Flexible Green Supply Chain Management in Emerging Economies: A Systematic Literature Review.

The purpose of this research is to synthesize the fragmented extant knowledge on flexible and green supply chain management (FGSCM) in the context of emerging economies and to unearth research gaps to motivate future research. We adopted a novel structured systematic literature review by triangulating a systematic literature review, text mining, and network analysis. Institutional theory and contingency theory were employed to analyze the results of the review. The results show that, firstly, research on FGSCM in emerging economies, despite its importance, is immature compared to general FGSCM literature. Second, the specificities of strategies and practices that distinguish this topic in emerging economies are discussed and the drivers and barriers are identified with respect to sources of institutional pressure. Third, a research framework for FGSCM in emerging economies is developed and 12 gaps for future research are identified. This study has exclusively developed a research framework for FGSCM in an emerging economy which has received the least consideration in the literature and practice. The framework was developed to synthesize the existing literature and to identify the research gaps to inspire future research.

Double zero tillage and foliar phosphorus fertilization coupled with microbial inoculants enhance maize productivity and quality in a maize-wheat rotation.

Maize is an important industrial crop where yield and quality enhancement both assume greater importance. Clean production technologies like conservation agriculture and integrated nutrient management hold the key to enhance productivity and quality besides improving soil health and environment. Hence, maize productivity and quality were assessed under a maize-wheat cropping system (MWCS) using four crop-establishment and tillage management practices [FBCT-FBCT (Flat bed-conventional tillage both in maize and wheat); RBCT-RBZT (Raised bed-CT in maize and raised bed-zero tillage in wheat); FBZT-FBZT (FBZT both in maize and wheat); PRBZT-PRBZT (Permanent raised bed-ZT both in maize and wheat], and five P-fertilization practices [P100 (100% soil applied-P); P50 + 2FSP (50% soil applied-P + 2 foliar-sprays of P through 2% DAP both in maize and wheat); P50 + PSB + AM-fungi; P50 + PSB + AMF + 2FSP; and P0 (100% NK with no-P)] in split-plot design replicated-thrice. Double zero-tilled PRBZT-PRBZT system significantly enhanced the maize grain, starch, protein and oil yield by 13.1-19% over conventional FBCT-FBCT. P50 + PSB + AMF + 2FSP, integrating soil applied-P, microbial-inoculants and foliar-P, had significantly higher grain, starch, protein and oil yield by 12.5-17.2% over P100 besides saving 34.7% fertilizer-P both in maize and on cropping-system basis. P50 + PSB + AMF + 2FSP again had significantly higher starch, lysine and tryptophan content by 4.6-10.4% over P100 due to sustained and synchronized P-bioavailability. Higher amylose content (24.1%) was observed in grains under P50 + PSB + AMF + 2FSP, a beneficial trait due to its lower glycemic-index highly required for diabetic patients, where current COVID-19 pandemic further necessitated the use of such dietary ingredients. Double zero-tilled PRBZT-PRBZT reported greater MUFA (oleic acid, 37.1%), MUFA: PUFA ratio and P/S index with 6.9% higher P/S index in corn-oil (an oil quality parameter highly required for heart-health) over RBCT-RBCT. MUFA, MUFA: PUFA ratio and P/S index were also higher under P50 + PSB + AMF + 2FSP; avowing the obvious role of foliar-P and microbial-inoculants in influencing maize fatty acid composition. Overall, double zero-tilled PRBZT-PRBZT with crop residue retention at 6 t/ha per year along with P50 + PSB + AMF + 2FSP while saving 34.7% fertilizer-P in MWCS, may prove beneficial in enhancing maize productivity and quality so as to reinforce the food and nutritional security besides boosting food, corn-oil and starch industry in south-Asia and collateral arid agro-ecologies across the globe.

Thermal imaging in total knee replacement and its relation with inflammation markers.

