One-year anthropometric follow-up of South African preterm infants in kangaroo mother care: Which early-life factors predict malnutrition?

BACKGROUND: Preterm infants often have poor short- and long-term growth. Kangaroo mother care supports short-term growth, but longer-term outcomes are unclear. METHODS: This study analysed longitudinally collected routine clinical data from a South African cohort of preterm infants (born <37 weeks gestation) attending the outpatient follow-up clinic of a tertiary-level hospital (Tshwane District, South Africa) for 1 year between 2012 and 2019. At 1 year, small-for-gestational age (SGA) and appropriate-for-gestational age (AGA) infants were compared with regard to age-corrected anthropometric z-scores (weight-for-age [WAZ], length-for-age [LAZ], weight-for-length [WLZ] and BMI-for-age [BMIZ]) and rates of underweight (WAZ < -2), stunting (LAZ < -2), wasting (WLZ < -2) and overweight (BMIZ> + 2). Multiple regression analysis was used to investigate associations between maternal/infant characteristics and rates of underweight, stunting, wasting and overweight. RESULTS: At 1 year, compared with AGA infants (n = 210), SGA infants (n = 111) had lower WAZ (-1.26 ± 1.32 vs. -0.22 ± 1.24, p < 0.001), LAZ (-1.50 ± 1.11 vs. -0.60 ± 1.06, p < 0.001), WLZ (-0.66 ± 1.31 vs. 0.11 ± 1.24, p < 0.001) and BMIZ (-0.55 ± 1.31 vs. 1.06 ± 1.23, p < 0.001), despite larger WAZ gains from birth (+0.70 ± 1.30 vs. +0.05 ± 1.30, p < 0.001). SGA infants had significantly more stunting (34.2% vs. 9.1%; p < 0.001), underweight (31.2% vs. 7.2%; p < 0.001) and wasting (12.6% vs. 4.3%, p = 0.012), with no difference in overweight (4.5% vs. 7.7%, p = 0.397). In multiple regression analysis, birth weight-for-GA z-score more consistently predicted 1-year malnutrition than SGA. CONCLUSION: Preterm-born SGA infants remain more underweight, stunted and wasted than their preterm-born AGA peers at 1 year, despite greater WAZ gains. Interventions for appropriate catch-up growth especially for SGA preterm infants are needed.

Optimising diagnosis and management of kidney disease: an implementation trial of a clinical decision support system future health today.

BACKGROUND: Chronic kidney disease affects more than 10% of the world's population and is a non-communicable disease of global concern and priority. There is a significant implementation gap between best practice guideline recommendations and current kidney disease management. Previous research has shown the need to partner with primary care to improve education, collaboration, and kidney disease awareness. This implementation trial will explore use of an innovative clinical decision support software, Future Health Today, to improve screening, diagnosis, and management of kidney disease in primary care. The program will be supported by tertiary care outreach services. The primary aim is to test the hypothesis that the Future Health Today implementation program will improve screening, diagnosis, and management of kidney disease. Secondary aims are to evaluate primary care satisfaction and broader health service impacts. METHODS: This pre-post implementation trial using an interrupted time series design will evaluate the clinical and service outcomes of Future Health Today, using a mixed methods study in twenty general practices with an estimated population size of 150,000. Deidentified patient data will be extracted from participating practices to examine the primary aims of the study. Surveys and semi-structured interviews with general practice will inform secondary hypotheses. Data linkage between primary care and tertiary care data will examine the broader health service impacts. DISCUSSION: This investigator driven trial will assess the impact of Future Health Today software coupled with education and clinical outreach support. Investigators hypothesise that there will be improvement in appropriate screening, diagnosis, and management of kidney disease. This program has the potential to be scaled more broadly. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry: ACTRN12623001096640.

Difference thresholds for primary and secondary ride of a vehicle on a 4-poster test rig.

