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/ .

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.

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.

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.

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.

Circulating microRNA's as a diagnostic tool for hepatocellular carcinoma in a hyper endemic HIV setting, KwaZulu-Natal, South Africa: a case control study protocol focusing on viral etiology.

BACKGROUND: A wide range of studies has investigated the diagnostic proficiency of extracellular microRNAs (miRNAs) in hepatocellular cancer (HCC). HCC is expected to increase in Sub-Saharan Africa (SSA), due to endemic levels of viral infection (HBV/HIV), ageing and changing lifestyles. This unique aetiological background provides an opportunity for investigating potentially novel circulating miRNAs as biomarkers for HCC in a prospective study in South Africa. METHODS: This study will recruit HCC patients from two South African cancer hospitals, situated in Durban and Pietermaritzburg in the province of KwaZulu-Natal. These cases will include both HBV mono-infected and HBV/HIV co-infected HCC cases. The control group will consist of two (2) age and sex-matched healthy population controls per HCC case randomly selected from a Durban based laboratory. The controls will exclude patients if they have any evidence of chronic liver disease. A standardised reporting approach will be adopted to detect, quantify and normalize the level of circulating miRNAs in the blood sera of HCC cases and their controls. Reverse transcription quantitative polymerase chain reaction (RT-qPCR) will be employed to quantity extracellular miRNAs. Differences in concentration of relevant miRNA by case/control status will be assessed using the Wilcoxon rank-sum (Mann-Whitney U) test. Adjustment for multiple testing (Bonferroni correction), receiver operating curves (ROC) and optimal breakpoint analyses will be employed to identify potential thresholds for the differentiation of miRNA levels of HCC cases and their controls. DISCUSSION: Although there is a growing base of literature regarding the role of circulating miRNAs as biomarkers, this promising field remains a 'work in progress'. The aetiology of HBV infection in HCC is well understood, as well as it's role in miRNA deregulation, however, the mediating role of HIV infection is unknown. HCC incidence in SSA, including South Africa, is expected to increase significantly in the next decade. A combination of factors, therefore, offers a unique opportunity to identify candidate circulating miRNAs as potential biomarkers for HBV/HIV infected HCC.

Is Clinical Research in Oesophageal Cancer in South Africa in Crisis? A Systematic Review.

Oesophageal cancer (OC) is responsible for the second highest number of cancer-related deaths in South Africa (SA). Squamous cell carcinoma is the most prevalent type with an incidence of 46.7/100,000 and 19.2/100,000 for males and females. This is a systematic review of the clinical diagnosis and management of OC within the South African context. This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD42016034053) with adherence to PRISMA guidelines. An online search was performed using MEDLINE, EBSCOHost and PubMed. Eligibility criteria for articles included published, original peer-reviewed research addressing clinical management of oesophageal cancer in South Africa. Review articles, case reports, scientific letters and studies published in languages other than English or Afrikaans were excluded. The research terms were 'etiology', 'human', 'esophageal cancer', 'esophageal carcinoma', 'oesophageal cancer', and 'oesophageal carcinoma', 'squamous cell carcinoma', 'Africa' and 'South Africa'. A total of 336 articles were identified. Of these, 146 were immediately excluded and a further 159 were excluded after review. A total of 31 appropriate articles, i.e. 9.2% of searched articles, were included. Thirteen articles addressed chemotherapy and/or radiotherapy, 9 oesophageal luminal therapy, 7 oesophageal surgery and 2 screening. OC research of in SA over the last two decades has mainly been in the form of reviews and opinion papers. Clinical research, auditing and prospectively analysing OC management and outcomes in SA hospitals are sorely needed and should be promoted by both healthcare workers and policy makers alike.

Space-time patterns in maternal and mother mortality in a rural South African population with high HIV prevalence (2000-2014): results from a population-based cohort.

