Eisenia fetida-driven vermitechnology for the eco-friendly transformation of steel waste slag into organic amendment: An insight through microbial diversity and multi-model approach.

The processing of steel waste slag from the black metallurgical sector seriously threatened the ecology. To counter these dangers, appropriate detoxification methods were required. Vermitechnology was one such strategy that could successfully convert this industrial waste into nutrient-rich products suitable for use in agriculture. This research primarily focuses on employing vermitechnology for the transformation of waste steel slag into vermicompost and to determine changes in microbial composition, nutrient cycling, and metal detoxification facilitated by earthworms (Eisenia fetida). Earthworm populations in steel waste vermibeds (sw-vermibeds) increased by 2.87-3.07 folds. T1(SW + CD-1:1) comparatively showed increased levels of nutrients such as nitrogen, phosphorus, and potassium. Microbial and enzymatic parameters were more pronounced in treatment T1. The findings of phospholipid fatty acid (PLFA) diversity demonstrate microbial diversity and fatty acid composition. Based on PLFA Sobol Sensitivity Analysis (SSA), PUFA and cyclo were the most sensitive inputs to the presence of heavy metal (HMs) concentrations in SW. In accordance with Taylor-based modelling, R-tree, and Mars were the most trusted regression models for predicting HMs toxicity on microbes. The bioavailable metal fractions of HMs (Fe, Ni, Cd, Cu, Pb, and Cr) decreased by 61-83%. The correlation was performed for 0 and 90 days for metal microbial interactions r (0 days), [BSR vs Fe, Cd, Cu, Ni = -0.99, -0.82, -0.43, -0.99] and r (90 days), [FDA vs Fe, Cu, Ni = -0.97, -0.47, -0.95]. Overall, the results indicated that T1(1:1 SW + CD) provided more favorable conditions for the development of microbes and Eisenia fetida. This research presents a new perspective to the world community on the transformation of harmful steel waste slag into advantageous biological resources by introducing a novel method of employing Eisenia fetida to remediate hazardous steel waste slag.

Imparting child nutritional assessment skills among medical students using hybrid problem-based learning approach in a community setting.

Background: Malnutrition affects up to a third of children in India, with severe and acute malnutrition prevalent among under five children. Nutritional assessment skills for detecting malnutrition in children in primary care settings are vital. Hybrid problem-based learning (HPBL) is an innovative, collaborative, and adaptable instructional learning strategy that can be used to teach medical students clinical skills in a community setting. Methods: A two-month quasi-experimental study was undertaken in a rural setting with third-year medical students. Faculty members were sensitized and subject experts developed a training module addressing the knowledge, attitude, communication, and practice domains. The students underwent a 3-week training module where pre-testing, case presentation, and group formation in first week, an anchoring lecture, tutorial and self-directed learning and role-play by students in subsequent week, and in last week, case discussion, post-testing, and feedback rounds were done. Results: In all domains, knowledge (3.8, 0.01), practice (4.3, 0.01), attitude and communication (3.7, 0.01), and proportional satisfactory responses, the HPBL approach resulted in a significant improvement in nutritional assessment competency. Teachers preferred the practical and engaging character of the approach, stating that doubts and questions were better addressed and that they would use it to teach similar topics. Conclusion: HPBL is an excellent teaching method for clinical skills, like nutritional assessment in simulated/field settings. The novel teaching-learning approach was well received by students and faculty members. Learning outcomes and satisfaction rates enhanced in students and faculty were encouraged to apply the approach to other topics.

Use of exemplars-based feedforward to improve the performance of medical students in constructed response assessment.

Background: Exemplars are the graded responses to theory questions from previous examinations and are considered as means to guide students about what is valued by assessors; hence giving feed forward to students before the exam and developing self-regulated learning among students. The present study was undertaken to compare the effect on performance of students between intervention (didactic lecture and exemplar) and control group (didactic lecture). Methods: This study was an interventional study conducted among 256 students of a medical college in Rajasthan, India. Participants were randomized to either the control group A or to the interventional group B. Outcomes included a post intervention test evaluating the knowledge gained after the session and students 'attitudes about the same. A focus group discussion was conducted investigating the perceptions. The feedback from faculty was also taken. Results: The mean post test score of intervention group was found to be 6.1 ± 1.74 and of the control group was 5.5 ± 1.6; significantly higher with p-value of 0.03. Out of 128 participants in group B, majority (n = 94,73%) believed that exemplars improve learning and created their interest in topic (n = 78, 60.9%). Most of students (66%) were of the opinion that exemplars should be regularly used with didactic lectures. Key themes identified from focus group were: advantages of the exemplars-based feedforward, challenges in implementation and ways to improve the method. Conclusion: Exemplars improved the performance of students. The faculty members and students agreed that they are an effective tool to enhance learning.

