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Summary Background Loss of sensations in the sole following diabetic sensorimotor polyneuropathy (DSPN) leads to diabetic foot ulcers and its sequelae. We hypothesized that sensory reinnervation of sole by transfer of saphenous nerve (SN) to sensory fascicles of posterior tibial nerve (PTN) in these patients may reverse the neuropathy. Methods This prospective interventional case series included patients with advanced DSPN and intact sensory supply of SN. PTN was neurotized by transfer of SN nerve in the tarsal tunnel and postoperatively sensations of the sole were tested. Any existing ulcers on sole were noted and their healing was monitored. Finding A total of 17 patients (22 feet), 9 male and 8 female, were included. Seven patients had ulcers in the feet. At 6 months follow-up all patients developed protective sensation in the sole. The average 2 PD improved from 60 mm to 45.5 mm, average vibration perception improved from 34.12 V to 24.33, Medical Research Council (MRC) score improved from S0 in 12 feet and S1 in 10 feet to S3+ in 13 feet, S3 in 5 feet, and S2 in 2 feet at 6 months along with healing of ulcers in all 7 feet. Interpretation Transfer of SN to PTN for sensory neurotization is an innovative and simple option to prevent complications of DSPN. This procedure has the potential to change the natural history of DSPN.

Clinical trials in Surgery are central to research; however, very few surgical clinical trials are conducted in India. Such paucity of surgical trials is a cause for concern, and prompted us to explore the recent landscape of surgical trials in India. We reviewed all clinical trials from general surgery or subspecialties of general surgery registered with the Clinical Trials Registry of India website between 2018 to 15 th May 2021. Specific details such as the surgical subspecialty, study design, multicentric or single institution and funding were obtained. We found a total of 16,710 trials, out of these 4119 (24.6%) were related to all surgical fields. Only 136 (0.8%) trials were found from general surgery and its subspecialties. Most trials were registered from Central Government Institutions (48%), followed by State Government Medical Colleges (11%). Most number of trials was registered from GI surgery (32%). Most (90.5%) trials were single centre based. Common barriers to research are well known; if the State Government Medical Colleges can mentor a culture of research from an early stage of surgical training it can improve research productivity. Multicentre trials, involving smaller hospitals from tier 2 and tier 3 cities, are a potential solution to one of the major obstacles of surgical trials i.e. small number of patients; especially in this pandemic induced draught of elective surgical operations. A positive change in attitude of surgeons and provision of necessary funding can encourage more surgical clinical trials in India.

Diabetic sensorimotor polyneuropathy (DSPN) is the commonest form of neuropathy which leads to insensate sole, diabetic foot ulcers (DFU) and its complications. We share our experience in recovery of sensation in the sole after prophylactic surgery such as nerve decompression (ND) or sensory neurotization by nerve transfer (NT) in patients having Diabetic sensorimotor polyneuropathy DSPN. 32 patients (46 feet) were selected for either nerve decompression or sensory neurotization depending upon presence or absence of Tinel’s sign at tarsal tunnel. At 6 month post-operatively perception of touch and pain recovered in all feet; temperature and pressure perception recovered in ∼95% feet; average vibration perception threshold returned to normal range and 2-Point Discrimination came down significantly. There were no ulcers or amputation in operated limbs during follow up period of 6 months. Prophylactic surgery in the form of ND and NT can be offered with minimal complications which significantly improve sensations in the sole in selected cases of DSPN. These have the potential to improve the quality of life of patient and change the natural course of disease.

Complex soft-tissue defects of the distal third of the leg, foot and ankle with exposed bones/joints, tendons and implants need a flap for their closure. Distally based sural flap is commonly used, but it has a high partial necrosis rate due to venous insufficiency. We addressed this issue with AV supercharging by dorsalis pedis artery with short saphenous vein. Eight patients (seven males, mean age 34.12 years) with post traumatic lower limb defects over heel and foot were included. All flaps survived and healed although four flaps developed superficial partial epidermolysis. Average healing time was 20.12 days. Closure of the AV fistula was not required in any of the patients. At mean follow-up of two months, all patients were ambulatory with well settled flap. Arteriovenous supercharging of distally based sural flap through short saphenous vein improves the distal arterial perfusion in the flap and prevents distal flap necrosis.

A new boosted active-capacitor (BAC) architecture using LC -tuned active-impedance-conversion is presented. In the chosen frequency range, the proposed BAC acts as a tunable capacitance multiplier and negative-transconductance, but where the positive-transconductance is not multiplied. The BAC is used as a low-loss tunable capacitor bank element for designing a wide tuning range voltage-controlled oscillator (VCO). A current-reuse technique is used to lower power consumption and suppress potential parasitic oscillation modes. A zero-capacitance-variation biasing is proposed for a BAC-VCO robust against process, voltage, and temperature variations. The BAC designed in a 65 nm bulk CMOS process achieves a capacitance tuning ratio of 7.8 with a quality factor of higher than 20 across VCO’s tuning range. The BAC-VCO prototype has a tuning range of 8.3-14.3 GHz using less than 5 mW core power and achieves FoMT of up to −202.4 dBc/Hz.

Awareness of second victim syndrome and available support systems in South Asia is quite limited. We conducted this survey to assess its prevalence and impact among the surgeons from South Asia. A multiple choice pattern web-based cross-sectional Google forms questionnaire was developed which focused on demographics of respondent, prevalence, impact (physical, personal and professional), available coping mechanisms, gap in support systems, and future suggestions for dealing with “second victim” syndrome. Answers were sought from surgeons of all surgical specialties from South Asia. A total of 658 surgeons responded to the survey, 91.03% (n = 599) reported having experienced the “second victim” syndrome. Majority (54.3%) of respondents was from India; surgeons from 8 other countries also responded to the survey. Prevalence of “second victim” syndrome was found similar among the two genders, different experience groups, and different specialties (p > 0.05). A varied set of physical, psychological, and professional impacts were noted; however, any structured institute-based support system was lacking and victims sought help from colleagues. Development of a structured “crisis plans” providing emotional, psychological, and legal support, minimizing the trauma, and guiding the second victim through the recovery process is the need of the hour.

