFL) introduced a player draft in 1986, and to refine its operation, a draft value index (DVI) was introduced in 2015. The DVI allocates a numeric value to each individual player draft pick, with these values determined by the AFL using historic player compensation or wage and salary data. The AFL DVI plays an essential role in the operation of its player draft; however, other research has questioned the validity of such indexes. This paper aims to produce an alternative to the AFL DVI. The former index uses career compensation as the determinant of value, whereas we use other measures of player performance. First, various models were developed to predict on-field performance, such as games played (both in a recruit’s career and season) after a draftee was selected for the first time by a team. This was then retrofitted to the pick used to select these draftees to create the new DVIs. Even though the predicted DVI followed an inverse monotonic function like the existing index, the decline in value for the DVI produced here was less steep, unlike the AFL’s. This allowed us to conclude that players’ salaries did not always strongly correlate to performance. The change in performance between players selected at different points in the draft did not vary as much as their wages. Though this scheme is applied to the AFL, the underlying concept could be directly exported to other player drafts. Rottenberg  applied Understanding this concept, professional sporting leagues have introduced many policies such as revenue sharing among teams and salary caps to induce competitive balance . Concurrently, various measures have also been developed to evaluate the validity of these policies . HoweverWith respect to many indicators, such as television ratings, viewership and revenue generation, the AFL is the most popular professional team sporting league in Australia . HoweverThe league has continued to refine these competitive balance policies, and in 2015, introduced the DVI  and National Hockey League (NHL) refer to it as the Pick Value Chart (PVC)), which will be the focus of this paper. Through this mechanism, the league administers a numerical value to each individual draft pick using historical player salary data. This is used for a number of purposes, including providing priority access for clubs to players through the father–son rule, and players from within club-academies, as well as imposing draft penalties on clubs for misconduct.The father–son rule has been in effect within the league since 1949. The rule means that teams have the choice to recruit the sons of former players, which portrays and markets the AFL as a family-oriented legacy affair  for a noBefore 1997, players eligible under this criterion would be taken up by their prospective teams before the beginning of the draft itself. However, in 1997, the AFL decided to incorporate this rule within the draft, causing teams to effectively pay a price (by using a pick) for their priority access to such players. These nominations would usually happen right after post-season play but before the trading period and the draft, giving teams little to no time to make informed decisions. Under these stipulations, teams would generally use their next available selection  to draft eligible players . This process did not accurately display the market value of these players .The club academy principle was first introduced in 2010 after revising the existing scholarship system, where the four northern clubs , Brisbane and Gold Coast) were allocated a geographical zone to set up and train junior footballers in these areas where the most popular football code is rugby league rather than Australian football. The intention was to promote the sport by guaranteeing amateurs a pathway into the sport with their hometown. The clubs that ran these academies were further granted priority access (not exclusive) to amateurs who graduate from them through the national draft. The first academy graduates were eligible for the draft in 2011, and parent clubs could acquire these amateurs with their next available pick by nominating them before the beginning of the draft, akin to F/S players. This caused a similar dilemma to that observed in the F/S scenario, where amateur players were selected at picks that were not consistent with their draft value.The main problem faced in both F/S and C/A situations was the indivisibility of potential draftees or draft picks. This meant that the priority access club had the opportunity of procuring F/S or C/A players by using their next available pick rather than matching the pick of the competing club. Even if the priority access club wanted to compensate the competing club for losing the player in question, there was no standard measure to equate the lost value. Moreover, the draftee’s market value was withered down to his subsequent selection compared to the initial bid by the competing club .To circumvent this problem, the league introduced the DVI in 2015. Official AFL communications specified that the DVI was obtained through fitting salaries paid to draftees at various points over 15 drafts (2000 to 2014), ‘which assigns a relative points value for each pick in the National Draft’ . The choAs mentioned earlier, the primary reason for the existence of the DVI is because of the new bidding system introduced in 2015 for F/S and C/A players. Before 2015, for both of these recruitment concessions, teams were allowed to nominate players prior to the draft and select them with their next available draft pick, should another rival team bid for them earlier on in the draft.Under the new rules, any bid by a rival club for either an F/S or C/A player has to be met in kind by the priority access club with a discount. As a rule, teams matching the bids for F/S and C/A players are entitled to a 20% discount on the DVI points of the competing bid they are required to match up until pick 18. Any selections made after this is given a constant discount of 197 points, which is equivalent to 20% of the eighteenth pick’s DVI points. The 20% discount on the DVI awarded to clubs that are making use of either the F/S or C/A rules is an arbitrary amount. This discount is because the AFL still wants clubs to use these rules, but they do not want them to gain too much of an advantage from them.Moreover, the new bidding system is conducted during the draft, unlike the earlier method, which was held straight after the post-season games, giving the nominating and bidding teams the ability to analyse their draft positions and needs effectively. The following example will put this into perspective.In 2014, before the introduction of the DVI, Jack Steele was a C/A player from the GWS club and was eligible to be drafted. North Melbourne had the fifteenth pick in the draft and nominated Steele as their choice. However, GWS invoked the C/A rule to select Steele. Under the rules in 2014, GWS could match this bid with their next available pick, which at the time was the twenty-third selection. Thus, North Melbourne was forced to select another player at pick 15, while GWS acquired Steele with pick 23. This happened before the draft, after post-season games had been completed, but before the trade period. Due to this, GWS could not effectively analyse if they needed Steele, as there was a possibility that their needs would differ following the trade period. Under the new bidding system used since 2015, GWS would still be eligible to invoke the C/A rule privileges during the draft and not before but would have to provide more than just the twenty-third pick to do so . These 75 points would be deducted from their next available pick, which would be the twenty-fourth selection, valued at 785 points. In doing so, GWS would be left with 710 points, which is roughly equivalent to the twenty-seventh selection. Thus, GWS’s twenty-fourth pick would be moved down to 27, while the picks between 24 and 27 would move up one step.Overall, the aim of the DVI would be achieved here in terms of making sure that teams bidding for F/S and C/A players pay something close to market value for their picks. As the example suggests, Steele would be drafted to an AFL club as a first-round draft pick , unlike the second-round selection he was recruited with under the old bidding system.The new system allows the priority access clubs to use up all their DVI points for the current year in bidding for F/S and C/A players while also allowing them to go into a deficit to a total of 1,723 points. The deficit is recovered from the team’s following year DVI points at the same round in which the deficit was created. For example, if GWS ran up a deficit of 100 points in selecting F/S or C/A players in the current year for a second-round pick, 100 points would be deducted from their next year’s point balance from their second-round pick.The changes to the bidding system and the introduction of the DVI have shifted the strategy behind preparing for the draft. Previously, clubs traded picks based on acquiring the best talent early on. Now, the bidding system encourages clubs to trade for points and not just picks, as their priority access gives them the opportunity to recruit the player they desire, as long as they have the points to pay for them. Second, there is the potential for false bidding. Although never proven, bidding teams do have the ability to engage in false bidding. Such a scenario would be a colluded effort by multiple teams to nominate multiple F/S or C/A players for one rival team in the first round. In doing so, they will deplete the points balance of the priority team early on, preventing them from running for other potential draftees.Moreover, the choice of player payments to determine the value of the DVI raises further questions. First, as draftees in the AFL are not strictly amateurs , their pay reflects their experience  and starTo circumvent this, Mitchell et al.  and StewThe aim of this paper is to estimate alternative models for player performance using games played, time on field and Brownlow Medal Votes (a system where umpires vote for the three best players on the field per game). We then construct respective DVIs by predicting players’ performance. Finally, we compare the AFL DVI to these alternate indices.A database of all selections in the AFL national player