Total knee replacement is an end-stage surgical treatment of osteoarthritis patients to improve their quality of life. The study presents a thermal imaging-based approach to assess the recovery of operated-knees. The study focuses on the potential of thermal imaging for total knee replacement and its relation with clinical inflammatory markers. A total of 20 patients with bilateral knee replacement were included for thermal imaging and serology, where data was acquired on pre-operative day and five post-operative days. To quantify the inflammation, the temperature-based parameters (like mean differential temperature, relative percentage of raised temperature) were evaluated from thermal images, while the clinically proven inflammation markers were obtained from blood samples for clinical validation. Initially, the knee region was segmented by applying the automatic method, subsequently, the mean skin temperature was calculated and investigated for a statistical relevant relationship with inflammatory markers. After surgery, the mean skin temperature was first increased (>2.15 ℃ for different views) then settled to pre-operative level by 90th day. Consequently, the mean differential temperature showed a strong correlation with erythrocyte sedimentation rate (r > 0.893) and C-reactive protein (r > 0.955). Also, the visual profile and relative percentage of raised temperature showed promising results in quantifying the temperature changes both qualitatively and quantitatively. This study provides an automatic and non-invasive way of screening the patients for raised levels of skin temperature, which can be a sign of inflammation. Hence, the proposed temperature-based technique can help the clinicians for visual assessment of post-operative recovery of patients.

Knee flexion strength deficits correlate with distal extent of tendon regeneration after hamstring harvest. Preliminary data from an Ultrasound based classification.

BACKGROUND: As more evidence comes to light that hamstring harvesting may not be as benign a procedure as previously thought, considerable interest is being generated towards corelating the knee flexural strength deficits with the degree of tendon regeneration. The current study aimed to corelate knee flexion strength deficits with ultrasonographically quantified degree of hamstring regeneration after tendon harvest. STUDY DESIGN: 31 patients of ACL reconstruction with hamstring grafts were divided into 2 groups (6 months and 1-year post op) according to time of follow up. Ultrasonography of both the knees to assess Semitendinosus tendon dimensions was done. Regeneration was classified as non-significant, mild (Zone 1, till 4 cm above the lateral joint line), moderate (Zone 2 ,at the level of the lateral joint line) and significant (Zone 3, 1.5 cm below the lateral joint line) as the regenerate happens from proximal to distal. Regenerate dimensions were compared with US measurements from the opposite knee. Bilateral isokinetic strength tests of the knees were done to evaluate flexion strength, and strength deficits were compared with degree of tendon regeneration. RESULTS: 14 (45%) of cases had no regeneration at both time periods. 7 patients (41%) in the 6-month post-op group showed some form of regeneration, and 10 patients (71%) in the 1-year post-op group showed regeneration. 29/31 patients had some flexion strength deficit. Strength deficit correlated with the level and degree of tendon regeneration, with non-significant regeneration cases showing higher strength deficit (mean - 28.51%), and cases with significant regeneration showing least amount of strength deficit (mean - 3.66%). CONCLUSION: Flexion strength deficits after hamstring harvest are significant and corelate with degree of tendon regeneration, which improves over time. US is adequate to quantify degree of tendon regeneration, which in turn can help prognosticate return of flexion strength.

Changing Pattern of Orthopaedic Trauma Admissions During COVID-19 Pandemic: Experience at a Tertiary Trauma Centre in India.

INTRODUCTION: COVID-19 has emerged as a medical threat to mankind, with a serious disruption of lifestyle in 2020. This has not only changed the way we live and work but has also changed the pattern of hospital admissions and medical care. To see if there was significant change in the pattern and management of trauma in our region, we evaluated data from our centre for the lockdown period and compared it with data from the previous year, and also with some available international data. METHODS: We collated data from our Tertiary care hospital for two periods, i.e. from 25th March 2020 to 3rd May 2020 signifying strict lockdown and then from 4th May to 31st May during which some conditional relaxations were given. This was compared to data from similar periods in 2019. We looked at patient demographics, fracture types, injury mechanisms, and even changes in treatment protocols. RESULTS: Significant reductions in caseloads were noted; open injuries were less, road accidents were infrequent, but cases due to falls, especially children and the elderly were still seen, although slightly reduced. The plan to minimize operative interventions could not be fully implemented due to complex nature of trauma seen by us. Only one case of bilateral amputation turned out to be positive, with no infectious consequences to the treating staff. CONCLUSIONS: COVID-19 pandemic led to significant reductions in trauma caseload and change in injury patterns. Doctor responses and patient management needs significant alteration to prevent spread of disease.

Single-stage "Fix and Flap" gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study.