BACKGROUND: International organs such as, the African Union and the South African Government view maternal health as a dominant health prerogative. Even though most countries are making progress, maternal mortality in South Africa (SA) significantly increased between 1990 and 2015, and prevented the country from achieving Millennium Development Goal 5. Elucidating the space-time patterns and risk factors of maternal mortality in a rural South African population could help target limited resources and policy guidelines to high-risk areas for the greatest impact, as more generalized interventions are costly and often less effective. METHODS: Population-based mortality data from 2000 to 2014 for women aged 15-49 years from the Africa Centre Demographic Information System located in the Umkhanyakude district of KwaZulu-Natal Province, South Africa were analysed. Our outcome was classified into two definitions: Maternal mortality; the death of a woman while pregnant or within 42 days of cessation of pregnancy, regardless of the duration and site of the pregnancy, from any cause related to or exacerbated by the pregnancy or its management but not from unexpected or incidental causes; and 'Mother death'; death of a mother whilst child is less than 5 years of age. Both the Kulldorff and Tango spatial scan statistics for regular and irregular shaped cluster detection respectively were used to identify clusters of maternal mortality events in both space and time. RESULTS: The overall maternal mortality ratio was 650 per 100,000 live births, and 1204 mothers died while their child was less than or equal to 5 years of age, of a mortality rate of 370 per 100,000 children. Maternal mortality declined over the study period from approximately 600 per 100,000 live births in 2000 to 400 per 100,000 live births in 2014. There was no strong evidence of spatial clustering for maternal mortality in this rural population. However, the study identified a significant spatial cluster of mother deaths in childhood (p = 0.022) in a peri-urban community near the national road. Based on our multivariable logistic regression model, HIV positive status (Adjusted odds ratio [aOR] = 2.5, CI 95%: [1.5-4.2]; primary education or less (aOR = 1.97, CI 95%: [1.04-3.74]) and parity (aOR = 1.42, CI 95%: [1.24-1.63]) were significant predictors of maternal mortality. CONCLUSIONS: There has been an overall decrease in maternal and mother death between 2000 and 2014. The identification of a clear cluster of mother deaths shows the possibility of targeting intervention programs in vulnerable communities, as population-wide interventions may be ineffective and too costly to implement.

Defining predictors of mortality in pediatric trauma patients.

BACKGROUND: The aim of this study was to describe our cohort of pediatric trauma patients and to analyze their physiological data. The intention was to highlight the difficulty in using systolic blood pressure (SBP) readings in this population and to investigate the role of base excess (BE) in predicting clinical outcomes in pediatric trauma patien. METHOD: The Pietermaritzburg Metropolitan Trauma Service (PMTS) maintains a prospective digital trauma registry, and all pediatric trauma patients admitted to the service for the period January 2012 - July 2016 were included. RESULTS: Out of an original dataset of 1239 pediatric trauma patients admitted to the emergency departments of the PMTS, 26 elective patients and 216 patients with missing SBP were excluded to leave a sample size of 997 patients. The majority of the sample was male accounting for 669 patients (67.2 %) with 327 females (32.8%) and 1 (0.1%) missing data. The mean age (SD) was 7.7 years (3.9) and the median age (IQR) was 8 years (5 - 11). There were 58 children < 2 years of age, 177 between the age of 2 to < 5 years of age, 402 between 5 to < 10 years of age and 360 between 10 and < 15 years of age. The predominant mechanism of injury was blunt trauma (78.4% or 782/997). Penetrating trauma accounted for 11.0% of cases (110/997). The mean systolic BP (SD) across the whole cohort was 110.1 mm Hg (16.9) and the median systolic BP (IQR) was 110 mm Hg (100-119). Mortality rate remains low and then precipitously increases below a SBP of 93 mm Hg in children older than 2 and below 89 mm Hg in children younger than 2. This suggests that a SBP of 93 mm Hg or less in children older than 2 and 89 mm Hg or less in children under 2 years is clinically significant. Similarly, as BE decreased, the mortality risk also increased prominently. CONCLUSION: This study has used a previously described methodology based on large developed world trauma databases and confirms the current thinking that SBP is a late marker and thus not useful in the pediatric population and a better system/ approach is needed. The use of BE in conjunction with SBP may be a more useful means of identifying shock.

Oesophageal squamous cell cancer in a South African tertiary hospital: a risk factor and presentation analysis.

