Knowledge, attitudes and practices towards lung cancer among adults in KwaZulu-Natal, South Africa: a cross-sectional survey.

Background: Lung cancer remains the number one cause of cancer mortality estimated at 1.8 million deaths. There are limited studies in resource poor countries regarding knowledge, attitudes and practices towards lung cancer. Objective: This study aimed to describe the knowledge, attitudes and practices regarding lung cancer in selected communities in KwaZulu- Natal, South Africa. Methods: An observational, analytic cross-sectional study design was conducted using a standardized questionnaire. A stratified random cluster sampling method was applied across five communities. A regression model was developed to identify the predictors of the level of knowledge. Results: About 59.9% (95% CI 52.0-67.3) of the participants reported to have heard of lung cancer. The mean knowledge score was 41.8% (95% CI 35.7-47.9%). Coughing blood was the most recognized symptom (61.0%, 95% CI 52.1-69.1). About 17% (95% CI 14.7-21.5) of participants reported to be smokers. Many respondents reported that they would go to a health centre or clinic in case they were coughing blood (72.4%, 95% CI 93.9-79.5). Less than 10% (95% CI 3.9-8.1) of participants was screened for lung cancer at the time. Gender, history of working in the chemicals industry, screening for lung cancer, and time taken to seek health care when sick were significant predictors of lung cancer knowledge. Conclusions: Public health interventions should be explored to increase the levels of community awareness regarding lung cancer, particularly focusing on the importance of screening, early diagnosis and treatment. Keywords: Lung cancer, community awareness, screening, prevention.

Modelling and predicting the spatio-temporal spread of COVID-19, associated deaths and impact of key risk factors in England.

COVID-19 caseloads in England have passed through a first peak, and at the time of this analysis appeared to be gradually increasing, potentially signalling the emergence of a second wave. To ensure continued response to the epidemic is most effective, it is imperative to better understand both retrospectively and prospectively the geographical evolution of COVID-19 caseloads and deaths at small-area resolution, identify localised areas in space-time at significantly higher risk, quantify the impact of changes in localised population mobility (or movement) on caseloads, identify localised risk factors for increased mortality and project the likely course of the epidemic at high spatial resolution in coming weeks. We applied a Bayesian hierarchical space-time SEIR model to assess the spatiotemporal variability of COVID-19 caseloads (transmission) and deaths at small-area scale in England [Middle Layer Super Output Area (MSOA), 6791 units] and by week (using observed data from week 5 to 34 of 2020), including key determinants, the modelled transmission dynamics and spatial-temporal random effects. We also estimate the number of cases and deaths at small-area resolution with uncertainty projected forward in time by MSOA (up to week 51 of 2020), the impact mobility reductions (and subsequent easing) have had on COVID-19 caseloads and quantify the impact of key socio-demographic risk factors on COVID-19 related mortality risk by MSOA. Reductions in population mobility during the course of the first lockdown had a significant impact on the reduction of COVID-19 caseloads across England, however local authorities have had a varied rate of reduction in population movement which our model suggest has substantially impacted the geographic heterogeneity in caseloads at small-area scale. The steady gain in population mobility, observed from late April, appears to have contributed to a slowdown in caseload reductions towards late June and subsequent start of the second wave. MSOA with higher proportions of elderly (70+ years of age) and elderly living in deprivation, both with very distinct geographic distributions, have a significantly elevated COVID-19 mortality rates. While non-pharmaceutical interventions (that is, reductions in population mobility and social distancing) had a profound impact on the trajectory of the first wave of the COVID-19 outbreak in England, increased population mobility appears to have significantly contributed to the second wave. A number of contiguous small-areas appear to be at a significant elevated risk of high COVID-19 transmission, many of which are also at increased risk for higher mortality rates. A geographically staggered re-introduction of intensified social distancing measures is advised and limited cross MSOA movement if the magnitude and geographic extent of the second wave is to be reduced.

An urgent need for African spirometry reference equations: the Paediatric and Adult African Spirometry study.

