ABSTRACTS
Use of autologous platelet rich fibrin in minimally invasive treatment of perianal abscess
Anoop vasudevan pillai, Riju Ramachandran

Introduction:
Fistula in ano, once called “The Royal Disease” has been described from the time of Hippocrates. The earliest successful treatment described in literature is for King Louis XIV. This common ano-rectal disorder still continues to cause significant discomfort for patients. The traditional management of perianal abscess is a cruciate incision & drainage, resulting in morbidity. The wound takes months to heal with chronic pain, scarring and discomfort. Literature reports fistula formation in 35-50% following treatment of perianal abscess.

Methodology:
This is a case series of 5 patients (3males & 2females) who presented with perianal abscess. MRI done showed intersphincteric tract in 3 patients, horse shoe abscess in one and trans-sphincteric collection in one patient. Under anesthesia, a 3mm incision was placed at the region of maximum induration. Methylene blue+ hydrogen peroxide was injected into the cavity and internal opening was visualized. A 3mm fistuloscope was inserted into the cavity through the incision and the entire cavity was visualized upto the internal opening. All slough and unhealthy tissue was removed and the walls of the cavity fulgurated(Video). The internal opening was then closed using 2-0 vicryl in a “figure of 8” pattern. Horizontal centrifugation-Platelet rich fibrin (H-PRF) was placed into the treated cavity. Patients were discharged next day and followed up for 3 months postoperatively. All patients reported minimal pain for 2-3 days and complete cessation of discharge by 2nd week without progression to fistula.

Discussion:
Conventional treatment of acute perianal abscess is a large cruciate incision at the region of maximum fluctuation and breaking the septa within the abscess cavity. This may cause damage of the sensory nerves supplying the perianal region. Use of minimally invasive methods prevents this disruption in the anatomy of the region reducing morbidity and hastens healing. Escherichia Coli and skin commensals like Staphylococcus aureus are the most common isolates from a perianal abscess. H-PRF has tissue factors that can accelerate wound healing and also has an antimicrobial effect against E.Coli and staphylococcus.

Conclusion:
Minimally Invasive Treatment of AnoRectal Abscess with H-PRF instillation helps in efficient, early, cosmetic and cost-effective healing of this painful condition.
A large section of the population in low resource or rural settings can be benefitted by this procedure with minimal modification to the operative technique.

Machine Learning based mortality prediction model for COVID-19 patients admitted in a tertiary care hospital, New Delhi.
Sanjeev P E Khanth, Manukumar Shetty, Vandana Roy, Lalit Gupta

Introduction: SARS corona virus 2 is found to be responsible for the COVID-19 pandemic. It caused severe acute respiratory illness with a high mortality rate. This deadly disease infected around 4 crore population in India and costs around 5.2 lakh deaths. This enveloped RNA virus is transmitted from the aerosols of infected patients. The virus attaches to the host with its spike protein to ACE2 receptors of lung epithelial cells and begins its replication. The symptoms can range from mild severity like sore throat, fever, and cough to severe category like pneumonia and ARDS which leads to increased mortality. There is a huge interindividual variation in response to the virus. It is often unpredictable to decide the course of the disease. Comorbid conditions like diabetes, hypertension, and major organ failures have been known to increase the severity of the disease. Therefore, the aim of this study was to apply an interpretative Artificial intelligence algorithm for identifying the main features which decide the course of the disease.

Methods: It is an observational study of hospitalized COVID-19 patients. 1181 RT-PCR confirmed COVID-19 patients (both alive and dead) data was used to predict the factors responsible for the course of the disease using a ML model. Twelve features were used to train [75%] and test [25%] the datasets using logistic regression and 2 machine learning methods [ XG Boost, Random Forest (RF)]. AI model interpretability was analyzed using a SHAP summary plot.

Results: Among those patients analyzed using different AI models the Random Forest algorithms had higher sensitivity (83%) and accuracy (81%) on test datasets. Among the 12 features, AI interpretable SHAP summary plot showed age, kidney disease, heart disease, diabetes, male sex, and hypertension among the top rank features which have a high impact on the outcome of the disease (death).

Conclusions: We observed that AI interpretable model ranks the major factors that are contributing to the death of the patient and is able to predict the key ranking features with 83% sensitivity. Higher the age higher the risk of mortality. It also predicts that patients with heart disease, kidney disease, and diabetes are at higher risk for mortality. This model can be implemented in all healthcare facilities for risk stratification in COVID-19 patients. It helps in the proper management and taking necessary precautions beforehand.

An Innovative Surgical Method to Operate the Zygomatico-maxillary-orbital Complex in the Absence of Intraoperative Computer Tomography or Intraoperative Navigation using Novel Zygoma Analysis and Virtual Surgical Planning software
Prem Kumar Rathod, Rahul Yadav

Introduction: Post-traumatic residual deformities of the Zygomaticomaxillary orbital complex (ZMOC) are challenging to operate on and require intraoperative CT or navigation. Two major reasons for this are 1) Such devices costs crores of rupees, and 2) there is no method to quantify the amount of asymmetry of ZMOC. The purpose is to evaluate the surgical outcomes in the absence of intraoperative CT or Navigation using innovative zygoma analysis software planning and novel surgical protocol in operating these patients.
Methodology: In this prospective study, a Zygoma analysis software planning was designed. Unilateral post-traumatic residual deformity of ZMOC (>10 weeks) was included. The uninjured side of the face was used to mirror, measure, and formulate the surgical plan after comparison with the injured side using this virtual surgical software planning. The primary objective was the symmetry and stability of ZMOC. Secondary outcome variables were changes in orbital volume, diplopia, ocular motility, mouth opening, and patient satisfaction. P < .05 was considered statistically significant. Measurements were assessed on affected and unaffected sides preoperatively, postoperatively, and six months postoperatively using MIMICS. Paired t-test was used to compare the continuous variables. The continuous variable changes with time were evaluated using repeated measure ANOVA, followed by multiple comparisons using the Bonferroni test. The McNemar test assessed the changes within the categorical variable. P <.05 was considered statistically significant.
Results: Ten patients were included (mean age = 29.2 ± 9.97 years; male:female = 9:1; right:left = 4:6). The mean duration of the residual deformity was 8.02±7.21 months. There was an improvement in the symmetry, and all parameters remained stable when measured at six months postoperatively. Patients reported a median satisfaction score of 4 out of 5. There was a significant improvement in orbital volume(P = .001) and mouth opening(P = .014).
Discussion: The zygoma analysis virtual surgical planning software protocol results are comparable to those with intraoperative CT and navigation, thus proving a cost-effective innovation. These results proved to be stable over at least a 6-month follow-up period. Measuring the asymmetry of ZMOC and formulating a surgical plan becomes easy with zygoma analysis. This method is a solution in decision-making for treating bilateral residual deformities of the midface, aesthetic malar augmentation, aesthetic malar reduction cases, bilateral fractures of zygomaticomaxillary complex, etc. It is now possible to operate such cases in rural settings where intraoperative CT or intraoperative navigation facilities may not be available.

Perceived impact of trauma audit filters on trauma care in a tertiary care hospital: a qualitative analysis
Jyothis Greeshma Abraham, Anurag Mishra

Trauma, external injury in combination with the body’s response, is a major threat to global population. Trauma care is time sensitive, early identification of fatal injuries and conditions are very essential for survival and care of the person. Quality of trauma care remains a big concern in LMICs. Trauma has also been recognised by SDG 3 and targets to reduce trauma burden.

We at Maulana Azad Medical College (MAMC), New Delhi conducted a survey in a hybrid setup (in-person, phone call) with Trauma Audit Board (TAB) members associated with another ongoing Project on Trauma Filters at MAMC.

AIM: To know, the creation of TAB has been useful or burden in patient, hospital management or with Physicians etc.

Composition of TAB- Medical Director of the hospital, Heads of Emergency, Anaesthesia, Radiology, Orthopaedics, Surgery etc., and Investigators associated with the project.

Method of Survey:
A semi-quantitative questionnaire to record their feedback and impression via means using hybrid setup as per the clinician’s convenience, about TAB and their opinion about such audit board meetings, it’s impact on Trauma Care and other hospital-based problems.

Link to questionnaire:
https://docs.google.com/forms/d/e/1FAIpQLSdx8qT6LKZVYTbogCbBcRGRN8rK0lpcZ0-126C0Cus-Fw6twg/viewform?usp=sf_link

Results:
Each clinician associated with project was 3.81 years. Only the MD of the hospital changed after his tenure of 2 years. Board was intact since its inception from 2017.

Clinicians noted a mean average of 7.27 on a scale of 1 to 10, after the implementation of TAB meetings.

To exemplify the scale, 2-3 popular responses as follows:
• Monitoring of Vitals like GCS, Respiratory rate, Blood pressure were noted which were earlier missed.
• Ultrasound machines were setup near patient bedside in Casualty.
• Trauma patients were managed in a more systematic way without wastage of time in inter departmental referrals.
• More responsible, more vigilant and aware as data were recorded and cases were studied in audit meetings

Other than trauma care an impact was seen in overall hospital functioning with inter-departmental co-ordination, more productivity in patient management were seen even during Covid waves with easy referrals with just an update on WhatsApp group which were initially created for the board meetings.
Many Clinicians even realised an impact on themselves with change in behavioural, attitudinal and inter-personnel skills, with such meetings they could learn from cases and functioning of other departments which would otherwise be missed. On a scale ranging from 1 to 10 when asked about how much of a burden it was attending TAB meetings on an average only 2.36% of a burden on a monthly basis which is quite negligible, as more clinicians looked upon learning more things for better patient care. Recommendation to other Institutes about such TAB meetings was a definite Yes.

Conclusion:
Findings suggest a significant difference in healthcare management in the hospital.
Results and opinions suggest such meetings should be more periodically conducted and should be recognised as part of Hospital standardization.

An innovative surgical method to operate zygomatico-maxillary-orbital complex in the absence of intraoperative computer tomography or intraoperative navigation using novel zygoma analysis and virtual surgical planning software
Dr. Prem Kumar Rathod, Dr. Rahul Yadav

Introduction:
Post-traumatic residual deformities of the Zygomaticomaxillary orbital complex (ZMOC) are challenging to operate on and may require intraoperative CT or navigation. Two major reasons for this are 1) Such devices costs crores of rupees, and 2) there is no method to quantify the amount of asymmetry of ZMOC. The purpose is to evaluate the surgical outcomes in the absence of intraoperative CT or Navigation using innovative zygoma analysis software planning and novel surgical protocol in operating these patients.

Methodology:
In this prospective study, a Zygoma analysis software planning was designed. Unilateral post-traumatic residual deformity of ZMOC (>10 weeks) was included. The uninjured side of the face was used to mirror, measure, and formulate the surgical plan after comparison with the injured side using this virtual surgical software planning. The primary objective was the symmetry and stability of ZMOC. Secondary outcome variables were changes in orbital volume, diplopia, ocular motility, mouth opening, and patient satisfaction. P < .05 was considered statistically significant. Measurements were assessed on affected and unaffected sides preoperatively, postoperatively, and six months postoperatively (Figure 1 showing measurements of zygoma analysis and virtual surgical planning). Paired t-test was used to compare the continuous variables. The continuous variable changes with time were evaluated using repeated measure ANOVA, followed by multiple comparisons using the Bonferroni test. The McNemar test assessed the changes within the categorical variable. P <.05 was considered statistically significant.

Results:
Thirteen patients were included (mean age = 28.38 ± 9.54 years; male:female = 5.5:1; left:right = 7:5). The mean duration of the residual deformity was 6.66±6.43 months. There was an improvement in the symmetry, and all parameters remained stable when measured at six months postoperatively. Patients reported a median satisfaction score of 4 out of 5. There was a significant improvement in orbital volume(P = .001) and mouth opening(P = .014).

Discussion:
The zygoma analysis virtual surgical planning software protocol results are comparable to those with intraoperative CT and navigation, thus proving a cost-effective innovation. These results proved to be stable over at least a 6-month follow-up period. Measuring the asymmetry of ZMOC and formulating a surgical plan becomes easy with zygoma analysis and virtual surgical planning. This method is a solution in decision-making for treating bilateral residual deformities of the midface, aesthetic malar augmentation, aesthetic malar reduction cases, bilateral fractures of zygomaticomaxillary complex, etc. It is now possible to operate such cases in settings where intraoperative CT or intraoperative navigation facilities may not be available.