Blueprint designing and validation for competency-based curriculum for theory assessment in community medicine.

Background: Blueprint provides a base for assessment by assigning proportionate weightage to various content areas and helps the paper setter to construct a uniform and valid assessment. This study aimed to design and validate a blueprint for theory in Community Medicine as per the new curriculum for Medical Undergraduates in India. Methods: Blueprint in community medicine was designed by assigning impact score (I) and frequency score (F) for the competencies. Blueprint was validated using the Content Validity Index (CVI), and inter-rater agreement for subject experts using Fleiss' kappa statistics was calculated. Feedback from faculty and students was obtained afterward to assess the postimplementation response. Results: Blueprint was designed by an expert group where impact score and frequency score were assigned to 146 competencies in the theory of Community Medicine. In Delphi survey I, 63.2% of subject experts responded, while in Delphi survey II, a response rate of 58.3% was achieved. Value of the Fleiss' Kappa test for an inter-rater agreement was 0.68, i.e. "substantial agreement," while CVI among the raters came out to be 0.86, i.e. overall valid assessment. Feedback of faculty (n = 11) suggested that the blueprint was helpful and standardized the paper setting, whereas feedback from students (n = 138) depicted that it helped in preparing for exams, and they would recommend it to other students. Conclusion: Validated blueprint by consensus of subject experts has impact score and frequency score along with topic-wise distribution of marks for the convenience of faculty and its utility is well proven among learners too.

Correlation of non-invasive parameters with upper gastrointestinal endoscopy findings for presence and grading of gastroesophageal varices in liver cirrhosis patients.

Background: Development of esophageal varices is one of the major complications of liver cirrhosis, and endoscopy is used to see the presence, grading, and long-term monitoring of esophageal varices which is an invasive and unpleasant procedure. There is no adequate data available showing noninvasive methods can be used for the same. Methods: Seventy patients with liver cirrhosis participated in the study. Factors like portal vein diameter, spleen size, platelet count, serum bilirubin, Child-Pugh score, prothrombin time (PT), and PT INR were observed and correlated endoscopically with the presence and grading of esophageal varices in all patients. Results: The platelet count, portal vein diameter, serum bilirubin, spleen bipolar diameter, and PT had statistically significant correlations with the presence of varices. Among them, platelet count, portal vein diameter, and serum bilirubin also had statistically significant correlations with the grading of varices. Monitoring of these noninvasive parameters can help in monitoring variceal growth. Conclusions: Noninvasive parameters can be used effectively to predict the presence and grading of esophageal varices and at the same time keep the rate of undiagnosed varices acceptably low. By using noninvasive parameters, patients can be benefited by decreasing the requirement of repeated endoscopic evaluation which is an unpleasant procedure and availability is also limited.

Cytogenetic toxicity of Aloe vera (a medicinal plant).

The cytogenetic toxicity of the crude leaf extract of Aloe vera, a medicinal plant, was evaluated in two test systems, onion and Swiss albino mice, using their root tip meristematic and bone marrow cells, respectively. No significant increase in structural abnormalities in chromosomes was observed, but a marked increase in cells with chromosome-number anomalies was found. The extract, however, significantly increased the mitotic index of both cell types.

Umbilical Artery Systolic/Diastolic Ratio and Amniotic Fluid Index in Prediction of Adverse Perinatal Outcome in Term Pregnancies.