BACKGROUND: The GLI2012 (Global Lung Initiative 2012) has provided the largest data set to date for multi-ethnic spirometry reference equations; however, data on African populations are limited. In pulmonary function testing, diagnosis of lung disorder is based on comparing the individual's lung function to a reference appropriate for sex and ethnicity.METHODS: We conducted a systematic review of studies reporting spirometry results in healthy children and adults in Africa. Data from these studies were collated for Z-scores of forced expiratory volume in 1 sec (zFEV1), forced vital capacity (zFVC) and zFEV1/FVC compared to GLI reference equations.RESULTS: Nine studies, covering a total of 4750 individuals from North, South, East, West and Central Africa (52% were female), were reviewed. Marked differences were noted between individuals from North Africa and sub-Saharan Africa. The Southern zFEV1 (-0.12 ± 0.98), zFVC (-0.15 ± 0.98) and zFEV1/FVC (0.05 ± 0.89), Central zFEV1 (-0.16 ± 0.79), zFVC (-0.09 ± 0.83) and zFEV1/FVC (-0.17 ± 0.71) and East African zFEV1 (0.10 ± 0.88), zFVC (0.16 ± 0.85) and zFEV1/FVC (-0.10 ± 0.95) cohorts had an excellent fit with the GLI-African American. The West African showed a poor fit to all reference equations. The North African group showed the best fit for the GLI Caucasian zFEV1 (-0.12 ± 1.37), zFVC (-0.26 ± 1.36) and zFEV1/FVC (0.25 ± 1.11). The zFEV1/FVC ratios were stable across all the populations.CONCLUSION: Current evidence seems to support the use of GLI2012 reference values in North African and sub-Saharan African populations after taking into account ethnic correction factors.

The effects of HIV/AIDS on the clinical profile and outcomes post pericardiectomy of patients with constrictive pericarditis: a retrospective review.

OBJECTIVE: The clinical profile and surgical outcomes of patients with constrictive pericarditis were compared in HIV-positive and -negative individuals. METHODS: This study was a retrospective analysis of patients diagnosed with constrictive pericarditis at Inkosi Albert Luthuli Central Hospital, Durban, over a 10-year period (2004-2014). RESULTS: Of 83 patients with constrictive pericarditis, 32 (38.1%) were HIV positive. Except for pericardial calcification, which was more common in HIV-negative subjects (n = 15, 29.4% vs n = 2, 6.3%; p = 0.011), the clinical profile was similar in the two groups. Fourteen patients died preoperatively (16.9%) and three died peri-operatively (5.8%). On multivariable analysis, age (OR 1.17; 95% CI: 1.03-1.34; p = 0.02), serum albumin level (OR 0.63; 95% CI: 0.43-0.92; p = 0.016), gamma glutamyl transferase level (OR 0.97; 95% CI: 0.94-0.1.0; p = 0.034) and pulmonary artery pressure (OR 1.49; 95% CI: 1.07-2.08; p = 0.018) emerged as independent predictors of pre-operative mortality rate. Peri-operative complications occurred more frequently in HIV-positive patients [9 (45%) vs 6 (17.6%); p = 0.030]. CONCLUSIONS: Without surgery, tuberculous constrictive pericarditis was associated with a high mortality rate. Although peri-operative complications occurred more frequently, surgery was not associated with increased mortality rates in HIV-positive subjects.

Oesophageal cancer in Area 2 of Kwazulu-Natal: predictors of late presentation.

BACKGROUND: There are limited prospective data sets on clinical characteristics, stage of presentation and treatment of patients with Oesophageal Squamous Cell Carcinoma (OSCC) in South Africa. This study aimed to assess the frequency and severity of clinical characteristics associated with late presentation of patients with OSCC presenting to a cancer referral centre in KwaZulu-Natal, South Africa. METHODS: A prospective consecutive series of patients presenting with confirmed OSCC treated at Greys Hospital in 2016/2017 were enrolled. Data collected included: age, gender, home language, referral centre, clinical and laboratory characteristics: dysphagia score, Eastern Cooperative Oncology Group (ECOG) performance status, body mass index (BMI), serum albumin, tumour pathology and treatment administered. RESULTS: One hundred patients were analysed. Ninety four percent spoke isiZulu. The mean age was 61 with a male to female ratio of 1.5:1 Ninety percent had palliative treatment as their overall assessment precluded curative treatment. Five patients underwent curative treatment. The age standardised incidence (ASR) was 25.2 per 100 000. The factors associated with late presentation and their frequency were: advanced dysphagia grade (

Home-based intervention to test and start (HITS) protocol: a cluster-randomized controlled trial to reduce HIV-related mortality in men and HIV incidence in women through increased coverage of HIV treatment.

