Health Financing Options for Sri Lanka: What, and Why?

The purpose of this paper is to renew and stimulate the national discourse on how to further Sri Lanka's aspirational goal of achieving Universal Health Coverage (UHC [1]) in line with the global sustainable development goals (SDG) to which Sri Lanka is a signatory. After a brief status update about UHC in Sri Lanka, the paper focuses on the financing function, justified on the basis of its central role in addressing the problems confronting the health system, in terms of its inherent inefficiencies as well as the specific context of the economic crisis which the country is currently facing. The paper argues for a well-managed prepaid, pooled health financing mechanism (such as the current tax-based system or social health insurance schemes), incorporating strategic purchasing approaches, leveraging the private sector (both for-profit and non-profit), in order to increase efficiency, equity and accountability by separating the financing and purchasing functions from service delivery.

Factors that Influence Placement of Gastrostomy Tube in Infants with Complex Congenital Heart Disease: A Single Center Study.

BACKGROUND: Factors that determine the need for Gastrostomy tube (G-tube) placement in infants with complex congenital heart defects (CHD) are variable. We aim to identify factors that improve counseling of expectant parents regarding postnatal outcomes and management. METHODS: We performed a retrospective review of medical record of infants with prenatal diagnoses of complex CHD between 2015-2019 in a single tertiary care center and assessed risk factors for G-tube placement with linear regression. RESULTS: Of the 105 eligible infants with complex CHD, 44 infants required G-tube (42%). No significant association was observed between G-tube placement and chromosomal abnormalities, cardiopulmonary bypass time or type of CHD. Median days on noninvasive ventilation (4 [IQR 2-12] vs. 3 [IQR 1-8], p = 0.035), time at which gavage-tube feeds were started postoperatively (3 [IQR 2-8] vs. 2 [IQR 0-4], p = 0.0013), time to reach full-volume gavage-tube feeds (6 [IQR 3-14] vs. 5 [IQR 0-8], p = 0.038) and intensive care unit (ICU) length of stay (LOS) (41 [IQR: 21 - 90] vs. 18 [IQR: 7 - 23], p < 0.01) were associated with G-tube placement. Infants with ICU LOS duration longer than median had almost 7 times the odds of requiring a G-tube (OR: 7.23, 95% CI: 2.71-19.32; by regression). CONCLUSIONS: Delay in initiation and in reaching full-volume gavage-tube feeds after cardiac surgery, increased number of days spent on non-invasive ventilation and in the ICU were found to be significant predictors for G-tube placement. The type of CHD and the need for cardiac surgery were not significant predictors for G-tube placement.

Trends in Practice Among Shoulder Specialists in the Management of Frozen Shoulder: A Consensus Survey.

Background: The management of frozen shoulder (FS) differs depending on experience level and variation between scientific guidelines and actual practice. Purpose: To determine the current trends and practices in the management of FS among shoulder specialists and compare them with senior shoulder specialists. Study Design: Consensus statement. Methods: A team of 15 senior shoulder specialists (faculty group) prepared a questionnaire comprising 26 questions regarding the definition, terminology, clinical signs, investigations, management, and prognosis of FS. The questionnaire was mailed to all the registered shoulder specialists of Shoulder and Elbow Society, India (SESI) (specialist group; n = 230), as well as to the faculty group (n = 15). The responses of the 2 groups were compared, and levels of consensus were determined: strong (>75%), broad (60%-74.9%), inconclusive (40%-59.9%), or disagreement (<40%). Result: Overall, 142 of the 230 participants in the specialist group and all 15 participants in the faculty group responded to the survey. Both groups strongly agreed that plain radiographs are required to rule out a secondary cause of FS, routine magnetic resonance imaging is not indicated to confirm FS, nonsteroidal anti-inflammatory drugs should be administered at bedtime, steroid injection (triamcinolone or methylprednisolone) is the next best option if analgesics fail to provide pain relief, passive physical therapy should be avoided in the freezing phase, <10% of patients would require any surgical intervention, and patients with diabetes and thyroid dysfunction tend to fare poorly. There was broad agreement that routine thyroid dysfunction screening is unnecessary for women, a single 40-mg steroid injection via intra-articular route is preferred, and arthroscopic capsular release (ACR) results in a better outcome than manipulation under anesthesia (MUA). Agreement was inconclusive regarding the use of combined random blood sugar (RBS) and glycosylated hemoglobin versus lone RBS to screen for diabetes in patients with FS, preference of ACR versus MUA to treat resistant FS, and the timing of surgical intervention. There was disagreement over the most appropriate term for FS, the preferred physical therapy modality for pain relief, the most important movement restriction for early diagnosis of FS, and complications seen after MUA. Conclusion: This survey summarized the trend in prevalent practices regarding FS among the shoulder specialists and senior shoulder surgeons of SESI.