Background: Antenatal fetal surveillance is a field of increasing importance in modern obstetrics. It is based on fetal heart rate monitoring using nonstress test and contraction stress test, ultrasound biometry and amniotic fluid assessment, Doppler blood flow studies of fetal and uteroplacental circulation, and an evaluation of biophysical fetal parameters. The combination of these methods leads to improvements in fetal morbidity and mortality. Aim: The present study aimed to assess the sensitivity, specificity, and positive and negative predictive values of umbilical artery (UA) systolic/diastolic (S/D) ratio, and amniotic fluid index (AFI) in term pregnancies for the prediction of perinatal outcome and their relation with perinatal outcome. Methods: This study was conducted at a tertiary care hospital on 100 pregnant women where all the term singleton pregnancies (37-42 weeks) admitted in maternity were subjected to color Doppler for UA S/D ratio assessment and AFI estimation. Further, management of patients was done according to color Doppler findings and their relation with perinatal outcome. Results: Out of 100 pregnant women, 68% had AFI >8 (normal), while 32% of women had AFI <8 (abnormal), with the mean AFI being 9.39 ± 2.55 cm, whereas70% had S/D ratio <3 (normal) and 30% of women had S/D ratio >3 (abnormal), with the mean S/D ratio of 2.61 ± 0.450. UA S/D ratio had better performance values (i.e., sensitivity, specificity, and positive and negative predictive value) than AFI in predicting adverse perinatal outcomes. Conclusion: AFI and UA S/D ratio are important for predicting low appearance, pulse, grimace, activity, and respiration score, meconium, respiratory complications, and perinatal mortality in high as well as low-risk pregnancy cases. However, UA S/D ratio is a better predictor of perinatal outcome in high-risk pregnancies.

Occupational lower back pain among bus conductors of Udupi district, Karnataka.

Although studies have reported lower back pain (LBP) in professional drivers, the conductors travelling in the same bus who share the same working environment are often neglected. Thus, the present study was undertaken to assess the prevalence of LBP and the factors associated with it. The study included 237 bus conductors from government bus depots. The data regarding occupational, non-occupational and environmental factors were collected by interview technique using a structured questionnaire. Self-reported back pain in the last 12 months in or near the lumbosacral spine was considered a case of LBP. The study revealed that 27.4% had LBP. The multivariate analysis suggested that tobacco smoking, self-reported bad road conditions and lack of enough breaks during work were significant risk factors. Thus, to conclude, the conductors are at risk of LBP that can be attributed to occupational as well as non-occupational factors.

Predictors and Perceptions of Healthcare Workers Regarding Vaccines Safety in the Initial Phase of COVID-19 Vaccination Drive in Western Part of India: A Regression Analysis.

Background The COVID-19 vaccination was launched in a phased manner by the government of India prioritizing healthcare workers. This study assessed the perception of healthcare workers regarding COVID-19 vaccination. Methods This cross-sectional study was conducted among healthcare workers vaccinated at a tertiary care center of southern Rajasthan. Logistic regression analysis was used to note the association of perception regarding vaccine safety and other variables. Results Out of 3,102, 56.8% were male, and the majority (73.7%) were in the age range of 20-35 years. Out of the total, 80.7% and 73.2% of subjects perceived the vaccine as safe and effective, respectively. The perception regarding the timing of rolling out of vaccine and readiness for COVID-19 appropriate behavior after vaccination was statistically significant (p<0.001). The commonest undesirable effect following vaccination was pain at the injection site. Most of the subjects did not report undesirable effects following vaccination. Logistic regression analysis showed that the involvement in the direct care of COVID-19 patients (OR: 1.58; 95% CI: 1.29, 1.94), the experience of COVID-19 infection in the past (OR: 0.68; 95% CI: 0.50, 0.91), the timing of the rollout of vaccine (OR: 3.60; 95% CI: 3.24, 4.10) showed a significant association with perception of the safety of COVID-19 vaccine. Conclusions The vaccine was perceived safe and effective by healthcare workers and reported minimal undesirable effects. The COVID-19 vaccine safety is also dependent on the past COVID-19 infection, involvement in patient care, and time of rollout of the vaccine.

Effect of doxycycline and doxycycline with carica papaya on thrombocytopenia and leucopenia in acute dengue fever patients.