BACKGROUND: Squamous carcinoma of the oesophagus (SCO) is the most common form of oesophageal cancer in South Africa (SA). Risk factors include male gender, smoking, alcohol consumption and low socio-economic status (SES). This study assessed the risk factors for SCO in KwaZulu-Natal. METHOD: Information on patients managed at Inkosi Albert Luthuli Central Hospital (IALCH), Durban, South Africa, between 1 October 2013 and 31 December 2014 was retrieved from a prospective database of Oesophageal Cancer (OC). Data collected included demographics, risk factors, symptoms and clinical findings. RESULTS: One hundred and fifty-nine patients (159) with SCO were identified. The site of tumour location was in the middle 96 (60.4%), distal 42(26.4%) and proximal 17(10.6%) oesophagus. The male to female ratio was 1:1 with an age range of 22-93 years (mean 60.6; SD±12.1). Females were significantly older than males (p = 0.018). Eighty-eight per cent were Black African. Dysphagia was reported in 158 (99.4%) of patients and loss of weight in 149(95.5%). Thirty-six patients were HIV positive (age 52.8; SD±9.7) and significantly younger than those without HIV infection (age 61.2; SD±11.5). Most patients had low SES and poor dental health. Male patients were significantly more likely to use tobacco (p < 0.001; Odds Ratio (OR) 7.8) and consume alcohol (p < 0.001; OR 7.7) than females who were 2.5 times more likely to report a family history of cancer (p = 0.017; OR 2.6). CONCLUSION: An equal gender distribution was observed. Male patients with SCO reported the expected risk factors; however these were not observed amongst women. SES may contribute to the development of SCO. Poor dental health may be a surrogate marker for low SES and a possible risk factor for SCO. HIV positive individuals present a decade younger when compared with HIV negative patients.

Barriers to accessing ATLS provider course for junior doctors at a major university hospital in South Africa.

BACKGROUND: Advanced trauma life support (ATLS) is the international standard of care and forms the basis of trauma training in South Africa. Previous local studies demonstrated a low completion rate among junior doctors (JD). This study was designed to determine the reasons and identify possible barriers of JDs to accessing the ATLS course at a major university hospital. METHOD: This was a prospective study utilising a structured survey that included all JDs who were undertaking their internship training. RESULTS: A total of 105 JDs completed the survey. Sixty-two percent were female (65/105) and the mean age was 25 years. Forty-eight percent (50/105) of all JDs were post graduate year 1 (PGY 1) and the remaining 52% were post graduate year 2 (PGY 2) JDs. Sixty-two percent (65/105) of all respondents had completed their mandatory rotation in surgery. The reasons for non-attendance of ATLS were: unable to secure a place on course (52%), unable to afford course fee (18%), permission for attendance not granted (14%), unable to obtain study leave (10%) and lack of interest (5%). Subgroup analysis comparing the reasons for PGY1s vs PGY2s demonstrated that not being able to secure a place on course was more common among PGY2s [19% vs 33%, p < 0.001] while financial reasons were more common among PGY1s [18% vs 0%, p < 0.001]. CONCLUSION: The primary barriers for JDs to attending ATLS training is difficulty in accessing the course due to oversubscription, financial reasons, followed by difficulty in obtaining professional development leave due to staff shortage. There is an urgent need to improve access to the ATLS training course for JDs in our environment.

Quantifying the funding gap for management of traumatic brain injury at a major trauma centre in South Africa.