Impact of early postnatal exposure of red blood cell transfusions on the severity of retinopathy of prematurity.

BACKGROUND: Postnatal exposure to red blood cell transfusion (RBCT) in premature infants is an important risk factor for Retinopathy of Prematurity (ROP) progression. We hypothesized that higher number and earlier timing of RBCT are associated with worse ROP severity and result in laser treatment at an earlier postmenstrual age (PMA) in very low birth weight (≤1500 g, VLBW) infants. METHODS: A retrospective medical record review of 631 VLBW infants over a 5-year period was performed. Demographic features and potential clinical risk factors including number of RBCT, ROP severity, and progression to laser treatment were collected to evaluate predictors of severe ROP. ANCOVA, pairwise post-hoc analyses, and multivariate regression were used to determine associations between frequency and timing of RBCT and ROP severity. RESULTS: Of the 456 eligible infants, 61 developed severe ROP (13%). There was significant correlation between number of RBCTs and ROP severity, adjusted for gestational age and birthweight (Adjusted R2 = 0.53; p < 0.001). Compared to infants with No/Mild and Type 2 ROP, infants with Type 1 ROP received more RBCTs, with higher number of RBCTs per week during the first month of life (mean RBCT in ROP No/Mild 5.7±0.4 vs Type 2 16.3±1.8 vs Type 1 22.4±1.5, p = 0.042). Laser-treated infants received a higher number of RBCTs than non-treated infants (mean RBCT 22.3 vs. 6.5, p < 0.001) but no correlation was observed between number of RBCTs and PMA at time of laser treatment. CONCLUSION: Higher number of RBCTs in early postnatal life of VLBW infants was associated with more severe ROP.

Management Guidelines for Infection After ACL Reconstruction: Expert Opinion Statement Based on the Modified Delphi Survey of Indian Arthroscopy Surgeons.

AIM: Infection after anterior cruciate ligament (ACL) reconstruction, though rare, is a potentially devastating complication and the evidence-based recommendation on the various topics in its management is limited. The purpose of this study was to develop recommendations for the prevention and management of infections in ACL reconstruction surgery by performing a structured expert consensus survey using Delphi methodology. MATERIALS AND METHODS: 22 topics of relevance in the prevention and management of infection following ACL reconstruction were chosen from an extensive literature review. 30 panelists were requested to respond to a three-round survey, with feedback, to develop a consensus statement on the topics. RESULTS: Consensus statements could be prepared in eleven out of twenty-two topics including: the graft is retained at the first arthroscopic debridement, the graft is removed when repeated debridement are needed, and revision ACL reconstruction is needed only if the patient develops instability. Concurrence could be obtained in the topics including: longer duration of antibiotics is needed in immunocompromised patients, soaking graft in antibiotic solution reduces infection risk, and knee swelling without warmth does not suggest infection. CONCLUSIONS: A proper skin preparation, a longer course of antibiotics in immunocompromised patients, and soaking the graft in antibiotics reduces the risk of infection. In case of infection, a healthy-looking graft must be retained at the first debridement and if the graft must be removed, revision ACL reconstruction is advised only if the patient develops instability. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00363-z.

Dural Venous Sinus Stenosis: Why Distinguishing Intrinsic-versus-Extrinsic Stenosis Matters.