INTRODUCTION: Grade 3B/C open tibial fractures with grossly contaminated degloving injuries have poor outcomes, with or without vascular injuries. Treatment decision oscillates between limb salvage and amputation. The standard protocol of repeated debridement and delayed wound cover is a challenge in developing countries due to overcrowded emergencies and limited operating room availability. We present results of our modified protocol involving primary stabilisation with external fixation and immediate wound cover as an aggressive modality of treatment. MATERIAL AND METHODS: Thirty-three patients with severe open tibial shaft fractures were managed using a standardised protocol of emergent debridement, external fixation and immediate wound cover with free distant/local rotational muscle flaps and fasciocutaneous flaps, and with vascular repair in Grade 3C fractures. Intra-articular fractures were excluded. Patients were followed for a minimum of three years, with an assessment of clinical, radiological and functional outcomes. RESULTS: Wound cover was achieved with 24 distant free muscle flaps, four local rotational muscle flaps and five fasciocutaneous flaps. All fractures united with an average time to union of 40.3 weeks (16-88). Fifteen patients (45.4%) underwent only a single major surgery using primary definitive external fixation. Deep infection was seen in four patients (12.1%). Nineteen patients had excellent to good outcomes, six were fair, and eight were poor. CONCLUSION: "Fix and Flap" in the same sitting, using immediate wound cover and external fixation, has given good results in our hands despite the delayed presentation, the neurovascular deficit and the degloving injury. This may be a better management strategy in overcrowded tertiary care centres of developing countries, with a single surgical procedure in almost half the cases.

Comparison of adductor canal block for analgesia in arthroscopic surgery with ropivacaine alone and ropivacaine and clonidine / Comparação do bloqueio do canal adutor para analgesia em cirurgia artroscópica com ropivacaína isolada e ropivacaína + clonidina

Abstract Background and objectives: Inadequate pain relief after anterior cruciate ligament reconstruction affects mobility leading to development of adhesions, weakened ligament insertion and muscle atrophy. Adductor canal block for postoperative analgesia preserves quadriceps strength. The present study was conducted to compare pain free period in patients undergoing arthroscopic anterior cruciate ligament reconstruction, receiving ultrasound-guided adductor canal block with ropivacaine alone and ropivacaine with clonidine. Methods: A prospective randomized double blinded study was conducted including sixty-three adult, ASA class I, II patients undergoing anterior cruciate ligament reconstruction. They were randomized into three groups: Group S - control group received adductor canal block with 30 mL saline, Group R - ropivacaine group received adductor canal block with 30 mL of 0.375% ropivacaine and Group RC - clonidine group received adductor canal block with 30 mL of 0.375% ropivacaine with clonidine 1 µg.kg-1. The primary aim was to compare the pain free period in patients receiving adductor canal block with ropivacaine alone or ropivacine with clonidine. The secondary outcomes were pain score at rest and movement, total analgesic requirement, sedation score and postoperative nausea and vomiting. Results: The mean pain free periods were 20 min, 384.76 min and 558.09 min for Group S, Group R and Group RC, respectively and this difference was statistically significant (p < 0.001). There was no significant difference between Group R and Group RC in terms of pain scores at rest and movement and total analgesic requirement. Conclusion: Addition of clonidine to ropivacaine in USG guided adductor canal block led to significant prolongation of pain free period though pain score at rest and movement, and rescue analgesic requirement, did not differ.