An innovative surgical method to operate the zygomatico-maxillary-orbital complex in the absence of intraoperative computer tomography or intraoperative navigation using novel zygoma analysis and virtual surgical planning software
Prem K Rathod, Rahul Yadav, Ongkila Bhutia, Ajoy Roychoudhury, Krushna Bhatt

Introduction:
Post-traumatic residual deformities of the Zygomaticomaxillary orbital complex (ZMOC) are challenging to operate on and may require intraoperative CT or navigation. Two major reasons for this are 1) Such devices costs crores of rupees, and 2) there is no method to quantify the amount of asymmetry of ZMOC. The purpose is to evaluate the surgical outcomes in the absence of intraoperative CT or Navigation using innovative zygoma analysis software planning and novel surgical protocol in operating these patients.

Methodology:
In this prospective study, a Zygoma analysis software planning was designed. Unilateral post-traumatic residual deformity of ZMOC (>10 weeks) was included. The uninjured side of the face was used to mirror, measure, and formulate the surgical plan after comparison with the injured side using this virtual surgical software planning. The primary objective was the symmetry and stability of ZMOC. Secondary outcome variables were changes in orbital volume, diplopia, ocular motility, mouth opening, and patient satisfaction. P < .05 was considered statistically significant. Measurements were assessed on affected and unaffected sides preoperatively, postoperatively, and six months postoperatively (Figure 1 shows measurements of zygoma analysis and virtual surgical planning). Paired t-test was used to compare the continuous variables. The continuous variable changes with time were evaluated using repeated measure ANOVA, followed by multiple comparisons using the Bonferroni test. The McNemar test assessed the changes within the categorical variable. P <.05 was considered statistically significant.

Results:
Thirteen patients were included (mean age = 28.38 ± 9.54 years; male:female = 5.5:1; left:right = 7:5). The mean duration of the residual deformity was 6.66±6.43 months. There was an improvement in the symmetry, and all parameters remained stable when measured at six months postoperatively. Patients reported a median satisfaction score of 4 out of 5. There was a significant improvement in orbital volume(P = .001) and mouth opening(P = .014).

Discussion:
The zygoma analysis virtual surgical planning software protocol results are comparable to those with intraoperative CT and navigation, thus proving a cost-effective innovation. These results proved to be stable over at least a 6-month follow-up period. Measuring the asymmetry of ZMOC and formulating a surgical plan becomes easy with zygoma analysis. This method is a solution in decision-making for treating bilateral residual deformities of the midface, aesthetic malar augmentation, aesthetic malar reduction cases, bilateral fractures of the zygomatico-maxillary-orbital complex, etc. It is now possible to operate and provide predictable outcomes in these cases when intraoperative CT or intraoperative navigation facilities may not be available.

Carica papaya fruit in the management of chronic non healing ulcer wounds
Divyata A Vasa, Tapan A Shah, Mukesh S Suvera, Jaimin D Shah, Yagnik N Katara

Introduction
The concept of using papaya as a debriding agent came from the use of papaya latex as a debriding agent in Ayurvedic practice. Carica papaya contains proteolytic enzymes namely papain and chymopapain in the fruit, latex, leaves, stems, and roots.It contains antioxidants like caffeic acid, myricetin, alphatocopherol and kempferol. Its proteolytic action is marked in acid, alkaline, and neutral solutions and has a digestive power at a wide range of temperatures and pH. This study aims to deduce the role of Carica papaya pulp in the management of chronic non healing ulcer wounds. Method: The study was, open-labeled interventional study carried out for 18 months in the inpatient department of General Surgery at L.G. Hospital. All patients with chronic non-healing ulcer wounds including diabetic foot ulcers, who consented to participate in the study were included. Patients with pre-existing cardiac conditions or immunocompromised states, patients younger than 15years of age, mentally challenged patients and severely anemic (Hb<6gm/dl) patients were excluded.
Detailed history of the enrolled patients was taken and details like age, history of allergies and atopic nature, and any significant past surgical and medical history were noted. Local examination of the wound was done, the presence of slough, type of discharge, and nature of granulation tissue at the base of the wound.
Patients received papaya dressing – placing autoclaved dressing gauze containing well-cleaned, peeled, and quarter sliced, steam disinfected raw papaya on the wound bed which remained in situ for 24 hours. The dressing was removed after 24hours and the condition of the wound was noted. The dressing was continued in both groups till the presence of healthy granulation tissue; serous non–foul smelling discharge; and complete absence of slough at the center of the wound. Number of days for which dressing was required before achieving the end point was noted. Results
The study included 28 patients: 26 males, 2 females from ages 18 to 65 years (mean age 51 years).
The average day on which health granulation appeared was 3rd day (mean 2.8 SD 0.93).
The average end point of therapy was 7th day (mean 7.6, SD 1.7). Mean hemoglobin at the start and end of therapy was 11.10g/dl (SD 2.14) and 10.7g/dl (SD 1.97) respectively, showing relatively less blood loss.
10 (35.7%) of the patients were diabetics.
Patients reacted to the visual analog scale (with 1 being mild bearable and 10 being the severe unbearable pain experienced) with moderate bearable pain (mean 5 SD 1.4).Conclusion:In India, with the average cost of chronic ulcer wound care being USD1956/Patient and per capita income being USD 2191/Person, the financial burden of management of chronic non-healing ulcer wounds is overwhelming. Current management methods include betadine with H2O2, silver-based dressing materials, surgical debridement, enzyme extracts, etc. Dressing with Carica papaya significantly reduces the overall cost burden owing to its easy availability, reduced hospital stay and visits. The overall patient compliance is better owing to the reduced cost of treatment and reduced/no need for surgical debridement following papaya dressing.

The Buddy System: An initiative to slow down the antibiotic misuse
Taranjot Kaur, Ishaan Wazir, Alia Naaz

The dearth of new antibiotics and rising antimicrobial resistance (AMR) is a global challenge. With almost 700,000 people losing the battle to AMR every year and another 10 million projected to die from it by 2050, AMR is killing more people than cancer and road traffic accidents combined, in India.

Easy availability of drugs, prevailing misinformation, and the absence of proper guidelines for public use have resulted in irrational antibiotic consumption. Our innovation – the “Buddy System” is in no way an alternative to these antibiotics, but, it does have the capability to slow down this process and buy us sufficient time to make amends.

AMR has multifactorial causation, however, but our focus, here, is on the patient aspect (mainly self-diagnosis and treatment). With a population of 1.38 billion, it is extremely tough to impose the regulations, so our best bet is to increase awareness. We aim to educate the general public about the rising trends of AMR and judicial use of antibiotics, enabling them to make prudent and informed choices, resulting in lesser antibiotic abuse and a flattened curve of AMR.

The Buddy System uses a hybrid of the orthodox concept of PHONE TREES and modern tactics. Our vision is to form a network, wherein interested medical students (Buddy officers) will be allotted one school each, where they will make a team of students and educate them. These school students will further train their acquaintances, relatives, and the general public, expanding our reach exponentially.

We have planned our Buddy System from scratch and have formulated a detailed plan that addresses the financial, structural, and therapeutic hurdles, including some major challenges like the lack of consistency, standardisation of data, large population size, monitoring, and feedback.

Our intervention is unique because the person at the top of this hierarchy will be a trained medical officer and hence, the data will be evidence-backed and medically sound. Further, we plan to use our biggest challenge, i.e., huge population, as our mighty asset to expand our reach. All we need is a roadmap to create a working model by reallocating and recruiting the general public in this machinery to create this self-sustaining, community-based model of preventive health care. The sole use of trained manpower makes this project very cost-sufficient and feasible.

The most critical part, however, will be to find the source of continuous motivation for all, which we know would not be easy. We are betting on our convincing skills to try and rope in the local authorities and the educational institutes. We also hope that once we will set up a basic working model, it will be easier to get good backup from our government as well as the international agencies.

Millions of dollars are being invested globally to develop antibiotics; however, our intervention provides a much cheaper and time-effective alternative. Feeding the public correct and unadulterated information and making them realise how their everyday choices will have a much wider impact than they think, will help us win the battle against AMR.

SOCH – India (Students’ Orbit for Collaborative Healthcare – India)
Students' Orbit for Collaborative Healthcare - India

A study reported that 25 Indian medical institutions published more than 100 articles in a year, accounting for 40.3% of the country’s total research output between 2005 and 2014, while 332 medical colleges in the country had no publications. There is a need to encourage medical students to learn about evidence-based medicine. It helps achieve the Triple Aim’s objectives of improved quality, improved patient satisfaction, and reduced costs by influencing treatment, healthcare management and policies. However, there currently exist several lacunae in the Indian medical curriculum to involve understandings of evidence-based medicine and research in its formal training programmes. Local, regional & global collaborations can help promote research, leadership, and capacity building between medical students & health professionals. SOCH – India (Students’ Orbit for Collaborative Healthcare – India) derived from the Hindi word ‘SOCH’ which means ‘a thought / an idea’ is one of India’s first medical student-led national research collaborative networks (SCRNs). It aims to provide Indian medical students with unique applied academic training experiences, as observed in UK trainee-led collaborative study models like STARSurg.

The structure of the collaborative network involves:
1. Senior mentor guidance: Higher degrees of credibility, scientific validity, efficient methodology, and impact are made possible by faculty representatives serving as the collaborative network’s guides.
2. Core Support Team: Student members of the collaborative serve as the study’s coordinators, advancing the collaborative’s goals and objectives. They are grouped into a steering committee, operations committee, research capacity building committee, writing group, statistics group and data validators.
3. Regional, State and Local Leads: Students from different regions of the country collaborate to provide data for improved generalisability.
4. Authorship: It is inclusive and stated before participation in the study. Under a single collaborative network, all members can pose as citable authors.

There are currently 606 medical colleges offering 92115 seats for medical aspirants, according to the National Medical Commission (NMC) India, the regulating body in charge of medical education and professionals. A significant proportion of this future healthcare workforce is yet to participate in research. The most common barriers medical students face to engaging in research during all years of study include lack of formal training, inadequate knowledge, time commitments, a lack of opportunities, and the absence of research culture at their universities. SCRNs can help overcome these obstacles and promote research among medical students. Furthermore, the quality and quantity of research can be potentially increased with such collaborative research models. Due to regional diversity, collaborative networks allow a multi-centric approach study with high numbers of patients in a rapid time frame. They strengthen the principles of repeatability, validity, consistency, and timely reporting of study results. SCRNs have benefits by making research more accessible, increasing time efficiency with collective training, and cultivating research into clinical practices.

As SOCH-India expands opportunities for medical students across India, a low- and middle-income country with limited resources, it can potentiate an increase in the country’s research output. It paves the long-term path forward by promoting the use of evidence-based medicine in clinical practice, therefore, enhancing the healthcare system.

Need of an Autopsy Kit in resource limited settings
Mrinal Patnaik, Arneet Arora

Introduction: Autopsy is a primary source of anatomical and pathological research in human body. The instruments required in autopsy depend upon the degree of detail required in dissection and the method of autopsy used. Availability of surgical instruments, in adequate quantity or variety, their logistics to the site of autopsy is a challenge.
Methodology: The question was what decisions are made regarding supplies and sterile instruments in autopsies. Systematic analysis of literature was done where research papers dedicated to Operating room inventory, field necropsy procedures and surgical kits for different parts of human body and manuals and/or guidelines for autopsies were reviewed.
Results: The number, type and cost of instruments required in autopsy depend upon the method of dissection and type of autopsy performed, viz. Minimally Invasive Autopsy (MIA), Partial Autopsy, Complete Autopsy, Complete Diagnostic Autopsy (CDA) or Virtual autopsy, decided on technical grounds, feasibility, consent and the mandate of the authority requesting the autopsy.
Discussion: A comprehensive cost effective autopsy kit with necessary inventory of commonly used instruments could be promptly made available upon requirement with essential equipments and additional instruments as needed for special circumstances to satisfy a balanced outcome.