We describe a low-cost simulation model for teaching core needle biopsy to surgical trainees in Low- and Middle-income countries (LMICs). Pre-session and post-session surveys showed that correct core sampling (ability to hit the beetroot) after training was 91.4% compared to 75.7% before demonstration and improved adequacy (68.5% before v. 85.7% after). This low-cost model using locally available products is designed to simulate a palpable breast lump and can easily be incorporated into surgical training in LMICs, where a palpable breast lump is the commonest presentation of breast cancer.

The work pressure, challenging environment, and the difficult terms/conditions of the course lead to several unique problems amongst general surgery trainees in India. Self-assessment of one’s strengths and weaknesses is essential to maximally avail the opportunities and combat professional threats. SWOT stands for Strengths, Weaknesses, Opportunities, and Threats, a technique that is utilized in formulating strategies for success. Despite a strong and time-tested training module in India, trainees perceive many deficiencies in the general surgery training viz. high work pressure, burn-out, limited time for research/publications, long and hefty rural service bond, etc., which leads to a negative impact on their personal and professional trajectory. Despite such challenges in majority of trainees, only a small minority of them discuss this with their mentors. We propose a self SWOT analysis matrix, constructed in collaboration of the trainees with their mentors, helping them to develop strategies to self-manage their training period.

This study was conducted to assess outcomes of propeller flaps for reconstruction of small- to medium-sized defects in the distal third of the leg. Of 53 lower third leg defects covered using the propeller flap, 43 survived without complications. Only minor complications were seen and no flap was lost completely. The propeller flap is thus a safe option for medium-sized defects of the lower leg.

Shortage of plastic surgeons is well known in the developing countries, and this leads to denial of plastic surgery facilities to a very large population especially in the rural area. We report a retrospective review of our experience with 60 rural plastic surgery camps in Central India over 16 years. A total of 4317 patients were operated, and majority (~ 65%) of patients had cleft lip/palate and post-burn contractures. Results were satisfactory, and there were no major complications. Usefulness of such camps is obvious, and we wish to share lessons learnt during these camps.

Background: Internet has become the major source of health-related information, leading to a growing trend toward unsupervised self-medication using internet. This survey was conducted to assess the extent of internet use to obtain health information/self-medication, their perception regarding side effects of drug used, types/quality of information, and which site was commonly surfed for information. Materials and Methods: A web-based tool (Google Forms) was used to develop a questionnaire to obtain information about extent and impact of internet on self-medication by general population. The questionnaire included 9 questions along with demographic details of participants. The questionnaire was sent to participants by WhatsApp and E-mail and their responses were analyzed. Results: Four hundred and forty-eight (56%) persons responded to survey. There were 226 (50.4%) males and 222 (49.6%) females. The average age of responders was 35.10 years. Overall, 59.8% of responders used internet to obtain health information and self-medication. Out of these, 54.47% took allopathic medications without consulting the doctors. The majority of persons self-medicated for minor illnesses, but 11.6% of persons self-diagnosed and self-medicated for serious illnesses such as heart disease, diabetes, cancers, and psychological problems. 23.2% of peoples think that information on internet carries no risk for self-medication and 21% think that internet use can be a substitute for consulting a doctor. Google was the most common site (93.8%) surfed by participants. The health information provided on net was perceived as very good by 43.7%. Conclusions: There are growing trends toward the self-medication using internet. The health information on internet should be made easier, simpler, and safer to achieve positive health outcomes, but patients should be discouraged for self-medication. To support the safe and appropriate use of nonprescription medicines, minimum practice standards should be set by the governing medical bodies in each country.

Background The purpose of this study was to evaluate the functional outcomes of a modified technique of double rectangle pattern for correction of severe ptosis. Methods This is a retrospective study over a period of 8 years including patients who underwent correction of ptosis by double rectangle using autologous fascia lata sling. Surgical outcomes were assessed postoperatively by distance from the corneal light reflex to the upper eyelid margin (MRD1) and levator function. Results Twenty-six eyelids were operated in 20 patients. There were 9 males and 11 females, with age ranging from 4 to 35 years. Preoperatively, all patients had poor MRD1 and poor levator function. Postoperative MRD1 was good in 13 patients (17 eyelids), fair in 5 (7eyelids), and poor in 2 patients (2 eyelids). Postoperative levator function was excellent in 12 patients (15 eyelids), good in 6 (9 eyelids), and fair in 2 patients (2 eyelids). At a mean follow-up of 12 months, adequate correction was achieved in 24 eyelids, and 2 eyelids had undercorrection. Conclusion Frontalis sling with a double rectangle is simple and more efficient, as it provides a straight line of pull to the eyelid for correction of severe ptosis.

Objective The transfer of peripheral nerves originating above the level of injured spinal cord into the nerves/roots below the injury is a promising approach. It facilitates the functional recovery in lower extremity, bladder/bowel and sexual function in paraplegics. We assessed anatomical feasibility of transfer of lower intercostal nerves to S2 ventral root in human cadaver for management of neurogenic bladder dysfunction in patients with spinal cord injury. Methods Study was performed in five formalin fixed cadavers. Cadavers were placed in prone position. A transverse incision was made along 11th ribs on both sides and 10th, 11th Intercostal nerves (ICN) and subcostal nerve were harvested up to maximum possible length. In four cadavers the ventral root of S2 was exposed by endoscope and in one by the standard open laminectomy. Intercostal nerves were brought down to lumbo-sacral region, S2 ventral root was cut cranially and feasibility of intercostal to S2 anastomosis was assessed. Results The mean length of intercostal nerves was 18.4 cm for the 10th 19.5 cm for the 11th and 22.15 cm for the subcostal nerve. The length of harvested nerve and the nerve length necessary to perform sacral roots neurotization were possible in all cases by only by subcostal nerve while T11 and T10 ICN fall short of the required length. Conclusion For Spinal cord lesions located at the conus, subcostal nerve could be connected to ventral root of S2 in an attempt to restore bladder function while 10th and 11th ICN had enough length to neurotize lumbar plexus.