Not only is it important to know how large the overall change in vibration should be for occupants to perceive an improvement in comfort, but also how large this change should be in specific frequency bands. Relative difference thresholds (RDT) of primary (0.5-4 Hz) and secondary (9-80 Hz) ride are estimated for 14 automotive engineers seated in a vehicle on a 4-poster test rig over two roads. Resulting stimuli differed in magnitude and spectral shape. The median RDTs estimated for primary and secondary ride were 16.68% and 13.82% on the smooth road, and 9.50% and 24.67% over the rough road. Statistically significant differences were found in the medians of the RDTs between (1) primary and secondary ride on the two roads and (2) the two roads for changes in the primary and secondary ride, suggesting that Weber's law does not hold.

Relative difference thresholds of primary and secondary ride are estimated that can be used to evaluate whether modifications to vehicle characteristics result in perceivable changes of vehicle vibration. Results suggest that Weber's law does not hold implying that relative difference thresholds should be used that closely match the stimuli characteristics.

Infant growth by INTERGROWTH-21st and Fenton Growth Charts: Predicting 1-year anthropometry in South African preterm infants.

Post-natal growth influences short- and long-term preterm infant outcomes. Different growth charts, such as the Fenton Growth Chart (FGC) and INTERGROWTH-21st Preterm Post-natal Growth Standards (IG-PPGS), describe different growth curves and targets. This study compares FGC- and IG-PPGS-derived weight-for-postmenstrual age z-score (WZ) up to 50 weeks postmenstrual age (PMA50) for predicting 1-year anthropometry in 321 South African preterm infants. The change in WZ from birth to PMA50 (ΔWZ, calculated using FGC and IG-PPGS) was correlated to age-corrected 1-year anthropometric z-scores for weight-for-age (WAZ), length-for-age (LAZ), weight-for-length (WLZ) and BMI-for-age (BMIZ), and categorically compared with rates of underweight (WAZ < -2), stunting (LAZ < -2), wasting (WLZ < -2) and overweight (BMIZ > + 2). Multivariable analyses explored the effects of other early-life exposures on malnutrition risk. At PMA50, mean WZ was significantly higher on IG-PPGS (-0.56 ± 1.52) than FGC (-0.90 ± 1.52; p < 0.001), but ΔWZ was similar (IG-PPGS -0.26 ± 1.23, FGC -0.11 ± 1.14; p = 0.153). Statistically significant ΔWZ differences emerged among small-for-gestational age infants (FGC -0.38 ± 1.22 vs. IG-PPGS -0.01 ± 1.30; p < 0.001) and appropriate-for-gestational age infants (FGC + 0.02 ± 1.08, IG-PPGS -0.39 ± 1.18; p < 0.001). Correlation coefficients of ΔWZ with WAZ, LAZ, WLZ and BMIZ were low (r < 0.45), though higher for FGC than IG-PPGS. Compared with IG-PPGS, ΔWZ < -1 on FGC predicted larger percentages of underweight (42% vs. 36%) and wasting (43% vs. 39%) and equal percentages of stunting (33%), while ΔWZ > + 1 predicted larger percentages overweight (57% vs. 38%). Both charts performed similarly in multivariable analysis. Differences between FGC and IG-PPGS are less apparent when considering ΔWZ, highlighting the importance of assessing growth as change over time, irrespective of growth chart.

Introducing a secondary segmentation to construct a radiomics model for pulmonary tuberculosis cavities.