Resumo Justificativa e objetivos: O alívio inadequado da dor após a reconstrução do ligamento cruzado anterior afeta a mobilidade, leva ao desenvolvimento de aderências, inserção do ligamento enfraquecido e atrofia muscular. O bloqueio do canal adutor para analgesia pós-operatória preserva a força do quadríceps. O presente estudo foi feito para comparar o período sem dor em pacientes de reconstrução artroscópica do ligamento cruzado anterior, submetidos ao bloqueio do canal adutor guiado por ultrassom com ropivacaína isolada e ropivacaína + clonidina. Métodos: Um estudo prospectivo, randômico e duplo-cego foi conduzido com 63 pacientes adultos, estado físico ASA I-II, submetidos à reconstrução do ligamento cruzado anterior. Os pacientes foram randomizados em três grupos: Grupo S, que recebeu bloqueio do canal adutor com 30 mL de solução salina para controle; Grupo R, que recebeu bloqueio do canal adutor com 30 mL de ropivacaína a 0,375%; Grupo RC, que recebeu bloqueio do canal adutor com 30 mL de ropivacaína a 0,375% e 1 µg.kg-1 de clonidina. O desfecho primário do estudo foi comparar o período sem dor nos pacientes que receberam bloqueio do canal adutor com ropivacaína isolada ou ropivacina + clonidina. Os desfechos secundários foram escores de dor em repouso e movimento, necessidade total de analgésicos, escore de sedação, além de náusea e vômito no pós-operatório. Resultados: Os períodos médios sem dor foram 20 min, 384,76 min e 558,09 min para os grupos S, R e RC, respectivamente, e essa diferença foi estatisticamente significativa (p < 0,001). Não houve diferença significativa entre os grupos R e RC em termos de escores de dor em repouso e movimento e a necessidade total de analgésicos. Conclusão: A adição de clonidina à ropivacaína em bloqueio do canal adutor guiado por ultrassom levou a um prolongamento significativo do período sem dor, embora os escores de dor em repouso e movimento, e a necessidade de analgésico de resgate, não tenham diferido.

[Comparison of adductor canal block for analgesia in arthroscopic surgery with ropivacaine alone and ropivacaine and clonidine]. / Comparação do bloqueio do canal adutor para analgesia em cirurgia artroscópica com ropivacaína isolada e ropivacaína + clonidina.

BACKGROUND AND OBJECTIVES: Inadequate pain relief after anterior cruciate ligament reconstruction affects mobility leading to development of adhesions, weakened ligament insertion and muscle atrophy. Adductor canal block for postoperative analgesia preserves quadriceps strength. The present study was conducted to compare pain free period in patients undergoing arthroscopic anterior cruciate ligament reconstruction, receiving ultrasound-guided adductor canal block with ropivacaine alone and ropivacaine with clonidine. METHODS: A prospective randomized double blinded study was conducted including sixty-three adult, ASA class I, II patients undergoing anterior cruciate ligament reconstruction. They were randomized into three groups: Group S - control group received adductor canal block with 30mL saline, Group R - ropivacaine group received adductor canal block with 30mL of 0.375% ropivacaine and Group RC - clonidine group received adductor canal block with 30mL of 0.375% ropivacaine with clonidine 1µg.kg-1. The primary aim was to compare the pain free period in patients receiving adductor canal block with ropivacaine alone or ropivacine with clonidine. The secondary outcomes were pain score at rest and movement, total analgesic requirement, sedation score and postoperative nausea and vomiting. RESULTS: The mean pain free periods were 20min, 384.76min and 558.09min for Group S, Group R and Group RC, respectively and this difference was statistically significant (p < 0.001). There was no significant difference between Group R and Group RC in terms of pain scores at rest and movement and total analgesic requirement. CONCLUSION: Addition of clonidine to ropivacaine in USG guided adductor canal block led to significant prolongation of pain free period though pain score at rest and movement, and rescue analgesic requirement, did not differ.

Bleeding during percutaneous dilatational tracheostomy - What to do while waiting for the surgeon?

A patient suffered significant bleeding during an attempt at percutaneous dilatational tracheostomy due to an aberrant anterior jugular vein. Bleeding was controlled with pressure temporarily, but quickly returned necessitating conversion to an open technique. We present an algorithm for the management of significant peri-procedural bleeding during this procedure.

Hamulus Stress Fracture in a Batsman: An Unusual Injury in Cricket - A Case report and Review of Literature.

INTRODUCTION: Hamulus fractures are uncommon injuries constituting 2-4% of carpal fractures and are usually reported in athletes. Stress fractures of hamulus are even rarer and very few cases have been reported till date. In this case report, we present the first documented case of stress fracture of hamulus in a cricket batsman and review the existing literature on hamulus fractures, both acute and stress fractures, in sportspersons in general. CASE REPORT: A 23-year-old, right-handed, cricket batsman presented with pain in the hypothenar region of his left hand of 7 weeks duration. The pain typically worsened during batting, and he had difficulty in gripping the bat. Plain radiographs were largely inconclusive; magnetic resonance images, however, demonstrated a stress fracture of the hamate hook. The patient was put on conservative management, and his bat grip was modified. He recovered completely within 12 weeks and went back to playing professional cricket. CONCLUSIONS: Hamulus stress fractures should be considered in cricketers presenting with chronic, non-traumatic, and ulnar-sided hand pain. The nonleading hand is more likely to be involved in a batter, as seen in other sports with a double haSnd grip. Nonoperative treatment, change of grip and adequate rehabilitation give good outcomes in most cases.