Background: Dengue fever is a mosquito borne disease commonly manifest leucopoenia and thrombocytopenia. Dengue fever and its complications like bleeding manifestation can be life threatening. This study was conducted to study the effect of doxycycline and doxycycline with carica papaya on thrombocytopenia and leucopoenia in acute dengue fever patients. Methods: This case control study was conducted amongst the patients suffering from dengue fever with thrombocytopenia. Cases were dengue patients with thrombocytopenia and leucopenia both. Controls were dengue patients with thrombocytopenia with normal leukocyte count. An effect of doxycycline and doxycycline with carica papaya was observed on platelet and leukocyte counts at baseline and first, second, fourth, and seventh day in cases and comparison was done. Results: The maximum improvement in mean platelet count and leukocyte count was observed in doxycycline with carica papaya group followed by doxycycline alone group followed by controls (conservative treatment) in decreasing order on day 4th and 7th day of admission. Reduced hospital stay was also in the same order. Conclusion: The study results indicate that doxycycline and carica papaya are useful modality to improve leucopenia and thrombocytopenia in dengue patients and to minimize hospital stay.

Sociodemographic and clinical characteristics associated with COVID mortality among hospitalized patients in Rajasthan: A retrospective observational study.

BACKGROUND: It has been over a year since the declaration of novel coronavirus disease (COVID-19) as pandemic by World Health Organization on March 11, 2020. Although mortality in India is low, as compared to western countries, the steady increase in the number of cases is still a worrying sign. The objectives of this study were to identify and quantify the association between sociodemographic and clinical characteristics with mortality among patients, suffering from COVID-19 at a tertiary care hospital in Udaipur, Rajasthan. MATERIAL AND METHODS: This retrospective observational study involved 824 patients hospitalized for COVID 19 at a tertiary hospital in Udaipur, who were discharged or had died. Electronic health records of the patients were accessed to retrieve the sociodemographic information (age, gender, residence, religion, socioeconomic status), history of exposure, clinical characteristics on admission, comorbidities, and outcomes (recovery or death). The Cox regression model was used to calculate associations between mortality and baseline characteristics in the form of hazard ratios (HRs). RESULTS: Mortality in this study was found to be 5.82%. The mean age of the patients was 48.14 ± 16.2 years. The median time from time of admission to discharge was 8 days (interquartile range (IQR) 5-11), whereas the median time to death was 5 days (IQR 4-10). The variables found to be associated with higher mortality were age (HR 1.17; 95% confidence interval (CI) 1.15-1.24), residing in urban area (HR 1.29; 95% CI 1.17-2.15), diabetes mellitus (HR 1.3; CI 1.02-5.57), and patients having both diabetes and hypertension (HR 2.4; CI 1.69-3.14). CONCLUSION: Sociodemographic variables and comorbidities impact the mortality among COVID 19 patients. The variables most clearly associated with a greater hazard of death were older age, urban area, diabetes, and having both diabetes and hypertension.

Predictors of 'Out-of-Pocket Expenditure' on Routine Immunization of Under-Five Children: A Regression Analysis.

INTRODUCTION: 'Out-of-pocket expenditure' (OOPE) is the expenditures at the point of receiving health care directly by households which affects the economic stability of the household. When the expenditure on immunization of under-five children results in OOPE, it affects the motivation of parents for vaccination inversely. AIM: This study was planned to evaluate the out-of-pocket expenditure and to assess predictors of OOPE on routine immunization practices. SETTINGS AND DESIGN: This was a cross-sectional community-based study conducted from May to August 2019 at one of the immunization sites at primary health centers under a tertiary care institute of southern Rajasthan. MATERIAL AND METHODS: At the selected health facility, randomly 75% of beneficiaries of routine immunization were enrolled for the study. Data were collected using a pre-designed, pre-tested semi-structured questionnaire about direct and indirect expenses during the process of immunization incurred by the parents of the vaccinee by interview technique. RESULTS: In the study, 72.36% were infants, and 56.10% had first birth order. Mother accompanied nearly half of the vaccinee (49.6%) to the vaccination centre and the most used mode of transportation was the personal vehicle (63%). Mean loss of wages among parents/caretakers was 0.58 (±0.66) USD (median = 0.69; interquartile range (IQR) = 0.69; 95% confidence interval (CI) = 0.42-0.73) while average cost of transportation worn was 0.16 (±0.20) USD (median = 0.07; IQR = 0.21; 95% CI = 0.12-0.19) and mean duration of travelling to reach health facility was 11.87 (±7.53) minutes (median = 10; IQR = 10; 95% CI = 10.53-13.20). Vaccination at the centre was free of cost (zero USD) and no cost was incurred for drugs or registration. Average OPPE was 0.74 (±0.97) USD (median = 0.35; IQR = 0.62; 95% CI = 0.56-0.91) and regression analysis predicted significant contributors as age of vaccinee (p = 0.00; OR = 0.11; 95% CI = 0.04-0.34), religion (p = 0.04; OR = 0.34; 95% CI = 0.12-0.97) area of residence (p = 0.00; OR = 6.77; 95% CI = 2.37-19.32), birth order of vaccinee (p = 0.02; OR = 0.3; 95% CI = 0.11-0.85), longer waiting time (p = 0.03; OR = 0.16; 95% CI = 0.03-0.85), travelling time (p = 0.00; OR = 3.47; 95% CI = 1.49-8.09) and long distances (p = 0.00; OR = 10.40; 95% CI = 2.56-42.03) travelled to reach vaccination centre. CONCLUSION: The hidden cost of vaccination in the form of loss of wages and time, travel cost due to stretched distance traveled by family members to accompany vaccinee to immunization facility is experienced as OOPE by the families and could be one of the impediments in vaccination coverage. Amendments in the existing policies are required to reduce this invisible cost of vaccination.