Temporo-mandibular joint (TMJ) ankylosis is characterized by a decreased mouth opening which affects mastication, speech, and facial aesthetic. Interpositional arthroplasty using autologous tissue is accepted treatment for TMJ Ankylosis; however, harvesting autologous tissue is associated with additional morbidity. In this article we report our results of silicon interpositional arthroplasty for TMJ ankylosis. 20 patients with TMJ ankylosis were included in the study. All patients underwent standard operative procedure using preauricular incision for release of TMJ ankylosis by excision of at least 1 cm of bony block and insertion of 2 cm thick silicon block in the joint space. Postoperatively early mobilization of TMJ was advised from 3rd day onwards. Post operative result was evaluated by assessing the mouth opening as inter incisor distance (IID). 20 patients (27 joints) of TMJ ankylosis were included in the study. There were 8 male and 12 female patients with age ranged from 3–35 years. According to Sawhney classification bony ankylosis was present as Type-IV (n = 13 joints), Type-III (n = 12 joints) and Type-II (2 joints). Preoperative mean IID was 7.15 mm and post operative mean IID was 43.5. There was no facial nerve paresis, malocclusion or recurrence but infection and extrusion of implant occurred in 1 case each. Silicon interpositional arthroplasty is an effective procedure for the treatment of TMJ Ankylosis; as it restores mouth opening and function, maintains the vertical ramus height, and prevents re-ankylosis without any donor site morbidity.

Injury to the pudendal nerve leads to bowel/bladder incontinence which compromises the quality of life in these patients. Many peripheral nerves have been used to neurotize the pudendal nerve in order to regain bladder continence. The aim of this study was to assess the anatomic feasibility, by ultrasound, of transfer of the femoral nerve’s motor branch to the vastus lateralis (MNVL) to the pudendal nerve for restoring continence. Thirty healthy male volunteers were randomly selected, irrespective of age. The origin of MNVL was traced in the distal thigh, to the level the nerve was visible using high-frequency ultrasound probe. The length of the nerve was measured with the help of a measuring tape. The pudendal nerve was identified just medial to the ischial tuberosity on the same side. The distance between the origin of MNVL and the pudendal nerve was measured. The same procedure was performed in the opposite side. MNVL has enough length and calibre to neurotize the pudendal nerve in 28/30 (93.33%) individuals on the right side, and in 29/30 (96.66%) individuals on the left side. On ultrasonography, length of MNVL was found sufficient to reach the pudendal nerve in majority of the patients. USG can be a tool to assess the feasibility of transfer of MNVL to the pudendal nerve. Level of evidence: Level IV, risk/prognostic study.

Traditional Halstead teaching, which is time- and opportunity-dependent, has often been replaced by ‘boot’ camps which involve expensive modules and are usually a grand one-time event. This does not suit the complex teaching and learning needs of low- and middle-income countries (LMICs). We studied the impact of a needs-driven surgical training course implemented instead. The course was taken by 17 first-year residents of surgery, and included a pre-course knowledge assessment test, pre-test skills assessment, as well as post-test assessment and feedback impressions. Mean post-test scores improved significantly ( P

Differentiating motor and sensory fascicles before anastomosis is essential for achieving an excellent postoperative functional outcome for peripheral mixed nerves injuries. However, identifying them is not easy. There are several techniques to address this important issue. Each identifying technique has its own pros and cons; this narrative review highlights the salient features of each of these. Many of the newer techniques need to be tested in humans before they can be recommended for regular use; till then we have to rely mainly on per operative electrical stimulation of nerve to differentiate between sensory and motor fascicles to improve postoperative functional outcome.

Objective Glasgow Coma Scale (GCS) assessment is vital for the management of various neurological, neurosurgical, and critical care disorders. Learning GCS scoring needs good training and practice. Due to limitation of teachers, the new entrants of the clinical team find it difficult to learn and use it correctly. Training through videos is being increasingly utilized in the medical field. This study aimed to evaluate the efficiency of video teaching of GCS scoring among general surgery residents. Materials and Methods A prospective study was done utilizing the freely available video at glasgowcomascale.org. The participants (general surgery residents, 1st–3rd year) were asked to assess and record their responses related to GCS both before and after watching the video. A blinded neurosurgeon recorded the correct responses separately. Statistical Analysis The difference between correct responses of the residents before and after watching the video was calculated using the “chi-square test.” p-Value ≤ 0.05 was taken as significant. Results There was a significant improvement in GCS scoring by residents after watching the videos (p < 0.05). On estimating the responses separately, all the three responses (eye, verbal, and motor) improved significantly for 1st-year residents while only the motor response improved significantly for 2nd- and 3rd-year residents. The mode subjective improvement for the 1st-, 2nd-, and 3rd-year residents was 5, 4, and 3, respectively. Conclusion Training GCS scoring through videos is an effective way of teaching the surgery residents with maximum benefit to the junior-most ones.

Split-thickness autografts offer the best form of wound coverage, but limited donor sites and donor site related morbidity have resulted in the search for alternatives in the form of microskin graft. Twenty-five consecutive patients with post burn, post traumatic, and post cellulitis raw area were included in this study. After appropriate preparation of recipient bed, microskin graft was applied under general/regional anaesthesia. The assessment of microskin graft was done clinically on 5th, 7th, 10th, and 14th days and until the wound healed. Percentage of microskin graft take/loss, presence of infection, and duration of wound healing were noted. Complete wound healing was considered the endpoint of the study. Late assessment was done at 3 and 6 months postoperative to assess the scar. There were 19 male and 6 female patients with mean age of 27.52 years (range 18–54 years). Mean size of wound was 337.48 cm2 (range 120–770 cm2). All wounds healed in ~ 17.28 days without the need of secondary skin grafting. There was no clinically evident infection in the grafted wounds. Overall graft survival rate was ~ 94.76%. After 2 months, homogenous scar was present but there was hypo-pigmentation in 4 cases. There was no hypertrophy or scar contracture at 6 months. Micrografting is a feasible alternative for wound coverage and a useful tool for surgeons when donor sites are limited. Level of evidence: Level IV, therapeutic study.