BACKGROUND: To realize the full benefits of treatment as prevention in many hyperendemic African contexts, there is an urgent need to increase uptake of HIV testing and HIV treatment among men to reduce the rate of HIV transmission to (particularly young) women. This trial aims to evaluate the effect of two interventions - micro-incentives and a tablet-based male-targeted HIV decision support application - on increasing home-based HIV testing and linkage to HIV care among men with the ultimate aim of reducing HIV-related mortality in men and HIV incidence in young women. METHODS/DESIGN: This is a cluster randomized trial of 45 communities (clusters) in a rural area in the uMkhanyakude district of KwaZulu Natal, South Africa (2018-2021). The study is built upon the Africa Health Research Institute (AHRI)'s HIV testing platform, which offers annual home-based rapid HIV testing to individuals aged 15 years and above. In a 2 × 2 factorial design, individuals aged ≥15 years living in the 45 clusters are randomly assigned to one of four arms: i) a financial micro-incentive (food voucher) (n = 8); ii) male-targeted HIV specific decision support (EPIC-HIV) (n = 8); iii) both the micro incentives and male-targeted decision support (n = 8); and iv) standard of care (n = 21). The EPIC-HIV application is developed and delivered via a tablet to encourage HIV testing and linkage to care among men. A mixed method approach is adopted to supplement the randomized control trial and meet the study aims. DISCUSSION: The findings of this trial will provide evidence on the feasibility and causal impact of two interventions - micro-incentives and a male-targeted HIV specific decision support - on uptake of home-based HIV testing, linkage to care, as well as population health outcomes including population viral load, HIV related mortality in men, and HIV incidence in young women (15-30 years of age). TRIAL REGISTRATION: This trial was registered on 28 November 2018 on, identifier https://clinicaltrials.gov/ .

Civilian cerebral gunshot wounds in rural South African patients are associated with significantly higher mortality rates than in urban patients.

INTRODUCTION: This study focuses on a specific and often dramatic injury, namely gunshot wounds (GSW) of the head in order to determine whether there is a discrepancy in outcome between patients who sustain their injury in a rural setting and those who sustain it in an urban setting. MATERIALS AND METHODS: This study involves a retrospective review of our prospectively maintained regional electronic trauma registry. All patients who sustained a cerebral GSW from January 2010 to December 2014 were reviewed. RESULTS: During the 5-year study period, a total of 102 patients sustained an isolated cerebral GSW. Ninety-two per cent (94/102) were male and the mean age was 29 years. Ninety-four per cent (94/102) of injuries were related to interpersonal violence. Of the 102 patients in the study, 54% (55/102) were urban and were transported directly to our trauma centre. The remaining 46% (47/102) were rural and were transported to a rural district hospital prior to being referred to our trauma centre. The time of injury was available in 60% (61/102) of patients. The mean time from injury to arrival for all patients was 11 h (SD 7). The mean time from injury to arrival was significantly shorter for urban versus rural, 6 h (SD 5) and 15 h (SD 5), respectively (p < 0.001). The median admission GCS score was significantly lower in rural compared to urban patients (p = 0.022). The need for neurosurgery, need for ICU admission or length of hospital stay was not significantly different between rural and urban patients. Rural patients have a fourfold higher mortality compared with urban patients (36 vs 9%, p = 0.001). Amongst survivors, there was no significant difference in median length of hospital stay or mean discharge GCS. CONCLUSIONS: Cerebral GSWs are highly lethal injuries associated with significant mortality. Rural patients have a significantly longer transfer time, lower GCS on arrival and higher mortality than urban patients. Efforts should be directed at improving the pre-hospital EMS system in order to reduce delay to definitive care so that patient outcome can be optimised.

Investigating risk factors for under-five mortality in an HIV hyper-endemic area of rural South Africa, from 2000-2014.