Knowledge, attitude and practices toward health behavior and cardiovascular disease risk factors among the patients of metabolic syndrome in a teaching hospital in India.

BACKGROUND: Indian subcontinent has highest rates of cardiovascular diseases (CVDs) worldwide. Metabolic syndrome (MS) is a condition which can lead to many complications including CVDs. Most of the studies in India have been done about prevalence of MS; this study intends to study their awareness and perceptions about CVD risk factors, which can help to plan and implement the educational health programs in a better and effective manner to prevent complications in these patients. MATERIALS AND METHODS: It was a cross-sectional study conducted from April 2017 to March 2018 in a teaching hospital of Udaipur, Rajasthan. It involved 402 patients of MS diagnosed using National Cholesterol Education Program - Adult Treatment Panel III criteria with an anthropometric modification of waist circumference (WC) value that is specifically applicable to South Asians. A 43-item questionnaire was used to assess knowledge, attitude, and health-seeking behavior (KAP) toward CVD disease risk factors. KAP scores were characterized into poor, average, and good. Data were analyzed using descriptive statistics, Chi square, and ANOVA. RESULTS: Majority (58%) of the MS patients were males and belonged to middle socioeconomic status (63%). The study subjects were found to have average knowledge and good attitude but poor practices. Males, patients with lower WC, and lower fasting blood sugar showed significantly better knowledge scores. Good attitude scores were associated with education and WC. Younger subjects, patients having better sugar control, and lower WC had significantly better practices. CONCLUSION: Despite having good attitude, MS patients were not following good lifestyle practices to prevent CVD. Results in this study call for intensive educational interventions required to prevent complications in these patients.

A Comparative Study of Shift Work Effects and Injuries among Nurses Working in Rotating Night and Day Shifts in a Tertiary Care Hospital of North India.

BACKGROUND: Shift work can have an impact on the physical and psychological well-being of the healthcare worker, affecting patients as well as their own safety at the workplace. This study was conducted to compare the health outcomes and injuries, along with associated risk factors between the nurses working in rotating night shift (RNS) as compared to day shift (DS) only. MATERIALS AND METHODS: It was a cross-sectional study conducted from June to November 2016 in a tertiary care hospital of Delhi. It involved 275 nurses working in RNS and 275 nurses from DS of various departments, selected through simple random sampling. Standard Shift Work Index Questionnaire (SSI) was used as the study instrument, with selected variables (according to objectives of the study). Data were analyzed using descriptive statistics, Chi-square, t-test, and multivariate regression. RESULTS: Female nurses had more sleep disturbance, fatigue, and poor psychological health. Working on a contractual basis, RNS, and living outside the hospital campus were associated with higher odds of having needle stick injury (NSI). The nurses working in RNSs were found to have significantly lower mean scores in job satisfaction (p = 0.04), sleep (p < 0.001), and psychological well-being (p = 0.047) as compared to DS workers. CONCLUSIONS: Health outcomes among nurses working in RNSs call for the interventions, focused on various factors which can be modified to provide supportive and safer working environment.

Mobile phone use and possible cancer risk: Current perspectives in India.