Background Diabetic sensorimotor polyneuropathy (DSPN) is the commonest form of neuropathy. Loss of sensations in sole leads to diabetic foot ulcers (DFU) and its complications. Surgical decompression has been used in the treatment of diabetic peripheral neuropathy, however; its effectiveness has been questioned. Purpose of this study was to evaluate the sensory recovery in sole after tarsal tunnel decompression (TTD) in patients having DSPN. Methods Thirteen patients (Age28-70 years, average 35.57 years; 7 Males, 6 Females; 20 feet) with DSPN and positive Tinel's sign over the tarsal tunnel were included in the study. Pre and post-operative sensory tests performed on the sole included tests for touch, pain, temperature, pressure, vibration perception threshold (VPT) and two-point discrimination (2-PD). Results were classified as per British Medical Research Council (MRC) scoring system. Results –Sixteen feet were followed-up for 6 months. In all feet perception of touch, pain and pressure recovered. Temperature perception recovered in 75% feet. VPT came to normal range (16.81V) from 40.37 V and 2-PD came down to average of 6.0 mm from preoperative average of11.2 mm.MRC scale improved from S0 in 5 feet and S2 in 15 feet to S3+ in all 16 feet.There were no ulcers or amputation in operated limbs during follow up period of 6 months. Conclusions TTD improves plantar sensations in diabetic neuropathy and prevents ulcers and its related complications.

Qualitative studies in Surgery are important because they contextualize the previously missing social facets of the surgical narrative and inquire into the crucial issues of quality of life/well-being, gender and other discriminations and biases faced by surgeons and patients, surgical education/training, mental issues and burnout, etc. This has resulted in an increasing trend of qualitative studies in surgery. Authors, editors and journals have to ensure that the principles of scientific rigour in qualitative research are followed; otherwise, the answers will not be valid, thus rendering the whole exercise futile. More studies, addressing these fascinating ‘social’ facets of surgery, are needed.

Contraction in a skin flap is unavoidable after it is raised because of its elastic content and despite the best of planning a flap may fall short which may lead to some necrosis. This study was conducted to ascertain the extent of contraction of flaps and the factors that might influence this contraction. This prospective study included 25 patients who underwent reconstructions of defects with different types of skin and fascio-cutaneous (FC) flaps. Clinical data including age; sex; body mass index; site/type of flap; and the flap’s surface area, thickness, and its contraction in relation with the relaxed skin tension lines (RSTL) were recorded and analyzed. The outcome of the success or failure of the flap was ascertained by clinical examination. There were 20 males and 5 female patients and their age ranged from 10 to 67 years. Mean flap contraction was 20.01% in skin flaps and 20.38% in FC flaps; overall mean contraction was 20.19%. Flaps retracted more when constructed parallel to RSTL, in females and in patients with high BMI. Age did not affect the contraction. Skin flaps can be stretched to a certain extent, but not up to pre-flap area without compromising the blood supply. Therefore, adequate allowance should be provided to avoid stretching, and subsequent necrosis and dehiscence. The most practical way of providing this allowance is by planning in reverse which flap size is always bigger than the defect, therefore providing margins for flap contraction. Level IV, risk/prognostic study

This paper presents a new predistortion linearization technique for high linearity and high modulation efficiency in millimeter-wave (mm-wave) CMOS power amplifiers (PA) for fifth-generation (5G) mobile communications. Our proposed linearizer adopts a transformer-based (i.e., inductive) self-compensated predistortion network at the input of the PA whose amplitude-modulation to phase-modulation (AM–PM) response is opposite compared with the AM–PM response of a CMOS PA, resulting in an AM–PM cancellation effect. This proposed inductive linearization method mitigates the large gain reduction problem in traditional capacitor-based linearization approaches while consuming no extra dc power or without introducing additional control circuitry. As a result, a significant improvement in power-efficiency and linearity is achieved with high-order complex modulation signals. To validate the proposed linearization method, a PA prototype in 65-nm CMOS technology was fabricated and tested, and it exhibited $\vert $ AM–PM $\vert $ distortion at $P_{\mathrm {o,1\, dB}}$ over 4 GHz of bandwidth (27–31 GHz). At 28 GHz, the measured saturated $P_{\mathrm {o}}$ and peak power-added-efficiency (PAE) was 15.6 dBm and 41%, respectively, while achieving a 6-dB $P_{\mathrm {o}}$ back-off PAE of 25%. To assess PA’s large-signal performance for 5G communications, the prototype was measured with the 64-quadratic-amplitude modulation (QAM) signal at 2-Gb/s data rates at 28 and 30 GHz, and the PA achieves modulated-PAE of 18.2%/17.6% and average- $P_{\mathrm {o}}$ of 9.8 dBm/10 dBm, respectively, while maintaining $2\times $ improvement in comparison with the recently reported 28-GHz linear CMOS PAs. Also, the PA occupies a compact active-area of 0.24 mm2.