Device for non-invasive detection of meconium stained amniotic fluid
Purushotham Tanjeri, E Geethanjali

Need of an innovation: Meconium passes after the baby’s delivery, but about 10-20% of the fetus may release inside the uterus. And its only recognized after the membrane ruptures and the amniotic fluid starts coming out. But the aspiration of meconium can occur even before the obstetrician recognizes passage, leading to mortality and morbidity.
Currently, there is no direct measurement system that could detect the presence of meconium without rupture of the membrane. The fetal heart is not a reliable indicator of taking the sole obstetric decision, and it could change for several other reasons. With this limitation, we are introducing a new exclusive, portable and non-invasive device for detecting the passage of meconium before the rupture of membranes and giving the status of meconium information to the obstetrician. It provides better management for clinicians to avoid neonatal complications with our propriety algorithm using the properties of meconium. It works based on optoelectronics.
Utility, Impact, and cost-effectiveness of the proposed innovation: This device builds based on microcontrollers (MC), Photodiodes(PD’s), LEDs (chosen based on experiments – which will penetrate and identify) and flexible silicone material for adhesive to the skin. The propriety software is built to control accurately and interpret the mother and newborn signals to alarm the individual if any abnormality is found in the amniotic fluid. The microcontroller will operate the amount of light to be sent according to the skin tone [skin color meter], and PD will detect the presence of meconium by sending photons to the tissue layers till the amniotic fluid. The Present innovation will fill the unmet need in identification of meconium before rupture of membrane. It will create impact more in resource limited settings where resuscitation facilitation and expertise is less. Helpful for the doctors who can rule out patient from meconium stained and triage them for better care and even can refer them to higher healthcare center based on assessment of the mother condition. Still product needs more validation from different clinical data and processed with multiple skin tones to accurately measure the meconium presence and stage of meconium grade. We partnered with multiple experts to disentangle the obstacle and get the more evidence-based product by iterating differential experiments. This product exclusively works for meconium detection and guides them for timely clinical intervention. To get remote expert opinions and operate in the deep-rooted rural areas, it comes with cloud monitoring tool to update the information in real-time to the nearest hospital by taking necessary precautions beforehand. We aim to deliver the product less than the average smartphone price and bringing to all deserved clinical settings.

A Novel Stethoscope In COVID 19 Times
Prachi Agrawal

Need of an innovation: In the era of the ongoing pandemic, the existing stethoscope has a lot of limitations to its use. They are indispensable part of patient care; however the binaural stethoscope is practically impossible to use in the PPE while digital stethoscopes are expensive, need expertise and are not easily available in a resource-limited set-up. With this innovation we seek to offer novel solution to this problem. We devised a portable digital stethoscope that can record auscultatory sounds without the need for an earpiece, simultaneously offering the advantage of recording and reproducing the same with the help of a (1) stethoscope, (2) silicone tubing, (3) earphones with a microphone and 3.5 mm stereo plug and (4) mobile phone with a sound recording function. We removed the earpiece, attached a silicone tube of 5 cm length and 6mm inner diameter to it and inserted a condenser microphone on the other end of the tube to ensure a proper seal. The 3.5mm stereo plug on the other end of the earphones was connected to the mobile, thus facilitating the recording of the auscultatory sounds. This stethoscope can be used for the clinical assessment of COVID-19-infected patients with multiple comorbities needing clinical evaluation of their cardiac and respiratory function thus enabling better patient assessment and care. This innovation has its utility in all domains of medical care be it the operating room, intensive care or patients needing post-surgical care. This small modification has wide implications, is cost effective and has its utility in all setups of medical care. Because it is rightly said, this global pandemic is a war, and small inventions and modification like these can make a big difference.

Explainable AI decision model for ECG data of cardiac disorders
Dikshant Sagar, Atul Anand, Tushar Kadian, Manu K Shetty, Anubha Gupta

Need of an innovation: Diagnosing heart diseases via an efficient AI model on ECG signals which can save considerable time for cardiologists resulting in effective triage at peripheral levels, and effective referral service that can save patients’ lives.

Novelty: Our study is among the first to develop AI models to diagnose cardiac disorders using ECG along with the interpretability of the AI model. We have benchmarked the performance of the recent Deep Learning architectures for the detection of cardiac disorders on a large ECG dataset, PTB-XL, that is publicly available. We have proposed our custom-designed CNN architecture (DL model) and compared its performance with these state-of-the-art methods. In order to test the generalizability of our proposed best performing DL model, we have assessed its performance on another ECG dataset of arrhythmia patients.

Utility and Impact: Our AI model can help non-cardiologists in easy diagnosis and triage of patients with chest pain and other symptoms as a screening system for cardiovascular disorders. Moreover, our model exhibits the explainability/interpretability of the disease class prediction on the ECG waveforms that are characteristic of those cardiac diseases, helping medical doctors and caregivers trust the decisions made by the AI model. Interpretability of the automated ECG AI model augments the effectiveness of cardiologists in diagnosing heart disease accurately with less human error, especially in overloaded healthcare setups in low/middle-income countries such as India. Furthermore, it helps to gain confidence and improve the trust of the cardiologist toward an automated ECG AI model. Therefore, it can be implemented in a clinical setup, where low/middle-income countries struggle with a high burden of heart disease and poor healthcare delivery infrastructure.

This AI model can be used to diagnose cardiac disorders using the web app (https://ecgdetect.sbilab.iiitd.edu.in/). The decision taken by the AI model for any particular patient’s ECG can be interpreted using the ShAP plot, highlighting the abnormal ECG waves. We made a web app as open source for anyone to access. This interpretability also works as the validation of the efficacy of the model proposed and trained in this work.

Satyanveshi: A New Age Mentorship Program in Medical School
Bhavya R Maroo

Need of an innovation: Medical training has its own unique challenges that advocate the need of an apprentice model and active mentorship for improved learning experience. However, unlike other disciplines, mentorship is in the nascent stages at most medical schools in India.

Novelty: Through Satyanveshi, a Gurukool initiative, we aimed to introduce a systematic mentorship program encapsulating faculty-student and peer mentoring in a structured yet informal manner.

Innovation: Satyanveshi program involved the voluntary participation of mentors and mentees from Maulana Azad Medical College. The mentees indicated their needs, and mentors shared their respective interests, abilities, and roles where they would mentor. A dyad of mentor-mentee was then established through mutual consensus and ice-breaking sessions were held. The program was not restricted to academics and instead incorporated extra-curricular activities, personality development, research, sports, technology, mental health, and sociocultural adjustments. A monitoring team comprising of faculty and student representatives supervised the matching process and ensured the smooth execution of the program. The first cycle matched 43 Mentees and 34 Mentors across a range of fields. Feedback from the involved mentors and mentees indicated high satisfaction scores and appreciation for the project. Through this project, we aim to benefit mentees by making them more comfortably placed on campus, attending to their hardships, guiding them towards best clinical and research practices, and making them into a wholesome professional medical graduate. We also aim to provide mentors with a rewarding experience through instilling a sense of satisfaction and fulfilment and enhancing their own personal and professional development.

Predict Easy :Pre-eclampsia Risk Stratification Tool
Vaishali Sundaresan, Yaswin K S Sagar, Carolin Solomi, A Revanth

Problem Statement: Unavailability of accurate screening tool for pre-eclampsia in low resource settings leading to preventable maternal, perinatal mortality and morbidity.

Need of an innovation: Our product Predict Easy is a machine learning based software that provides risk stratification for pre-eclampsia based on routine antenatal markers. Our product will be placed on the cloud, clinicians can access it through the web interface. Input parameters are entered through the portal, risk analysis is performed on the cloud and risk report is generated.

Pre-eclampsia Opportunity: Pre-eclampsia is a multisystem disorder that typically affects 2% – 5% of pregnant women around the world. In India, the incidence is reported to be 8%-10 %. Globally,76,000 women and 500,000 babies die each year because of pre-eclampsia. Thus, identification of women who are at high risk of developing pre-eclampsia at early stage becomes necessary so that necessary measures can be initiated early enough to improve the pregnancy outcome. The current existing screening methods for pre-eclampsia using biophysical and biochemical markers are expensive, require sophisticated equipment and well-trained manpower which might not be available in all the resource settings.

Mean Arterial Pressure, Proteinuria, Red Blood Cell Distribution Width, Maternal Characteristics, Medical history are some of the markers that are routinely collected during antenatal care that are cost effective and require minimal equipment. Multiple studies have been performed to associate these markers with pre-eclampsia individually or in combination of two or three. We intend to combine all these markers and come up with a simple machine learning based risk stratification tool for pre-eclampsia. This tool could be implemented in low resource settings where women with possibility of developing pre-eclampsia can be identified early and frequent antenatal care can be provided to high risk women.

Novelty, Differentiation, Value Proposition:
• Easy to implement
• Simple, based on routine antenatal markers
• No additional tests and sophisticated equipment required
• Risk interpretation based of Indian population
• Best use of available resources
• Cost effective in comparison with the existing the methods.

Impact: Our product Predict Easy will address the need for an accurate screening tool for preeclampsia. In the resource limited settings, it will help the ANMs and healthcare workers in detecting the complication at early stage without having to go for other expensive tests. Product is currently in the development stage with data collection in progress.

SutureSure-A multifunctional laparoscopic device for simple and effortless minimally invasive surgeries
Nikhil Mamoria, Himanshu Laddha

Need of an innovation: Laparoscopic suturing is the most difficult skill to master as the surgeon needs to constantly change the orientation of the needle to find an accurate position because of the limitations of laparoscopic surgery. Without necessary experience and practice, it increases the surgeons’ effort leading to Physical fatigue resulting in an increased level of errors and poor stitches quality, whereas mental stress results in increased operating time and anesthesia used.

The patented product SutureSure is a multifunctional device that makes laparoscopic surgeries simple and effortless by empowering surgeons to do stitching, knotting, and grasping with just 2 clicks. It helps surgeons to perform complex suturing procedures minimally invasively, in an affordable way -by combining the benefits of robotics with the simplicity of laparoscopy. It provides surgeons 6 degrees of freedom through a joystick, thus enabling them to reach the desired angle, control bites, secure, and tighten the knot. It is a reusable autoclavable instrument that uses a disposable suture cartridge to make laparoscopy affordable.

SutureSure will be of great value to surgeons, as it provides easier access, efficient suturing, and more control with greater dexterity. It will remarkably reduce the training time required by new surgeons to master suturing skills. Hospitals will also be benefitted from decreased OR time, Increased MIS procedures, and improved quality of care dispensed to the patient.

RI2 -Retract, Isolate, and Illuminate: 3 in 1 Affordable solution for effective Community Dental Program
Sonal Bhatia, Radhika Gupta, Vikrant Mohanty

Dental surgery, including any preventive or therapeutic dental procedure, requires continuous isolation from saliva, illumination of oral cavity and retraction of soft tissues. There are many commercially available instruments to solve this purpose, but only a handful solves all three problems at once. Furthermore, leading isolation pose certain problems. Hence, there is a dire need for a comprehensive system which provides all three: isolation, illumination and retraction of soft tissues simultaneously. The Retract, Isolate and Illuminate (RI2) system is an economical alternative to current isolation systems so that it can be a feasible option for every community setting which makes isolation easy and efficient.

A new approach to stoma management
Neeraj Kumar, Pranav Chopra

A new approach to stoma management Neeraj Kumar, Pranav Chopra nkumar@crimsonhealthcare.in AIIMS New Delhi, IIITDM Jabalpur Need of an innovation: People suffering from Colorectal cancers, IBD and other intestinal pathologies undergo surgery which result in an ostomy. Continence is lost, and stool comes out into a disposable bag stuck on to the abdomen. The Quality of life of ostomates becomes poor due to loss of continence, skin excoriations and social stigma.

Our unique platform device, SphinX provides a safe, secure, and discreet solution to stoma management while restoring continence to the patient. Our device is disposable device that needed to be replaced every 10 days and 28 days for colostomy and ileostomy patients respectively, and does not need supporting accessories such as adhesives, belts etc. It also eliminates bag associated skin excoriations.