Management of neglected ACL avulsion fractures: a case series and systematic review.

INTRODUCTION: Neglected tibial eminence avulsion fractures of the anterior cruciate ligament (ACL) are uncommonly seen in modern times, but are fairly common due to a missed diagnosis/mismanagement in developing countries. OBJECTIVES: To determine the outcomes after open reduction and internal fixation of late presenting ACL avulsion fractures, and to review the literature for similar cases, in an attempt to evaluate the ideal surgical management in this unique scenario. STUDY DESIGN: Retrospective observational study and systematic review MATERIALS: The study included 10 male and 2 female cases (mean age 29.9 years). Patients were assessed for the pre-operative knee range-of-motion (ROM), flexion deformity and stability; functional assessment was conducted using the Lysholm scale, both pre and post-operatively. Open reduction and internal fixation with two partially threaded screws (via a mini anterior approach) was performed in all 12 cases. All patients were clinically followed up for a minimum duration of 12 months. We searched PubMed, Embase and Cochrane databases from the period of inception to January 15, 2017 for similar case series/reports involving management of chronic/neglected ACL avulsion fractures and systematically reviewed these studies following standard PRISMA guidelines. RESULTS: The median duration of presentation after injury was 12 months (range 3 to 312 months; mean 45.3 months). The mean follow-up duration was 24.1 months (range 12-48 months). All patients achieved normal knee extension except one patient who had a residual 5° flexion contracture. On physical examination, Lachman and pivot-shift tests were negative in all but 1 patient. No case required ACL reconstruction, and the fractures united radiologically within 12 weeks; all patients regained former activity levels. DISCUSSION: Eleven published studies, mainly case reports, reported on the management of chronic/neglected ACL avulsion fractures. Arthroscopic suture/wire fixation, arthroscopic debridement of avulsed fragment and open reduction, internal fixation (ORIF) with screws are the described techniques for this uncommon entity. However, anatomic reduction of ACL avulsion fractures is difficult arthroscopically as crater depth assessment and repositioning of the avulsed fragment become a problem; the avulsed fragment may also hypertrophy, and some contractures in ACL may develop. A mini-open procedure does not add to the morbidity, overcomes reduction obstacles and allows easy fixation with screws, and can be done even in centers that do not have arthroscopic experience. The key point is accurate reduction and rigid fixation, ensuring no impingement on full extension CONCLUSIONS: Mini-open fixation allows accurate, anatomic reduction and stable fixation with screws, and should be the preferred method of fixation for late presenting ACL avulsion fractures; embedding the fragment deep into the crater or size reduction are key to preventing extension deficits.

Effects of thermo-photoperiod on induction and termination of hibernation in Chilo partellus (Swinhoe).

Determination of critical threshold for induction and termination of diapause (hibernation) are important for better understanding the bio-ecology and population dynamics of Chilo partellus (Swinhoe) under varying climatic conditions. We studied initiation and termination of hibernation under five temperature and photoperiod regimes viz., 27°C + 12L:12D, 22°C + 11.5L:12.5D, 18°C + 11L:13D, 14°C + 10.5L:13.5D and 10°C + 10L:14D under fixed and ramping treatments, and the observations were recorded on various phenological and developmental characteristics at weekly intervals. Present studies revealed that the induction of hibernation in C. partellus larvae takes from 46 to 56 days depending upon temperature and photoperiod conditions. Induction of hibernation varied from 7.9 to 18.3% across treatment conditions, indicating that not all C. partellus larvae undergo diapause under prevailing environmental conditions. Weight, length and head capsule width of diapausing larvae were found significantly lower than the non-diapausing larvae. The non-diapausing C. partellus larvae required a thermal threshold of 1068 degree-days under ambient conditions, while in case of hibernating larvae it varied significantly across treatment conditions. Diapausing larvae underwent up to five supernumerary moults, wherein highest percentage of diapausing larvae (35.7%) exhibited two supernumerary moults. The developmental time of diapausing larvae varied from 94.9 to 160.4 days across treatments. A population loss of 17.2-28.3% was recorded in C. partellus due to hibernation, which has implications for population buildup of post-hibernation first brood and management strategies.