draft from 2003 through to 2016, supplemented by their performance in the league’s home and away seasons (H/A) from 2004 to 2017 was constructed. Although the national draft has been operational since 1986, this study only considers players selected from 2003 onwards. A multitude of factors has led to the decision to use this cut-off point including accuracy and completeness of the data. In the period leading up to 2003, the number of players selected in each draft varied considerably due to the introduction of new teams and foundation selections. Post-2003, the data obtained (and used in this paper) have been more consistent.Unlike most professional sporting leagues that use a draft, the AFL also allows players who have played before in the league to be selected in the draft. To avoid biases created by such players, any draftee who had played before in the AFL or was a rookie listed player and elevated as a senior player through the draft has been excluded from this dataset. Furthermore, as the main objective of this paper is to compare the player performance based DVI against the existing AFL DVI which terminates at pick 73, any player selected after pick 73 is also excluded from the dataset. Coincidentally, most observations that are excluded due to the ‘played before’ exception forms a major part of the second exclusion filter. This leaves 907 cross-sections (players) in the career aggregate dataset or a panel of 4,777 player seasons. This sample is used to estimate the models defined of draftees selected from 2003 to 2016, with their respective performance from seasons 2004 to 2017. Our primary outcomes of interest to measure player performance are 1) games played, 2) time on field and 3) Brownlow Medal Votes (BMV) for all regular season games. These variables are restricted to regular season home and away games to ensure each player is comparable irrespective of the teams they played for .The choice of the three performance variables is based on relevance and controls of similar work. Previous studies indicate that games played (and time on field) cannot be used to determine performance because it may include potential decisional biases contrary to the nature of the sport. Hence, many authors have chosen games started , rankingTo account for seasonal effects in a draftee’s development, As a precursor to the econometric models, in We specify separate models for career performance and seasonal performance. The choice to use the entire career to create the DVI was based on two key reasons. Firstly, young amateur players who get drafted only play a small number of games in their initial years and peak around season eight or nine , player weight, height, year when drafted, race, position played, amateur league and recruiting team are used.Each of these models is estimated for three different measures of player performance: a) number of games played, b) time on field and c) BMVs. The equation used here was partly built in accordance with the empirical model specified in Stewart et al. . Since titSeasonal Performance is the performance of the ith player at time t. In addition to the explanatory variables in Unfortunately, with career aggregates, it is not possible to include in-season anomalies such as injuries, not being listed to play and varying career lengths (48% of the sample is still actively playing the league as at 2017). Thus, another model is specified for the seasonal performance of draftees after they were inducted into the AFL, similar to the model defined by Mitchell et al.  and StewAs a starting point, an Ordinary Least Squares (OLS) model for all three performance indicators  is estimated using Drafting age is significant across all models, whereby for every additional year in the age at which they are first drafted, a player will play 3.22 fewer games, spend 212.60 fewer minutes on the field and receive 1.51 fewer BMV. This suggests that good players are generally recruited early on. Weight is positively associated with performance, with 3.80 games played for an additional kilogram, while height is negatively related to performance. Moreover, except for Sydney, all other drafting teams yield insignificant results. Relative to the Adelaide Crows, Sydney draftees play 26.87 fewer games over their careers.The bidding system for F/S and C/A players yield insignificant results on all specifications. Conversely, the indigenous or non-indigenous player status is positive and highly statistically significant. This suggests that an Aboriginal and Torres Strait Islander player plays an additional 33.59 games relative to their equivalent non-indigenous counterparts. However, this variable is not statistically significant in the BMV model. This could indicate some form of discrimination where umpires fail to acknowledge the performance of Aboriginal and Torres Strait Islander players, consistent with Parsons et al. , who fouThe seasonal performance model  is estimLike the career model, the results for both games played and time on field per season mimic each other. Both season age and the quadratic component (a proxy for player’s experience) are statistically significant. The effects of all other variables remain consistent with those in the career model, apart from drafting age which is statistically insignificant in both games played and time on field models. However, it remains statistically significant in the BMV model (column 12). For example, with each additional year at which the player was drafted, seasonal BMV drops by 0.32. Being traded to another team prior to the start of the season (traded), in general, does not affect performance except for the number of games played (at the 10% level of significance). The statistical significance of the IMR in all three tables provides evidence of selection bias and justifies using the sample selection model. Again, the model based on season performance confirms that many of the included factors are important determinants of player performance.1 and β2 are unknown parameters. Transforming (Average Predicted Performance per Pick) = ln β1 + β2 ln Pick), enables us to estimate it using OLS (the results can be obtained from the authors upon request.). After individually estimating Using the respective estimated models, we next predict players’ performance for each of the three different measures  using the regression results obtained from Tables As expected, we find a downward sloping monotonic relationship between predicted performance and pick. Fitted career games and time on field fall at a relatively lower rate with respect to pick than does career BMV see , like thSimilar trends are observed with performance per season see . As the The current AFL DVI, as mentioned earlier, was created by regressing career player salaries of draftees selected over 15 years. We argue that draftee payments do not necessarily reflect their performance. The main purpose of this paper is to create a DVI based on post-draft performance and compare it with the current AFL DVI.To recap, we have modelled performance using three indicators in both a player’s career and individual seasons. The predicted outcomes are then averaged per pick and fitted using a power model. However, as all three performance measures used in this paper have different scales, comparing them to the AFL DVI proves difficult. Hence, the predicted career and season (here we used predictions from the mixed-effects model adjusting for selection bias.) performance are retrospectively scaled to the AFL’s DVI as presented in 0 < Pick <74, we can observe two varying phenomena . Previous literature suggest that games played is not an accurate indicator of draftee performance . Other aOur findings clearly show a mismatch between performance and player salary in the AFL. Similar to the PVC in the NFL, the surplus (difference between performance and payments) increases with the progression of the draft . The purThe AFL DVI was primarily created to value the selections that teams had to forgo when nominating F/S and C/A players. While this new bidding system proved to be fairer than the previous rules, the number of draftees recruited under these systems has decreased since 2015. Since teams tend to weigh the picks that they forgo when they enforce the PAS rules, especially if such a player is contested in the first round, some forgo matching a bid for a player due to the high price of the selection. While Chandrakumaran  concludeThe primary purpose for the AFL to create a DVI was to introduce a pricing structure so that the league could recuperate value from teams who utilise the F/S and C/A rules. However, the choice of player payments as the determinant of value has been found to be inadequate when compared to the alternative models presented in the literature , 32, 36 In this paper, we estimated various models for player performance using alternative measures of performance, namely, number of games played, time on field and Brownlow Medal Votes. We then used predicted players’ performance to construct respective DVIs. We found that games played and time on field based DVIs both declined at a much lower slower rate. These findings are consistent with competing interests that selectors have in ensuring their recruits perform (or at least appear to have performed) to validate their sunk investments. The flatness of the games played-based DVI questions the effect the draft has on the league in disseminating amateur talent to teams since there is not much variation in the time players spend on field relative to the pick used to recruit them. A similar question is raised by Motomura et al.  in the Nrd  selection which they had at the time. However, unlike under the AFL’s DVI rule, where their 24th pick was substituted by pick 27, to cater for the difference in values between selections 14 and 23, they would be given the 43rd pick instead. Furthermore, given that the proposed DVI declines at a much slower rate than the current AFL’s DVI, the 20% discount given on bidding ascensions for picks in the first round need not be entertained as well .In comparison, the BMV-based DVI proved to be more adequate because it characterises a player’s actual contribution as adjudged by an umpire. Yet, this index has a flatter slope than the AFL’s current DVI, suggesting that the latter may not adequately reflect actual performance, and its use within the context of other competitive balance policies will not necessarily be effective. Instead, a BMV-based DVI is highly recommended as it defines draftee value in terms of actual output instead of what a team is willing to pay to secure that player (which can be based on a variety of factors). Utilising the example of Jack Steele, had the league used our proposed alternative (