In this paper, a compact, low-loss, dual-path phase-switched inductor suitable for millimeter-wave (mmWave) transceiver subblocks is proposed. The signal path through the structure is determined by the relative polarity of two differential excitation signals applied to the four-port structure. Because inductance is varied by altering signal path through the inductor, signal-path MOSFET switches are avoided. The inductor, therefore, demonstrates high, mode-invariant quality factor, facilitating the design of high-performance dual-band mmWave transceiver subblocks. Based on the proposed inductor, a dual-band Ka-band oscillator is designed in a 65-nm CMOS technology which covers two frequency bands from 14.8 to 18.7 GHz and from 20.8 to 26.6 GHz. The proposed inductor facilitates a widely tunable, dual-band frequency range while maintaining the state-of-the-art phase noise, power consumption, and figure of merit (FoM). The oscillator achieves measured fractional tuning ranges of 23.3% and 24.5% and phase noise of −115.1 dBc/Hz at 2-MHz offset while consuming only 4.8-mW dc power. A peak tuning-range FoM of −195.1 and −194.9 dBc/Hz is demonstrated across the low- and high-frequency bands.

Aim Restoration of bladder and bowel continence after pudendal nerve anastomosis has been shown successfully in animal models and may be applicable in humans. Aim of this cadaveric study was to assess feasibility of pudendal nerve neurotization using motor fascicles from sciatic nerve. Methods Pudendal and sciatic nerves were exposed via gluteal approach in 5 human cadavers (10 sites). Size of pudendal and sciatic nerves and the distance between two nerves was measured. Results There were four male and one female cadavers. Mean age was 62 (range, 50–70) years. Mean pudendal nerve diameter was 2.94 mm (right side) and 2.82 mm (left side). Mean sciatic nerve diameter was 11.2 mm (right side) and 14.2 mm (left side). The distance between two nerves was 23.4 mm on both sides. Conclusion Transfer of the motor fascicles from sciatic nerve to pudendal nerve to restore the bladder and bowel continence is feasible.

Low-cost healthcare innovations which are designed for economic reasons, popularly called frugal innovations (FI), are all about ‘doing more and better with less for more people’.1 Often synonymous with ‘work-arounds’ or ‘good-enough’ innovation, what FIs lack in sophistication or complexity they make up for in affordability, without scrimping on safety or effectiveness. Some good examples of FIs include the low-cost ECG machine GE MAC 400, Kangaroo Care, the Ponseti treatment for congenital clubfoot and mosquito net mesh used for hernia repair; each of which has a demonstrable evidence base for clinical effectiveness at extremely low cost.2–5 The philosophy of FI originates from grassroots, resource-constrained milieus, where most abundant of all-natural resources—human ingenuity—is used to optimise limited resources to solve problems.6 Any FI must result in substantial (at least one-third) cost reduction without compromising on its core functions and optimum performance level.7 Some FIs, although designed in the developing world, have been found useful for the developed world too and are labelled as ‘reverse innovation’, although this term is considered to be pejorative by some.8 9 Innovation, although central to the development of medical science, is a complex process and its definition continues to be debated.10 Its complexities are further reflected in challenges in its evaluation and reporting even though frameworks such as Idea, Development, Exploration, Assessment and Long-term monitoring, a widely accepted benchmark, are available.11 In a recent systematic review, the measurement and reporting of surgical innovations continues to be inconsistent, and there is a need for standardisation and guidance.12 FIs reporting is made even more complex for two reasons (1) that they are work-arounds and unconventional solutions for reducing the complexity and cost of an idea, oftentimes unpatented, not commercialised, without financial backing or simple changes in practice or technique, and …

Violence at work is becoming an alarming phenomenon worldwide affecting the millions of health care workers. This study was conducted to assess the violence towards Resident doctors in Indian teaching hospitals. Google forms questionnaire was developed and circulated electronically to resident doctors working in India. Data were collected and managed using the Google forms electronic tool. Vast majority (86%) of respondents reported having experienced violence with no difference among two genders. Prevalence of violence was maximum (35.5%) in general surgery. Verbal threat and abuse was the commonest (∼94%) form of violence. Mostly these acts of violence happened in Emergency/Trauma room. The most common reasons for violence in hospital were patient's death. Over 94% residents accepted that they had never received any training to deal with work place violence. Majority (80%) of the respondents favoured better communication, strict Laws and strengthening of security measures in hospital to prevent WPV. Workplace violence prevention should be addressed aggressively and comprehensively in health care. A workplace violence prevention program should be a required component of all health care organizations.

Background: Measurement of two-point discrimination (2-PD) is used in clinical practice to evaluate the severity of nerve injuries, neuropathy, and recovery of patients following nerve repair. Commercially available 2-PD testing devices are costly and therefore not available everywhere. Methods and Material: We made an economical indigenous 2-PD testing device from off-the-shelf components and tested its efficacy in volunteers. Statistical Analysis: The data were analyzed using Minitab Statistical Software Version 17.0 and Kappa statistics were used in the assessment of agreement between two devices. Results: A total of 30 (23 men, 7 women) subjects were included in the study. There was good agreement between the measurements of static 2-PD with the two different test devices: from fair (Kappa = 0.408, P = 0.018) to strong (Kappa = 0.618–0.795, P = 0.000). Conclusions: This device is simple to make, very economical, and obtains accurate 2-PD measurements.

Plasma is one of the mainstays of traumatic haemorrhage treatment. Fresh frozen plasma (FFP) is the commonest plasma formulation used. A recent in-vitro study showing significantly less growth factors (that play a role in angiogenesis, cell growth, and cell proliferation) and more pro-inflammatory chemokines in FFP, as compared to Never Frozen Plasma (NFP), has prompted a debate about preferred plasma formulation for transfusion in trauma patients. Hence, infusion of large amount of FFP may exacerbate an already activated inflammatory cascade. FFP has been shown to be associated with increased short-term mortality and enhanced risk of systemic inflammatory response syndrome, infection and sepsis. In light of these studies, a call can be made for increasing the use of NFP, which is safer, has immediate availability, a longer storage life, preserves potentially advantageous growth factors and avoids previously unrecognized possible harmful cytokines.