BACKGROUND AND PURPOSE: Dural venous sinus stenosis has been associated with idiopathic intracranial hypertension and isolated venous pulsatile tinnitus. However, the utility of characterizing stenosis as intrinsic or extrinsic remains indeterminate. The aim of this retrospective study was to review preprocedural imaging of patients with symptomatic idiopathic intracranial hypertension and pulsatile tinnitus, classify the stenosis, and assess a trend between stenosis type and clinical presentation while reviewing the frequencies of other frequently seen imaging findings in these conditions. MATERIALS AND METHODS: MRVs of 115 patients with idiopathic intracranial hypertension and 43 patients with pulsatile tinnitus before venous sinus stent placement were reviewed. Parameters recorded included the following: intrinsic or extrinsic stenosis, prominent emissary veins, optic nerve tortuosity, cephalocele, sella appearance, poststenotic fusiform enlargement versus saccular venous aneurysm, and internal jugular bulb diverticula. χ2 cross-tabulation statistics were calculated and recorded for all data. RESULTS: Most patients with idiopathic intracranial hypertension (75 of 115 sinuses, 65%) had extrinsic stenosis, and most patients with pulsatile tinnitus (37 of 45 sinuses, 82%) had intrinsic stenosis. Marked optic nerve tortuosity was more common in idiopathic intracranial hypertension. Cephaloceles were rare in both cohorts, with an increased trend toward the presence in idiopathic intracranial hypertension. Empty sellas were more common in idiopathic intracranial hypertension. Cerebellar tonsils were similarly located at the foramen magnum level in both cohorts. Saccular venous aneurysms were more common in pulsatile tinnitus. Internal jugular bulb diverticula were similarly common in both cohorts. CONCLUSIONS: In this cohort, most patients with idiopathic intracranial hypertension had extrinsic stenosis, and most patients with pulsatile tinnitus had intrinsic stenosis. Awareness and reporting of these subtypes may reduce the underrecognition of potential contributory stenoses in a given patient's idiopathic intracranial hypertension or pulsatile tinnitus.

Decreased Sestrin levels in patients with type 2 diabetes and dyslipidemia and their association with the severity of atherogenic index.

PURPOSE: We earlier reported that Sestrin2 regulates monocyte activation and atherogenic events through AMPK-mTOR nexus under high-glucose and dyslipidemic conditions. However, the statuses of Sestrins in diabetes and dyslipidemia are not known. We report here on the status of Sestrins and their association with diabetic dyslipidemia and atherosclerosis. METHODS: Individuals with normal glucose tolerance (NGT) (n = 46), dyslipidemia (n = 42), and patients with Type 2 diabetes with (n = 41) and without dyslipidemia (n = 40) were recruited from a tertiary diabetes centre, Chennai, India to study the mRNA expression levels of Sestrins (1, 2, and 3) in monocytes by RT-qPCR. Serum levels of Sestrins were measured using ELISA. Atherogenic index of plasma was calculated as log (triglyceride/HDL). RESULTS: mRNA expressions of Sestrin1 and Sestrin3 were significantly reduced in monocytes under dyslipidemic conditions but not in diabetes condition. Interestingly, Sestrin2 mRNA expression was significantly reduced in all disease conditions including dyslipidemia, and diabetes with and without dyslipidemia. Sestrin2 mRNA levels were negatively correlated with glycemic and lipid parameters and plasma atherogenic index. Furthermore, circulatory Sestrin2 was also found to be significantly decreased in dyslipidemia (415.2 ± 44.7 pg/ml), diabetes (375 ± 45 pg/ml), and diabetes with dyslipidemia (319.2 ± 26.3 pg/ml) compared to NGT (706.3 ± 77 pg/ml) and negatively correlated with glycemic, lipid parameters, and plasma atherogenic index. CONCLUSION: We report for the first time that Sestrins levels are significantly decreased in diabetes and dyslipidemic conditions. More strikingly, Sestrin2 had a strong association with atherogenic risk factors and severity of atherogenic index and we suggest that Sestrin2 may be used as a biomarker for assessing atherogenesis.

Management of Talar Body Fractures.