Due to the Coronavirus disease 19 (COVID-19) related social distancing measures and health service suspension, physical activity has declined, leading to increased falling risk and disability, and consequently, compromising the older adult health. How to improve the quality of older adult life has become a crucial social issue.In traditional rehabilitation, manual and repetitive muscle training cannot identify the patient’s rehabilitation effect, and increasing the willingness to use it is not easy. Therefore, based on the usability perspective, this study aims to develop a novel smart somatosensory wearable assistive device  combined with wireless surface electromyography (sEMG) and exergame software and hardware technology. The older adult can do knee extension, ankle dorsiflexion, and ankle plantar flexion rehabilitation exercises at home. Meanwhile, sEMG values can be digitally recorded to assist physicians  in judgment, treatment, or diagnosis.To explore whether the novel SSWAD could improve the older adult willingness to use and motivation for home rehabilitation, 25 frail older adult  perform the rehabilitation program with the SSWAD, followed by completing the system usability scale (SUS) questionnaire and the semi-structured interview for the quantitative and qualitative analyses. In addition, we further investigate whether the factor of gender or prior rehabilitation experience would affect the home rehabilitation willingness or not.Learnability”  and “Confidence” . On the contrary, male older adult without rehabilitation experience are more willing to adopt new technologies , and perform better in “Learnability”  and “Confidence”  with the SSWAD. In addition, the result of the semi-structured interview shows that the operation of the SSWAD is highly flexible, thus reducing older adult burden during the rehabilitation exercise and using them long-term.According to the overall SUS score, the novel SSWAD has good overall usability performance (77.70), meaning that the SSWAD makes older adult feel interested and improves their willingness for continuous rehabilitation at home. In addition, the individual item scores of SUS are shown that female older adult with prior rehabilitation experience perform better in “This novel SSWAD receives consistently positive feedback regardless of the gender or prior rehabilitation experience of elders. The SSWAD could be used as a novel way of home rehabilitation for elders, especially during the COVID-19 pandemic. Older adult can do rehabilitation exercises at home, and physicians could make proper judgments or adjust suitable treatments online according to the sEMG data, which older adult can know their rehabilitation progress at the same time. Most importantly, older adult do not have to go to the hospital every time for rehabilitation, which significantly reduces time and the risk of infection. Due to the current global spread of the Coronavirus disease 19 (COVID-19) pandemic, various disease prevention measures, such as social distancing have been implemented worldwide. Such actions aggravate the health problems of the older adult, including chronic diseases, declining immunity, reduced neurocognitive function and mental health, lack of exercise, and increased risk of death . Even inWearable devices have been promoted by advances in wireless sensing technology . MeanwhiFurthermore, wearable devices currently allow 24-h monitoring of our comprehensive physiological data, including heart rate, blood oxygen, and sleep status, and consequently the production of a multi-dimensional health database for preventive health services. With its improved accuracy, wearable devices have become a standard effective monitoring tool to provide medical professionals with health data for disease diagnosis and follow-up , 10. ForThis study aims to develop a novel smart somatosensory wearable assistive device , combined with sEMG and exergame software and hardware technology for rehabilitating the lower limb muscles of the older adult –15. More2.This section presents a literature review on the e-health system, wearable devices for the older adult, market trends, and the significance of functional fitness for the older adult. This section also discusses the status and the design principle of somatosensory game rehabilitation for frail elders, which is used as the basis for developing a novel wearable device in subsequent sections of this study.2.1.The decline of multiple physiological functions often accompanies the aging process. With the transformation of social and demographic structures, it has become challenging for the older adult to maintain their quality of life (QoL). Because frailty not only increases the burden of healthcare but also elevates the risk of functional decline and mortality among the older adult, inevitably increasing their healthcare demands each year. Owing to the growing medical and care unmet needs in our aging society, e-health has become an important direction in improving the value of medical services. The development of e-health can bring substantial benefits to the medical industry by reducing travel time to healthcare facilities and the incidence of hospital-acquired infection, even globally . In addiWith rapid changes in the global medical industry, the e-health system can improve the existing workflow, efficiency, and accuracy of the healthcare system, thereby facilitating the intelligentization of healthcare services. As a novel type of healthcare, e-health, and telemedicine provide precise and personalized medical services through behavioral science theories and gamification, thereby increasing users’ motivation for self-management and long-term participation , 19. The2.2.As the physiological functions of the older adult decline with increasing age, their demand for self-health management increases. Meanwhile, the care for the older adult has increased the expenditure burden of healthcare, long-term care, and social welfare systems. Wearable devices have a wide range of applications in the medical field, including monitoring patients’ acute or chronic diseases and general health conditions, both inside and outside the clinical environment, and providing real-time automated medical services within time and space constraints . By incoWearable devices designed for the older adult are among the products with the highest development potential. Among different types of wearable devices, those that provide health and home monitoring have been the focus of various industries. The ultimate goal is to make wearable devices capable of collecting physiological data, improving service processes, and ultimately establishing a comprehensive ecosystem , 19. Wea2.3.With advances in science, technology, and medicine, the average life expectancy of the global population is increasing each year. Therefore, the lifestyle, physiological evaluation, and medical needs of the older adult have become an essential societal issue . MoreoveDeclines in both the quality and the strength of the muscle accelerate the rate of frailty and, consequently, the impairment of gait and balance, thereby decreasing mobility and increasing the risk of disability. The interaction of physiological aging and chronic diseases can indirectly or directly induce frailty, further aggravating diseases, sarcopenia, and related conditions, creating a vicious circle of health conditions in the older adult that eventually leads to disability . The mos3.This study aims to develop a user-friendly SSWAD for frail older adult doing rehabilitation exercises at home (as shown in 3.1.The smart somatosensory wearable assistive device (SSWAD) proposed in this study utilizes low-noise sensing elements that could capture sEMG signals to detect the activities of various muscle groups during rehabilitation exercise training. The SSWAD integrates ICT and uses exergame rehabilitation to improve older adult motivation for muscle strength training. Subsequently, the SSWAD is optimized for clinical rehabilitation that could prevent and improve degenerative diseases, such as frailty and sarcopenia. The following sections provide in-depth discussions on the three major aspects of the product design, including hardware and software integration, design process, and final design.3.1.1.The sensor elements of the proposed wearable device, developed with commercially available modules, consist of electrode patches and sEMG sensors. The sEMG sensors measure the performance of the joint operation of muscles and nerves. Together with electrode patches on the surface of the skin, they can detect weak potential differences generated by muscle contraction on the skin surface and collect the signal through the sensing unit. Subsequently, the collected signals are amplified, processed in the amplifying team, and sent to the host so that data can be displayed on the screen in real-time. Meanwhile, relevant signals are stored in the host and can be accessed immediately. The stored signals are then transferred to the Unity game software, which serves as an interactive multimedia medium to provide users with visual feedback  from a community activity center in Tainan, Taiwan. They are between 60 and 83 years of age (with an average of 69.3 years), and attend social activities 2–3 times per week. In addition, 16  have no rehabilitation experience, whereas the remaining 9  have prior rehabilitation experience. All subjects have the ability to perform simple movements with their lower limbs, have normal cognitive ability, and are able to clearly express their thoughts. The recruitment criteria are as follows: (1) Older adult could be with a clinical frailty scale of 4–6 ; (2) Old3.2.2.Willingness (I1), Complexity (I2), Convenience (I3), Stress (I4), Integration (I5), Inconsistency (I6), Learnability (I7), Cumbersomeness (I8), Confidence (I9), and Difficulty (I10) . After the