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INTRODUCTION: Corneal endothelial damage following phacoemulsification is still one of the major concerns of modern day cataract surgery. Although many techniques have been proposed, the risks of posterior capsular rupture and corneal endothelium damage persist. In theory, damage to the corneal endothelium is minimised by delivering the lowest phaco energy only in the direction necessary to emulsify the lens nucleus. Hence, it is believed that the bevel of the needle should be turned towards the nucleus or the nuclear fragment (ie, bevel-down. However, there is a difference of opinion among ophthalmologists with reference to the phaco tip's position (bevel-up vs bevel-down) during phacoemulsification. This subject has not been extensively studied earlier. METHODS AND ANALYSIS: This is a prospective, triple-blinded (trial participant, outcome assessor and the data analyst), randomised controlled trial with 2 parallel groups and with an allocation ratio of 1:1. It will be conducted in a tertiary care hospital, Mangaluru, India. The objective is to compare the postoperative central corneal thickness changes between the bevel-up and bevel-down techniques of phacoemulsification. Patients aged >18 years with immature cataract undergoing phacoemulsification will be selected for the study. The important exclusion criteria are the history of previous significant ocular trauma or intraocular surgery, corneal pathology, pseudoexfoliation syndrome, intraocular inflammation, a preoperative fully dilated pupil 4. After randomisation, patients will undergo phacoemulsification surgery either by a bevel-up or bevel-down procedure. With an estimated power of 80%, the calculated sample size is 55 patients in each group. The recruitment will start from April 2016. ETHICS AND DISSEMINATION: Yenepoya University Ethics Committee, India has approved the study protocol (YUEC/148/2016 on 18 February 2016). It complies with the Declaration of Helsinki, local laws and the International Council for Harmonization-good clinical practices. TRIAL REGISTRATION NUMBER: CTRI/2016/02/006691; Pre-results.

Background Owing to frequent outbreaks witnessed in different parts of the country in the recent past, scrub typhus is being described as a re-emerging infectious disease in India. Differentiating scrub typhus from other endemic diseases like malaria, leptospirosis, dengue fever, typhoid, etc. is difficult due to overlapping clinical features and a lower positivity for eschars in Asian populations. Hence, the diagnosis heavily relies on laboratory tests. Discussion Costs and the need of technical expertise limit the wide use of indirect immunoperoxidase or immunofluorescence assays, ELISA and PCR. The Weil-Felix test is the most commonly used and least expensive serological test, but lacks both sensitivity and specificity. Hence, the diagnosis of scrub typhus is often delayed or overlooked. With due consideration of the cost, rapidity, single test result and simplicity of interpretation, rapid diagnostic tests have come into vogue. However, evaluation of rapid diagnostic tests for scrub typhus in the Indian population is needed to justify or discourage their use. Conclusion Research studies are needed to find the most suitable test in terms of the rapidity of the result, simplicity of the procedure, ease of interpretation and cost to be used in the Indian populace. Electronic supplementary material The online version of this article (doi:10.1186/s40249-016-0137-6) contains supplementary material, which is available to authorized users.

Introduction: The sonographic findings are of help in evaluating the nephrological diseases. Glomerular filtration rate is another parameter for assessing the reserved renal function and an indicator of prognosis. In clinical practice GFR estimation (eGFR) is done by using a mathematical formula. In our study, we compared the sonographic grading of renal parenchymal changes with eGFR calculated using Modified Diet in Renal Diseases formula based on serum creatinine, age, gender and ethnicity. Aim: To evaluate the relevance of sonographic grading of renal parenchymal changes in assessing the severity of the renal disease and comparing it to the eGFR calculated using MDRD formula based on the age, gender and serum creatinine value of the patient. Materials and Methods: The adult patients with suspected kidney disease referred for sonography of abdomen were our study participants. As per our study design following strict inclusion and exclusion criteria, patients were selected as study participants and for each of the patient’s renal parenchymal status, serum creatinine, age, gender and ethnicity were documented. Results: A total of 70 patients were our study participants, out of which 67.1% were males and 32.9% were females. Our study showed a linear correlation between sonographic grading of renal parenchymal changes with eGFR. Conclusion: We conclude that by evaluating the kidneys with sonography and calculating eGFR using MDRD formula the renal status will be more accurately interpreted.