Drill bit failure and retrieval during arthroscopic ACL reconstruction.

A case of broken drill bit during arthroscopic ACL reconstruction and the technique adopted to overcome this complication is presented. We also review the literature for intra-operative incidents and technical complications during arthroscopic ACL reconstruction and various precautions we should implement to prevent such technical pitfalls from coming into reality.

Epidemiological profile of sports-related knee injuries in northern India: An observational study at a tertiary care centre.

BACKGROUND: Sports-related knee injuries occur commonly in athletes. However, there is no published epidemiological study from India till date. OBJECTIVES: The purpose of this study was to identify common injuries sustained by Indian athletes participating in different sports and to study various associated demographic features. A secondary objective was to investigate different factors, which may affect return to sport by the athlete. STUDY DESIGN: Cross-sectional study (observational study). STUDY CENTRE: Sports injury clinic, PGIMER, Chandigarh. METHODS: Out of 465 athletes who presented to us with sports-related knee injuries over a 5-year period, 363 athletes (from 24 different sports) with complete records were identified. Data were analysed for demographic features, type of sport, mechanism of injury, injury scenario, athlete's level of play, injury duration at presentation, injury patterns and type of management. Telephonic interviews were conducted with each athlete to enquire about return to sport and time lost in sport due to the knee injury. Factors associated with return to sport were investigated using statistical tests of association. RESULTS: Soccer was found to be the most common sport associated with knee injuries accounting for 30.6% of the injuries followed by kabaddi (20.9%). The most common mechanism was non-contact injury (64.4%). Competitive injuries were found to be significantly more than practice/training injuries (p < 0.0001). The most common injuries noted were ACL tears (n = 314) followed by meniscus injuries (n = 284) and the most common combination of injuries were an ACL tear with medial meniscus tear (n = 163). Only 39.8% of the athletes returned to sport. Mean duration of time lost in sport among those who returned to sport was 8.84 months. Return to sport was significantly associated with body mass index, level of competitiveness of the athlete and type of management (p = 0.017, 0.045 and <0.0001, respectively). CONCLUSION: Knee injuries take a huge toll on an athlete's career as observed in this study. Prevention of knee injuries is of paramount importance and more focussed epidemiological studies are needed for formulating policies to prevent sports injuries in both professional and amateur athletes. LEVEL OF EVIDENCE: IV.

Assessment of Bt trait purity in different generations of transgenic cottons.

Adequate expression of Bt (Bacillus thuringiensis) toxins and purity of seeds of Bt-transgenic cottons are important for controlling bollworms, and thereby increasing the cotton productivity. Therefore, we examined the variability in expression of Bt toxin proteins in the seeds and in leaves of different cotton (Gossypium hirsutum (L.) hybrids (JKCH 226, JKCH 1947, JKCH Durga, JKCH Ishwar, JKCH Varun KDCHH 441 and KDCHH 621) expressing Bt toxins in F1 and F2 generations, using bioassays against the cotton bollworm, Helicoverpa armigera (Hübner), and the lateral flow strip (LFS) test. Toxicity of Bt toxin proteins in the seeds of Bt-transgenic cottons to H. armigera correlated with their toxicity in the leaves in one- toxin Bt cotton hybrids. The Bt-F1 and Bt-F2 seeds of JKCH 1947 were more toxic to H. armigera than those of JKCH Varun seeds. The seeds and leaves of F1s showed greater toxicity than the F2 seeds or leaves of one-toxin (cry1Ac) Bt cotton hybrids. However, no significant differences were observed for the two-toxin (cry1Ac and cry2Ab) hybrid, KDCHH 621. Toxicity of leaves to H. armigera increased with crop age, until 112 days after seedling emergence. The Bt trait purity in F1 seeds of four two-toxin Bt cotton hybrids ranged from 86.7 to 100%. The present study emphasizes the necessity of 95% Bt trait purity in seeds of transgenic cotton for sustainable crop production.