rehabilitation training, a five-point SUS questionnaire was completed to collect the older adult perceptions of the SSWAD, during which their verbal responses were recorded by the researchers. In addition, semi-structured interviews were conducted to understand the older adult subjective feelings and willingness to use the device, as well as any issues they encountered during the operation. The length of the interview was approximately 15 min for each elder (as shown in 4.A five-point SUS questionnaire is used to investigate whether the factor of gender or prior rehabilitation experience would affect older adult home rehabilitation willingness or not.4.1.Investigation of the usability of the wearable device for older adult is carried out mainly via a SUS questionnaire to understand the older adult perceptions of 10 aspects of the SSWAD (as shown in Good” benchmark (including –Good  and +Good) (Items 1–5 and Item 9) (Average” level (including −Average and +Average). It responds to the previous result that the overall SUS score of the SSWAD has “Good” usability performance. From Item 7 (Learnability) for “Female” only gets the “Poor” benchmark (the single item score being 3.46), thus suggesting that there is much room for improvement in the “Learnability” for the female elders. To further examine the effects of prior rehabilitation experience and gender, the following t-test analyses are conducted.To further investigate,  Item 9) , 41, whi4.2.p > 0.05). For example, for Item 1 (Willingness) of the SUS questionnaire, “I think I would like to use this Smart Somatosensory Wearable Assistive Device (SSWAD) frequently,” the t value is 0.17 (p = 0.86). Similarly, for Item 3 (Convenience), “I thought the SSWAD was easy to use,” the t value is-0.11 (p = 0.92). The results suggest that the subjective feelings of both males and females regarding the use of the SSWAD for rehabilitation are no significant difference.This section explores the effect of gender on the acceptance of the novel SSWAD developed in this study. From Item 9 (Confidence), “I felt very confident using the SSWAD,” the result shows a significant difference between different genders . In contrast, according to Item 7 (Learnability) in t = 2.18, p = 0.04).To provide in-depth discussions, further gender analysis is carried out by stratifying older adult into those with prior rehabilitation experience and those without rehabilitation experience. Item 1 (Willingness) and Item 3 (Convenience) show they are not affected by the gender factor. However, significant gender differences are observed in the “Confidence” level (Item 9) for older adult with prior rehabilitation experience and in the “Learnability” level (Item 7) for those without rehabilitation experience. In this regard, female older adult with prior rehabilitation experience are likelier to master new products (or systems), and male older adult without rehabilitation experience are easier to learn new products (or systems).In summary, the results of 4.3.Item 4 (Stress), “I think that I would need the support of a technical person to be able to use this SSWAD” , and Item 8 (Cumbersomeness), “I found the SSWAD very cumbersome to use.” , are no significant differences. These results reveal that both the ability to use and the perceived complexity of the SSWAD are consistent between older adult with and without rehabilitation experience. In other words, neither the usability nor the operational complexity of the SSWAD would introduce additional pressure or rejection among the older adult regardless of prior rehabilitation experience. By contrast, for Item 1 (Willingness), the t value is-2.32 (p = 0.02), suggesting that in terms of “willingness to use,” older adult without rehabilitation experience are more willing to continuously use the SSWAD than those with prior rehabilitation experience. This is likely because older adult without rehabilitation experience are willing to try easy-to-access wearable rehabilitation devices.This section is to identify the acceptance of the novel SSWAD among the frail older adult who have participated in traditional rehabilitation for lower limbs and to explore whether prior rehabilitation experience would affect the willingness to use the SSWAD for rehabilitation. The t-test analysis is performed between older adult with and without prior rehabilitation experience as well as between older adult of different genders, as shown in Item 1 (Willingness)  and Item 9 (Confidence)  having significant differences between them with and without prior rehabilitation experience   having a significant difference between them with and without rehabilitation experience , Item 7 (Learnability), and Item 9 (Confidence) according to the previous results. For example, is there any interaction between the gender and the prior rehabilitation experience on the dependent variable ?For further analyses, we use the two-way ANOVA  to exploItem 9 (Confidence), suggesting that no matter what the gender is or prior rehabilitation experience is, it will influence older adult confidence. It is consistent with the results presented in Sections 4.2 and 4.3. In addition, a simple main effect is used to examine why an interaction exists and what causes the interaction happened (happened . A simplItem 1 (Willingness)  has a statistical significance of the ‘main effect’ on the prior rehabilitation experience. With further analysis, we find strong evidence that older adult without prior rehabilitation experience have a higher willingness (4.31) than those with prior rehabilitation experience (3.33), which is consistent with the results presented in Sections 4.1 and 4.3. The further discussion will be presented in Section 5.From 5.This study aims to develop a user-friendly SSWAD for frail older adult doing rehabilitation exercises at home. This section will provide in-depth discussions of the quantitative analysis of the usability of the SSWAD as well as the qualitative analysis of semi-structured interviews.In the analysis of the gender factor, the results show that the subjective feelings of both males and females regarding the use of the SSWAD for rehabilitation are no significant difference. While the pathophysiology that results in frailty is not well identified, an individual’s gender appears to be an important factor influencing the aging trajectory. Gender differences in the effectiveness of gamification interventions in frailty have not been addressed in the research literature to date . This fiPoor” benchmark on Learnability (Item 7). These findings are worthy to further investigate in the future.In the further gender analysis, the results show that female older adult with prior rehabilitation experience are more confident in using the novel assistive device, suggesting that they are more capable of mastering new products than male elders. Interestingly, male older adult without rehabilitation experience are more likely to learn to use the new product than females. The male older adult may have a profound experience in digital technology in the past , and conFrom analyses of the effects of gender and prior rehabilitation experience, older adult generally provide positive feedback on the design of the novel SSWAD. In addition, both the wearing and the operation of the device are simple enough to prevent additional pressure or rejection among the older adult, making it suitable for the general frail older adult population. These results also show that female older adult with prior rehabilitation experience find it easier to learn and master the device, and help them establish their confidence in the device and thus escalate their willingness to use the device in the long term. Interestingly, similar results are obtained from male older adult without rehabilitation experience. With the spread of the COVID-19 pandemic, the traditional medical industry has substantially transformed. Despite their declining physical function, older adult have gradually become acquainted with telemedicine, improving their learning ability of new technologies .In addition, semi-structured interviews are conducted to understand the frail older adult’s subjective feelings toward using the SSWAD for lower limb rehabilitation. Results of the qualitative analysis show that the operation of the SSWAD is highly flexible as it is made of fabric materials and utilized a detachable design. As a result, the device could reduce user burden during the rehabilitation exercise, resulting in their positive feedback on wearing comfort. In addition, by being equipped with sensors that could detect muscle movement during the rehabilitation exercise, the device could help the older adult understand the outcomes of the exercise. Since the device integrates innovative technology for data transfer and record, it could also provide medical professionals with references for follow-up evaluation and the personalization of the rehabilitation training program. With these advantages, the proposed device in this study could improve the older adult’s acceptance of technological aids and telemedicine during the post-pandemic era, consistent with previous studies’ findings , 13, 23.The product looks techy, feels interesting, and is comfortable to wear.I already have trouble moving around, not to mention going to the hospital for rehabilitation. If such a device is available, it will be our savior.I can use the device for home rehabilitation without going to the hospital, which is very convenient.To make the design of the device more human-oriented, the study also explores difficulties encountered by frail older adult while using the novel SSWAD. It summarizes the older adult requirements for the format and content of lower limb rehabilitation. From the results of the semi-structured interviews, some improvements are identified. For example, the wearable device is designed to be individually adjustable and detachable to reduce the older adult’s burden of wearing it. However, this design also results in multiple steps while putting the device on, and the lack of clear operation instructions could increase the risk of operational errors. Therefore, a fault-proof mechanism is introduced to prevent possible errors in device operation.There are so many steps involved in putting on the device, which feels complicated. It is easy to forget how to wear the device without clear instructions.I need someone to guide me step by step to be able to use the device.In summary, the older adult feedback on the wearing comfort of the SSWAD is generally positive. Although the detachable design of the device allows a high degree of operational freedom, it also makes the wearing process relatively complicated, which is consistent with the findings of previous research , 15, 31.6.Willingness,” “Confidence,” and “Learnability” of the SSWAD. In this regard, male older adult without rehabilitation experience are more receptive to the SSWAD. Since the SSWAD is easy to learn and use, the older adult confidence could be improved, resulting in their increased willingness to use the device for rehabilitation continuously.With the advancement of wireless sensing technology and lifestyle transition under the COVID-19 pandemic, wearable devices have emerged as an essential area of the medical industry. By integrating a wearable assistive device for lower limbs that could capture sEMG signals with gaming contents, this study has developed a novel smart somatosensory wearable assistive device (SSWAD) for clinical rehabilitation to help prevent and improve degenerative diseases such as frailty and sarcopenia. 