SphinX will provide a leak free system which will prevent any stool from contacting the peristomal skin thereby significantly reducing complications like skin excoriation, dermatitis and inflammation. SphinX will improve the patient’s overall quality of life and provide them confidence in performing day-to-day activities while eliminating all skin complications caused by current products.

Two million people are living with an ostomy globally. Most of these patients fall in the 25-60 year age bracket; i.e. the productive working age. The Disability Weights for the Global Burden of Disease 2013 study published in Lancet Global Health 2015 puts the disability weight for stoma at 0.095 which is much more than the disability weight for single arm amputation with treatment (0.039). This illustrates the difficulty in leading a normal life for an ostomate.

Current solutions are cumbersome and restrictive for the patients, limiting their physical activity, exacerbated by the emotional trauma associated with this condition. In addition, state-of-the-art ostomy bags also create many skin complications. SphinX is a safer, more secure, easy-to-use, continent ostomy management system that will allow ostomates to live a normal life once again and overcome a disability (loss of sphincter function). We have started manufacturing our device and completed user testing with more than 12 colostomy patients in association with Ostomy Association of India, Mumbai. We plan to launch our device by the end of next month.

Using our device, we believe more than two million ostomates will be able to live a normal life, exercise, travel, have intimate relations thus significantly improving their lives.

Neonatal care platform to facilitate the practice of delayed cord clamping
Devendra M Ghodki, Nidhya Joghee

Need of an innovation: The prevalence of the clinical practice of Delayed Cord Clamping (DCC) particularly during caesarean deliveries is low. The challenges faced by the health professionals include unavailability of continuous vital monitoring for assessing the newborn during DCC. The novelty of the proposed innovation is to monitor the physiological changes in babies through the intact umbilical cord. In addition, essential newborn care through a sterile adjustable cradle attached to a mobile trolley is facilitated. Optional features like weight measurement, attachments like mayo tray can be further added to the trolley as required. Our proposed innovation would provide the optimal first intervention to maximise the benefits of DCC and also, to ensure a shock-free and smoother transition to extra-uterine life by monitoring the physiological changes in the newborn. Current research evidences indicate benefits of physiological based cord clamping, especially to preterm babies, such as decreased incidences of respiratory morbidities, lower incidence of necrotizing enterocolitis & intraventricular haemorrhage, improved transitional circulation, better establishment of red blood cell volume, reduced need for blood transfusions, and less anaemia.

Urine congophilia dipstick test for preeclampsia screening in resource limited settings
Nidhya N Joghee, Nivedha N Joghee

Need of an innovation: Performance limitations exist with current screening tools (blood pressure and proteinuria dipstick) for preeclampsia (PE) in low-resource settings leading to preventable mortality and morbidity. Biomarker based tests show promise in improving the diagnostic accuracy, but commercial diagnostics have cost and operational characteristics not amenable for widespread use in low-resource settings (LRS). The innovation is a PE biomarker-based urine dipstick test with product characteristics aligned with WHO ASSURED criteria (Affordable, Sensitive, Specific, User-friendly, Rapid and Robust, Equipment-free and Deliverable to end users). Urine Congophilia was selected as the PE biomarker after initial desk research on assessment of promising urine biomarkers for preeclampsia, considering the technical and commercial feasibilities. The test consists of a strip that has to be dipped in urine and enables a simple yes/no visual interpretation within 15 minutes. Urine congophilia has been previously reported to have better sensitivity, specificity and predictive value for preeclampsia and adverse outcomes, than blood pressure and proteinuria dipstick, about 10 weeks prior to clinical symptoms. The impacts of increased accessibility to affordable PE diagnostics to LRS include enabling timely clinical interventions, reduced adverse outcomes due to PE, reduced preventable hospital expenditures for patients and optimal use of hospital resources. The test could also be explored for potential use as doctor-prescribed home testing for PE monitoring.

Lap-Pack: a low fidelity laparoscopic box trainer
Manish Chauhan, Noel Aruparayil, Jesudian Gnanaraj, Sukumar Maiti, Anurag Mishra, Aaron Quyn, William Bolton, Joshua Burke, David Jayne, Pietro Valdastri

Need of an innovation: The requirement for high-quality training to maximize the benefits of laparoscopic surgery is well documented. Laparoscopic training for rural surgeons operating in low resource settings is limited due to access to expensive commercial training equipment, lack of training opportunities, poorly developed training program, financial constraints, and limited health system.

Innovation: ‘Lap-Pack’ is a low-fidelity, sturdy, lightweight, portable, low-cost laparoscopic trainer. It comprises a user-adjustable (slide back-forth, rotate, twist in an angular direction and be fixed in a suitable position) camera (compatible with phone, tablet, laptop etc.) for monitoring the operative field.

Utility: Lap-Pack has been evaluated to train 85 participants through a structured training program, the TARGET study through 2 stages. In stage, laparoscopic simulation training was based on the 5 domains of fundamentals of laparoscopic surgery, which assessed skill acquisition across 7 rural surgeons from North-East India. The MISTELS criteria was used to statistically analyse trainee performance between pretraining and post-training sessions. Also, Lap-Pack was qualitatively compared with a commercial box trainer, Inovus Pyxus HD. Stage II involved a multi-centre usability study in 2 centres of India and the United Kingdom (2019).

Impact: Stage I, the total post-training MISTELS score for Lap-Pack was higher, that is 773.37 (SD: 183.67) than the pretraining score, is 351.2 (SD: 471.5). The post-training scores showed laparoscopic skill acquisition with statistically significant (P< 0.05] out of a possible 6. It scored highest (scale: 1= low to 7=high) in Usability 6.14 (95% CI: 6.05–6.22, P< 0.05) and Camera 6.14 (95% CI: 6.01–6.27, P <0.05).

Conclusion: Lap-Pack allowed simulated skills acquisition that was at least as good as a commercially available laparoscopic trainer. The low-cost design and portability make it particularly attractive for low resource settings.

Future: Lofto Design, an Indian design organization is a proud partner of the University of Leeds in taking LapPack to the commercial market. Lap-Pack is proposed to integrate with a smartphone-based learning module that tracks the learning progress of the trainees.

DOST
Gautam Garg

Need of an innovation: The prevalence of mental health problems is increasing at an alarming rate among medical students, with those at risk left further vulnerable by the stigma associated with mental health. Concrete, sustainable, and effective initiatives to identify and help students suffering from these problems in a stigma free environment are scarce.

Novelty DOST aims to increase awareness regarding mental health among students, empowering them to identify and help their peers who may be suffering with care and empathy This is achieved through various procreative activities. The “DOST Box” and the DOST email provide an effective recourse for anyone to seek help regarding their mental health issues, including addiction and substance abuse, and receive proper screening and counselling through our Department of Psychiatry and hired psychologists, with full confidentiality. The self- sustaining peer counselling model involving regular meetings of “peer support groups” provides an empathetic ear and better problem solving through teamwork.

Utility: We have received a large number of applications for counselling and have been able to successfully get them the required help via therapy. Another collateral benefit of our organisation is providing a platform for creative expression and personality development by producing content, art and managing events, which increases harmony, team-spirit, confidence, leadership skills and self-satisfaction.

Impact: 97% students who attended believe that our regular cultural events on campus have managed to increase the sensitivity and awareness of our students making them more empathetic and considerate towards mental health issues, resulting in a stigma-free community. We have successfully identified and facilitated counselling for students suffering from anxiety, depression, suicidal thoughts, OCD, PTSD, and other common disorders. We have been able to successfully encourage students to introspect and take actions to help increase their mental well-being on an individual level by adopting skills like mindfulness, journaling, exercising, self-care, contact with nature, opening up and also following up on their friends, thus creating self-sustainability in the community. Not only this, we also identify and provide guidance for academic and non-academic struggles faced by the students, by increasing informal and free-wheeling senior-junior interactions.

Cost effectiveness: The screening for mental health is provided by utilising the Department of Psychiatry and then referring to hired counsellors if needed. The cost of raw material for decoration and other materials required for events is borne by the society. Our Peer Support Group model is self-sustainable, as they are managed by peer facilitators who are volunteers from the campus itself, trained by the HandNHand team through their InItTogether program, based in Australia.

Innovative multi-modality segmentation and 3d fusion in the management of giant abdominopelvic chondrosarcoma
Lokesh Goyal, Lalit Maini, Sumit Arora, Lovenish Bains, Sunil Jha, Abhay Meena

Tumors arising from the pelvis pose challenges for treating orthopaedic surgeons owing to their complex anatomical location and proximity to the vital organs. Meticulous preoperative planning is important in safe surgical excision of giant abdominopelvic chondrosarcoma as intraoperative assessment is generally difficult due to its complex three-dimensional spread.

We present a case of a 35-years-old female who had giant abdominopelvic chondrosarcoma and underwent type-I pelvic resection using virtual planning on MIMIC and 3-Matic (Materialise, Belgium). Three-dimensional virtual models of the pelvis, great vessels, and tumor were segmented from MRI, NCCT, and CT angiography and fused. It revealed the tumour relationship with neurovascular and urogenital structures. A patient-specific 3D-printed jig was created for tumour resection intraoperatively. Safe surgical excision with wide margins was achieved successfully in the case and she was asymptomatic when last followed up at 12 months.

The multi-modality fusion of medical image segmentation has a significant impact on the clinical practice of musculoskeletal oncology. A bone tumor fused model can be obtained by MR-CT registration after obtaining segmentation in both MR and CT. In this way, a high-resolution 3D model including tumor, pelvic bones, and vital organs can be obtained for subsequent surgical planning.

Malunited lateral tibial plateau fracture managed by intra-articular osteotomy with help of 3D printing
Mudit Sharma

Malunion after lateral tibial plateau fractures often results in chronic subluxation, pseudo-instability, stiffness and early arthrosis. There are only a few treatment options reported in literature, intra-articular osteotomy being one of them. However, it is technically demanding as accurately deciding the osteotomy site is a big challenge for surgeons. We present a case of a 35-years-old male with malunited tibial plateau fracture managed by double intra-articular osteotomy and fixed with anatomically contoured raft-plate and bone grafting. The preoperative planning was done using a full scale femursubtracted 3D printed model of tibia and patient specific 3D printed jig for accurately defining osteotomy lines. CT DICOM files were used to create VRT images of tibia using Mimics and 3-Matic software. Osteotomy lines were planned on the VRT image of bone in the 3-Matic software and jig was created corresponding to the planned osteotomy lines. 3D bone model and patient specific jig were printed and osteotomy was simulated pre-operatively to achieve anatomical reduction of articular surface.

SurgiPod -The Smallest Portable Modular OT
Akash Satpathy, Ankit Sahoo

The innovation presented aims to solve the availability and accessibility of Operation Theatres in low resource, disaster and military settings. It aims to reduce the cost and resources involved in the setting and running of an OT, including consumables and as a result, reduce the waste generated. It will help in creating an ambient temperature around the operated area to reduce the risk of SSI. Having a smaller surface area, it is convenient to sterilise and thus reuse. While the concept of portable OTs is not new with significant innovations being done in the field of mobile OTs, not much has actually reached the field. However, a revolutionary product with the concept of a portable OT of the size of the patient’s body is novel, cheap, scalable and easily deployable. It is aimed to develop a portable, transparent, air conditioned ‘Surgical Pod’ which will provide a sterile, illuminated, safe, temperature regulated field to carry out minor as well as life-saving surgeries.

Doctors On Community Service -An attempt to shift focus from Classroom to Community among medical students
Vishwa Jinwala, Komal Yadav

Problem statement: Academic learning, clinical exposure through hospital services and community exposure are perceived to be the pillars of medical education. 65.5% of Indian population resides in rural settings whereas healthcare is skewed towards urban areas. To fill the lacunae of perceptual learning among medical students in low-resource/rural settings, an initiative -– Doctors on Community Service (DOCS), was started.

Novelty of Idea: Currently, community based medical education is provided through family visits in second and third year. Following shortcomings were identified in current curriculum:

• Most communities do not represent a low resource setting adequately, which fails to sensitize medical students towards the basic needs of the marginalized sections of the society.
• Limited hours in community does not provide an in-depth view of their living condition.
• There is also a lack of intent among medical undergraduates to serve the community.