Multilingual abstracts in the six official working languages of the United Nations. (PDF 350 kb)

Findings of liver function test among patients with scrub typhus and serum bilirubin >3 mg/dl in a tertiary care hospital of Meghalaya, India, Sept 2011–Aug 2012 (n = 11). (DOCX 13 kb)

Multilingual abstract in the six official working languages of the United Nations. (PDF 770Â kb)

Background Construction sites are potential breeding places for some species of mosquitoes. Construction workers usually stay at the construction sites, thus being extremely susceptible to malaria. For malaria control, a special focus on them is warranted as they often seek treatment from unregulated, private vendors, increasing their risk of exposure to substandard drugs. Objectives To elicit the socio-demographic factors associated with comprehensive malaria knowledge (symptoms, mode of spread, and preventive measures) and treatment-seeking pattern (preferred source and type of treatment) among the construction workers in Mangaluru, India; and, to study the association among their comprehensive malaria knowledge, past suffering from malaria (within 1 year) and treatment-seeking pattern. Methods A community based cross-sectional study was conducted in nine randomly selected construction sites of Mangaluru, a high-risk city for malaria with an annual parasite incidence of >2/1000/year, from June–September 2012. A sample size of 132 was estimated assuming at least 30 % of them have satisfactory malaria knowledge, 10 % absolute precision, 95 % confidence level, design effect of 1.5 and 10 % non-responses. A semi-structured interview schedule was used, and knowledge scores were computed. Multivariate linear (for knowledge score) and logistic regressions (for preferred source and type of treatment) were applied. Results One hundred and nineteen workers participated in the study (total approached-138). 85 % (n = 101) of them were males. Mean knowledge score was 9.95 ± 3.19 (maximum possible score-16). The majority of them were aware of the symptoms and the mode of malaria transmission. However

Agriculture is one of major sectors of Indonesia economic source with the high volume of pesticide used. Unfortunately, adverse health effect of neurotoxic pesticide has never been reported in Indonesia. This study aimed to determine effectiveness of personal protective equipment (PPE) during the use of pesticides to neurological symptoms in farmers. This study was cross-sectionally conducted from April to May 2016 in Purworejo District. About 125 farmers were selected using purposive sampling, and restriction was applied in male farmers due to the high proportion of male sprayer. Data was collected by observation and interview. Logistic regression showed protective result of PPE used during preparing (POR = 0.40; 95% CI= 0.11-1.42) and spraying (POR = 0.38; 95% CI = 0.11-1.32), also following wind direction (POR = 0.88; 95% CI = 0.27-2.87) and bathing after spraying (POR = 0.33; 95% CI = 0.04-3.01) after controlled by confounders. Proper PPE used during preparing and spraying pesticide, following wind direction during spraying, and bathing after spraying can decrease risk of neurological symptoms because of pesticide exposure.

Background: Stress, an integral part of our lifestyles to some extent improves management skills, job performance but when crosses the limit results adversely on physical and mental health. Work related stress has been known to cause many ill-effects on the body. Objectives: The present study was carried out, to find out the stress levels among working middle-aged males through a questionnaire based analysis and to study the effects of work related stress on Blood Pressure (BP), Obesity markers like Body Mass Index (BMI) WaistHip ratio (W/H), Blood parameters like Blood glucose and Lipid profile. Methods: Based on the analysis of job stress levels from a validated questionnaire, sixty male bank employees (35–60 years) were divided into nonstressed and stressed group. Their age, work experience, BP, BMI, Waist/Hip ratio were recorded. Their RBS and Lipid profile parameters were analyzed. Results: The results showed that stressed group had more BP, BMI, W/H, RBS, LDL, Triglyceride, TG/HDL levels and Atherogenic Index compared to the non-stressed. Conclusions: Work stress results in the derangement of the cardiometabolic parameters. While addressing the complications of job stress, a more aggressive working health policy has to be implemented at all work places.