25 older adult with frailty are recruited to test the SSWAD, determine the design criteria of wearable rehabilitation devices, and assess the device’s usability. The effects of gender and prior rehabilitation experience on the device’s usability are explored. In addition, the qualitative interview is performed to understand the older adult subjective perception of the SSWAD and any difficulties they encounter. The result shows that older adult with different genders and different rehabilitation experiences have significant differences in perceived “However, there are some limitations of this study. Firstly, due to the declining physical function of the older adult, visual stimulation elements may need to be introduced to future products to reduce possible user errors and operational complexity. For example, a fault-proof design (such as assigning different parts of the device with different shapes and colors) is recommended to guide the wearing process. Secondly, efforts should be made to achieve an integrated wearing design that features fewer adjustable slots and easier operations. Additionally, other assistive technologies should be considered to optimize the usability for the older adult. Thirdly, the sample size is small (25 subjects), and, for future studies, a larger sample size should be considered to get more precise analysis results. Lastly, there is another limitation the subjects are recruited from a community activity center in Taiwan, which the social context of the older adult and the measures taken during the COVID-19 pandemic in Taiwan are not the same as in other nations. For future studies, it should be verified in different contexts or nations to be extended and generalizable.In conclusion, the SSWAD developed in this study receives positive feedback from the older adult, due to its appropriate wearability, operational usability, and integrated physiological sensing technology with exergame rehabilitation. Therefore, the SSWAD can serve as a health promotion tool to improve the older adult’s health and well-being. In the future, the health ageing platform could be built so older adult can do rehabilitation exercises at home, physicians could adjust suitable treatments online for them, and older adult can know their rehabilitation progress. It is a virtuous cycle that may represent a promising solution for home rehabilitation or telemedicine.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving humans were approved by National Cheng Kung University Human Research Ethics Committee, No. NCKU HREC-F-109-497-2, on 4 Feb 2021. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.This research was partly supported by the Ministry of Science and Technology, Taiwan, under Grant nos. MOST 110-2622-H-006-008, MOST 110–2823–8-006-003, and MOST 111-2923-E-006 -002 -MY3.The authors declare that the research was conducted without any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Androgen receptor splice variants (AR-SVs) contribute to the aggressive growth of castration-resistant prostate cancer (CRPC). AR-SVs, including AR-V7, are expressed in ~30% of CRPC, but minimally in treatment-naïve primary prostate cancer (PCa). Compared to Caucasian American (CA) men, African American (AA) men are more likely to be diagnosed with aggressive/potentially lethal PCa and have shorter disease-free survival. Expression of a truncated AR in an aggressively growing patient-derived xenograft developed with a primary PCa specimen from an AA patient led us to hypothesize that the expression of AR-SVs could be an indicator of aggressive growth both in PCa progression and at the CRPC stage in AA men. Tissue microarrays (TMAs) were created from formalin-fixed paraffin-embedded (FFPE) prostatectomy tumor blocks from 118 AA and 115 CA treatment-naïve PCa patients. TMAs were stained with AR-V7-speicifc antibody and with antibodies binding to the N-terminus domain (NTD) and ligand-binding domain (LBD) of the AR. Since over 20 AR-SVs have been identified, and most AR-SVs do not as yet have a specific antibody, we considered a 2.0-fold or greater difference in the NTD vs. LBD staining as indication of potential AR-SV expression. Two AA, but no CA, patient tumors stained positively for AR-V7. AR staining with NTD and LBD antibodies was robust in most patients, with 21% of patients staining at least 2-fold more for NTD than LBD, indicating that AR-SVs other than AR-V7 are expressed in primary treatment-naïve PCa. About 24% of the patients were AR-negative, and race differences in AR expression were not statistically significant. These results indicate that AR-SVs are not restricted to CRPC, but also are expressed in primary PCa at higher rate than previously reported. Future investigation of the relative expression of NTD vs. LBD AR-SVs could guide the use of newly developed treatments targeting the NTD earlier in the treatment paradigm. Approximately 270,000 men in the United States were diagnosed with prostate cancer (PCa) and 34,000 died of PCa in 2022 . GloballStudies have shown that AR-SVs are expressed in CRPC, but minimally in primary PCa ,17,18. SAdvanced CRPC patients treated with enzalutamide and abiraterone expressed AR-V7 at 39% and 19%, respectively, and AR-V7-positive patients had statistically significant lower PSA response rates . SeveralTo our knowledge, it is currently unknown whether AR-SV expression levels or patterns differ with race, and no large patient cohorts have been analyzed for a comprehensive expression of AR-SVs in treatment-naïve primary PCa. Compared to Caucasian American men (CA), African American (AA) men have a 63% higher overall PCa incidence. These patients are more likely to be diagnosed with aggressive PCa , are 2.4Further characterizing AR-SVs in diverse clinical populations could provide new treatment approaches. In the last decade, several groups have identified molecules that bind to the N-terminus domain (NTD) and inhibit and/or degrade AR and AR-SVs ,34,35,36In this study, we evaluated the expression of AR and AR-SVs in treatment-naïve primary PCa from AA and CA men in the mid-south USA. Only two primary prostatectomy PCa tumors stained for AR-V7, both in AA men. However, 20% of the patient specimens stained for NTD at a rate 2.0-fold higher than LBD, indicating AR-SVs other than AR-V7 may serve as potential targets in primary PCa.AR NTD antibody was procured from Millipore, Burlington, MA, USA (06-680-MI), AR-LBD antibody C19 was from Sigma, St. Louis, MO, USA (SAB5500007), and AR-V7 antibody was obtained from Abcam, Cambridge, UK (ab198394). n = 221) were evaluated for staining with AR NTD and LBD antibodies and 192 cases for AR-V7-binding antibody. We used three AR NTD antibodies  and AR-441 (in addition to PG-21) to optimize staining and chose to use PG-21 antibody for the staining of TMAs. Similarly, the AR-V7 Abcam antibody was compared with RevmAb AR-V7 antibody and chose to continue with the Abcam antibody. Results were scored by two independent pathologists for intensity of staining (0–3) and the number of cells (0–100), and H score was calculated ranging between 0 and 300. Patient specimens were collected under an UTHSC Institutional Review Board (IRB)-approved protocol. Patient details were redacted before the clinical information was released to the researchers. The patient specimens that were collected and stored since 1990 were obtained from the UTHSC center for cancer research biorepository core. Each patient specimen had multiple blocks, and sections were made from each block and sent to the pathologist (FK) for marking the tumor areas. Cores from identified sections were obtained from each block and TMAs were created with a total of 233 specimens (each TMA containing 30 specimens). Twelve specimens showed insufficient tumors and were excluded from the study. Staining was optimized using LNCaP and 22RV1 cells that expressed AR and AR and AR-SV, respectively, with selected PCa slides. Immunohistochemistry protocol was optimized using an automated processor . Cases -approved protocol. Animals were maintained in a 12 h light:dark cycle and were provided with water and food ad libitum. Patient specimens collected from surgical suites in RPMI medium supplemented with penicillin:streptomycin and fungizone were fragmented using collagenase and implanted subcutaneously in male NSG mice.Tumor tissue from PDX was minced and protein extracted by three freeze thaw cycles in a lysis buffer that contained protease and phosphatase inhibitors. Western blot was performed according to a method previous published .Since AR-V7 is the only AR-SV with a clinically validated assay, there is a higher chance that the expression of other AR-SVs could be overlooked. Hence, the actual percent of AR-SVs expressed in primary PCa or in CRPC is underestimated. We expected that the approach shown in A prostatectomy PCa specimen UT-1335) from an AA patient aggressively grew from implantation to 2000 mm [35 from aTo address this hypothesis, we created nine tissue microarrays (TMA) from 233 treatment-naïve prostatectomy