To tackle this issue, DOCS organises trips for students in groups 10-12 with a common intent of serving the community, working towards sustainable change and inching the community further towards self reliance. Collaboration with local voluntary health organizations helps in better penetration and understanding of local communities. Focussed group discussions with public health specialists and professors provide better insights about health education, nutrition, sanitation and health-seeking behaviour thus enabling them to develop empathy, leadership skills and encourages problem solving. The concept of DOCS has helped students to conceptualize “Health for All” and enabled medical undergraduates to become better health caregivers.

Automatic Uterine Incision closure device
Girija S Mohanty, Aashima Arora, Vanita Suri

Rationale: The incidence of lower segment cesarean section ranges from 20-to 50% in different countries. (1) There are non-uniformity in suturing the incised lower segment uterine edges as most of the LSCS was done by the newly learning obstetricians. Because of this, there is an increased incidence of placenta accreta syndrome in a future pregnancy, weak scar leading to increased risk of uterine rupture during subsequent pregnancy, adhesion formation and isthemocele formation/ (Niche). (2) Because of prolonged and nonsymmetrical approximation during suturing, there is more blood loss from uterine lower segment incised edges. Aim of any surgery is to restore the anatomy to near normal condition.

Novelty of the invention: LSCS is one of the main procedures in Obstetrics is the cesarean section, which is closed only by hand suturing with a needle holder. Due to the limitations of hand suturing method, a novel automatic handheld suturing machine was conceptualized and 3D designed and equipped with a needle-driving system, a thread control mechanism, and a linear mechanism, which is applicable in uterine incision by making continuous sutures, which will be symmetrically placed by the device . The main advantages of this machine are employing bio-compatible sutures from the tissue’s adaptation point of view and making a uniform suturing pattern, independent of the surgeon’s skill, thus offering greater strength than the hand-sutured specimen. Many studies have concluded that a more uniform suture will result in greater mechanical strength of the sutured tissue. This machine is designed to take a bite with an elongation rate of 5-10 mm/bite. From the mechanical strength point of view, the optimum pattern is fixed for this automatic suturing device that each bite will follow, h10 d10 ( h = distance of suture from the edge of the tissue = 10 mm, and d = distance between stitches = 10 mm). (3) This will ensure apposition of decidua to decidua , myometrium to myometrium ,preventing bulding out of the decidua to out side. Finally, the clamp used to hold the uterine margin during suturing will reduce the total amount of blood loss during surgery.

Aerosol Evacuation Funnel
Abhishek Nagaraj

Aerosol evacuation has become a necessary factor for safe healthcare practice. This article aims to mention various levels at which aerosol evacuation should be done and the devices which may be utilized to address aerosol evacuation at these levels. These devices have been formulated and patented as part of an innovation drive to address growing need for such effective devices which may utilize available clinical operatory resources for creation of a safe working environment for healthcare professionals and their patients.

Advanced technology especially 3D printing has provided us with this unique opportunity to apply and elevate the practice of dentistry way beyond the possibility of any disruption caused by infectious diseases. Innovating devices such as these may be our best answer to succeed over challenges posed by pandemics. Trial and error have always been a part of all innovations which aim to re-invent method of practice. But, without such cost-effective innovations, profitable dental profession may become obsolete or depend perennially on the discounts offered on heavily priced, imported, standalone machines.

Apart from use of such devices, our recommendations include use of built-in filtration systems within the dental chair or suction units for purified air environment. To unclog and regularly disinfect the air and suction channels for better evacuation of aerosols. Make sure to use personnel protection equipment and pre-procedural mouthwash.

OsteQuant -A comprehensive bone age and bone health estimation tool
Jyothisri Lokanadham

Introduction: Bone age is being used by pediatricians since decades to assess skeletal maturity and development. Bone age is used in the diagnosis and management of growth and puberty related diseases which are of increasing prevalence, diagnosis of severity of malnutrition and severe stunting which has a nationwide prevalence of 35% on an average, age verification in sports, immigration, refugees, and minority related legal cases. The currently used methods of bone age estimation are time consuming, cumbersome and unreliable. The existing methods either require manual assessment or are expensive. Hence, we aim to design OsteQuant which is an automatic bone age assessment tool that is a standalone software which automatically analyses the X-Rays to provide the bone age results within minutes.

Methodology: The product development involves primary data collection of Hand and wrist radiographs from Indian population followed by training of a deep learning model, followed by refining the model to arrive at an acceptable accuracy. Various factors such as ethnicity, BMI, past medical history are taken into consideration while choosing the subjects. Subjects from 0 to 18 years are taken into consideration. Currently, ethical clearance has been obtained from Madras medical college and hospital and data collection up to 12 years has been collected. The images are being used to train a deep learning model, with an aimed accuracy of 95%.

Discussion: This application would also aid in reduction of the number of X-Rays required for bone age estimation, thus reducing X-Ray exposure. It would have a marked impact on age verification for legal purposes. Apart from improving the accuracy we also aim for the application to be customized to the health professional, thus being able to have an exclusive patient record of the results. The future scope of this application includes screening for Vitamin D deficiency disorders such as rickets, leukemic lines and osteoarthritis. Currently, ideation is going on in developing the tool into a comprehensive bone health estimation tool, that would be a one stop solution for the diagnosis of bone diseases.

Efficacy of local application of colistimethate sodium in non-healing wounds infected by multidrug resistant bacteria
Sanju Samuel

Introduction: Multi drug resistant(MDR) bacteria infecting wounds have become important in recent years due to increased prevalence and their possible deleterious consequences. Such wounds have been treated successfully using surgical debridement or by parenteral antibiotics based on Culture and sensitivity(C/S). Oral or parenteral antibiotic therapy then becomes the cornerstone of treating such conditions. However, treatment of multi drug resistant bacteria that are sensitive only to reserve antibiotics is a cause of concern. These antibiotics are expensive and have a higher risk of renal, liver and multisystem compromise.

Methodology: We present a case series of five patients with non-healing wounds infected by MDR bacteria treated with local application of colistimethate sodium(CMS).All the five patients had sepsis, deranged renal functions and grew MDR gram negative bacteria(Kliebsiella/Pseudomonas) sensitive to colistin only. Two patients also had a compromised liver. Wound size was measured and C/S was done at start of treatment and at three weeks to assess response. After an initial surgical debridement, one vial of CMS powder was mixed with a tube of ointment containing papain 521700IU+urea 100mg and the mixture was applied locally on the wound twice a day for 1week till healthy granulation tissue appeared or negative culture report. There was a good response and healing in all five patients.

Discussion: Overuse or abuse of empirical antibiotics poses a difficult challenge to the Health care system causing multi drug resistance. Parenteral CMS is expensive and causes renal toxicity. An 8 hourly regimen of colistimethate(CMS) (4.5million IU) for 7 days would cost about 70,000 INR, while local application of colistin+debridase costed about 5,000 INR for the same period without the additional renal toxicity. Addition of hydrolytic enzymes in the wound converts CMS to colistin by hydrolysis. This innovation can be adopted with other reserve antibiotics and can help healthcare professionals in low resource areas to provide source control and treat sepsis with MDR infected wounds cost effectively.

D-Cleft
Ruchi Gupta

Babies born with cleft palate anomaly suffer from feeding problems which interfere with their nutrition for growth and development; thereby, hampering the criteria for subsequent corrective surgery. The palatal cleft interferes with nursing and causes insufficient suckling or aspiration/nasal regurgitation of food. Because of altered anatomy and presence of oro-nasal fistula, baby tends to present suction difficulties due to lack of negative intraoral pressure. Presented here is an innovative solution – D-Cleft – A patented device for attaching on commercially-available feeding bottles to facilitate effective nutrition method.

The device was tried and tested successfully in many neonates born with cleft palate. It has been successfully used to feeding neonates by their mothers/care-takers with almost no training required. D-Cleft provided good seal of palatal defect from nasal regurgitation and was found to act as a scaffold against pressing of feeding-bottle’s nipple during suckling movements. It has overcome several disadvantages presented by in-dwelling tubes or long-term intra-oral attachment methods most importantly constant irritability for child. Other drawbacks such as impression procedure, sterilization and hygiene issues are almost non-existent.

MeeT: A Platform for Innovation
Kunal Kalani

India’s medical industry and infrastructure is the talk of the world. However, nothing is perfect. Doctors come face to face with the shortcomings of this industry every day. As professionals with a deep understanding of the system, they are the best poised to lay down a foundation to the solutions to these problems. However, modern technological advances, which play a major role in solving such obstacles, is not something that doctors are expected to be experts in. Thus, an idea fails to formulate due to the lack of tools.

Our proposed solution, MeeT, is platform where professionals of the medical and engineering industries can cooperate and coordinate to develop a plethora of answers to the problems the industry feels burdened with. Having a specialist to consult at their fingertips can allow doctors to delve deeper into the mechanisms of these previously unreachable problems and unravel them into achievable goals that can be tackled by the partnership.

The Metaverse as a platform for education and training within medicine and surgery
Karamveer Narang

Introduction: Virtual Reality in Medicine and Surgery (VRiMS) has successfully demonstrated a scalable and affordable method of utilising immersive technology in medical education. VRiMS has hosted 5 one-week cadaveric live streaming courses at Brighton and Sussex Medical School (BSMS) utilising 360VR cameras and the last course co-hosted a global medicine initiative with GASOC (Global Anaesthesia, Surgery and Obstetric Collaborative) streaming the Bellwether procedures of caesarean section, spinal anaesthesia, and gasless laparoscopy to surgeons from 43 countries. The next step in development involves utilisation of the metaverse. The metaverse is, by definition, a virtual-reality space in which users can interact with a computer-generated environment and other users. The development of this resource can have a wide scale impact within global surgery and medicine as it would allow people to meet in an immersive environment to facilitate learning as well as exchange ideas.
Methodology: We utilised Mozilla Hubs in order to develop a meeting space utilising virtual reality and the metaverse. A proof of concept was created, and a meeting held with 5 members of our working group. Content from VRiMS was used to facilitate discussion and the share ideas. The meeting space could be accessed either via a VR headset or via an internet browser.

Results: As this is a proof of concept involving a small sample size, results were predominantly obtained via qualitative methods and consisted mostly of feedback from the users. Feedback obtained was generally positive in terms of the ease of access to the technology and the potential for it to be used as a meeting space. There were also issues identified such as the need for a stable internet connection as well as the limit on what type of content could be shared via the Mozilla Hub platform.

Discussion:The development of remote learning has been accelerated not only within medicine but in all other domains due to the COVID pandemic. We feel that the metaverse could be an exciting way to bridge the gap between face-to-face learning vs online learning. This could have major implications within global medicine and surgery as it allows wider access to training and resources especially towards lower income countries and healthcare systems.

An inexpensive surgical glove bag for gall bladder retrieval during laproscopic cholecystectomy
Rahul Bhatia

Introduction: Surgical site infection complicates 2.4-3.2% of elective cholecystectomy. During surgery, GB is commonly extracted using a retrieval bag. Cost of retrieval bag increases the overall expenditure of surgery. We have deceived a safe, sterile and cheap retrieval bag using latex gloves and conducted the study on 150 patients undergoing elective cholecystectomy to clarify whether it plays a role in preventing infection.

Methodology: The study was conducted in department of General Surgery in LNJP Hospital for a period of 1 year. A total of 90 surgeries were done in the specified period. Inclusion criteria: Patients between age 18 to 60 years having gall bladder calculi Exclusion criteria: Acute cholecystitis Lap converted to open cholecystectomy. Evidence of bile spillage Gall bladder rupture during removal from cystic plate Evidence of CBD injury

Results: 2.2% rate of surgical site infection was observed during extraction.

Discussion: The minimal presence of complication and low cost makes routine use of glove bag a wise option for extraction. The use of glove bag seems to reduce the risk of contamination with bacteria, bile and gall stone. It may also reduce the contamination by malignant cells in case of unexpected GB Carcinoma.