Background.The nurse’s role in healthcare waste management is crucial.Objectives.(1) To appraise nurses quantitatively and qualitatively regarding healthcare waste management; (2) to elicit the determinants of knowledge and attitudes of healthcare waste management.Method.A cross-sectional study was undertaken at a tertiary care hospital of Mangalore, India. Self-administered pretested questionnaire and “nonparticipatory observation” were used for quantitative and qualitative appraisals. Percentage knowledge score was calculated based on their total knowledge score. Nurses’ knowledge was categorized as excellent (>70%), good (50–70%), and poor (<50%). Chi square test was applied to judge the association of study variables with their attitudes and knowledge.Results. Out of 100 nurses 47 had excellent knowledge (>70% score). Most (86%) expressed the need of refresher training. No study variable displayed significant association(P>0.05)with knowledge. Apt segregation practices were followed except in casualty. Patients and entourages misinterpreted the colored containers.Conclusion.Nurses’ knowledge and healthcare waste management practices were not satisfactory. There is a need of refresher trainings at optimum intervals to ensure sustainability and further improvement. Educating patients and their entourages and display of segregation information board in local language are recommended.

We read the article titled “HIV/AIDS awareness among VCT clients: a cross-sectional study from Delhi, India” by Mehra et al. [1], with curiosity. This study emphasizes the poor knowledge and prevailing misconceptions about HIV/AIDS among the clients of a VCT facility in Delhi, India. However, the following issues and concerns need to be addressed. The authors have conducted a cross-sectional analysis at the VCT facility of a tertiary care health centre situated in Delhi, India. Two hundred consecutive clients who were ≥18 years of age and consenting for participation were included. However, the following should have been mentioned: How was the sample size calculated? When VCT monthly attendance is 1100, do 200 consecutive clients represent the VCT clients attending the study setting? Study sample adequacy and representativeness are the prerequisites to ensure the internal validity of the study findings. Hence, authors should have calculated the sample size based on the published literature or hypothesis and, instead of consecutive clients, systematic random sampling (e.g., every fifth VCT client) should have been adopted. VCT centre [now renamed as Integrated Counseling and Testing Centre (ICTC)] is a place where a person is counseled and tested for HIV, of his own free will or as advised by a medical provider [2]. However, it is not the mandate of a VCT centre to counsel and test everyone in the general population [2]. But the authors mention that 31.5% of the VCT clients had never heard of HIV/AIDS. If they had never heard of HIV/AIDS, then how come they were in VCT for HIV/AIDS Counseling and Testing? Whom did the authors consider as a “VCT client”? In Table 5 of the study by Mehra et al. [1], chi-square (χ2) calculation for age and education is questionable as the sample size in “unaware” categories was very small. How many cells had an expected count less than 5? Did the authors consider Yates's correction or any other apt correction for chi-square (χ2)? Authors should have clearly addressed this in Materials and Methods. Authors could have reduced the degree of freedom by logically clubbing the age and education subgroups. The authors conclude that a significant proportion of Indian population is unaware of HIV/AIDS to the extent that they have not even heard of it and the prevalence of misconceptions regarding HIV transmission is also high in the Indian population. However, VCT clients do not represent the general population and extrapolating the findings of single VCT centre based study to Indian population is highly questionable [3]. In fact, authors should have stated it as a limitation. Nonetheless, we must applaud the authors for investigating an important public health problem.