Fractures of talar body are uncommon injuries often associated with fractures of other long bones and in polytraumatized patients. The integrity of the talus is essential for the normal function of the ankle, subtalar, and midtarsal joints. The relative infrequency of this injury limits the number of studies available to guide treatment. They occur as a result of high-velocity trauma and are therefore associated with considerable soft tissue damage. Axial compression with supination or pronation is the common mechanism of injury. Great care is necessary for diagnosing and treating these injuries. Clinically, talar body fractures present with soft tissue swelling, hematoma, deformity, and restriction of motion. Associated neurovascular injury of the foot should be carefully examined. The initial evaluation should be done with foot, and ankle radiographs and computed tomography is often done to analyze the extent of the fracture, displacement, intraarticular extension, comminution, and associated fractures. Differentiating talar neck from body fractures is important. Optimal treatment relies on an accurate understanding of the injury and the goals of treatment are the restoration of articular surface and axial alignment. Indications for nonoperative management are seldom indicated and are few as in nonambulatory patients, or in with multiple comorbidities who are not able to tolerate surgery. Splinting, followed by short leg casting for 6 weeks until fracture union should be undertaken. Surgery is indicated in most of the cases, and different approaches have been described. Sometimes, a dual approach with a malleolar osteotomy is necessary for articular restoration. Clinical outcomes depend on the severity of the initial injury and the quality of reduction and internal fixation. The various complications are avascular necrosis, malunion, infections, late osteoarthritis, and ankylosis of subtalar joint.

Reversible Dilation of the Superior Ophthalmic Vein in Intubated Patients.

BACKGROUND AND PURPOSE: Superior ophthalmic vein enlargement has typically been associated with increased intracranial or orbital pressure. This study evaluates the incidence of superior ophthalmic vein enlargement in intubated patients without pre-existing intracranial or intraorbital pathologies. MATERIALS AND METHODS: Two cohorts (patients with trauma and epilepsy patients undergoing stereotactic intracranial lead placement) who underwent CT while intubated and shortly following extubation and a cohort of 30 outpatients with a history of headache and normal head CT findings (healthy controls) were included. The superior ophthalmic vein diameter was measured on all scans. RESULTS: Seventy patients intubated for trauma and 45 patients with intraoperative CT were included (n = 115). While intubated, 66% of the total sample had at least unilateral superior ophthalmic vein dilation of >2.5 mm and 48% had bilateral dilation. Fifty-seven percent of patients with trauma and 84% of intraoperative patients with dilated superior ophthalmic veins showed reversal of mean superior ophthalmic vein dilation to <2.5 mm on postextubation CT. The mean superior ophthalmic vein diameter decreased an average of 1.2 mm following extubation. Changes in superior ophthalmic vein diameter between intubated and extubated states were statistically significant (P < .001). Differences between the control group and the extubated subjects were not statistically significant (P = .21). CONCLUSIONS: Bilateral dilation of the superior ophthalmic vein is common in intubated patients and usually reverses following extubation. In the appropriate clinical setting, this knowledge will prevent misinterpretation of prominent superior ophthalmic veins as automatically indicative of an underlying pathology.

Distributed Newton Methods for Deep Neural Networks.

Deep learning involves a difficult nonconvex optimization problem with a large number of weights between any two adjacent layers of a deep structure. To handle large data sets or complicated networks, distributed training is needed, but the calculation of function, gradient, and Hessian is expensive. In particular, the communication and the synchronization cost may become a bottleneck. In this letter, we focus on situations where the model is distributedly stored and propose a novel distributed Newton method for training deep neural networks. By variable and feature-wise data partitions and some careful designs, we are able to explicitly use the Jacobian matrix for matrix-vector products in the Newton method. Some techniques are incorporated to reduce the running time as well as memory consumption. First, to reduce the communication cost, we propose a diagonalization method such that an approximate Newton direction can be obtained without communication between machines. Second, we consider subsampled Gauss-Newton matrices for reducing the running time as well as the communication cost. Third, to reduce the synchronization cost, we terminate the process of finding an approximate Newton direction even though some nodes have not finished their tasks. Details of some implementation issues in distributed environments are thoroughly investigated. Experiments demonstrate that the proposed method is effective for the distributed training of deep neural networks. Compared with stochastic gradient methods, it is more robust and may give better test accuracy.

Endovascular treatment for acute basilar thrombosis via a transradial approach: Initial experience and future considerations.