Frugal indigenous methods for chest tube insertion and venesection
Rahul Bhatia

Simulation is a very good way of acquiring new skills. Mannequins for simulation are expensive, and not easily available, especially in far flung areas of low and middle income countries. Short training programs to impart clinical skills near the palace of work of medical officers can be useful to minimize the time away from work for medical officers performing duties in remote regions. The authors conducted such a training program regarding initial management of a trauma victim at Keylong, Himachal Pradesh, India. Due to adverse weather and road conditions, the vehicle carrying the mannequins failed to reach the destination on time. Since the participants had travelled distances varying from 50-100 km to come for the training, the authors did not wish to let the lack of the mannequins derail the training program and created ingenious simulators out of materials available in the community health centre and the surrounding environment.

The authors created a box to simulate a thoracic cavity to trainees to practice chest tube insertion, and a leg model to practice venous cutdown. Conclusion: This paper describes the process of creation of these models as an example of the Indian concept of frugal engineering. The feedback from the trainees was very encouraging and the enthusiastic participants agreed that it simulated well for the landmarks, the procedure and increased their understanding.

Digital videoproctoscopy: a new diagnostic test in proctology
Rahul Bhatia

The proctological examination is usually simple, it can be done even without specific preparation. It is completed by proctoscopy, enabling the surgeon to confirm a clinical suspicion and make a differential diagnosis. Proctoscopy, however, may present a number of difficulties: the embarrassing position (both in the Sims and in the genupectural position; the operator is very close to the perineum of the patient); it is not possible to provide visual evidence of the pathology; there are no data archives; no comparison of two examinations can be made after a certain period of time (e.g. to test the validity of the therapy adopted). For these reasons patients are often invited to undergo a video-colonoscopy, which also presents limitations such as low patient compliance, difficult medium- and short-term repetition; ineffective discrimination of anal canal diseases, and, last but not least, the cost, which is substantially higher than that of anoscopy.

The author presents the results of experimentation with digital Videoproctoscopy, performed with the aid of a bar on which is situated a separate-head digital camera, a solid light source with an optical fibre guide. The top of the bar can be attached with a bayonet coupling to a disposable rigid proctoscope. The tool is connected to a high-resolution LCD monitor or a mobile, allowing the surgeon to record images on an SD card. Seventy-six digital videoproctoscopies were carried out, enabling the author to make a correct diagnosis of the anal, perianal and rectal pathologies.

Identifying palliative care needs for tribal-rural populations
Shilpa Khanna

Non-communicable diseases are major cause of deaths and morbidity across the world. This is true for any setting be it rural or urban. Their cost of treatment is often unaffordable by many. Palliative care by a holistic view aims to improve quality of life. We highlight problems in the daily lives of people suffering from debilitating conditions such as advanced cancer, stroke, paraplegia, advanced OA knees and so on. These people belong to tribal-rural communities and have unique micro-habitat conditions that make usual methods/pathways of care irrelevant or exuberant.

We defined the problem statement based on the current evidence of burden of disease, with listing of five major gaps/barriers in improving quality of life along-with the current standard of care/best practice for the same. The gap/ barrier is elaborated further with current alternatives in their socio-cultural environment and highlighted through lived patient experiences in the form of five social-case studies. We talk about the gaps in management of wounds, shortages in the availability of specialists, need for affordable solutions to air mattress, diapers, and commode chairs for the disabled or end-of-life care, lack of infra-structure for transportation of people or medicines or diagnostics, and system gap for guidance across all healthcare-levels by a social-worker cum patient navigator.

There is a need to focus on problem-based innovation in the realms of space, stuff, staff and system to improve the lives of those already marginalised and offer them the best possible life.

Training 750 General surgeons in this decade for district hospitals in Kenya
Kaneej Wazirali, Pankaj Jani

Background: Kenya has a dire shortage of surgeons at the District Hospitals (DH) The impact of COSECSA with 25 accredited hospitals, most of which are in non-metropolitan towns, and with a capacity to train 65 surgeons per year can be a solution to this problem.

Methods: Analysis from the records of COSECSA training centers, with collation of data from the 3 other University based training programs, that train post graduates in surgery in Kenya. The primary goal was to work out if 3 general surgeons can be trained, in this decade, for each of the 250DH’s, to provide the desperately needed Emergency and Essential General surgery and also lead to a national plan for provision of surgical services in Kenya.

Results: The surgical capacity study in 2018 Kenya revealed that 80% of the district hospitals in Kenya do not have a full time General Surgeon. The COSECSA model has proven that surgeons willing to work at DH can be trained. Most COSECSA accredited hospitals, including Tenwek, Kijabe, Chogoria, Letein and Kikuyu have trainers who are COSECSA fellows, and such efforts can achieve the goal of having general surgeons at the DH’s. Together with the 3 Universities, it is possible to train 750 General Surgeons in this decade of 2020 to 2030.

Conclusion: Kenya can achieve, in this decade, the goal of training 3 General surgeons for each DH for the provision of the desperately needed surgical care.

Feasibility of the frugally-engineered ‘LeVe CPAP’ from pilot data in healthy volunteers at Mengo Hospital, Uganda; with potential for use in patients with acute hypoxaemic respiratory failure associated with COVID-19 and other respiratory illnesses
Peter Culmer, Edith Namulema

Introduction: Continuous positive airway pressure (CPAP) is the gold-standard non-invasive ventilatory support in many cases of acute hypoxaemic respiratory failure (AHRF), which increased exponentially during the COVID-19 pandemic. However, such ventilatory systems are not designed for use in resource-limited settings.

Methodology Due to the sudden increase in cases of AHRF in low-resource settings during the COVID-19 pandemic, we engineered a frugal ‘LeVe’ CPAP flow generator. This device uses a lowvoltage electric fan-blower, with an oxygen source and humidifier, to deliver oxygen-enriched airflow at pressure levels between 5-12cm H20. A safety and tolerability pilot study was conducted in healthy volunteers from local healthcare staff in the Intensive Care Unit (ICU) at Mengo Hospital, Kampala. This is the initial stage of a planned cross-over randomisation trial using the device for severe cases of COVID-19. Ethical and administrative approval was gained from the Ugandan National Council for Science and Technology (UNCST), the National Drug Authority, and Mengo Hospital Research & Ethics Committee (REC).

Results: Ten healthy participants were recruited, 50:50 male:female ratio, mean age 24.9 years (range 22-30). The LeVe CPAP Flow Generator was initiated through escalation of pressures in four stages (5, 7.5, 10, 12.6 cm H20). Monitoring of oxygen saturation revealed oxygen saturation was well maintained >95% for all participants at all pressures (median minimum SpO2 97.3%, range 95- 98%). Monitoring of end tidal CO2 levels revealed safe pressures maintained < 3.6KPa for all participants at all pressures (median maximum ETCO2 4.4 KPa, range 3.6-4.9). The median respiratory rate was within normal range at pressures of 10cm H20 was 17.8 (range 10-25). Participants reported overall comfort of the device 4.4 median (Likert-Scale of 5 being ‘very comfortable’). Levels of anxiety, claustrophobia and difficult breathing were self-reported as low (<2.1 on Likert-Scale).

Discussion/Conclusion: Outcomes from the pilot study demonstrates that the LeVe CPAP flow generator is safe and well tolerated in healthy volunteers. Due to the significant reduction in COVID19 cases in Uganda, we have not yet conducted the next phase of study. However, we are exploring the potential use of the LeVe CPAP system to address other acute respiratory conditions in low resource settings.

The RAIS device for low-resource laparoscopic surgery: development, evaluation and future perspectives
Millie M Webb, Philippa Bridges, Noel Aruparayil, Tim Ho, Tim Beacon, Anurag Mishra, Tamandeep Singh, Sundeep S Sawhney, Lovenish Bains, Richard Hall, David Jayne, Jesudian Gnanaraj, Peter Culmer

Background: Over 5 billion people have no access to safe or affordable surgery, despite it being the primary life-saving treatment for many common conditions. Access is worst in resource-scarce regions, exaggerating this inequity in healthcare. Gas Insufflation-Less Laparoscopic Surgery (GILLS) is a technique which can address this inequity, bringing the advantages of laparoscopic surgery with low resource use. Unfortunately, extant GILLS instrumentation does not meet modern standards, limiting wider use. Accordingly, our aim was to address the clinical need for contextappropriate GILLS instrumentation by developing RAIS: the Retractor for Abdominal Insufflationless Surgery (RAIS).

Methods: Employing participatory design principles, we assembled a multidisciplinary team of engineers, designers, surgeons and healthcare experts from the UK and India, clinical stakeholders and a commercial partner. We used a combination of medical-device design methodologies, with an iterative development process featuring regular stakeholder evaluation, to address the unique challenges of designing for resource-scarce environments. A final commercialisation phase was then conducted, led by our surgical and commercial partners in consultation with regulatory and clinical bodies in India.

Results: The design approach proved an effective means of integrating stakeholders within the development process. A series of prototypes were produced and tested, concluding with a candidate system meeting all major clinical requirements. This was evaluated in workshops with rural surgeons using RAIS with cadaveric models. Feedback informed revisions to optimise surgical performance, cleaning, maintenance and transportation. A commercial version of RAIS was then produced (XLO Ortho) obtaining regulatory approval for use in India. Our clinical team used this in patient cases at GILLS training workshops across India. Surgeon feedback revealed it provides a high-quality surgical experience and enabled new teams to perform GILLS independently in resource-scarce environments.

Conclusions: Using participatory design principles with a motivated multidisciplinary team was crucial to achieving a successful commercial version of RAIS. This surgical instrument is being used by an expanding team of surgeons in resource-scarce regions of India; realising our ambition of moving from clinical need to clinical use. Our focus is now to use RAIS to support translation of GILLS to other world-regions which can benefit from this approach.

Introduction of WALANT in Kenya: An innovative method to alleviate poverty
Pankaj Jani

Introduction: Wide Awake Local Anaesthesia No Tourniquet surgery is a disruptive and innovative method of treating Trauma and other surgical patients, since id reduces the costs of treatment drastically. 5 workshops have so far been held and approx.. 180 doctors trained in WALANT
Methods: Reports of the 5 training courses were perused and analysis done to arrive at the number of doctors trained in WALANT and also the number of patients treated so far and the savings in costs, compared to conventional treatments, to work out alleviation of poverty.
Results: Details of more than 180 doctors, including Medical Officer’s, General surgeons, Orthopedic surgeons and Plastic surgeons who trained at 5 workshops in the WALANT method of treating surgical patients, will be presented. At least 15 hospitals actively perform WALANT procedures on a regular basis. Over 1000 patients have been treated successfully with WALANT with tremendous reduction in costs to these patients, showing that poverty due to surgery can be alleviated thro practicing WALANT surgery. Machakos, Kikuyu, Kisumu, Karen, Bungoma, Mombasa and many other hospitals have established dedicated WALANT theatres and are actively performing WALANT surgeries.

Conclusion: WALANT is a disruptive and innovative form of surgery, that has revolutionised the care of trauma and other surgical patients by tremendously decreasing the costs incurred by patients for surgical care, thereby alleviating poverty.

Condition monitoring of Ilizarov frames using vibration sensors
William Bolton

Introduction: Maintaining adequate tension within the wires of an Ilizarov frame is key to clinical efficacy. There is currently no method for in-situ measurement of wire tension after the initial pretension has been applied during fitment. Being able to measure this may be valuable in helping to advise frame adjustment, fracture healing and timing of frame removal.

Methodology: One method of assessing the tension of a wire is through analysis of the vibrating frequency after an impulse has been applied; like a guitar string, increased tension results in higher frequency vibration (emitted as a sound) in output. We have developed a piezoelectric vibration sensor which can be placed on the fixation bolt at the end of the wire and used to directly measure the transmitted wire vibration and thus minimise the influence of external environmental (auditory) noise. The vibration signal is measured and recorded by a microcontroller system, post-hoc analysis then uses a Fast Fourier Transform to determine the dominant vibrational frequency in the response. The sensor was fixed to a standard Ilizarov frame, modelled using two acrylic tubes to simulate a fractured bone. Static axial loads of 200-800 N where then applied to vary the tension in the wire. At each condition, a metal key was used to stimulate the wire and 5 repeat measures were recorded and analysed. This was then repeated with silicon pads added around the tubes to simulate soft tissues of the leg.

Results: Results show that a dominant vibrational frequency can be identified between 1500-2500 Hz. The frequency was sensitive to changes in the axial load, showing a repeatable and significant linear trend of increasing frequency with wire tension. This response was also evident with the addition of the silicon soft-tissue simulant, demonstrating that the technique has potential clinical relevance.