PURPOSE: Accurate segmentation (separating diseased portions of the lung from normal appearing lung) is a challenge in radiomic studies of non-neoplastic diseases, such as pulmonary tuberculosis (PTB). In this study, we developed a segmentation method, applicable to chest X-rays (CXR), that can eliminate the need for precise disease delineation, and that is effective for constructing radiomic models for automatic PTB cavity classification. METHODS: This retrospective study used a dataset of 266 posteroanterior CXR of patients diagnosed with laboratory confirmed PTB. The lungs were segmented using a U-net-based in-house automatic segmentation model. A secondary segmentation was developed using a sliding window, superimposed on the primary lung segmentation. Pyradiomics was used for feature extraction from every window which increased the dimensionality of the data, but this allowed us to accurately capture the spread of the features across the lung. Two separate measures (standard-deviation and variance) were used to consolidate the features. Pearson's correlation analysis (with a 0.8 cut-off value) was then applied for dimensionality reduction followed by the construction of Random Forest radiomic models. RESULTS: Two almost identical radiomic signatures consisting of 10 texture features each (9 were the same plus 1 other feature) were identified using the two separate consolidation measures. Two well performing random forest models were constructed from these signatures. The standard-deviation model (AUC = 0.9444 (95% CI, 0.8762; 0.9814)) performed marginally better than the variance model (AUC = 0.9288 (95% CI, 0.9046; 0.9843)). CONCLUSION: The introduction of the secondary sliding window segmentation on CXR could eliminate the need for disease delineation in pulmonary radiomic studies, and it could improve the accuracy of CXR reporting currently regaining prominence as a high-volume screening tool as the developed radiomic models correctly classify cavities from normal CXR.

Management of proximal rectus femoris injuries - do we know what we're doing?: A systematic review.

Rectus femoris (RF) injury is a concern in sports. The management RF strains/tears and avulsion injuries need to be clearly outlined. A systematic review of literature on current management strategies for RF injuries, and to ascertain the efficacy thereof by the return to sport (RTS) time and re-injury rates. Literature search using Medline via PubMed, WorldCat, EMBASE, SPORTDiscus. Eligible studies were reviewed. Thirty-eight studies involving hundred and fifty-two participants were included. Majority (n = 138; 91%) were males, 80% (n = 121) sustained RF injury from kicking and 20% (n = 31) during sprinting. The myotendinous (MT), (n = 27); free tendon (FT), (n = 34), and anterior-inferior iliac spine (AIIS), (n = 91) were involved. Treatment was conservative (n = 115) or surgical (n = 37) across the subgroups. 73% (n = 27) of surgical treatments followed failed conservative treatment. The mean RTS was shorter with successful conservative treatment (MT: 1, FT: 4, AIIS avulsion: 2.9 months). Surgical RTS ranged from 2-9 months and 18 months with labral involvement. With either group, there was no re-injury within 24 months follow-up. With low certainty of evidence RF injury occurs mostly from kicking, resulting in a tear or avulsion at the FT and AIIS regions with or without a labral tear. With low certainty, findings suggest that successful conservative treatment provides a shortened RTS. Surgical treatment remains an option for failed conservative treatment of RF injuries across all subgroups. High-level studies are recommended to improve the evidence base for the treatment of this significant injury.

Population health trends analysis and burden of disease profile observed in Sierra Leone from 1990 to 2017.

BACKGROUND: Sierra Leone, in West Africa, is one of the poorest developing countries in the world. Sierra Leone has experienced several recent challenges namely, a civil war from 1991 to 2002, a massive Ebola outbreak from 2014 to 2016, followed by floods and landslides in 2017.In this study, we quantified the burden of disease in Sierra Leone over a 27-year period, from 1990 to 2017. METHODOLOGY: In this descriptive study, we analysed secondary data from the Institute of Health Metrics and Evaluation, Global Burden of Disease (GBD) study. We quantified patterns of burden of disease, injuries, and risk factors in Sierra Leone. We report GBD data and metrics including mortality rates, years of life lost and risk factors for all ages and both sexes from 1990 to 2017. RESULTS: From 1990 to 2017, trends of mortality rates for all ages and sexes have declined in Sierra Leone although mortality rates remain some of the highest when compared to other developing countries. The burden of communicable, maternal, neonatal, and nutritional (CMNN) diseases are greater than the burden of non-communicable diseases (NCDs) due to the prevalence of endemic diseases in Sierra Leone. The most important CMNNs associated with premature mortality included respiratory infections, neglected tropical diseases, malaria, and HIV-Aids. Life expectancy has increased from 37 to 52 years. CONCLUSION: Sierra Leone's health status is gradually improving following the civil war and Ebola outbreak. Sierra Leone has a double burden of disease with CMNNs leading and NCDs progressively increasing. Despite these challenges, Sierra Leone has promising initiatives and programs pursuing the Universal Health Coverage 2030 Sustainable Developmental Goals Agenda. There is need for accountability of available resources, clear rules and expected roles for non-governmental organisations to ensure a level playing field for all actors to rebuild the health system.