BACKGROUND: Trauma is an eminently preventable disease. However, prevention programs divert resources away from other priorities. Costing trauma related diseases helps policy makers to make decisions on re-source allocation. We used data from a prospective digital trauma registry to cost Traumatic Brain Injury (TBI) at our institution over a two-year period and to estimate the funding gap that exists in the care of TBI. METHOD: All patients who were admitted to the Pietermaritzburg Metropolitan Trauma Service (PMTS) with TBI were identified from the Hybrid Electronic Medical Registry (HMER). A micro-costing model was utilised to generate costs for TBI. Costs were generated for two scenarios in which all moderate and severe TBI were admitted to ICU. The actual cost was then sub-tracted from the scenario costs to establish the funding gap. RESULTS: During the period January 2012 to December 2014, a total of 3 301 patients were treated for TBI in PMB. The mean age was 30 years (SD 50). There were 2 632 (80%) males and 564 (20%) females. The racial breakdown was overwhelmingly African (96%), followed by Asian (2%), Caucasian (1%) and mixed race (1%). There were 2 540 mild (GCS 13-15), 326 moderate (9-12), and 329 severe (GCS ≤8) TBI admissions during the period under review. A total of 139 patients died (4.2%). A total of 242 (7.3%) patients were admitted to ICU. Of these 137 (57%) had a GCS of 9 or less. A total of 2 383 CT scans were performed. The total cost of TBI over the two-year period was ZAR 62 million. If all 326 patients with moderate TBI had been admitted to ICU there would have been a further 281 ICU admissions. This was labelled Scenario 1. If all patients with severe as well as moderate TBI had been admitted there would have been a further 500 ICU admissions. This was labelled Scenario 2. Based on Scenario 1 and Scenario 2 the total cost would have been ZAR 73 272 250 and ZAR 82 032 250 respectively. The funding gaps for Scenario 1 and Scenario 2 were ZAR 11 240 000 and ZAR 20 000 000 respectively. CONCLUSION: There is a significant burden of TBI managed by the PMTS. The cost of managing TBI each year is in the order of sixty million ZAR. A significant funding gap exists in our environment. This data does not include any data on the broader social costs of TBI. Investing in programs to reduce and prevent TBI is justified by the potential for significant savings.

Endovascular Therapy for Large Vessel Vasculopathy in HIV-infected Patients.

OBJECTIVES: To evaluate outcomes after endovascular treatment of patients with aneurysmal or occlusive vasculopathy in HIV-infected patients. METHODS: Retrospective analysis of a prospective database of treatment outcomes in patients with HIV related vasculopathies between April 2005 and September 2015. RESULTS: Sixty HIV patients presented with post-traumatic pseudoaneurysm formation (n = 7), aneurysmal disease (n = 24) or occlusive disease (n = 29 (48%)). The majority were male (42/60 (70%)), with a mean age of 43.9 years (SD ± 12.6). All seven patients with a post-traumatic pseudoaneurysm were treated by insertion of a covered stent (n = 6) or coiling (n = 1). All were successfully treated at 30 days, but only one patient returned for late surveillance. 23/24 patients who underwent insertion of a stent graft/covered stent for aneurysmal disease returned for 30 day review (one asymptomatic stent graft occlusion). Only 11 patients attended for late surveillance; 9/11 were asymptomatic with patent stent grafts. Late stent occlusion occurred in two (no further action (n = 1), major limb amputation (n = 1). In the 29 patients who underwent endovascular treatment for occlusive disease, 9 (31%) had immediate treatment failure (including 8 amputations (28%)). Of the sixteen who returned for serial review, 8 (50%) suffered further complications including 4 amputations. Overall, 12/29 treated patients (41%) ultimately underwent amputation. CONCLUSIONS: In the immediate short term, an 'endovascular first' strategy was associated with good outcomes in HIV patients with aneurysmal disease. By contrast, outcomes were poor in HIV patients with occlusive disease. Whether this relates to the underlying natural history of HIV occlusive vasculopathies remains unclear. One major problem in trying to formulate meaningful management strategies is a generalised reluctance for HIV patients to return for surveillance.

The Role of Planned and On-Demand Relaparotomy in the Developing World.