Conclusions: The sensing system presented here offers a viable method to quickly and easily monitor any tension loss that occurs either during the initial installation of the frame, or over time due to cyclic loading during use. This has wider implications in areas where X-ray access is limited, there are limited orthopaedic specialists, or where travelling from remote regions may make follow-up after frame surgery challenging and costly.

The Impact of Gurukool on College Students, Residents, Faculties, and Campus life in a Medical College of New Delhi
Sulakshna Aggarwal

Introduction: Studies on goal oriented interventions by campus organizations showed variable results on their effect on the environment and behaviour among college students. Gurukool is a similar student led initiative with a vision towards holistic development of the students and making the campus a better place. The purpose of this study was to assess the impact of Gurukool on college students, residents, faculties , and campus life.

Methodology: It was a questionnaire based cross sectional study conducted among students, residents &faculty of Maulana Azad medical College, New Delhi. The questionnaire asked for general demographic, their role in Gurukool, and average time devoted for Gurukool activities in a week. The impact of Gurukool was assessed via self assessment on improvement in personality domains (organizational skills, leadership skills, communication skills, responsibility towards community, interpersonal relationships, ability to tackle stress, and academic performance) since the inception. It assessed the impact of Gurukool on parameters like strengthening the relationships, making campus life more enjoyable, and creating a positive change in the environment. The data was cleaned and analyzed using Microsoft excel.

Results: 64 participants participated in the study which consisted of 23.4% core members, 32.8% volunteers, and 43.75% attendees. On an average, in a week, 29.7% participants devoted five to ten hours, 50% participants devoted less than 5 hours, while 20.3% participants did not devote their time to Gurukool activities. Participants with more time devotion in Gurukool showed significantly more improvement over less time devotees in the domains of communication skills (p<0.001), responsibility towards community (p<0.001), organizational skills (p<0.001), leadership skills (p<0.001), and improvement in ability to tackle stress (p=0.02). Core members showed a significant improvement over volunteers and attendees in communication skills (p=0.02), responsibility towards community (p=0.02), organizational skills (p<0.001)), leadership skills (p=0.01). Majority agree that Gurukool has made the campus life more enjoyable (78.1%) and created a positive change in the environment (82.8%).

Discussion- As evidenced by several studies, interventions through campus organizations plays a significant role in introducing students to new arenas to explore and making the campus life more enjoyable and a better place to live.

Efficacy of Platelet-Rich Plasma in Reduction of Post-Operative Split-Thickness Skin Graft Loss and Hematoma Formation: A Meta-Analysis
Apurv Gupta

Introduction: Split-thickness skin grafting is a popular technique of wound closure, especially for large wounds. The success rate of a split-thickness skin graft (STSG) has consistently been in the range of 70-90%. We evaluated the impact of Platelet-rich plasma (PRP) use on the survival of STSG through a meta-analysis.

Methods: We conducted the analysis in accordance to PRISMA protocol and performed a literature search using the following databases: PubMed, Cochrane, and ClinicalTrials.gov. A total of 126 articles were yielded by the search, out of which four RCTs were included according to our eligibility. The intervention group received PRP application to the wound bed before applying the graft while the control group received treatment with conventional fixation procedures (sutures and staples). We estimated the pooled odds ratio with a 95% confidence interval (CI). The total number of participants in the analysis were 460. Post-operative graft loss and hematoma formation were taken to be the primary and secondary outcome measures, respectively.

Results: 34 participants suffered graft loss of differing extent in the control group while 3 participants suffered graft loss in the intervention group. The pooled odds ratio for graft loss was 0.15 (95% CI: 0.05-0.49; I2=38%; p=0.184). For our secondary outcome measure, 440 participants were studied. 44 participants suffered hematoma formation in the control group versus 11 in the intervention group. The pooled odds ratio for hematoma formation was calculated as 0.21 (95% CI: 0.09-0.50; I2=0%; p=0.869).

Conclusions: The use of PRP decreased the odds of graft loss by 85% and the odds of hematoma formation decreased by 79%. PRP appears to significantly impact graft survival, and further studies are needed to strengthen the evidence base for its use in split-thickness skin grafting.

Spontaneous common bile duct perforation presenting as extrahepatic bilioma: a rare clinical presentation of gall stone disease
Princy Gupta

A 45 years old female presented to surgery emergency with 5 days history of pain right upper abdomen with high grade fever, chills and rigors associated with yellowish discoloration of eyes and skin with generalized itching all over body. On examination, patient was febrile (101°F), tachypneic with tachycardia of 108/min, dehydrated and icteric. Abdomen was soft with tenderness present at right hypochondrium and right lumbar region. Murphy’s sign negative. Laboratory investigation revealed TLC of 9700 cells/mm3 with total bilirubin of 5.68, direct bilirubin of 3.49, and normal liver enzymes with elevated alkaline phosphatase (219). Ultrasound revealed dilated CBD, 12 mm at porta, distal CBD obscured with bilobar IHBRD and a contracted gall bladder. A diagnosis of acute cholangitis was made and patient was managed conservatively and was improving clinically as well as biochemically. On 3rd day of admission, patient developed abdominal distention, examination revealed a swelling of around 15×15 cm involving whole of the right abdomen, which was non tender. Her laboratory studies also demonstrated a marked increase in alkaline phosphatase level to 3529 from 219. Ultrasound revealed reduced distention of CBD to 7 mm with large thick walled collection with multiple internal echoes and dependent echogenic debri within in right lumbar region. Magnetic resonance cholangiopancreaticography revealed cholelithiasis with choledocholithiasis with resultant upstream bilobar IHBRD and a large thick walled hyperintense collection measuring 7.8x19x10 cm in subhepatic region, reaching upto right iliac fossa. The collection is reaching upto proximal CBD proximal to calculus, likely extra hepatic bilioma. Ultrasound guided pigtail catheter drainage was done which revealed stat output of 2000 mL of bilious fluid. Patient was taken up for exploratory laparotomy, which revealed a 2×2 cm perforation present over lateral edge of CBD with single large stone present just beneath the perforation site. Intrahepatic, normal, distended gall bladder with calculi, dense adhesions between liver, gall bladder, omentum and bowel and 10×10 cm well localized collection present in right lumbar region surrounded by omentum with pigtail in situ. Peritoneal lavage was done using warm normal saline. Cholecystectomy was done and CBD explored. CBD calculi removed and CBD closed over T tube, inserted through the perforation site. Patient improved symptomatically and biochemically. T Tube cholangiogram done on POD5 revealed a filling defect. T tube was clamped and repeat T tube cholangiogram revealed no abnormality. T tube was removed on POD15, and patient discharged on POD17. She was doing well on her first and subsequent visits for next 3 months.

Non traumatic perforation of extrahepatic bile ducts is a clinically rare entity seen more commonly in infants than adults. In infants, it is secondary to congenital anomalies like choledochal cyst, anomalous union of pancreatico-biliary ductal system, bile duct stenosis or atresia that weakens the common bile duct wall. Although the pathogenesis of spontaneous biliary perforation is poorly understood, the commonest cause for perforation was a stone in adults with the mechanism being impaction of stone followed by erosion. Other causes reported are tumor obstructing the lumen and increasing canalicular pressure, spasm of sphincter, intramural infection, mural necrosis secondary to mural vessel infarction, connective tissue defect, ischemic compromise or previous biliary tract surgeries. Kang et al. reviewed 70 cases of spontaneous bile duct perforations in adults. Among these, 42 patients had perforation in common bile duct, followed by hepatic duct in 28 cases. In our case, we attribute the perforation to the impacted stone within the CBD leading to ischemic compromise and eventually erosion of the duct. The presentation of CBD perforation may be acute or insidious, with the latter type being more common and characterized by progressive jaundice, painless abdominal distension and clay colored stools. The acute form is less common and presents with fever, vomiting and signs of fulminant peritonitis. Ultrasound findings in a case of extrahepatic biliary duct perforation reveals free fluid in peritoneal cavity with normal extra and intrahepatic biliary radicles. Failure to see distended gall bladder points towards the decompression of biliary system secondary to perforation. MRCP reveals the same finding with a collection communicating with the extra hepatic biliary ductal system, as in our case. In doubtful cases, radio isotope scanning can be done. Recommended standard of care in a case of spontaneous perforation of CBD is exploration of CBD with retrieval of stone and closure of CBD over T tube placed from the perforation site. If distal obstruction is anticipated, biliary enteric bypass can be done. Primary repair of CBD over CBD stent is hazardous in acute presentation due to local inflammation, especially if distal patency is not known.

External Fixation in Polytrauma Patients from Low and Middle Income Countries – A Case Report
Gopalkrishnan Murugesan, Vivek Udayachandran

Road traffic accidents is the largest cause of death in the age group of 15-29(1). It has been reported that India has one of the highest mortality rate from RTA in the world and polytrauma cases comprised 13.3% of all adult trauma cases. Time, cost, infrastructure, availability of implants, surgical expertise and complications are important factors when it comes to selection of the limited treatment choices available in low and middle income countries (LMIC)(5). The case report below explores the feasibility of external fixation in patients with pelvic and long bone fractures from LMIC.

The report comprises of the clinical, radiological findings and the management of a polytrauma patient from LMIC. This study implies the efficacy and wide use of external fixators in developing countries. It has been shown that, if used properly, external fixators can treat bone and with low risk and reasonably high success rates. The early management of fractures reduces significant mortality which has been possible for the above patient. However the study limits to a case report. The high cost of commercially available devices sent a dilemma to our health care which puts emphasis to the need for locally manufacture external fixators to avoid burden of imported devices in our health care systems. Different studies have demonstrated the superiority of surgical fixation over conservative methods but several factors impose a roadblock to adoption of these methods. Also, the mortality and morbidity of polytrauma patients depends on other extraneous factors and a multidisciplinary approach with rehabilitation is needed.

Lumbar Disc Degeneration, A Transdifferentiation Process-An Electron Microscopic Observation
Prashant B Lakhe

Introduction: Lumbar disc degeneration (LDD)is a common condition which affects quality of life. Repeated trauma, ageing and stress predispose to LDD. However exact mechanism is not fully understood. Transdifferentiation refers to a process where a one mature cell switches its phenotype and function to that of another mature differentiated cell type. Such mechanisms have been described in repair following fracture of bones. In order to understand it better, we conducted an electron microscopic study to analyze if LDD is a transdifferentiation process.

Methodology: After institutional ethics committee approval, patients who presented with LDD were subjected to preoperative MRI. Failure of medical management, and occurrence of neurological deficits formed the indication for surgery. Discoidectomy was done by standard microscopic techniques and the disc material was examined under electron microscopy. The disc material was collected and labelled according to proximity to adjoining osteophyte formation. The electron microscopic findings were correlated with clinical and radiological observations.

Results: Study was conducted from Jan 2020 – Dec 2021. A total of 50 patients with 28 males ,22 females with a mean age of 47 years were studied. Majority of the patients(26) had a prolapse at L4- 5 level with the mean duration of symptoms being 12 months. 80 % of patients had a VAS score of 7 and 8. Maximum (72 %) patients showed a Pfirrmann grade 4 of degeneration on MRI and type 2 Modic changes (64 %). Ten patients(20%) showed presence of posterior osteophytes. Electron microscopy showed chondrocyte clustering in 92 % patients, collagen abnormalities in 66% and intracellular inclusions in 60%. Chondrone formation was seen in 12 patients. Patients with higher pain severity and longer duration of symptoms showed increased chondrocyte clustering. Osteophyte formation was seen in patients with longer duration of symptoms. All the patients with osteophytes showed presence of chondrones.

Discussion: LDD is a process which can be explained on electron microscopy. Higher VAS score and longer duration of symptoms results in more chondrocyte clustering. In addition, formation of osteophytes was always associated with chondrone formation. These findings support our hypothesis that lumbar disc degeneration is a transdifferentiation process.