Personal protective equipment (PPE) plays a fundamental role in the prevention of spread to Health Care Professionals (HCP) ; especially in a surgical setting. This scoping review of surgery guidelines was performed to appraise the quality of appropriate PPE recommendations and propose a strategy to optimize the PPE usage. This rapid scoping review of guidelines on surgery during COVID-19 was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews protocol. Important databases were searched from January 1, 2020 to July 31, 2020, for relevant studies produced by a national/international academic association/organization, in English literature, using relevant keywords. Quality of evidence was graded according to GRADE guidelines. The searches yielded a total of 1725 studies, out of these 41 guidelines on surgery during COVID-19 matching with pre-defined criteria were evaluated. The level of evidence was uniformly rated "low," as assessed by GRADE guidelines and recommendations provided by them were mostly non-specific covering a narrow range of items. The crucial issue of optimization of PPE was not addressed at all. Economic implications demand optimization of PPE and conservation of resources. A simple decision-making algorithm addressing all the limitations of guidelines can be constructed, which allows HCPs to safeguard themselves and at the same time optimize/ conserving resources.

BackgroundSurgical correction of ulnar drift of metacarpo-phalangeal joint (MPJ) due to Rheumatoid arthritis (RA) is conventionally done by silicon joint arthroplasty which is expensive and may be associated with many complications. We report the outcome of low-cost autologous interpositional arthroplasty.Material and methodsFive patients (8 hands, 32 arthroplasties) underwent correction of ulnar drift of MPJ by dorsal capsule interpositional arthroplasty. Results were assessed according to the degree of recovery of movement at the MPJ and correction of ulnar drift. Functional improvement was graded as excellent, good and fair. Pain alleviation was assessed by visual analogue score (VAS) score.ResultsExcellent results were seen in 3 patients (5 hands, 20 arthroplasties), good in 1 patient (2 hands, 8 arthroplasties) and fair in 1 patient (1 hand, 4 arthroplasties). VAS score for pain decreased from mean preoperative 8.2/10 to 1/10. On average follow up of 1.4 years there was good hand function, no recurrence of deformities and patients were pain free.ConclusionInterpositional arthroplasty for MPJ using dorsal capsule for correction of post RA ulnar drift is a low-cost option which improves the hand function and cosmesis. Additionally, it avoids all the complications related with the use of silicon joints.

Disruption in surgical training during the COVID-19 pandemic has prompted many innovative "virtual" modules to address the loss of learning exposure during these difficult times. We suggest "GRASP" (Gain, Recognize, Analyze, Simulate, and Perform) module of self-assessment with virtual mentoring for uninterrupted surgical training. This idea merges the advantages of self-assessment and mentoring for the benefit of surgical trainees. Its embedded continuous close individualized mentoring can change the surgical training culture by initiating an assessment of surgical learning and skills right from the beginning of surgical training.

Phishing attacks are the threats that are ongoing in a campus and have become sophisticated as the time passes by. Target of phishing attacks are victims to affect their financial transactions and expose their personal information prone to risks. Social engineering techniques help the phishing attackers to gain and access the sensitive and personal information about a user. This may include personal details, username, password, financial details, etc. It has become very common to impersonate legitimate businesses, trick users by indulging them in business activities, and get their legitimate data as provided by them. Associative and classification algorithms can be extremely valuable in predicting phishing websites. It can give us replies about what are the most imperative cybercrime phishing site attributes and markers and how they identify with one another. WEKA tool is utilized for the usage of classifiers on an open dataset from NASA store. The inspiration driving this examination is to utilize data mining techniques and algorithms for the prediction motivation behind phishing sites and look at their viability as far as accuracy and errors. We evaluate and improve accuracy of predicting phishing websites and also reduce different types of errors, i.e., Mean Absolute Error (MAE), Relative Absolute Error (RAE), Root Relative Squared Error (RRSE), and Mean Squared Error (MSE), using cuckoo search algorithm as a feature selection technique, where random forest and BF-tree are used as classifiers.

Summary Reconstruction of posterior trunk defects can be challenging due to lack of reliable axial pattern flaps on back, poor elasticity of skin, large three-dimensional wound and a shortage of recipient vessels for microsurgical reconstruction. The idea by An L et al. “Design of a reliable surgery process for large back defects: Jigsaw puzzle flap concept based on free-style perforator” is interesting. However, we have some concerns with this type of coverage; which are presented in this letter to editor.

This paper presents a new boosted active-capacitor topology for wide tuning range voltage-controlled oscillators (VCO). A tuned inductor-based active-impedance-conversion circuit (LAIC) is used to multiply the capacitance of a capacitor bank and the negative-transconductance of LAIC in the proposed region of operation but without increasing losses. A boosted active-capacitor prototype in 65 nm CMOS process achieves a capacitance tuning ratio of 7.8 and a quality factor of higher than 20 across VCO's tuning range. An X-band VCO prototype with the proposed boosted active-capacitor achieves a 53 % measured fractional frequency tuning range and phase noise of -115 dBc/Hz at 1 MHz offset, resulting in an excellent figure-of-merit-with-tuning-range (FoMT) of -202.4 dBc/Hz.

This paper presents a triple-band voltage controlled-oscillator (VCO) with a new dual-path inductor. The change in inductance value of the proposed dual-path inductor is large while maintaining high Q, enabling to achieve low phase noise oscillation with octave frequency range. The inductances in the two modes of operation can be set independently, depending on the target frequencies. The inductance change is used as a coarse frequency tuning, while fine tuning is realized by a 2-bit capacitor bank with a small size varactor. As a proof of concept, a VCO in class-D biasing with the dual-path inductor has been implemented in a 65 nm CMOS process. The VCO achieves oscillation at three different frequency bands centered at 19, 28, and 36 GHz, while maintaining good phase noise and low power consumption. Measurement results show a peak figure of merit (FoM) of 185.7 dBc/Hz at 18.5 GHz, with 0.0875 mm2 (250 µm × 350 µm) area.