specimens from AA (118) and CA (115) patients. The patient characteristics and demographics are provided in n = 6; 3 AA + 3 CA) were randomly selected, RNA was extracted, and real-time PCR was performed with TaqMan probes binding to the NTD and LBD. The results at the mRNA level confirmed the observation made with IHC.Out of the 221 evaluable specimens, 53 specimens (24%) did not stain for AR with either antibody. This suggests that these patients may not respond to any AR-targeted therapeutics and could potentially develop AR-negative neuroendocrine PCa. No racial differences were observed (27 vs. 26) . The patWhile most studies are performed to detect the AR-SVs focus on CRPCs, we focused on primary PCa with the assumption that expression of AR-SVs at an early stage might correlate with late-stage aggressive cancer. This study is potentially one of a few to take a distinct approach to identify AR-SVs in prostatectomy specimens with a ratio of N-terminus to C-terminus staining as a defining measure of AR-SV expression. An earlier study utilizing the same approach did not identify AR-SVs in primary PCa . This apAR-V7 was detected in less than 1% of primary PCa specimens, while it was detected in over 75% of PCa specimens where the patients underwent androgen deprivation therapy (ADT) . This nuThough we expected a racial disparity in the expression of AR-SVs, with AA patients expressing at a higher rate than the CA patients, we did not find any statistical difference between the two races in terms of AR-SV expression. Interestingly, the CA patients had a higher proportion of AR-SV-positive tumors. n = 10) hormone-responsive bone metastasis specimens was performed to detect AR, AR-V7, AR-V1, and AR-v567es at mRNA levels. The study found that mRNA was detected in most of the primary tumors and metastasis, and this number increased in CRPC patient specimens [An earlier study with a small number of n =  hormone-Strengths of the analysis include large number of AA and CA specimens with comparable ranges of age, PSA, and Gleason scores. The assumption that higher NTD staining relative to LBD was indicative of AR-SV expression was based on in vitro analyses with LNCaP and 22RV1 cell staining. However, there are limitations, including the potential for the masking of the antibody epitope in specimens that stained weakly at the LBD, hence providing a false positive interpretation that AR-SVs are expressed in primary PCa. Our results need to be confirmed using one of the sequencing methods such as probe-capture sequencing. Irrespective of these limitations, the study provides evidence that the expression of AR-SVs is not limited to CRPC, as previously thought, but could be expressed in primary PCa at a much higher rate and that the expression of AR-SVs in primary PCa might be underestimated clinically.


Unnecessary Caesarean Section (CS) can have adverse effects on women and their newborns. Assisted vaginal birth/delivery (AVB/AVD) using a suction device or obstetric forceps is a potential alternative when delays or complications occur in the second stage of labour. Unlike CS, AVB using a suction device does not require regional or general anaesthesia, can often be performed by midwives, and does not scar the uterus, lowering the risk of maternal mortality and morbidity, in this and subsequent pregnancies. This study examined the appropriateness and outcomes of second stage CS (SSCS), and reasons for low levels of AVB use, in Kenya. Using a mixed methods study design, we reviewed case notes from women having SSCS births and AVB, and conducted key informant interviews with healthcare providers, from 8 purposively selected hospitals in Kenya. Randomly selected SSCS and all AVB case notes were reviewed by a panel of four experienced obstetricians, and appropriateness of the procedure assessed. Semi-structured interviews were conducted with obstetricians, medical officers and midwives, and analysed using a thematic approach. Review of 67 SSCS case notes showed 10% might have been conducted as AVBs, with a further 58% unable to be classified due to inadequate/inconsistent record keeping or excessive delay following initial CS decision. Outcomes following SSCS showed perinatal mortality rate of 89.6/1,000 births, with 11% of infants and 9% of mothers experiencing complications. Non-referred cases of AVB showed good outcomes. The findings of the 20 interviews explored the experience and confidence of healthcare providers in performing AVBs, and adequacy of the training they received. Key reasons for non-performance included lack of functioning equipment, lack of trained staff or their rotation to other departments. Reasons for non-performance of AVB were complex and often multiple. Any solutions to these problems will need to address various local, regional and national issues. Globally, caesarean section (CS) rates continue to rise, with the procedure accounting for 21% of all births in 2021, an increase of 14% since 1990 . Whilst CS are associated with a maternal mortality rate of 10.9 per 1,000 procedures in sub-Saharan Africa compared to 0.3 per 1,000 procedures in LMIC in Europe and central Asia . EmergenBy contrast, in SSA, AVB was found to have taken place within the previous three months, in only 53% of 1728 hospitals and 6% of nearly 10,000 health centres surveyed  since the training of [county], but I’ve done many from when I left medical school, but we were using the old equipment, we were not using the Kiwi. The Kiwi one I’ve used on three patients or so. I’m quite competent actually, personally I am okay, only a bit of refresher then everything will fall in place.” “In-house training was reported in a few of the facilities, with accounts of continuing medical education (CME) sessions, where medical interns tended to present on theoretical aspects of a particular subject, with little or no opportunities to practice skills. Although these seemed to be open to all cadres, limited staffing levels meant that in practice staff were sometimes too busy to attend.During the routine facility assessments, the most common reason given for not performing AVB within a facility was a lack of patients for whom the intervention was indicated. However, this was rarely mentioned by interviewees, with the majority expressing that they thought more AVB should be performed. Several reasons were offered by respondents for not performing AVB, including a lack of functional equipment, insufficient staff, lack of knowledge, skill or confidence, lack of training and fear of complications.The lack of operational equipment was a recurring theme, expressed by the interviewees as a reason for not performing AVB. One of the difficulties described in these settings, was that the preferred device for performing AVB, the Kiwi obstetric suction cup device, is designed to be single-use. However, due the cost of replacements and difficulties in procuring new devices, they are often sterilised and re-used.We sterilize using high level disinfection and we reuse it… I think it can do up to 12 patients” “In some instances, though, this led to problems where the device was no longer functioning properly. On another occasion, an interviewee explained that problems with a dysfunctional device had led to a woman having to undergo a SSCS following a failed AVB, resulting in the loss of the baby.When asked about the use of obstetric forceps, most respondents said that they either did not have them in their facility or that they were not used. One medical officer stated that they had used them once and a consultant admitted that they had never been trained in their use.In two of the hospitals, the staff had requested replacement Kiwi devices, but they were not available, and they had been provided with Malmstrom vacuum extractors instead. Although these are reusable, they require two people to operate and were not favoured by the staff interviewed.The levels of staffing were discussed during the interviews, with almost all interviewees reporting inadequate levels. Interviewees commonly described 1–3 nurses on duty per shift with fewer at night than during the day. These nurses may have covered only the labour ward in the large County Referral Hospitals but in the smaller facilities, they were also expected to cover the antenatal and postnatal wards.This shortage of staff was exacerbated in some instances by the rotation of experienced staff to different departments, either as part of the normal medical training process or because of industrial strike action. The frequency of rotation varied from weekly to 6 monthly resulting in a lack of AVB trained staff.The problem we have is high turnover of the MOs, so the ones we are having currently, I think they are not trained.” “In one instance the rotation of non-specialist medical staff was reported as a reason for non-medically indicated CS, as the rotated doctor was more interested in practising their surgical skills.The combination of low overall staffing levels and the rotation of trained staff was also reported as leading to a lack of support and on-the-job training opportunities for less experienced colleagues.Instances were described where a shortage of MOs, lead to a lack of medical staff on duty at times, resulting in the referral of women who developed complications in the second stage of labour.So, at night it’s always nurses and if we find any difficulty we always refer.” “This was also raised as an issue by receiving facilities, where due to delays caused by the women being transferred from one facility to another (up to 2 hours or more), AVB was not even attempted but the patient was taken straight to the operating theatre for caesarean section.This mother has travelled all the way more than 2 hours during second stage, I don’t wait, because I know, I just go direct and section this mother.” “Another reported effect of low staffing levels was the impact of the quality of patient care. Where a small number of nurses were caring for multiple women in labour, adequate monitoring of interventions such as augmentation of labour with oxytocin infusion was not possible. This resulted in the infusion being stopped, poor progress with failure to reach full dilatation or inadequate contractions and consequently the woman having a CS.