INTRODUCTION: Despite global progress, there remains a disproportionate burden of under-five year old deaths in sub-Saharan Africa (SSA), where four out of five child deaths occur. Substantial progress has been made in improving sanitation, controlling communicable diseases and the spread of HIV in most parts of the world. However, significant strides to address some key risk factors related to under-five mortality are still needed in rural SSA if they are to attain relevant 2030 SDG targets. The aim of this study is to investigate the risk factors for under-five mortality in an HIV hyper-endemic area of rural South Africa, from 2000-2014. Some of the key risk factors investigated are, for example: household wealth, source of drinking water, distance to the national road and birth order. METHODS: We conducted a statistical analysis of 759 births from a population-based cohort in rural KwaZulu-Natal Province, South Africa, from 2000 to 2014. A Cox Proportional Hazards model was used to identify the risk factors and key socio-demographic correlates of under-five mortality leveraging the longitudinal structure of the population cohort. RESULTS: Child mortality rates declined by 80 per cent from 2000 to 2014, from >140 per 1,000 persons in years 2001-2003 to 20 per 1,000 persons in the year 2014. The highest under-five mortality rate was recorded in 2002/2003, which decreased following the start of antiretroviral therapy rollout in 2003/4. The results indicated that under-five and infant mortality are significantly associated with a low wealth index of 1.49 (1.007-2.48) for under-fives and 3.03 (1.72-5.34) for infants. Children and infants with a lower wealth index had a significantly increased risk of mortality as compared to those with a high wealth index. Other significant factors included: source of household drinking water (borehole) 3.03 (1.72-5.34) for under-fives and 2.98 (1.62-5.49) for infants; having an HIV positive mother 4.22 (2.68-6.65) for under-fives and 3.26 (1.93-5.51) for infants, and period of death 9.13 (5.70-14.6) for under-fives and 1.28 (0.75-2.20) for infants. Wealth index had the largest population attributable fraction of 25.4 per cent. CONCLUSIONS: The research findings show a substantial overall reduction in under-five mortality since 2003. Unsafe household water sources and having an HIV-positive mother were associated with an increased risk of under-five mortality in this rural setting. The significant risk factors identified align well with the SDG 2030 targets for reducing child mortality, which include improved nutrition, sanitation, hygiene and reduced HIV infections. Current trajectories suggest that there is some hope for meeting the 2030 SGD targets in rural South Africa and the region if the identified significant risk factors are adequately addressed.

Interventional left atrial appendage closure may affect metabolism of essential amino acids and bioenergetic efficacy.

BACKGROUND: Interventional closure of left atrial appendage (LAAC) represents an alternative for stroke prevention in patients with non-valvular atrial fibrillation. Whether LAAC may affect metabolomic pathways has not been investigated yet. This study evaluates the impact of LAAC on the metabolism of essential amino acids, kynurenine and creatinine. METHODS: Peripheral blood samples of prospectively enrolled patients undergoing successful LAAC were taken before (T0) and 6 months after (T1, mid-term follow-up). Targeted metabolomic profiling was performed using electrospray ionization liquid chromatography-mass spectrometry (ESI-LC-MS/MS) and MS/MS measurements focusing on metabolism of essential amino acids. RESULTS: 44 patients with non-valvular AF (mean CHA2DS2-VASc score 4, mean HAS-BLED score 4) were enrolled. Changes in metabolites of essential amino acids, myocardial contraction and bioenergetic efficacy, such as phenylalanine (percentage change 8.2%, p = 0.006), tryptophan (percentage change 20.3%, p = 0.0006), tyrosine (percentage change 20.2%, p = 0.0001), creatinine (percentage change 7.2%, p > 0.05) and kynurenine (percentage change 8.3%, p = 0.0239) were found at mid-term follow-up. CONCLUSIONS: LAAC may affect the metabolism of essential amino acids and bioenergetic efficacy. ClinicalTrials.gov Identifier: NCT02985463.

A raised serum lactate level is an independent predictor of in-hospital mortality in patients with isolated cerebral gunshot wounds.