The theoretical danger of virus transmission during laparoscopic surgery (LS) via surgical smoke and laparoscopy gas has led to the formulation of many guidelines during the COVID-19 pandemic. This rapid scoping review of these guidelines was done to assess the quality of their evidence and appraise them for their impact on surgical services from the global south. A simple quality appraisal tool was constructed which can be used to evaluate rapidly emerging guidelines for evidence as well as for the needs of the global south. This rapid scoping review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews protocol. Electronic databases were searched with predefined strategy and retrieved papers were screened according to relevant criteria. A simple objective tool to assess the quality of rapidly emerging guidelines including evidence, methodology, ease, resource optimization, geography, and the economy was constructed. Twenty studies met the inclusion criteria. None of the guidelines qualified to be evidence-based clinical practice guidelines as the level of evidence was uniformly rated "low". A newly constructed tool showed good validation, reliability, and internal consistency. This rapid scoping review found two major research gaps: lack of systematic review of evidence during their development and insufficient weightage of their impact on surgical services from the global south. These significant issues were addressed by constructing a simple and more representative tool for evaluating rapidly emerging guidelines which also gives the rightful importance of their impact on surgical services from the global south.

Introduction Commonest cause of brachial plexus injury in adults is traction injury sustained in motorcycle accidents. This article reports the results of first 50 cases done in a tertiary referral center with a brief review of literature. Material and methods First 50 patients (46 male; 4 female, age from 12 to 45 years) with post traumatic brachial plexus palsy were included. There were 30 upper plexus and 20 pan plexus injuries, 27 had preganglionic and 23 postganglionic injury. Neurolysis was done in 19 patients and various combination of nerve transfer in 31. Mean follow-up period was 13.98 months. Results – Over all shoulder abduction was good in 10 patients, fair in 32 and poor in 8. Elbow flexion was good in 19 patients, fair in 18 and poor in 13 patients. Conclusion The upper plexus and partial injuries have a good outcome in a majority of cases, while the results in global palsy are far from satisfactory.

The worldwide COVID-19 pandemic has resulted in complete stoppage of elective surgery in most countries, which has created a huge backlog of waiting patients. This invited editorial comments on the current challenge of restarting elective surgery during/after COVID-19 pandemic.

This paper presents a high-efficiency neutralized continuous class-F (CCF) CMOS power amplifier (PA) design technique for millimeter-wave (mmW) 5G mobile communications. A parasitic-aware tuned-load with a high-order harmonic-resonance network is proposed to shape the current and voltage waveforms for the CCF PA. At mmW frequencies, the gate-drain capacitance ( $C_{\mathrm {gd}}$ ) creates adverse capacitive loading on harmonic-tuned output load networks. As a result, a CCF PA suffers from compromised power efficiency. To address this, we integrate a transformer with a tunable coupling coefficient between gate-drain of the power-device. This proposed technique allows accurate neutralization of $C_{\mathrm {gd}}$ , reducing detrimental loading effect on harmonic-tuned load while enhancing power efficiency and stability. We fabricated a CCF PA in 65-nm CMOS technology achieving >40% power-added efficiency (PAE) over 33.3% fractional bandwidth (25–35 GHz) and 46.4% peak PAE at 29 GHz. The measured peak saturated output power ( $P_{o,\mathrm {sat}}$ ) is 14.8 dBm at 30 GHz. The PA is tested with 64-quadrature-amplitude-modulated signal at a data rate of 1.5 Gb/s. Under this test setup, the PA achieves modulated PAE of 26%/24%/21.4% and average output power ( $P_{o,\mathrm {avg}}$ ) of 9.2/8.8/8.6 dBm at 28, 32, and 34 GHz, respectively, while maintaining better than −25 dB of error vector magnitude and −27 dBc of adjacent channel leakage ratio. To the authors’ knowledge, this design presents one of the highest reported PAEs among mmW CMOS PAs.

Introduction –Loss of radial nerve function leads to severe weakness of grip and tendon transfer is considered the standard treatment. However; there is continuing debate as to the best combination of tendon transfers in such patients. The aim of this study is to present the results of Flexor carpi radialis (FCR) combination of triple tendon transfer for radial nerve palsy. Material and methods It is a retrospective study conducted over 15 years. 58 patients of with irreversible radial nerve paralysis were included. Brands transfer was performed in all cases. The ranges of movement of the wrist, fingers and thumb were evaluated pre-operatively and postoperatively using Bincaz scale. Results Total 58 patients were included in the study, 47 were male and 11 female patients with mean age of 35.27 years. Causes of radial nerve palsy were comminuted open humeral fracture (n = 42), penetrating injuries (n = 13) and brachial plexus palsy (n = 3). Mean duration of palsy was 9.37 months (range = 9–12 months). The mean post-operative follow-up was 10 (range = 2–15) years. On evaluation with the Bincaz score, 6 patients had excellent results, 49 patients had good results, and 3 patients had poor results. There were 3 complications in 5 patients, including radial deviation of wrist, inadequate abduction of thumb and restricted wrist flexion. 55 patients (94.82%) were able to return to their normal daily work after ∼8 weeks. Conclusions - Tendon transfer is a standard procedure for radial nerve palsy but potential advantage of one method over the other has not been demonstrated. Brand’s transfer results in an acceptable restoration of hand function.

BackgroundA simple and efficient exercise test possible in a small space is welcome to supplement 6 min walk test (6MWT) that demands a 100 feet corridor to perform.MethodsThe proposed two chair test (2CT) makes a person to sit and move five times between two chairs placed face to face at 5 feet apart and note the changes in pulse-rate (PR) and arterial oxygen saturation (SpO2) at every 10 s for 2 min after that. Comparison of the post-exercise measurements (PR and SpO2) with a repeat performance in same patients was done for reproducibility and doing the same after 6MWT and 2CT in another set of patients was meant for for acceptability. The statistical analysis was made on moment to moment change, mean maximal difference and mean cumulative difference for the measurements using p value, z-score, r value and principal component analysis (PCA).FindingsA total of 40 and 60 volunteers were included for testing reproducibility and acceptability. On both the sets, the difference in most of comparisons between the measured variable (PR and SpO2) showed the p values remaining insignificant (>0.05), and z-score being 0.9). Furthermore, the PCA shows complete overlapping. The post-exercise changes did not corelate the walking distance in 6MWT.InterpretationThe proposed 2CT demands small space and appears reproducible and comparable with 6MWT in terms of its post-exercise impact on PR and SpO2. This novel test also appears more of cardiopulmonary reserve specific.