Acute basilar artery occlusion (BAO) secondary to emergent large vessel occlusion (ELVO) has an extremely poor natural history, with a reported mortality rate up to 95%. Mechanical thrombectomy in the setting of ELVO is generally performed via a transfemoral approach. However, radial access is increasingly being utilized as an alternative. We report our initial multi-institutional experience using primary radial access in the treatment of acute BAO in nine consecutive cases. Technical success defined as a TICI score of 2B or 3 was achieved in 89% of cases. Average puncture to revascularization time was 35.8 minutes. There were no complications related to radial artery catheterization. We contend radial access should potentially be considered as the first-line approach given inherent advantages over femoral access for mechanical thrombectomy for BAO.

Phase I single dose, two-period and two-sequence cross-over trial to evaluate the relative bioavailability of two oral pimasertib formulations in advanced cancer patients.

PURPOSE: A phase I two-period two sequence cross-over study compared the bioavailability of two pimasertib (MSC1936369B/AS703026) formulations (capsule versus tablet) in advanced cancer patients. METHODS: Patients with advanced solid tumors were randomized to one of two treatment sequences utilizing pimasertib tablet (test; 3 × 20 mg, PO QD) and capsule (standard; 2 × 30 mg, PO QD). The trial comprised a screening and baseline period, two time periods or parts A and B, and a trial extension phase. RESULTS: N = 38 patients were randomized to two treatment sequences S1 and S2. PK parameters t 1/2, CL/f, and V z/f were within the same range for the two formulations. Tablet had bioavailability comparable to capsule based on the analysis of AUC0-t, however, tablet administration resulted in an increase of ~25% in C max versus capsule. Common predicted adverse events of pimasertib included ocular events, diarrhea and creatine phosphokinase elevation. Disease control rate was ~29% with 1 partial response and 4 of 10 patients with stable disease >4 months. CONCLUSIONS: Pimasertib tablet was overall well tolerated, had a similar safety and efficacy profile to standard capsule formulation and had bioavailability comparable to capsule.

Ecological risk assessment of trace metal accumulation in sediments of Veraval Harbor, Gujarat, Arabian Sea.

In this study, different types of indices were used to assess the ecological risk of trace metal contamination in sediments on the basis of sediment quality guidelines at Veraval Fishery Harbor. Sediment samples were collected from three sectors in pre-, post-, and monsoon seasons in 2006. Trace metal concentrations were higher in the inner sector during post-monsoon, and it showed the highest statistical significance (p<0.01) among the stations. Pollution load index was higher than unity, indicating alternation by effluent discharge from industries. Enrichment factor and geo-accumulation index showed that Cd, Pb, and Zn were enriched in the northern part of the harbor and Pb had accumulated in the harbor sediment. The ecological risk assessment index revealed that Ni, Zn, and Pb were higher than the effect range median values, indicating their potential toxicity to the aquatic environment in the Veraval Harbor. Hence, the harbor is dominated by anthropogenic activities rather than natural process.

Medial Open Wedge High Tibial Osteotomy for Varus Malunited Tibial Plateau Fractures.

PURPOSE: To analyze radiologic and functional outcomes of varus malunited tibial plateau fractures managed with medial open wedge high tibial osteotomy (MOHTO). METHODS: Eighteen patients with symptomatic varus malunited tibial plateau fractures with less than stage II arthritic changes managed from July 2009 to October 2013 were included. Patients with complex intra-articular step malunions and severe arthritic changes (stage III and IV) were excluded. Initially, diagnostic arthroscopy was performed followed by MOHTO stabilized with locking plate and tricortical autograft (n = 11, 61%) or a Puddu plate and allograft (n = 7, 39%). Patients were evaluated radiologically for union, medial proximal tibial angle, and tibial slope angle, and functional assessment was performed with a knee outcome survey based on activities of daily living. RESULTS: The mean follow-up duration was 41.7 ± 12.1 months (range 25-61); all patients achieved radiologic union by a mean duration of 4.3 ± 1.2 months (range 3-8). The mean medial proximal tibial angle improved from 75.3° ± 3.7° (range 70.5°-85.2°) to a postoperative angle of 83.8° ± 3.6° (range 77.5°-90.4°) (P < .001). In 12 patients, an abnormal mean anterior slope of -5.5° ± 3.0° (range -1.1° to -13°) was corrected to a postoperative posterior slope of 5.8° ± 4.4° (range -1.1° to 14.1°) (P < .001). In 6 patients, a mean posterior slope of 17.4° ± 10.5° (range 1.4°-33°) was corrected to a postoperative posterior slope of 14.08° ± 5.6° (range 7.4-21.3) (P = .214). The mean knee outcome survey scores preoperatively were 25% ± 9.68% (range 8%-48%) and postoperatively were 85% ± 11.18% (range -52% to 98%, P < .001). CONCLUSIONS: MOTHO for varus malunited tibial plateau fractures is safe and effective procedure that provides excellent functional outcomes, acceptable radiologic outcomes, and carries minimal complications. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Is height the best predictor for adequacy of semitendinosus-alone anterior cruciate ligament reconstruction? A study of hamstring graft dimensions and anthropometric measurements.