Trail running injury risk factors: a living systematic review.

OBJECTIVE: To review and frequently update the available evidence on injury risk factors and epidemiology of injury in trail running. DESIGN: Living systematic review. Updated searches will be done every 6 months for a minimum period of 5 years. DATA SOURCES: Eight electronic databases were searched from inception to 18 March 2021. ELIGIBILITY CRITERIA: Studies that investigated injury risk factors and/or reported the epidemiology of injury in trail running. RESULTS: Nineteen eligible studies were included, of which 10 studies investigated injury risk factors among 2 785 participants. Significant intrinsic factors associated with injury are: more running experience, level A runner and higher total propensity to sports accident questionnaire (PAD-22) score. Previous history of cramping and postrace biomarkers of muscle damage is associated with cramping. Younger age and low skin phototypes are associated with sunburn. Significant extrinsic factors associated with injury are neglecting warm-up, no specialised running plan, training on asphalt, double training sessions per day and physical labour occupations. A slower race finishing time is associated with cramping, while more than 3 hours of training per day, shade as the primary mode of sun protection and being single are associated with sunburn. An injury incidence range 0.7-61.2 injuries/1000 hours of running and prevalence range 1.3% to 90% were reported. The lower limb was the most reported region of injury, specifically involving blisters of the foot/toe. CONCLUSION: Limited studies investigated injury risk factors in trail running. Our review found eight intrinsic and nine extrinsic injury risk factors. This review highlighted areas for future research that may aid in designing injury risk management strategies for safer trail running participation.PROSPERO registration numberCRD42021240832.

Performance of contrast-enhanced mammography for detecting multifocal and multicentric breast cancer and evaluating tumour size, and implications for surgical management: Early experience in a tertiary centre.

INTRODUCTION: To compare diagnostic accuracy of contrast-enhanced mammography (CEM) with standard 2D digital mammography (equivalent to low-energy image; LEM) for detection of multifocal and multicentric breast cancer and evaluation of tumour size and disease extent for preoperative planning. METHODS: Biopsy proven breast cancer patients who underwent CEM preoperatively between January 2021 and January 2023 were included in this study. CEM and LEM images were independently reviewed by at least two blinded readers. Lesion location, number, size (maximal diameter) and extension across the midline and/or nipple invasion were recorded. Tumour number and size estimated on imaging were compared with final operative histology, which served as the gold standard. RESULTS: Forty-nine patients (48 females and 1 male) and 50 cases (one patient had bilateral breast lesions) were included in the analysis. Median patient age was 60 (IQR 51, 69). CEM had significantly higher lesion detection rate compared with LEM, with sensitivities of 78% for LEM and 92% for CEM for the index tumour and 15% for LEM and 100% for CEM for multicentric and multifocal cancer. We found no statistically significant difference in median tumour size measurements on CEM and final surgical specimen (P value = 0.97); however, a significant difference was identified in the tumour size measured on LEM and surgical specimen (P value < 0.001). CONCLUSION: CEM is superior to standard 2D digital mammography for detection of multifocal and multicentric breast cancer and is a reliable and more accurate method for estimating tumour size.

Training for shorter ultra-trail races results in a higher injury rate, a more diverse injury profile, and more severe injuries: 2022 Mac ultra races.