“You as a doctor might start the augmentation but then the nurses will stop it because they can’t just monitor. They will call you after four hours that the patient has not progressed…” Where inadequate staffing was experienced, a few healthcare providers described the management of workloads by the juggling of patient care between cadres. Doctors were described as wanting an AVB to be done by the nurse, to avoid them having to take the patient to theatre, whilst the nurse wanted the woman to have a CS so that she was one less patient of labour ward.Varying levels of self-confidence were expressed by study respondents. Some were highly confident whilst others were less so. Levels of confidence were sometimes linked to training received and opportunities to practice. Respondents explained that their lack of confidence stemmed from a lack of any training or refresher training in performing AVB. They thought that with the necessary training they would be able to perform the procedure.Confidence between colleagues was expressed as an issue by some respondents, with a few doctors conveying a lack of trust in some of the nurses’ ability to monitor the progress of labour whilst some of the nurses did not trust the doctors to perform an AVB when it was indicated.A few of the respondents also articulated concerns they perceived colleagues had about potential adverse outcomes relating to the use of AVB, predominantly related to adverse outcomes for the mother and baby, particularly where the procedure was applied inappropriately.The thing we fear with the AVDs is the haematoma that sometimes is associated and possible dangers of having brain injuries as you do the AVDs, and I think some of these fears are what many practitioners fear… If you follow the correct guidelines on who qualifies for AVDs nobody should fear.” “Two neonatal deaths were reported following AVB, possibly giving rise to some of the concerns, but it was difficult to determine whether these were because of inappropriate use of AVB itself or as a consequence of the labour complications which necessitated the AVB.Despite the provision of EmONC training, including AVB, in the project supported counties, routine programmatic data showed that the use of AVB remained very low. We reviewed a selection of SSCS and AVB case notes from the included healthcare facilities and found that 10% of SSCS births might have been carried out as AVB, potentially reducing the risk of complications and future morbidity for these women and infants following the procedures. We also found that, whilst many clinicians were in theory appreciative of the benefits of AVB, a complex array of factors impacted on their practice, including staffing, equipment and training.The number of cases in the group categorised as ‘AVB should have been attempted’  suggests that there are women undergoing unnecessary SSCS. If the cases where it was not possible to determine the appropriate method of birth (due to lack of information or delays) are excluded, the proportion becomes even higher n = 7/29, 24%). In this study, although there were complications following both SSCS and AVB, the small number of AVB performed made it impossible to compare the outcomes from the procedures statistically. Both of the AVB cases where complications occurred, may have been compromised due to the duration of referral following full dilatation and thus delays in actually performing the procedure. Furthermore, based on studies by Nolens et al , 24%. In, if SSCSThe qualitative findings from the study clearly demonstrated the complexity of the situations in which many doctors and nurses found themselves. Despite many clinicians expressing support for the performance of AVB, the data collected from the healthcare facilities did not demonstrate this in practice. The barriers to performing AVB described by the interviewees can be categorised at 3 levels, personal (confidence and practice), facility  and national (staffing and pre-registration training), illustrated in the conceptual diagram . These lThe lack of functioning basic equipment was reported as a barrier to the practice of AVB in some instances, and in line with the findings of research in other high, middle, and low-income countries ,23,24. SWe found the lack of performance of AVB was in several cases attributed to a lack of knowledge and skills on the part of the clinicians. This was related to a lack of basic training, not just in AVB, but also in the care and assessment of women in labour, although most of the interviewees had received some AVB training as part of the EmONC programme. Significant improvements in knowledge, skills and clinical practice following competency based EmOC training have been found , howeverWithin this study there also seemed to be a preference for external agencies to provide essential refresher training rather than senior staff within facilities taking a lead in this process, particularly the practical, skills-based aspects. This may have been for a number of reasons including lack of confidence or experience in senior member of staff who might also be reluctant to admit this. The prospect of receiving per diems  and an extended time away from the normal workplace, might all potentially have a bearing on it . The lacThe rotation of staff to different departments was commented on in several of the interviews in this study and is likely to contribute to difficulties for staff in consolidating newly acquired knowledge and skills, such as AVB. While these rotations may be necessary to manage the limited work force, a system is needed at hospital or district level, to ensure that those deployed to maternity wards are trained and competent to provide EmONC.Overall, the quality of medical record keeping was poor, with almost a third  of the cases included in the sample not containing enough information to categorise the appropriateness of the decision for CS. Poor record keeping is not however limited to this study. Similar results have been found in other studies in LMICs . The lacThis study obtained first-hand accounts from healthcare providers of different cadres, who worked clinically on labour wards, providing care for women giving birth. They included obstetricians, medical officers and nurses from eight of the highest volume healthcare facilities, in five counties, across different regions of Kenya. We acknowledge that conducting the interviews remotely might have impacted the findings of this study, although the precise impact is difficult to determine. It is possible that remote interviews gave respondents an enhanced sense of anonymity, and enabled a greater degree of honesty, but conversely face-to-face interviews might have resulted in interviewers building a stronger rapport with respondents. Although questioning healthcare professionals about women’s perceptions of AVB is not a substitute for asking the women themselves, it can give insight into the attitudes and beliefs of the staff who care for the women. Further research into the views of women who have given birth by AVB might provide a broader, first-hand perspective on community level acceptability of AVB, but the scarcity of procedure might make recruitment of sufficient participants difficult.Challenges in obtaining the notes for women who had SSCS resulted in a relatively small sample size for the case note review. In most healthcare facilities, a new set of hospital records was started for each pregnancy. Due to the way in which notes were filed it was not possible to reliably locate the SSCS cases, so it was necessary to retrieve a random selection of emergency CS and identify the SSCS cases at the review stage. Also, a major limiting factor in the interpretation of the SSCS and AVB cases was the quality of the record keeping, including incomplete or missing partographs, or important information on labour progress not recorded. This varied considerably between facilities and in some cases had a notable impact on the reviewers’ ability to assess the need for, and outcomes of, the procedures.An increase in the appropriate use of AVB could avoid unnecessary cases of SSCS and the associated mortality and short- and long-term morbidity, as well as resulting in more efficient use of scarce resources and greater job satisfaction. This study highlighted a variety of issues relating to the under-utilisation of AVB in emergency obstetric care facilities in Kenya. Challenges included the lack of functional equipment, and lack of confident, competent staff on duty in labour wards, within facilities. Other factors included a lack of pre-registration training on the use of AVB, together with inadequate refresher training on practical skills for AVB, for some staff, and the lack of practical leadership in some instances. The complexity of the situation means that there was no single, simple solution to the under-performance of AVB. Interventions to address the problem will need to be comprehensive and sustainable. They will need to address personal, facility-level, local community and national-level barriers, and promote a culture of AVB within facilities.Several of the findings from this study have implications for clinical practice and future research. It is anticipated that implementation of the following could improve clinical practice:Provision of a hand-held, vacuum-extraction device, designed to be reused, and distributed at a price that is affordable to resource-limited health systems.Improvements in family planning provision to avoid unwanted pregnancies.Regular, in-house refresher training and mentorship to help maintain knowledge and skills of all staff working in maternity departments.Avoiding the rotation of EmONC trained staff to non-maternity departments.The use of a pre-formatted, rubber stamp could provide a low cost means of increasing the quality of medical documentation and supported improvement of care quality through standards-based audits.Regular audits of case notes to improve clinical practice and record keeping.A prospective intervention study, that addresses health system challenges, and incorporating a package of evidence-based interventions, could improve the quality of record keeping, prevalence and outcomes of CS and AVB, as well as reducing the risk of adverse outcomes from unnecessary procedures.S1 Text(DOCX)Click here for additional data file.