Designing Global Surgical Technology: Benefits of a Participatory Design Approach for the Surgeon
Tim Ho, Millie Marriot-Webb, William Bolton, Noel Aruparayil, Peter Culmer

Introduction: Participatory Design (PD) is an approach to technology development that aims to improve outcomes through close and equal involvement of stakeholders in the development process. This approach is increasingly prevalent in medical technology development – particularly in Global Surgery and low-resource healthcare interventions, where understanding of the clinical context is vital to design. It has been argued that PD projects should prioritize participant outcomes alongside project objectives to ensure project longevity and success, yet there is a paucity of research regarding the impacts on clinical stakeholders, and how to optimise their collaboration. Better understanding of the benefits for clinical stakeholders will help facilitate these aims and promote better collaborations.

Methodology: Clinical stakeholders, involved in the development of the “RAIS” (Retractor for Abdominal Insufflation-less Surgery) device, were identified for interview. Semi-structured interviews were conducted with each participant to ascertain their personal motivations, experiences of multidisciplinary and international collaboration, and to explore any opportunities or skills that were developed. Personal frustrations and barriers to collaboration were identified and solutions to these concerns explored.

Results: Stakeholders unanimously prioritised clinical results over personal enrichment as the primary motivation for participation, though academic and career opportunities were recognised as key benefits. A non-hierarchical relationship between clinical and design teams allowed the clinicians to contribute and influence the design process to meet their specific needs as the device’s intended users. The geographical distance between teams and the lengthy design process were major sources of frustration. However, effective communication channels, and integration into design considerations, reduced miscommunication and enhanced contributions from the surgical team who were able to provide more detailed and valuable feedback.

Discussion: This study aims to catalyse further research to determine the ideal participant and project outcomes and the optimal approach to facilitate these. Key considerations for innovators considering using a PD approach include:
Project Conception:
1. Prioritize input from a variety of stakeholders based in LMIC’s in the initial design phase
2. Collaborate with local stakeholders throughout the design process to ensure continuity
3. Establish stakeholder-specific goals as part of the project’s objectives
Communication:
4. Communicate interactively to understand the context and form collaborative relationships with stakeholders
5. Espouse an ethos of equal stakeholdership to facilitate bi-directional information flow, encourage feedback and ensure participant motivations
6. Validate interventions with stakeholders in the contextual environment
Sustainability:
7. Support the development of innovation networks and capacities within LMIC’s
8. Empower stakeholders to innovate, collaborate and disseminate their knowledge
9. Employ formal PD frameworks to guide long-term and sustainable stakeholdership

Music as an adjunct cost-effective therapeutic innovation for Management of Pain in Trauma Patients: A Systematic Review and Meta-analysis
Pratyush Kumar, Oshin Puri, Yogesh Bahurupi

Introduction: Music therapy reduces pain perceived, alleviates mood and promotes relaxation, regular breathing and rest. Being a readily available and inexpensive therapy, its efficacy for Management of Chronic Pain, such as that experienced by Trauma patients needs further exploration in low resource settings.

Objective: To determine the effectiveness of Music Therapy as an adjuvant therapeutic intervention in trauma patients of adult and pediatric age group in the pre and post procedural period.

Method: PubMed (n=175), Trip Medical Database (n=278) and ClinicalTrials.Gov (n=28) were searched for ‘Trauma’, ‘Music’ & ‘Pain’. Studies identified from inception were imported to EndNote X9 Library and duplicates removed. Only completed RCTs (Pubmed; n-16, TMD; n=2, CT.Gov; n=6) were screened using Title, Abstract and full text (n=41). Data extracted from 12 studies, was analyzed in Review Manager 5.4.

Result: Due to significant heterogeneity (Chi² = 365.17, P < 0.00001; I² = 97%), inverse variance random effect meta-analysis was done. Scores of the various pain measurement scales from a total of 852 patients from 12 studies revealed a pooled Standard Mean Difference of 0.31 [-0.61, 1.22]. Test for overall effect Z = 0.66 (P = 0.51) indicates that there is no significant difference in pain outcomes between Music Adjuvant therapy (MAT) Vs. Conventional Analgesic care. Subgroup analysis reveals a significant favor [Z = 1.18 (P = 0.24)] to MAT in patients of non-malignant pain of traumatic origin while in burn trauma patients it has no significant benefit [Z = 2.23 (P = 0.03)]. Similarly, as per pooled evidence, MAT is highly effective in the pediatric age group [Z = 1.00 (P = 0.32)] while no significant benefit in the adult age group [Z = 1.11 (P = 0.27)].

Conclusion: The pooled evidence suggests that both interventions significantly improve pain outcomes but Music therapy does not have any significant benefit over conventional therapy when compared as a whole. Although, in patients of non-malignant pain of traumatic origin, MAT has significantly high benefit while for Burn trauma patients, MAT has no proven significant benefit over conventional therapy. Evidence from the meta analysis indicates high efficacy of MAT in children while non such benefit can be proven in adult age group. Therefore, MAT could be a potential inexpensive therapeutic adjuvant in non-malignant pain of traumatic origin (for example post fracture reduction, post operative pain, etc.) and for pain management in children.

System Innovation in Laparoscopic Simulation Training for intra-corporeal tissue re-approximation, knot tying and suturing technologies
Murugankutty Gopalan

Minimally invasive procedures rule the domain of surgery worldwide. The simulator-based training in psychomotor skills necessary for doing ‘Intra-corporeal tissue re-approximation’ remains, the hardest obstacle, the greatest challenge and barrier for all the budding laparoscopic surgeons across the globe; especially in the areas of knot tying and suture placement techniques. As a solution to this issue, we offer our newly developed- hustle free, “trainee end- tool kit- with direct 3D vision as well as the 2D camera vision, with which one can have their psychomotor skills up- gradation within the comforts of their own home.

“Learn from Home” is the proposed system innovation here: As a practical solution to address the above issues, we have developed ‘Learn from Home Gear’ consisting of a Box Simulator + 24 x7 hours of web-based mentorship in combination. The new simulator box is foldable, lightweight, with no cables attached. And a web-based self-monitoring system, consisting of easy to-follow instructions, and well-defined checkpoints for easy self mentoring. These teaching contents shall be circulated to the registered trainees as short video clips.

We have started this training program since the last 6 years, on “one to one basis”- in our Amrita Clinical Skill simulation center and found to be very effective. We would like to diffuse and scale up to the maximum by opening an avenue for sharing this knowledge to the surgical fraternity all over the world taking advantage of the advancement in information- technology, which in turn will result in enhancing the healing power for the patients even at the remotest corner of the globe. With this we could achieve our aim to establish the easiest , simplest, remote skill learning with checkpoint aided self mentoring – the proposed system innovation –“Learn from Home Gear in Laparoscopic Simulation ”

Reverse Innovation in Healthcare from India
Muthu Singaram

Introduction: This review paper explores the innovations in healthcare arising from India and how many of these can be applied to the theory of reverse innovation This study demonstrates how Indian researchers can play a major role in reverse innovation application in healthcare. What is reverse innovation also as Trickle-up Innovation? This was first coined by two Dartmouth University Professors Vijay Govindarajan and Chris Trimble and GE’s Jeffrey R. Immelt. Later Vijay Govindarajan and Chris Trimble published the book Reverse Innovation (2012), these are innovations first arising in the developing countries which are later introduced in the western or developed markets.

Methodology: This study is based on scholarly publication in major journals we have studies over 100 articles and selected 50 for the purpose of our study. We have built nine case studies based on these articles and reliable publicly available data. These case studies shows us that if these success stories are applied lot more of the innovation coming out of India can fall into the reverses innovation from frugal innovation by apply the three box framework which would lead to a larger usage of these innovations and further hence Indian innovations and economic.

Results: The review paper would describe 14 Indian reserve innovations and their benefits to the world at large. Discussion This review paper looks at reverse innovation targeted at providing goods and services to the poorest people in the world and this would fall in the area of strategy-based innovation. This review paper makes a case for the fastest-growing new markets and entrepreneurial opportunities being found among the billions of people `at the bottom of the income pyramid’. BOP proposes that there are tremendous benefits for multi-national companies who prefer to serve these markets in ways aware of their needs.

Expressed breast milk: Awareness and opinion on storage and utilization among mothers in tertiary health care center, Belagavi
Reewen George D Silva

Introduction: For newborns and infants, breast milk is the best source of nutrition. To achieve optimal growth & development and health, the infants should be exclusively breastfed for the first six months of life [1, 2]. Various pieces of research show that the first time mothers and working mothers become a prey for formula feeds due to structural functional limitations.

Methodology: Cross sectional study was conducted by recruiting 200 subjects through Nonprobability purposive sampling from a tertiary health care center in Belagavi. A Gravid women between age group of 18-45 yrs attending IPD, OPD & follow up care and able to read & write were recruited. The data was collected post Institutional Ethical committee clearance and individual subject consent using a questionnaire. It constituted sections such as Knowledge, Attitude, Practice and Opinion regarding EBM.

Results: The mean age of subjects 28.79 (± 7.02) years. About 119 (59.5%) have not heard about EBM. About 162 (81%) had no idea of storage. 50.2% expressed requirement of professional help. 117(57.9%) said that Expressing will increase the milk production. Opinion on acceptance and need, 126 (63%) were willing to donate EBM, 160 (80%) expressed a need for EBM Bank, 166 (83%) expressed need for availability at every hospital. However 159 (79.5%) said creating awareness and making it a reality is a need of the hour. A χ2 computed shows that there was a significant association with age p <0.032, religion p <0.001, educational level p<0.001, learned on usage of EBM p <0.001 and idea on how to store and utilize EBM p<0.001.

Discussion: A similar study which was conducted by Rai S. concluded that 36% of participants had adequate knowledge[3]. The study by Prabhu P et al also reported that the knowledge about methods of breast milk expression and storage was not satisfactory[4]. An educated woman had higher scores, which was also reported by Ekambaram M et al., [5] there was a significant difference among religion, age, educational level which was statistically significant, which might be attributed to social and multifactorial constraints.

A New Innovation in Yogasan (A new Yogasan for quick relief of tension and sleeplessness)
K C Sharma, Uma Sharma

For relaxation of body & mind “SHAV ASAN” & “BALASAN” (Vishram Asan) have been well described & practiced. In today’s fast moving life, people want to put themselves to sleep quickly so that they relax fully & awake fresh for next work. Therefore to meet this requirement a modified Valasan has been introduced which quickly puts the body into complete relaxation followed by deep sleep in just 8 – 10 minutes at normal body & surrounding atmospheric temp depending upon weather. With deep sleep tension is obviously relieved.

Method: With appropriate routine pillow under the head, person lies down in Rt. Or left lateral position, flex the upper leg partially, and keep lower leg almost straight. Perineum is directed towards the bed. Weight of the Chest, abdomen & pelvis must fall anteriorly towards the bed. Keep neck on same side & face touching the bed, lower arm flexed at elbow & keep near the face resting on the bed, the upper hand be kept straight but relaxed just behind the greater trochanter of the femur i.e. highest point of hip in this position. Coordinate this position with mind and take one or two deep breath to go to sleep see photo I, II, III.

A Comparative Study of Ripasa Scoring System and Ultrasonography in the Clinical diagnosis of the Acute Appendicitis in Resource Limited Settings
Warad Nikhil, Devani Kavin

Background: Acute appendicitis is the commonest cause of acute abdominal pain in the surgical practice. Correct clinical diagnosis prevents unnecessary surgeries and complications. Various scoring systems are there to aid clinical diagnosis of the acute appendicitis.

Methods: A prospective observational study was carries out at the Department of Surgery, Lokmanya Tilak Municipal Medical College, Mumbai from February 2018 to December 2018. Demographic, clinical and laboratory investigations’ data was collected from consenting patients. The gold standard for the diagnosis was histopathological examination. The data was analyzed by IBM SPSS Statistics (2015). Sensitivity, specificity, accuracy and negative predictive value and positive predictive value (= precision) were compared.

Results: Majority of the patients with right iliac fossa pain were operated. RIPASA scores better than USG on all the 4 attributes viz. sensitivity (0.90 against 0.84), specificity (0.30 against 0.20), accuracy (0.80 against 0.73) and positive predictive value (= precision) (0.87 against 0.84). Conclusion: RIPASA is not only less reliant on the technology and skill but also better in guiding the prognosis. Thus, a useful tool in resource limited settings.

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