OBJECTIVES: Determine and compare the epidemiology, clinical characteristics, and injury severity among race entrants training towards different ultra-trail race distances. DESIGN: Retrospective cross-sectional study. SETTING: The six months training period before the 2022 Mac Ultra races (46 km, 80 km, 161 km and 322 km). PARTICIPANTS: Of the 245 race entrants, 162 (66% of Mac ultra-trail runners) consented to analyse their data. OUTCOME MEASURES: Injury rate (injuries per 1000 h of running), point prevalence (% of currently injured participants), injury severity (time loss), and the frequency (n, %) of injuries reported during pre-race medical screening in the six months before the race. Using inferential statistics, we compared the injury rates between the different race distance categories (46 km, 80 km, 161 km, 322 km). All tests were performed at a 5% level of significance. RESULTS: We reported a statistically significantly higher injury rate among 46 km study participants (3.09 injuries per 1000 h) compared to the injury rates reported among 80 km (0.68 injuries per 1000 h; p = 0.001) and 161 km (1.09 injuries per 1000 h; p = 0.028) participants. The lower limb (89%) was the most injured anatomical region, with only 46 km study participants reporting upper limb, trunk, and head injuries (11%). Muscle/tendon was the most reported injured tissue type (56%), with muscle injuries (31%) the most reported pathology type. Shorter distance ultra-trail runners reported the highest injury severity. CONCLUSION: Ultra-trail runners training towards shorter ultra-trail distance races presented with a higher injury rate, more diverse injury profile, and a higher injury severity.

Effects of no mask, a surgical mask and a fabric buff on peripheral oxygenation saturation during moderate intensity exercise: a randomised cross-over study.

Background: Mask-wearing caused significant reductions in coronavirus disease 2019 (COVID-19) transmission. We aimed to determine whether face mask-wearing during exercise caused reductions in peripheral oxygen saturation (SpO2) and whether it affected secondary physiological measures [end-tidal carbon dioxide (EtCO2), respiratory rate (RR), heart rate (HR), expired breath temperature (EBT)]. Subjective measurements included ratings of perceived exertion (RPE), ratings of perceived breathlessness (RPB), and symptomology. Methods: A randomised cross-over trial examined no mask (NM), surgical mask (SM) and a buff mask (BM). Thirty participants (30-45 years) cycled at 60% power output for 30 min in three exercise sessions, 24 h apart, within 6 days. Each session recorded all measures at resting baseline (T0), 9 min (T1), 18 min (T2), and 27 min (T3). Dependent statistical tests determined significant differences between masks and time-points. Results: SpO2 decreased for SM and BM between T0 compared to T1, T2 and T3 (all P<0.005). BM caused significant reductions at T1 and T2 compared to NM (P<0.001 and P=0.018). Significant changes in EtCO2 and EBT occurred throughout exercise and between exercise stages for all mask conditions (P<0.001). As expected for moderate intensity exercise, RR and HR were significantly higher during exercise compared to T0 (P<0.001). RPB significantly increased for each condition at each time point (P<0.001). RPE was not significant between mask conditions at any exercise stage. Conclusions: SM and BM caused a mild but sustained reduction in SpO2 at commencement of exercise, which did not worsen throughout short (<30 min) moderate intensity exercise. Level of perception was similar, suggesting healthy people can wear masks during moderate exercise and activities of daily living.

Illness is more prevalent than injury in trail runners participating in a mountainous ultra trail race.