Quadruple-negative breast cancer (QNBC) lacks traditional actionable targets, including androgen receptor (AR). QNBC disproportionately afflicts and impacts patients of African genetic ancestry. Kinesin family member C1 (KIFC1/HSET), a centrosome clustering protein that prevents cancer cells from undergoing centrosome-amplification-induced apoptosis, has been reported to be upregulated in TNBCs and African-American (AA) TNBCs. Herein, we analyzed KIFC1 RNA levels and their associations with clinical features and outcomes among AR-low and AR-high TNBC tumors in three distinct publicly available gene expression datasets and in the breast cancer gene expression database (bc-GenExMiner). KIFC1 levels were significantly higher in AR-low and basal-like TNBCs than in AR-high and non-basal-like TNBCs, irrespective of the stage, grade, tumor size, and lymph node status. KIFC1 levels were also upregulated in AR-low tumors relative to AR-high tumors among Black and premenopausal women with TNBC. High KIFC1 levels conferred significantly shorter overall survival, disease-free survival, and distant metastasis-free survival among AR-low and basal-like TNBC patients in Kaplan–Meier analyses. In conclusion, KIFC1 levels may be upregulated in AR-low tumors and, specifically, in those of African descent, wherein it may promote poor outcomes. KIFC1 may be an actionable cancer-cell-specific target for the AR-low TNBC subpopulation and could aid in alleviating racial disparities in TNBC outcomes. Breast cancer is the most common form of cancer that is diagnosed among women in the United States (US), excluding nonmelanoma skin cancer . It rank+/PR+/HER−), luminal B (ER+/PR+/−/HER2+ or ER+/PR+/HER− with Ki67%≥15%), HER2-enriched (ER−/PR−/HER2+), and triple-negative breast cancer  [The poor outcomes among AA women diagnosed with breast cancer can partly be attributed to the higher incidence of aggressive breast cancer subtypes among AA women. Breast cancers can be categorized into four major intrinsic molecular subtypes: luminal A  expression, which can be targeted pharmacologically. Approximately, 65–88% of TNBC lacks AR expression, suggesting that the vast majority of TNBC patients are not susceptible to AR-targeted therapies . FurtherKinesin family member C1 (KIFC1) is a minus-end directed microtubule binding protein that promotes the survival of cancer cells burdened with extra centrosomes or centrosome amplification ,26. The In recent years, KIFC1 has surfaced as an aggressiveness biomarker for breast cancer ,30. It iIn this multi-cohort study, we evaluated differential KIFC1 gene expression levels among AR-low and AR-high TNBCs and the associations of KIFC1 levels with demographic and clinical disease characteristics. We provide early evidence suggesting that KIFC1 may be associated with the aggressive tumor biology of AR-low TNBCs. Our preliminary evidence also suggests that KIFC1 could improve disease risk stratification for AR-low and basal-like TNBC patients and could serve as a promising target for therapeutic intervention in QNBC. Our work is unique in that it validates a potential QNBC biomarker in three separate and independent databases. Additionally, our initial findings support that KIFC1 targeting could aid in improving TNBC outcomes among Black/AA women and reduce the overall racially disparate burden in breast cancer.Low expression levels of AR in TNBC patients have been linked to unfavorable clinical characteristics, as well as younger age and AA ethnicity. We sought to verify these prior findings across all three publicly available datasets . As anticipated, AR-low tumors exhibited poorer clinical features than those of AR-high tumors, as displayed in To determine if KIFC1 is upregulated in QNBC, we compared KIFC1 RNA expression levels between the AR-low and AR-high TNBC samples across three different publicly available datasets, namely, RODY, METABRIC, and TCGA . We discMultiple groups have revealed that AR RNA expression is directly correlated with AR protein expression ,34. ThusSince younger and Black/AA women are disproportionately impacted by QNBC, we analyzed differences in KIFC1 RNA levels between AR-low and AR-high TNBC samples according to racial and menopausal status . Among BSince we have shown that KIFC1 RNA levels are notably higher in AR-low TNBCs than in AR-high TNBCs, next, we investigated whether KIFC1 could be driving the poorer prognosis observed in QNBCs relative to AR-positive TNBCs. Hence, we analyzed the influence of KIFC1 on survival outcomes. In Kaplan–Meier analyses, we discovered that high KIFC1 expression levels were significantly associated with poorer clinical outcomes . High KIAs previously mentioned, KIFC1 prevents cancer cells burdened with extra centrosomes from undergoing mitotic-error-induced cell death by clustering these extra centrosomes at opposite poles of the cell during mitosis. Therefore, KIFC1 is often upregulated alongside centrosome amplification . Thus, wThe management and treatment of aggressive breast cancers, such as TNBCs, continue to challenge clinicians. These “targetless” subtypes offer patients a dismal number of targeted treatment options. Since QNBCs also lack the potential TNBC target, AR, there is an urgent need to identify actionable biomarkers in this unique subgroup of breast cancers that disproportionately impacts individuals of African ancestry. In this study, we illuminated the potential role of an identified TNBC and Black/AA TNBC biomarker, KIFC1, as a biomarker of aggressive AR-low disease.+ and/or nestin+), and basal-like signatures (BL1 and BL2), which were linked to a poor prognosis, including short overall and breast-cancer-specific survival [Consistently with prior evidence, the AR-low group displayed unfavorable disease characteristics across three independent databases compared to the AR-high group. Specifically, AR-low tumors presented with more basal-like features and more advanced grade compared to AR-high tumors. Previously, the lack of AR expression in TNBC was associated with the expression of basal markers , proliferation markers (Ki-67), a basal-like phenotype . The accompanying clinical data, including survival outcomes and tumor characteristics, were downloaded for each sample. Only the RNA-seq data from the TNBC samples for each cohort were analyzed for this study. Only RNA-seq data from TNBC tumors with AR and KIFC1 were included in the analyses. The analyzed TNBC samples were categorized into AR-low and AR-high subgroups according to a 50% quantile threshold. To further support our analyses of publicly available databases, we exploited Affymetrix microarray TNBC primary tumor data from the online Breast Cancer Gene-Expression Miner v4.8 (bc-GenExMiner v4.8) and Kaplan–Meier (KM) Plotter tools.We downloaded RNA-seq output data from 1095 primary breast tumor specimens from The Cancer Genome Atlas (TCGA) database, 2509 from the Molecular Taxonomy of Breast Cancer International Consortium (METABRIC) database, and 579 from the GSE31519 (RODY) database by using the QIAGEN OmicSoft Studio V11.7 software. The RNA-seq output from the RODY database was log2-transformed to normalize the gene expression values for each sample  and R version 4.2.0 .Wilcoxon rank sum tests were performed to analyze differences in KIFC1 RNA expression between two groups . The Dunnett–Tukey–Kramer test was performed to determine differences in KIFC1 gene expression between the different TNBC subtypes. Pearson correlation coefficients were computed to determine the correlation between AR and KIFC1 gene expression. Survival curves and Kaplan–Meier curves were constructed to analyze the univariate associations of KIFC1 gene expression with survival outcomes according to the optimal cut-point. Log-rank tests were performed to determine p-values for statistical differences in the survival distributions.In the bc-GenExMiner v4.8 program, Wilcoxon rank sum tests were performed to analyze differences in KIFC1 RNA expression between two groups . The Dunnett–Tukey–Kramer test was performed to determine differences in KIFC1 gene expression between the different TNBC subtypes. Pearson correlation coefficients were computed to determine the correlation between AR and KIFC1 gene expression. Survival curves and Kaplan–Meier curves were constructed to analyze univariate associations of KIFC1 gene expression with survival outcomes according to the optimal cut-point. Log-rank tests were performed to determine