Mandatory fortification of rice in the public distribution system in India: An ethics perspective.

In response to the continuing high prevalence of anaemia recorded in the National Family Health Survey-5, the Indian government launched a policy for mandatory iron fortification of the rice provided through public nutrition programmes in India. This was done even though a rigorous evidence analysis had already concluded that rice fortification was not effective in preventing anaemia or iron deficiency at the population level. Fortification also poses a potential risk of iron toxicity over time, but there is no stated time period for the policy's implementation. The risk is particularly high in segments of the population who already have a high habitual iron intake, and who could be exposed to simultaneous fortification in different staples and food commodities along with the ongoing weekly Iron and Folic Acid tablets supplementation programme. Finally, this fortification policy also requires significant additional funding and resources to implement. It is crucial to examine such mandatory health actions, and to weigh the benefits and risks of harm, using the principles of public health ethics.

Atypical late presentation of muscular metastasis of melanoma in the contralateral limb.

A man in his 50s presented to plastic surgery again with a lesion on his left upper arm. He had previously been treated for a malignant melanoma (MM) on his right arm over 5 years earlier. Sentinel lymph node biopsy (SLNB) had been negative, and he had completed the recommended 5 years follow-up period. Imaging was suspicious for an intramuscular soft tissue malignancy within the triceps muscle. After discussion with the regional sarcoma service, a core biopsy was performed. Histopathology suggested a diagnosis of metastatic MM, which was confirmed after surgical excision. This case highlights a rare example of an isolated muscular metastasis of MM, which presented at a distant site, over 5 years from the original treatment. This case highlights the unpredictable nature of MM, reminding clinicians of the need for a low threshold for investigation of soft tissue masses in patients with a history of cutaneous malignancy.

Comparison of a virtual reality compression-only Cardiopulmonary Resuscitation (CPR) course to the traditional course with content validation of the VR course - A randomized control pilot study.

INTRODUCTION: Technology has been a major contributor to recent changes in education, where simulation plays a huge role by providing a unique safe environment, especially with the recent incorporation of immersive virtual reality (VR) training. Cardiopulmonary Resuscitation (CPR) is said to double, even triple survival from cardiac arrest, and hence it is crucial to ensure optimal acquisition and retention of these skills. In this study, we aim to compare a VR CPR teaching program to current teaching methods with content validation of the VR course. METHODS: A randomized single-blinded simulation-based pilot study where 26 participants underwent baseline assessment of their CPR skills using a validated checklist and Laerdal QCPR®. Participants were randomly allocated and underwent their respective courses. This was followed by a final assessment and a questionnaire for content validation, knowledge and confidence. The data was analysed using STATA 16.2 to determine the standardized mean difference using paired and unpaired t-test. RESULTS: Subjective assessment using the checklist showed statistically significant improvement in the overall scores of both groups (traditional group mean improved from 6.92 to 9.61 p-value 0.0005, VR group from 6.61 to 8.53 p-value 0.0016). However, no statistically significant difference was noted between the final scores in both the subjective and objective assessments. As for the questionnaire, knowledge and confidence seemed to improve equally. Finally, the content validation showed statistically significant improvement in ease of use (mean score 3 to 4.23 p-value of 0.0144), while for content, positivity of experience, usefulness and appropriateness participants showed similar satisfaction before and after use. CONCLUSION: This pilot study suggests that VR teaching could deliver CPR skills in an attractive manner, with no inferiority in acquisition of these skills compared to traditional methods. To corroborate these findings, we suggest a follow-up study with a larger sample size after adding ventilation and Automated External Defibrillator (AED) skills to the VR course with re-examination after 3-6 months to test retention of the skills.

Necrotizing Enterocolitis in Neonates: Has the Brain Taken a Hit 10 Years Later?

BACKGROUND: The neonate with necrotizing enterocolitis (NEC) is at risk of developing poor neurodevelopmental outcomes. There is a dearth of long-term follow-up studies in this field, with a majority of studies reporting a follow-up duration of 2 years. The aim of this study was to assess neurodevelopment of babies diagnosed with NEC more than a decade ago. This study was carried out in a tertiary hospital with neonatal surgery and intensive care units. MATERIALS AND METHODS: Retrospective review of notes and telephone interviews with parents of babies diagnosed with NEC between January 2007 and December 2008 was conducted. Evidence of motor, cognitive, and sensory impairment was recorded. Fisher's exact, χ2, and unpaired t-tests were used. P-values <0.05 were considered significant. RESULTS: Overall mortality in this cohort was 31%. Eighteen patients were followed up to an average age of 11.2 years. Of the 18 patients, 11 (61%) had a neurological impairment. Of the 15 surgically managed patients, 10 (67%) had an impairment and, of the 3 medically managed patients, 1 (33%) had an impairment. Cognitive impairment was the most common (10/18, 56%), followed by motor (6/18, 33%). Ten of 18 (56%) had special education needs, 9 of 18 (50%) had learning difficulties, 6 of 18 (33%) had speaking difficulties, and 4 of 18 (22%) had cerebral palsy. Patients also had behavioral conditions (3/18, 17%), visual impairment (2/18, 11%), and seizures (2/18, 11%). CONCLUSION: In the field of NEC, there is a hidden neurological burden that neonatal surgeons bequeath to the community. Sixty-one percent of patients are neurologically impaired, affecting the quality of life and function in the long-term. There should be appropriate parent counseling at the point of diagnosis and regular development checks for children with NEC.

Lack of association of cranial lacunae with intracranial hypertension in children with Crouzon syndrome and Apert syndrome: a 3D morphometric quantitative analysis.

PURPOSE: Cranial lacunae (foci of attenuated calvarial bone) are CT equivalents of "copper beating" seen on plain skull radiographs in children with craniosynostosis. The qualitative presence of copper beating has not been found to be useful for the diagnosis of intracranial hypertension (IH) in these patients. 3D morphometric analysis (3DMA) allows a more systematic and quantitative assessment of calvarial attenuation. We used 3DMA to examine the relationship between cranial lacunae and IH in children with Crouzon and Apert syndromic craniosynostosis. METHODS: Patients were divided into IH and non-IH groups defined on an intention-to-treat basis. Pre-operative CT scans were converted into 3D skull models and processed to quantify lacunae as a percentage of calvarium surface area (LCP). This was done on individual bone and whole skull basis. RESULTS: Eighteen consecutive children with Crouzon's syndrome and 17 with Apert syndrome were identified. Median age at CT scan was 135 days (range 6-1778). Of the 35 children, 21 required surgery for IH at median age of 364 days (range 38-1710). Of these 21 children, 14 had lacunae with mean LCP of 3% (0-28%). Of the 14 non-IH children, 8 had lacunae with mean LCP of 2% (0-8%). LCP was not significantly different between IH and non-IH groups. Parietal bones were most likely to show lacunae (IH 14/21, non-IH 9/14), followed by occipital (IH 8/21, non-IH 3/14), and frontal (IH 6/21, non-IH 2/14). CONCLUSION: Results suggest that cranial lacunae, measured using quantitative 3DMA, do not correlate with IH, in agreement with evidence from qualitative plain skull radiograph studies.