OBJECTIVES: Trail running is a popular off-road sport involving running in natural environments over various terrains, often in remote locations. This study aims to investigate the epidemiology and risk factors of injuries and illnesses, i.e. medical encounters, on race day among trail runners in a high-altitude ultra trail race. METHODS: This descriptive cross-sectional study on an ultra trail race (38 km, 65 km and 100 km) in South Africa, included participants 18 years or older. Of the 331 race participants, 285(86.1%) consented to participate in the study. Data collection included demographic details, injuries (body region, specific body area, tissue type, pathology) and illnesses (organ system, symptom cluster, etiology). Risk factor analysis includes sex, age, weight, height, race distance, illness and injury history, training and running experience. Frequency (n, %), prevalence (%) and odds ratios (OR; 95%CI) are reported. RESULTS: Eighty-nine (31.2%) individuals reported 131 medical encounters [49 injuries (37.4%); 82 illnesses (62.6%)]. Injuries were sustained by 14.7% of athletes, and 22.5% reported illnesses. For injuries, the lower limb was mainly involved (n = 41; 83.7%). Most injuries affected the foot (n = 18; 36.7%), ankle (n = 10; 20.4%) and knee (n = 7; 14.3%). Tissue types mainly involved skin (n = 21; 42.8%), ligament (n = 7; 14.3%) and muscle (n = 7; 14.3%). Multiple (n = 45; 54.9%) and gastrointestinal (n = 17; 20.7%) organ systems were mainly involved in illnesses. Only 100 km runners reported dehydration (n = 28; 31.5%), and one in every six of these runners (n = 5; 17.9%) did not finish. Runners reporting fatigue (n = 21; 23.6%) had a high (n = 8; 38.1%) did not finish rate. Two in every five participants (n = 36; 40.4%) with a medical encounter, did not finish. No medical encounter-associated risk factors were identified. CONCLUSIONS: Illnesses were more common than injuries during the mountainous ultra trail race. Sustaining a medical encounter increased the chance of not completing the race. Further research on the epidemiology of race day medical encounters in trail running is required.

Documentation of wounds in emergency departments through a forensic lens.

BACKGROUND: Nurses document wounds to direct and evaluate the care. People admitted to emergency departments with wounds should be regarded as potential forensic patients, requiring meticulous documentation for evidence purposes. AIM: To explore the documentation of wounds in emergency departments through a forensic lens and compare it between different levels of emergency departments. METHODS: In this descriptive retrospective study, we randomly sampled 515 paper-based medical files of patients who sustained wounds admitted to three selected emergency departments. The files were analysed using a structured data collection tool the data were descriptively analysed. RESULTS: All files included information on the type of wound (100%) and the site of the wound (100%) with most files including the mechanisms of injury (98.6%). Few files included information on blood loss (18.1%) and the size of the wound (15%). Only one file included information on the contents of the wound. No files included information on the wound's shape and the surrounding skin's condition. CONCLUSION: Wounds were poorly documented in emergency departments, irrespective of the level of care. Nurses in emergency departments should have strict guidelines for documenting wounds since accurate documentation protects patients' human rights and protects nurses.

Comparison of Feeding Practices and Growth of Urbanized African Infants Aged 6-12 Months Old by Maternal HIV Status in Gauteng Province, South Africa.

Appropriate feeding practices are protective against malnutrition and poor growth. We compared feeding practices and growth in HIV-exposed-uninfected (HEU) and HIV-unexposed-uninfected (HUU) between 6-12 months of age in urbanized African infants in South Africa. A repeated cross-sectional analysis was used to determine differences in infant feeding practices and anthropometric measures by HIV exposure status at 6, 9, and 12 months in the Siyakhula study. The study included 181 infants (86 HEU; 95 HUU). Breastfeeding rates were lower in HEU vs. HUU infants at 9 (35.6% vs. 57.3%; p = 0.013) and 12 months (24.7% vs. 48.0%; p = 0.005). Introduction to early complementary foods was common (HEU = 16.2 ± 11.0 vs. HUU = 12.8 ± 9.3 weeks; p = 0.118). Lower weight-for-age Z-scores (WAZ) and head circumference-for-age Z-scores (HCZ) were found in HEU infants at birth. At 6 months, WAZ, length-for-age Z-scores (LAZ), HCZ, and mid-upper-arm circumference-for-age Z-scores (MUACAZ) were lower in HEU vs. HUU infants. At 9 months, lower WAZ, LAZ, and MUACAZ were found in HEU vs. HUU infants. At 12 months, lower WAZ, MUACAZ, and weight-for-length Z-scores (-0.2 ± 1.2 vs. 0.2 ± 1.2; p = 0.020) were observed. HEU infants had lower rates of breastfeeding and poorer growth compared to HUU infants. Maternal HIV exposure affects the feeding practices and growth of infants.

Preventing antenatal stillbirths: An innovative approach for primary health care.