Alemayehu and Mekonnen [1] reported the prevalence of Skilled Birth Attendant Utilization and its correlates in North West Ethiopia. Authors' efforts are commendable. This study provides valuable information for the evidence based fine tuning of present reproductive and child health strategies in the study area. However, the following issues and concerns need to be addressed. Introduction part of the paper should be written in such a way that even a reader without subject expertise should be able to understand the present situation and need of the study [2]. In this paper, authors have nicely elaborated the present scenario about the skilled birth attendance utilization in the study area and stressed on the need of the study. However, keeping the international readers in mind, a word about the following would have been more informative: present strategies/programmes in Ethiopia to enhance the skilled birth utilization, role of Health Services Extension Workers (HSEWs), and the operational definition of a “kebele.” It is highly advisable to follow the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist while reporting cross-sectional studies [3]. The STROBE Statement is endorsed by a number of biomedical journals. Authors have justified the sample size and clearly delineated the multistage random sampling adopted in this study. They mention that the study mothers were randomly selected from the rosters of HSEWs. It appears that HSEWs keep a record of all the births irrespective of the place of birth in their area. The definition of “skilled birth attendant” should have been explicitly mentioned in Methods. In addition, reliability of records and measures taken to identify the missed cases from the records should have been stated. According to us, inclusion criterion should be any woman who delivered in the last year irrespective of the outcome (abortion/still birth/live birth) and place of delivery. While exploring the correlates of Skilled Birth Attendant Utilization, a brainstorming of all the possible factors which are likely to influence in deciding the place of delivery should be done. In this study, authors did consider key demographic and obstetric correlates. However, we believe that the authors have missed certain key factors such as knowledge risk factors/danger signs in pregnancy, discussion with spouse/family member about the place of delivery, bad obstetric history/bad experiences, and decision maker in the family [4, 5]. Epidemiological studies extrapolate the results from the study sample on study population. Hence, outcome variable should be reported with 95% confidence intervals [3]. In this study, the prevalence of Skilled Birth Attendant Utilization should have been reported as 18.7% (n = 70, 95% CI: 15.1–23.1). Regression analysis is an excellent way of adjusting the effect of confounders. However, it is highly advisable to assess and report the adequacy of applied regression model. Failure to do so may lead to misleading or incorrect inferences. Although the study sample was relatively large, a word about R2 (explaining the variance in the Skilled Birth Attendant Utilization) of the applied regression model would have been more affirmative. According to STROBE guidelines, one has to discuss limitations of the study, taking into account sources of potential bias or imprecision [3]. The associations observed in this cross-sectional study may not imply causality. In addition, there is a risk of recall bias as women who had delivered in 12 months prior to the study were included. Nonetheless, we must congratulate the authors for investigating an important public health issue on a large scale.

INTRODUCTION: According to Joint National Committee-7 (JNC-7) guidelines, a systolic blood pressure (SBP) of 120 to 139 mm Hg and/or diastolic blood pressure (DBP) of 80 to 89 mm Hg is considered as pre-hypertension. Existing evidence suggest that the cardiovascular morbidities are increasing among pre-hypertensive individuals compared to normal. OBJECTIVE: To assess the magnitude and factors associated with pre-hypertension among young adults (20-30 years) in coastal villages of Udupi Taluk (an area of land with a city or town that serves as its administrative centre and usually a number of villages), Udupi District, Karnataka state, India. DESIGN: Community based cross sectional study. SETTING: 6 (out of total 14) coastal villages of Udupi Taluk, Karnataka state, India. SAMPLE: 1,152 young adults (age group: 20-30 years) selected by stratified random sampling in 6 coastal villages of Udupi Taluk, Karnataka state, India. METHOD: A semi structured pre-tested questionnaire was used to elicit the details on socio-demographic variables, dietary habits, tobacco use, alcohol consumption, physical activity, family history of hypertension and stress levels. Anthropometric measurements and blood pressure were recorded according to standard protocols. Serum cholesterol was measured in a sub sample of the study population. Multivariate logistic regression was applied to identify the independent correlates of pre-hypertension among young adults (20-30 years). MAIN OUTCOME MEASURES: Prevalence, Odds ratio (OR) and adjusted (adj) OR for pre-hypertension among young adults (20-30 years). RESULTS: The prevalence of pre-hypertension in the study population was 45.2% (95%CI: 42.4-48). Multivariate logistic regression analysis revealed that age group of 25-30 years (adj OR: 4.25, 95% CI: 2.99-6.05), white collared (adj OR: 2.29, 95% CI: 1.08-4.85) and skilled occupation (adj OR: 3.24, 95% CI: 1.64-6.42), students (adj OR: 2.46, 95% CI: 1.22-4.95), using refined cooking oil (adj OR: 0.53, 95% CI: 0.29-0.95), extra salt in meals (adj OR: 2.46, 95% CI: 1.52-3.99), salty food items (adj OR: 6.99, 95% CI: 3.63-13.48), pre-obese (adj OR: 1.66, 95% CI: 1.03-2.67) and obese (adj OR: 9.16, 95% CI: 2.54, 36.4) were the significant correlates of pre-hypertension. CONCLUSION: In the study population, prevalence of pre-hypertension among young adults (20-30 years) was high (45.2%). Biological (age 25-30 years, pre-obesity and obesity) and behavioral (sedentary occupation, intake of extra salt in meals/salty food and not using refined cooking oil) factors were associated with pre-hypertension. Study emphasizes the need of community based screening of pre-hypertension under National Rural Health Mission. It also provides apt information for the evidence based designing of interventions for lifestyle modifications among high risk young adults in the study area.