BACKGROUND: Cerebral gunshot wounds (CGSWs) represent a highly lethal form of traumatic brain injury, and triaging these patients is difficult. The prognostic significance of the serum lactate level in the setting of CGSWs is largely unknown. OBJECTIVES: To examine the relationship between elevated serum lactate levels and mortality in patients with isolated CGSWs. METHODS: A retrospective review of the regional trauma registry was undertaken at the Pietermaritzburg Metropolitan Trauma Service, South Africa, over a 5-year period from 1 January 2010 to 31 December 2014. All patients with an isolated CGSW were included. RESULTS: A total of 102 patients with isolated CGSWs were identified. Of these, 92.2% (94/102) were male. The mean age (standard deviation) was 29 (8) years, and the in-hospital mortality rate was 21.6% (22/102). The mean serum lactate level was significantly higher among non-survivors than among survivors (6.1 mmol/L v. 1.3 mmol/L; p<0.001). Lactate levels among non-survivors were <2 mmol/L in 4.5%, 2 - 3.99 mmol/L in 9.1%, 4 - 5.99 mmol/L in 36.4% and ≥6 mmol/L in 50.0%. The odds ratio for mortality with a lactate level of 4 - 5.99 mmol/L was 67 (95% confidence interval (CI) 1.7 - 2 674.2), while for a lactate level of ≥6 mmol/L it was 1 787 (95% CI 9.0 - 354 116.1). The serum lactate level accurately predicted mortality even after adjustment for other variables. Based on a receiver operating curve analysis, an optimal cut-off of 3.3 mmol/L for serum lactate as a predictor for mortality was identified (area under the curve = 0.957). CONCLUSIONS: CGSWs are associated with significant mortality, and a raised serum lactate level appears to be an independent predictor of in-hospital mortality. It is a potentially useful adjunct in the resuscitation room for identifying patients with a very poor prognosis.

Operational assessment of point-of-care diagnostics in rural primary healthcare clinics of KwaZulu-Natal, South Africa: a cross-sectional survey.

BACKGROUND: The World Health Organization (WHO) called for new clinical diagnostic for settings with limited access to laboratory services. Access to diagnostic testing may not be uniform in rural settings, which may result in poor access to essential healthcare services. The aim of this study is to determine the availability, current usage, and need for point-of-care (POC) diagnostic tests among rural primary healthcare (PHC) clinics in South Africa's KwaZulu-Natal (KZN) province. METHODS: We used the KZN's Department of Health (DoH) clinic classification to identify the 232 rural PHC clinics in KZN, South Africa. We then randomly sampled 100 of 232 rural PHC clinics. Selected health clinics were surveyed between April to August 2015 to obtain clinic-level data for health-worker volume and to determine the accessibility, availability, usage and need for POC tests. Professional healthcare workers responsible for POC testing at each clinic were interviewed to assess the awareness of POC testing. Data were survey weighted and analysed using Stata 13. RESULTS: Among 100 rural clinics, the average number of patients seen per week was 2865 ± 2231 (range 374-11,731). The average number of POC tests available and in use was 6.3 (CI: 6.2-6.5) out of a potential of 51 tests. The following POC tests were universally available in all rural clinics: urine total protein, urine leukocytes, urine nitrate, urine pregnancy, HIV antibody and blood glucose test. The average number of desired POC diagnostic tests reported by the clinical staff was estimated at 15 (CI: 13-17) per clinic. The most requested POC tests reported were serum creatinine (37%), CD4 count (37%), cholesterol (32%), tuberculosis (31%), and HIV viral load (23%). CONCLUSION: Several POC tests are widely available and in use at rural PHC clinics in South Africa's KZN province. However, healthcare workers have requested additional POC tests to improve detection and management of priority disease conditions. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT02692274.

Percutaneous Closure of Left Atrial Appendage significantly affects Lipidome Metabolism.

Patients with non-valvular atrial fibrillation (AF) and a high risk for oral anticoagulation can be treated by percutaneous implantation of left atrial appendage occlusion devices (LAAC) to reduce the risk of cardio-embolic stroke. This study evaluates whether LAAC may influence lipid metabolism, which has never been investigated before. Patients with successful LAAC were included consecutively. Venous peripheral blood samples of patients were collected immediately before (T0, baseline) and 6 months after (T1, mid-term) LAAC. A targeted metabolomics approach based on electrospray ionization liquid chromatography-mass spectrometry (ESI-LC-MS/MS) and MS/MS measurements was performed. A total of 34 lipids revealed a significant change from baseline to mid-term follow-up after successful LAAC. Subgroup analysis revealed confounding influence by gender, age, diabetes mellitus type II, body mass index, left ventricular ejection fraction, creatinine and NT-proBNP. After multivariable adjustment within logistic regression models, these 34 lipids were still significantly altered after LAAC. Successful percutaneous LAAC may affect lipid metabolism and thereby may potentially affect pro-atherogenic and cardio-toxic effects.