BACKGROUND: In South Africa (SA), approximately 16 000 stillbirths occur annually. Most are classified as unexplained and occur in district hospitals. Many of these deaths may be caused by undetected foetal growth restriction. Continuous wave Doppler ultrasound of the umbilical artery (CWDU-UmA) is a simple method for assessing placental function. This screening method may detect the foetus at risk of dying and growth-restricted foetuses, allowing for appropriate management. METHODS: A cohort study was conducted across South Africa. Pregnant women attending primary health care clinics at 28-34 weeks gestation were screened using CWDU-UmA. Women not screened at those antenatal clinics served as control group 1. Control group 2 consisted of the subset of control group 1 with women detected with antenatal complications excluded. Women with foetuses identified with an abnormal CWDU-UmA test were referred and managed according to a standardised protocol. A comparison between the study and control groups was performed. RESULTS: The study group consisted of 6536 pregnancies, and there were 66 stillbirths (stillbirth rate [SBR]: 10.1/1000 births). In control group 1, there were 193 stillbirths in 10 832 women (SBR: 17.8/1000 births), and in control group 2, 152 stillbirths in 9811 women (SBR: 15.5/1000 births) (risk ratio: 0.57, 95% confidence intervals: 0.29-0.85 and 0.65, 0.36-0.94, respectively). CONCLUSION: Screening a low-risk pregnant population identified the low-risk mother with a high-risk foetus, and acting on the information as described was associated with a significant reduction (35% - 43%) in stillbirths. This demonstrates a step-change reduction in stillbirths and warrants screening in SA.

Maternity healthcare providers' self-perceptions of well-being during COVID-19: A survey in Tshwane Health District, South Africa.

BACKGROUND: Mental health manifestations such as depression and anxiety disorders became more marked during the coronavirus disease 2019 (COVID-19) pandemic as frontline healthcare workers struggled to maintain high-quality intrapartum care and essential health services. AIM: This study aimed to identify maternity healthcare providers' self-perceptions of changes in their feelings of mental well-being. SETTING: Ten midwife obstetric units and the labour wards of four district hospitals in Tshwane Health District, South Africa. METHODS: We conducted an anonymous, cross-sectional survey amongst a convenience sample of 114 maternity healthcare workers to gauge the changes in healthcare workers' experience and perceptions of well-being during the COVID-19 pandemic. Four items measured the perceived changes on a scale of 0-10 for the periods before and during COVID-19, respectively, namely feelings of fear or anxiety, stress, depression and anger. RESULTS: The majority of participants were professional nurses (37%) and advanced midwives (47%). They reported a significant change in well-being from before the pandemic to during the pandemic with regard to all four items (p 0.0001). The biggest 'before-during' difference was in perceptions of fear or anxiety and the smallest difference was in perceptions of anger. A framework was constructed from the open-ended responses to explain healthcare workers' understanding and perceptions of increased negative feelings regarding their mental well-being. CONCLUSION: The observed trends in the changes in healthcare workers' self-perceptions of their mental well-being highlight the need for further planning to build resilient frontline healthcare workers and provide them with ongoing mental health support and improved communication pathways.

The COVID-19 pandemic and disruptions in a district quality improvement initiative: Experiences from the CLEVER Maternity Care programme.

BACKGROUND: Many health systems were poorly prepared for the coronavirus disease 2019 (COVID-19) pandemic and found it difficult to protect maternity and reproductive health services. The aim of the study was to explore the influence of the COVID-19 pandemic on the ability of maternity healthcare providers to maintain the positive practices introduced by the CLEVER Maternity Care programme and to elicit information on their support needs. METHODS: This multimethod study was conducted in midwife-led obstetric units (MOUs) and district hospitals in Tshwane District, South Africa and included a survey questionnaire and qualitative reports and reflections by the CLEVER implementation team. Two five-point Likert-scale items were supplemented by open-ended questions to provide suggestions on improving health systems and supporting healthcare workers. RESULTS: Most of the 114 respondents were advanced midwives or registered nurses (86%). Participants from MOUs rated the maintenance of quality care practices significantly higher than those from district hospitals (p = 0.0130). There was a significant difference in perceptions of support from the district management between designations (p = 0.0037), with managers having the most positive perception compared with advanced midwives (p = 0.0018) and registered nurses (p = 0.0115). The interpretation framework had three main themes: working environment and health-system readiness; quality of patient care and service provision; and healthcare workers' response to the pandemic. Health-facility readiness is described as proactive, reactive or lagging. CONCLUSION: Lessons learned from this pandemic should be used to build responsive health systems that will enable primary healthcare workers to maintain quality patient care, services and communication.