PURPOSE: To predict adequacy of semitendinosus (ST) graft dimension for ACLR from anthropometric measures. INTRODUCTION: Single tendon harvest for autograft hamstring ACLR could be beneficial to limit donor site morbidity; however, concerns for reconstruction failure based upon inadequate graft size may limit this surgical technique. METHODOLOGY: To predict adequacy, prospectively, 108 patients who underwent ACLR by hamstring graft (STG graft) were enrolled for the study. Mean age was 33.028 years ± 9.539 SD (14-59) with 88 males and 20 females. Anthropometric measurements (height, weight, BMI, thigh and total limb length) and intraoperative data (graft dimensions and bone tunnel measurements) were collected for analysis. Semitendinosus graft can be used as 3-strand (ST3) or 4-strand (ST4) graft. Adequacy criteria for ST3 and ST4 graft dimensions were determined from data analysis. SPSS (v.17) Pearson's correlation coefficient and ROC curves were used for statistical analyses. RESULTS: A total of 74 out of 108 patients (68.52 %) had adequate graft dimensions for ST3 reconstruction. Height equal or greater than 158 cm was predictive of adequate graft for ST3 reconstruction. Only 23 patients (21.3 %) had adequate graft dimensions for ST4 reconstruction. Height equal or greater than 170 cm was predictive of adequate graft for ST4 reconstruction. Height variable had the highest ROC curve area of 0.840 and 0.910 for both ST3 graft and ST4 graft, respectively. Hence, height was used as best predictor to determine adequacy of the graft. CONCLUSION: Height can be predictive of adequate graft for single tendon ACL reconstruction.

Ipsilateral Hip and Knee Dislocation with Open Tibial Fracture: A Case Report of a Limb Threatening Injury.

INTRODUCTION: Hip or knee dislocations are usually treated as a surgical emergency, but ipsilateral hip and knee dislocation should be considered a dual emergency that must be addressed immediately and reduced at the earliest. We present here the sequence of events and the final functional outcome of one such rare injury manages by us. CASE REPORT: A 22-year-old male was involved in a road traffic accident. He presented to the emergency department in 4 h injury time with painful deformities of the right hip and knee, along with Type I open wound right leg with abnormal mobility suggestive of fracture in the ipsilateral leg. CONCLUSION: Simultaneous ipsilateral hip and knee fracture-dislocation with open tibial fracture is a rare injury that should be approached as limb-threatening injury and dual orthopedic emergency. We report this case for its rarity and to document that good results can be achieved with early appropriate treatment.

A Simple Label Switching Algorithm for Semisupervised Structural SVMs.

In structured output learning, obtaining labeled data for real-world applications is usually costly, while unlabeled examples are available in abundance. Semisupervised structured classification deals with a small number of labeled examples and a large number of unlabeled structured data. In this work, we consider semisupervised structural support vector machines with domain constraints. The optimization problem, which in general is not convex, contains the loss terms associated with the labeled and unlabeled examples, along with the domain constraints. We propose a simple optimization approach that alternates between solving a supervised learning problem and a constraint matching problem. Solving the constraint matching problem is difficult for structured prediction, and we propose an efficient and effective label switching method to solve it. The alternating optimization is carried out within a deterministic annealing framework, which helps in effective constraint matching and avoiding poor local minima, which are not very useful. The algorithm is simple and easy to implement. Further, it is suitable for any structured output learning problem where exact inference is available. Experiments on benchmark sequence labeling data sets and a natural language parsing data set show that the proposed approach, though simple, achieves comparable generalization performance.