Malignant and pre-malignant oesophageal pathology in a South African teaching hospital.

BACKGROUND: South Africa (SA) has one of the highest global incidences of squamous cell carcinoma of the oesophagus (SCC). A decreasing incidence of oesophageal SCC in SA has been suggested. The study aimed to assess whether the incidence of these malignant histopathological subtypes has changed in this setting. METHOD: A retrospective review of histopathological reports on pre-malignant and malignant oesophageal lesions over three time periods (TP), namely: 2003-4 (TP1), 2008-9 (TP2) and 2013-14 (TP3) was carried out at Inkosi Albert Luthuli Central Hospital, Durban, South Africa. RESULTS: A total of 1341 specimen reports were retrieved. TP1-3 consisted of 514 (39.3%), 320 (24.5%) and 474 (36.2%) patients respectively. Six hundred and forty-nine patients were male (48.3%), 642 were female (47.8%) and 50 were not specified. i.e. a sex ratio of 1.01:1. The mean age was 60.8 (± 11.8). There were 1197 Black patients (91.5%), 66 Asian (5.1%), 25 White (1.9%), 9 mixed ancestry (0.7%), and 11 of unknown race (0.8%). SCC was the most common cancer 1098 (89.1%) followed by adenocarcinoma (AC) 69 (5.6%). The ratio of SCC to AC remained fairly consistent over the total time period. Seventy-four oesophageal resections were performed with a yearly average resection rate of only 5.6%. CONCLUSION: SCC is still the most prevalent oesophageal cancer (OC) without an increase in the ratio of AC to SCC. The diagnosis of squamous cell dysplasia is concordant with previously cited rates. Barrett's oesophagitis remains uncommon. Resection rates for OC are low but similar to other South African referring centers.

Developing a simplified clinical prediction score for mortality in patients with cerebral gunshot wounds: The Maritzburg Score.

Introduction Cerebral gunshot wounds are highly lethal and literature on the clinical scores for mortality prediction is limited. Materials and methods A retrospective study was undertaken over a 5-year period at the Pietermaritzburg Metropolitan Trauma Service in South Africa. A simplified clinical prediction score was developed based on clinical and/or physiological variables readily available in the resuscitation room. Results A total of 102 patients were included; 92% (94/102) were male and the mean age was 29 years; 22% (22/102) died during the admission. The presence of visible brain matter (odds ratio 12.4, P = 0.003) and motor score less than 5 (odds ratio 89.6, P  < 0.001) allows the prediction success of 92% (sensitivity 73% and specificity 98%). The area under the receiver operating characteristic curve was 94% (95% confidence interval 88-100%, P  < 0.001). Conclusions The presence of visible brain matter, together with a motor score of less than 5, allows accurate identification of non-survivors of cerebral gunshot wounds. Further study is required to validate this score.

Developing a predictive model for fine particulate matter concentrations in low socio-economic households in Durban, South Africa.

In low-resource settings, there is a need to develop models that can address contributions of household and outdoor sources to population exposures. The aim of the study was to model indoor PM2.5 using household characteristics, activities, and outdoor sources. Households belonging to participants in the Mother and Child in the Environment (MACE) birth cohort, in Durban, South Africa, were randomly selected. A structured walk-through identified variables likely to generate PM2.5 . MiniVol samplers were used to monitor PM2.5 for a period of 24 hours, followed by a post-activity questionnaire. Factor analysis was used as a variable reduction tool. Levels of PM2.5 in the south were higher than in the north of the city (P < .05); crowding and dwelling type, household emissions (incense, candles, cooking), and household smoking practices were factors associated with an increase in PM2.5 levels (P < .05), while room magnitude and natural ventilation factors were associated with a decrease in the PM2.5 levels (P < .05). A reasonably robust PM2.5 predictive model was obtained with model R2 of 50%. Recognizing the challenges in characterizing exposure in environmental epidemiological studies, particularly in resource-constrained settings, modeling provides an opportunity to reasonably estimate indoor pollutant levels in unmeasured homes.