Identifying the High-Risk Fetus in the Low-Risk Mother Using Fetal Doppler Screening.

Identifying the high-risk fetus in the low-risk pregnant mother (LRM) is a neglected area of research. Fetal growth restriction (FGR) is a major cause of stillbirths, especially in low- and middle-income countries (LMICs). FGR is very poorly detected particularly in healthy pregnant women classified as low risk. Umbiflow is an inexpensive continuous-wave Doppler ultrasound (CWDU) apparatus that is suitable for use by low-level health care providers for screening low-risk pregnant populations. It can easily detect umbilical artery blood flow in the cord, which correlates well with placental function, and poor placental function correlates well with FGR.Use of CWDU to screen an LMIC population of more than 7,000 LRMs has demonstrated a high prevalence of abnormal umbilical artery flow of 13%, and absent end-diastolic flow, which is associated with end-stage placental disease, was found in 1.2%. This is 10 times higher than previously reported in high-income countries. Screening with CWDU together with a standard protocol managing those pregnancies with abnormal placental blood flow resulted in a 43% reduction in stillbirths (risk ratio: 0.57; 95% confidence interval=0.29, 0.85) in this LRM population. Further, follow-up of infants who had abnormal umbilical artery blood flow showed that these infants had significantly less fat-free mass at ages 6 weeks, 10 weeks, 14 weeks, and 6 months, than those with normal umbilical artery blood flow (P<.015), confirming that CWDU was able to detect true FGR.Thus, screening with CWDU can detect the fetus at risk of stillbirth, and infants likely to have suboptimal growth and development postnatally. Screening with CWDU in LRMs opens the door to a step change in preventing stillbirths in LMICs.

Evaluating prediction of COVID-19 at provincial level of South Africa: a statistical perspective.

What is the impact of COVID-19 on South Africa? This paper envisages to assist researchers in battling of the COVID-19 pandemic focusing on South Africa. This paper focuses on the spread of the disease by applying heatmap retrieval of hotspot areas, and spatial analysis is carried out using the Moran index. For capturing spatial autocorrelation between the provinces of South Africa, the adjacent as well as the geographical distance measures are used as weight matrix for both absolute and relative counts. Furthermore, generalized logistic growth curve modelling is used for prediction of the COVID-19 spread. We expect this data-driven modelling to provide some insights into hotspot identification and timeous action controlling the spread of the virus.

Development of a trail running injury screening instrument: A multiple methods approach.

OBJECTIVE: To develop a trail running injury screening instrument (TRISI) for utilisation as clinical decision aid in determining if a trail runner is at an increased risk for injury. DESIGN: Multiple methods approach. METHODS: The study utilised five phases 1) identification of injury risk factors 2) determining the relevance of each identified risk factor in a trail running context, 3) creating the content of the Likert scale points from 0 to 4, 4) rescaling the Likert scale points to determine numerical values for the content of each Likert scale point, and 5) determining a weighted score for each injury risk factor that contributes to the overall combined composite score. RESULTS: Of the 77 identified injury risk factors, 26 were deemed relevant in trail running. The weighted score for each injury risk factor ranged from 2.21 to 5.53 with the highest calculated score being 5.53. The final TRISI includes risk categories of training, running equipment, demographics, previous injury, behavioural, psychological, nutrition, chronic disease, physiological, and biomechanical factors. CONCLUSION: The developed TRISI aims to assist the clinician during pre-race injury screening or during a training season to identify meaningful areas to target in designing injury risk management strategies and/or continuous health education.