Wireless interconnects using near-field inductive coupling (NFIC) enables contactless vertical communications necessary for the design of energy efficient and robust 3-D manycore systems. However, the achievable performance, energy efficiency, bandwidth, and associated area overhead of NFICs are intertwined imposing significant design challenges and tradeoffs to explore the optimum link configuration. To address these challenges, in this paper, we propose a holistic design approach for exploring energy-efficient NFICs and target to exploit the benefits of the NFICs in the context of efficient and reliable network-on-chip (NoC) design. The proposed design framework employs statistical link analysis to select optimum NFIC-link configuration and is significantly more efficient in terms of energy efficiency and area overhead compared to the state-of-the-art counterparts. We demonstrate that 3-D NoCs incorporating NFIC-enabled links outperform through-silicon-via (TSV) counterparts. In addition, the overall reliability of TSV- and NFIC-enabled hybrid 3-D NoC is significantly better than only TSV-based NoCs in order to counteract the electromigration and workload-induced stress challenges.

Synthetic non-absorbable meshes are routinely used in hernia surgery for clean cases but are avoided in the case of clean-contaminated or contaminated hernia or dirty cases to minimize the risk of infection. The present study was conducted to evaluate the outcome of polypropylene mesh in the settings of bowel resection performed for strangulated hernias of the abdominal wall. This prospective observational study was conducted in the Department of Surgery of a teaching hospital in central India between 1st March 2015 and 31st Aug 2017. Adult patients > 18 years age, with abdominal wall hernias, presenting with strangulation, and requiring resection and anastomosis for gangrenous bowel were included in the study. Outcomes noted were wound infection, morbidity and mortality, need for the removal of the mesh, and recurrence of the hernia. 30 (22 men and 8 women) patients with strangulated hernias underwent emergency surgery with resection of gangrenous bowel and anastomosis. The 30 cases included 21 inguinal, seven incisional, one femoral and one umbilical hernia. 12 of the 30 cases having gross contamination of the operative wound due to perforated gangrenous bowel were classified as ‘dirty’; while the remaining 18 cases with non-perforated gangrenous herniating bowel were classified as ‘contaminated’. Wound infection occurred in 8/30 patients (26.67%); but these healed with antibiotics and dressing. Mesh removal was not required in any patient during entire study period. Two recurrences (6.7%; one inguinal and one incisional hernia) were observed. There was no mortality. The use of polypropylene mesh for contaminated and dirty strangulated hernias is effective and safe, with acceptable morbidity and good short-term results.

Acontractile bladder is very common after spinal cord injury which may lead to morbidity and even renal failure. The standard treatment options to facilitate bladder emptying include clean intermittent catheterization (CIC) or indwelling catheter (IC), which is also not free of complications. The purpose of this article is to review the treatment options for acontractile bladder; especially feasibility and effectiveness of muscle wrap around urinary bladder to improve voluntary voiding. We performed Rectus Abdominis Detrusor Myoplasty (RADM) in 5 patients of acontractile bladder following spinal cord injury. Postoperatively, all 5 patients could void urine immediately after removal of per-urethral catheter after 3 weeks. After RADM, Post Void Residual Volume, Bladder Contractility Index, Detrusor Pressure and urine flow rate (V-max) improved significantly (p < 0.05) in all patients. Rectus Abdominis Detrusor Myoplasty is a promising surgical option in a patient having hypocontractile or acontractile urinary bladder. In this mini review RADM and other treatment options for acontractile bladder have been reviewed.

In this paper, a high-efficiency frequency-reconfigurable CMOS power amplifier (PA) design technique is presented at 24 and 28 GHz using integrated tunable neutralization and matching networks. To cope with the adverse effects of gate–drain capacitance ( $C_{\mathrm {gd}}$ ) in millimeter-wave (mm-wave) CMOS PAs in deep-submicrometer technologies, we propose a reconfigurable coupling-coefficient-based transformer. This technique provides optimum neutralization of $C_{\mathrm {gd}}$ in a common-source configuration, while enabling tunable neutralization in a frequency reconfigurable PA. Furthermore, to reconfigure the PA’s input and output matching networks, a low-loss frequency-reconfigurable matching topology using a switched substrate-shield inductor is proposed. The adopted matching network addresses the high loss in a conventional frequency reconfigurable matching approach, while facilitating high efficiency in the proposed PA design. Using the proposed techniques, a class-AB PA is fabricated in a 65-nm CMOS technology. This prototype achieves measured saturated power-added efficiency (PAEsat) of 42.6%, saturated output power ( $P_{o,\mathrm {sat}}$ ) of 14.7 dBm at 24 GHz, and 40.1% PAEsat, and 14.4 dBm $P_{o,\mathrm {sat}}$ at 28 GHz while occupying an active area of only 0.11 mm2. At 24 and 28 GHz, the PA is tested under 16 and 64-quadrature amplitude modulation (QAM) signals with 250 MHz of channel BW. The PA achieves modulated PAE of 15.2%/14.1%, error vector magnitude of −26.4/−26.6 dB, and adjacent channel leakage ratio of −30/−32 dBc at an average output power of 7.1/7 dBm for a 64-QAM signal with 250-MHz BW at 24 and 28 GHz, respectively. To the best of the author’s knowledge, the design presents one of the highest PAEs among mm-wave CMOS PAs reported to date, while it also supports multiband operation.