INTRODUCTION/BACKGROUND: This study compares planned repeat laparotomy (PR) with on-demand repeat laparotomy (OD) in a developing world setting. MATERIALS AND METHODS: This study was conducted over a 30-month study period (December 2012-May 2015) at Greys Hospital, Pietermaritzburg, South Africa. All trauma and general surgery adult patients requiring a single relaparotomy were included in this study. Prospectively gathered data entered into an established electronic registry were retrospectively analysed. Full ethical approval for the registry and this study was granted by the University of KwaZulu-Natal Biomedical Ethics Committee. RESULTS: A total of 162 patients were included, with an average age of 36 years (standard deviation 17) and 69 % male predominance. Appendicitis and stab abdomen were the most common underlying diagnoses. PR strategy was used in 46 % and an OD approach in 54 %. Patients selected for the PR strategy had higher admission pulse rates, higher Modified Early Warning System (MEWS) scores and significantly higher rates of diffuse intra-abdominal sepsis at initial laparotomy. However, findings at relaparotomy were similar in both groups. The PR group had a much shorter time between operations, but much higher need for intensive care unit (ICU) admission. There was no difference between the groups in terms of open abdomen at discharge, length of hospital stay, morbidity or mortality. CONCLUSION: In our environment, a planned approach to relaparotomy shows no major outcome advantages over an on-demand approach. There is however increased need for ICU admission with the PR approach. This is in keeping with international literature. Of concern is the much longer time delay between index procedure and repeat operation in the OD group. Improved post-operative decision making may help address this.

International medical graduates in South Africa and the implications of addressing the current surgical workforce shortage.

BACKGROUND: The surgical workforce in South Africa is currently insufficient in being able to meet the burden of surgical disease in the country. International medical graduates (IMGs) help to alleviate the deficit, yet very little is known about these doctors and their career progression in our healthcare system. METHOD: The demographic profile and career progression of IMGs who worked in our surgical department in a major university hospital in South Africa was reviewed over a four-year period. RESULTS: Twenty-eight IMGs were identified. There were 23 males (92%) and their mean age was 33 years. Seventy-one per cent (20/28) were on a fixed-term service contract, and returned to their respective country of origin. The option of renewing their service contracts was available to the 16 IMGs who left. Three explicitly indicated they would have stayed in South Africa if formal training was possible. Eight of the 28 IMGs (29%) extended their tenure, and remained in the service position as medical officers. All of the eight IMGs stayed with the intention of entering a formal surgical training programme. CONCLUSION: IMGs represented a significant proportion of service provision in our unit. Over one third of IMGs stayed beyond their initial tenure, and of these, all stayed in order to gain entry into the formal surgical training programme. A significant proportion of those who left would have stayed if entry to the programme was feasible.

Prostate Cancer at a regional hospital in South Africa: we are only seeing the tip of the iceberg.

OBJECTIVES: The objectives were to document the presentation of prostate cancer in the Zulu population of KwaZulu-Natal in South Africa, to identify this as a high-risk population, and to determine the potential for under-diagnosis in this population. METHOD: All histopathology results confirming prostatic adenocarcinoma from biopsies preformed at Edendale hospital from 01/11/2012 to 30/04/2014 were collected. A total of 81 participants were enrolled, and a review of their outpatient records was performed. Patient presentation was analysed, younger patients were compared to older patients, and observed incidence was compared to expected incidence. RESULTS: The majority of patients (66%, 95% confidence interval [CI]:54-76%) presented with radiographic evidence of metastatic disease or PSA greater than 100 ng/ml. The median PSA level at presentation was 154 ng/ml (Interquartile range [IQR] = 39-448). Clinically staged T4 disease was present in 44% of patients and only 10% of patients presented with PSA detected disease. Poorly differentiated tumours (Gleason grades 8, 9 and 10) were found in 43% of patients. Only 81 out of a maximum potential of 625 incident prostate cancer cases were diagnosed. CONCLUSION: Black South African men from a predominantly rural Zulu population present late and with advanced and aggressive disease. We are missing the opportunity for remission in most patients in this high risk population group. The establishment of a National Prostate Cancer Registry and further research into a prostate cancer screening programme may be beneficial to this community.

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

[This corrects the article DOI: 10.1371/journal.pone.0207294.].

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.

Next generation 1.5 microm terahertz antennas: mesa-structuring of InGaAs/InAlAs photoconductive layers.

Mesa-structuring of InGaAs/InAlAs photoconductive layers is performed employing a chemical assisted ion beam etching (CAIBE) process. Terahertz photoconductive antennas for 1.5 microm operation are fabricated and evaluated in a time domain spectrometer. Order-of-magnitude improvements versus planar antennas are demonstrated in terms of emitter power, dark current and receiver sensitivity.