Rapidly increasing body mass index among children, adolescents and young adults in a transitioning population, South Africa, 2008-15.

Background: There is a global epidemic of overweight and obesity; however, this rate of increase is even greater in some low- and middle-income countries (LMIC). South Africa (SA) is undergoing rapid socioeconomic and demographic changes that have triggered a rapid nutrition transition. The paper focuses on the recent rate of change of body mass index (BMI) among children, adolescents and young adults, further stratified by key sociodemographic factors. Methods: We analysed mean BMI of 28 247 individuals (including children) from 7301 households by age and year, from anthropometric data from four national cross-sectional (repeated panel) surveys using non-linear fitted curves and associated 95% confidence intervals. Results: From 2008 to 2015, there was rapid rise in mean BMI in the 6-25 age band, with the highest risk (3-4+ BMI unit increase) among children aged 8-10 years. The increase was largely among females in urban areas and of middle-high socioeconomic standing. Prominent gains were also observed in certain rural areas, with extensive geographical heterogeneity across the country. Conclusions: We have demonstrated a major deviation from the current understanding of patterns of BMI increase, with a rate of increase substantially greater in the developing world context compared with the global pattern. This population-wide effect will have major consequences for national development as the epidemic of related non-communicable disease unfolds, and will overtax the national health care budget. Our refined understanding highlights that risks are further compounded for certain groups/places, and emphasizes that urgent geographical and population-targeted interventions are necessary. These interventions could include a sugar tax, clearer food labelling, revised school feeding programmes and mandatory bans on unhealthy food marketing to children.The scenario unfolding in South Africa will likely be followed in other LMICs.

The correlation between ATLS and junior doctors' anatomical knowledge of central venous catheter insertion at a major trauma centre in South Africa.

OBJECTIVE: To review the ability of junior doctors (JDs) in identifying the correct anatomical site for central venous catheterization (CVC) and whether prior Advanced Trauma Life Support (ATLS) training influences this. DESIGN: We performed a prospective, observational study using a structured survey and asked a group of JDs (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact site for CVC insertion via the internal jugular (IJV) and the subclavian (SCV) approach. This study was conducted in a large metropolitan university hospital in South Africa. RESULTS: A total of 139 JDs were included. Forty-four per cent (61/139) were males and the mean age was 25 years. There were 90 PGY1s (65%) and 49 PGY2s (35%). Overall, 32% (45/139) were able to identify the correct insertion site for the IJV approach and 60% (84/139) for the SCV approach. Of the 90 PGY1s, 34% (31/90) correctly identified the insertion site for the IJV approach and 59% (53/90) for the SCV approach. Of the 49 PGY2s, 29% (14/49) correctly identified the insertion site for the IJV approach and 63% (31/49) for the SCV approach. No significant difference between PGY1 and 2 were identified. Those with ATLS provider training were significantly more likely to identify the correct site for the IJV approaches [OR=4.3, p=0.001]. This was marginally statistically significant (i.e. p>0.05 but <0.1) for the SCV approach. CONCLUSIONS: The majority of JDs do not have sufficient anatomical knowledge to identify the correct insertion site CVCs. Those who had undergone ATLS training were more likely to be able to identify the correct insertion site.

Correction to: Occlusion of left atrial appendage affects metabolomic profile: focus on glycolysis, tricarboxylic acid and urea metabolism.

The article Occlusion of left atrial appendage aff ects metabolomic profile:focus on glycolysis, tricarboxylic acid and urea metabolism, written by K. Sattler, M. Behnes, C. Barth, A. Wenke, B. Sartorius, I. El-Battrawy, K. Mashayekhi, J. Kuschyk, U. Hoffmann, T. Papavasiliu, C. Fastner, S. Baumann, S. Lang, X. Zhou, G. Yücel, M. BorggrefeI, Akin, was originally published Online First without open access.