Mobile communication is now essentially ruling our daily lives through better connectivity and intelligent smartphone services. There has been a tremendous growth in Indian communication industry along with growing concerns regarding health effects of mobile radiation exposure. Concerns posed are especially regarding carcinogenesis and other health-related effects of mobile radiation exposure. In the effort to establish or refute any such concerns, many studies have been undertaken in the past three decades, mostly case-control designs or cross-sectional surveys. However, most of them considerably failed to establish causal association primarily owing to potential biases and errors in their conduct and analysis. Past cohort studies have provided contradictory results leading to continued uncertainty regarding tumorigenic potential of mobile radiation exposure. In India, there remains a huge knowledge gap pertaining to this particular topic and only few studies are presently underway such as the Indian Council of Medical Research (ICMR) cell phone study in the National capital region (NCR). International Agency for Research on Cancer (IARC) has classified radiofrequency electromagnetic fields associated with wireless phone use as possibly carcinogenic to humans (Group 2B), causing major concerns worldwide among mobile companies and subscribers equivocally. The World Health Organization (WHO) is presently carrying formal risk assessment of all studied health outcomes from radio frequency field's exposures and is likely to publish it by the year 2016.

A Comparative Study of Prevalence of RTI/STI Symptoms and Treatment Seeking Behaviour among the Married Women in Urban and Rural Areas of Delhi.

Background. In developing countries, women are at high risk for several reproductive health problems especially RTI/STIs. Since all RTIs/ STIs are preventable and most of them are curable, it is pertinent to study the determinants of the health seeking behaviour. Objectives. To compare the prevalence and treatment seeking behaviour about RTI/STI symptoms among the married women of reproductive age group (18-45 years) living in urban and rural area of Delhi. Methods. A cross-sectional study was done among the married women of reproductive age group residing in Pooth Khurd, a village in North West district of Delhi, and Delhi Gate, an urban locality situated in central Delhi. Results. In this study, the prevalence of RTI/STI symptoms was found to be similar in both urban (42.3%) and rural area (42%). In urban area, 73% sought treatment, while in rural area only 45.6% sought treatment. Prevalence of the symptoms was found to be higher among the study subjects who were not using any contraceptive method, had history of abortion, and were with lower educational status, in both urban and rural areas. Treatment seeking behaviour was significantly higher among the educated women, contraceptive users, and older age group women in both rural and urban area.

Sexual and Reproductive Health: Knowledge, Attitude, and Perceptions among Young Unmarried Male Residents of Delhi.

Context. Men play a significant role in all spheres of domestic life including reproduction. Youth is a period of critical development and ignoring sexual and reproductive health (SRH) needs of young men ought to have wider social and health consequences. Aims and Objectives. To assess the knowledge, attitude, and perceptions regarding SRH among young unmarried men (18-25 years). Settings and Design. A semiqualitative study conducted across four health centers (2 rural, 2 urban) across Delhi. Materials and Methods. Focus group discussions (FGDs) were held among sixty-four participants regarding various aspects of SRH. Data Analysis. The data generated were analyzed using free listing and thematic content analysis along with simple quantitative proportions for different variable groups. Results. Good knowledge regarding HIV/AIDS was observed though found poor regarding other STIs/RTIs. Inadequate knowledge and negative attitude towards SRH and condom use were observed among rural participants. Peer group and mass media were the commonest SRH information sources among rural and urban participants, respectively. Conclusions. Poor SRH knowledge, perceptions, and available nonformal, unreliable information sources expose young men to poor SRH outcomes. Early, comprehensive SRH information provision can have life-long protective benefits to them and their partners.

Maternal body mass index and pregnancy outcome.

OBJECTIVES: To evaluate the impact of the maternal body mass index on the pregnancy outcome. MATERIALS AND METHODS: Seven hundred eighty four women who had singleton pregnancies during a one year period, were categorized into 5 groups on the basis of their maternal Body Mass Index (BMI). The maternal and the neonatal outcome were noted in all the groups. RESULTS: In the underweight group, the incidences of anaemia and growth retardation were more, while the overweight and the obese women had a higher risk for PIH, gestational diabetes and Large for gestational age (LGA). The groups 4 and 5 had higher incidences of LSCS, wound sepsis and neonatal ICU admissions. There was no significant increase in the perinatal mortality rate. CONCLUSION: The health of women, throughout their childbearing ages, should be addressed, to improve their obstetrical and perinatal outcomes. Also, the high risk groups should be managed at tertiary centers.