Sir, I read the article by Chauhan et al1 with great interest. In this large scale community based cross-sectional study, authors have highlighted the magnitude of chronic obstetric morbidities (COM) and the factors associated in Nashik district, Maharashtra, India. It is recommended to follow the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) checklist while reporting cross-sectional studies2. The outcome variables (prevalence of reproductive, gynaecological and chronic obstetric morbidities in this study) should have been reported with 95% confidence intervals2. Authors report that 25 (5%) of 509 women detected with any reproductive morbidity had more than one morbidity. It would be interesting to know about the proportion of women with multiple gynaecological and COMs. Further, the authors have studied the association of gynaecological and COMs with key socio-demographic, obstetric and reproductive health service related factors. In addition, exploring the association of gynaecological and COMs with place of delivery (institutional vs. Home), mode of delivery (vaginal vs. Caesarian) and source of heath care (public vs. Private) would be more informative. The major gynaecological morbidities reported were genital candidiasis in 102 (8.7%) and vaginitis in 91 (7.8%) women. This finding has important implication in syndromic management of sexually transmitted infection/reproductive tract infection (STI/RTI) under National AIDS Control Programme in the study area. Similarly, genital prolapsed (7.1%) was the most common COM among them. There is a need to explore the possible risk factors for the same, i.e. Repeated births, lack of postnatal exercises, etc. In the study area. Such intuitive epidemiological reasoning or raising the apt research questions, keeping the socio-cultural background in mind, would be more informative and interesting. However, authors limited their discussion by comparing the results of various Indian and other studies with the present one. According to STROBE checklist, one has to discuss limitations of the study, taking into account the sources of potential bias or imprecision2. Authors have considered a few of them such as lack of external validity and clustering effect. In addition, reported significant correlates of COM in this study may not imply causality owing to cross-sectional nature of the study. Despite these limitations, the authors need to be congratulated for exploring an important public health problem in the study area.

Introduction: Each year, students get admitted to medical colleges with definitive objectives and attitudes. They are destined to serve the humanity in need irrespective of the geographical distribution of their placements. Now-a-days students graduating from the medical institutions are opting to work in urban than rural areas. This has resulted in acute shortage of qualified medical doctors serving the rural India. This alarming increase in population-to-doctor ratio in rural areas is a cumbersome issue for the governments. Aim: To study the attitudes toward rural health service and difference in their perceptions, career preferences, if any, based on gender, nationality and year of study among the medical students; the present work was carried out. Materials and Methods: A total of 160 students of 1 st year and final year course of a Private University Medical College in Karnataka state, India were included. 113 were Indians and 47 Malaysians. Content, construct validity and test retest reliability were applied to a questionnaire. Responses were compiled and statistically analyzed. Results: The results revealed that huge majority of students want to pursue postgraduation and work in urban than rural areas, which is equally seen among the study group. They were all aware about the health needs of rural population, but can work only for few years. Conclusion: Multiple factors contribute to the lack of motivation among the medical students to take up rural service. Well-planned rural incentive packages with effective retention strategies should be provided in a definitive framework benefiting the health workers.