Ganga hospital open injury score in management of open injuries.

INTRODUCTION: Open injuries of the limbs offer challenges in management as there are still many grey zones in decision making regarding salvage, timing and type of reconstruction. As a result, there is still an unacceptable rate of secondary amputations which lead to tremendous waste of resources and psychological devastation of the patient and his family. Gustilo Anderson's classification was a major milestone in grading the severity of injury but however suffers from the disadvantages of imprecise definition, a poor interobserver correlation, inability to address the issue of salvage and inclusion of a wide spectrum of injuries in Type IIIb category. Numerous scores such as Mangled Extremity Severity Score, the Predictive Salvage Index, the Limb Salvage Index, Hannover Fracture Scale-97 etc have been proposed but all have the disadvantage of retrospective evaluation, inadequate sample sizes and poor sensitivity and specificity to amputation, especially in IIIb injuries. METHODS: The Ganga Hospital Open Injury Score (GHOIS) was proposed in 2004 and is designed to specifically address the outcome in IIIb injuries of the tibia without vascular deficit. It evaluates the severity of injury to the three components of the limb--the skin, the bone and the musculotendinous structures separately on a grade from 0 to 5. Seven comorbid factors which influence the treatment and the outcome are included in the score with two marks each. The application of the total score and the individual tissue scores in management of IIIB injuries is discussed. RESULTS: The total score was shown to predict salvage when the value was 14 or less; amputation when the score was 17 and more. A grey zone of 15 and 16 is provided where the decision making had to be made on a case to case basis. The additional value of GHOIS was its ability to guide the timing and type of reconstruction. A skin score of more than 3 always required a flap and hence it indicated the need for an orthoplastic approach from the index procedure. Bone score of 4 and 5 will require complex reconstruction procedures like bone transport, extensive bone grafting or free fibular graft. Regarding the timing of reconstruction, injuries with a score of 9 or less indicated a low violence trauma and were amenable for early soft tissue reconstruction whereas injuries with a score of 10 or more indicated high violence injuries where a staged reconstruction policy must be followed. CONCLUSIONS: Ganga Hospital Open Injury Score was found to be highly useful in decision making regarding salvage in IIIB injuries. The individual tissue scores were also useful to provide guidance regarding the timing and type of bone and soft tissue reconstruction.

Early MRI Characteristics after MRI-Guided Laser-Assisted Cingulotomy for Intractable Pain Control.

BACKGROUND AND PURPOSE: Cingulotomy is a well-accepted stereotactic procedure in the treatment of debilitating pain syndromes. At our institution, we used a 980-nm diode laser to perform MR imaging-guided laser-assisted cingulotomy. We report the early MR imaging changes associated with this technique. MATERIALS AND METHODS: In this retrospective analysis, MR imaging-guided laser-assisted cingulotomy was performed in 4 patients with intractable pain secondary to metastatic disease. Patients were imaged at various time points postprocedure, with visual analysis of MR imaging changes in the cingulate gyri during that timeframe. RESULTS: Twenty-four hours postablation, 4 distinct zones of concentric rings reminiscent of an "owl eye" shape were noted in the cingulate gyri. Extrapolating from the imaging characteristics of the rings, we defined each zone as follows: The central zone (zone 1) represents a laser probe void with fluid, zones 2 and 3 have signal characteristics that represent hemorrhage and leaked protein, and zone 4 has a peripheral ring of acute infarction, enhancement, and surrounding edema. One patient with 1-year follow-up showed persistent concentric rings with resolution of enhancement and edema. CONCLUSIONS: Post-MR imaging-guided laser-assisted cingulotomy rings appear to represent a continuum of injury created by the laser probe and thermal injury. The imaging changes are similar to those described for laser ablation of tumor-infiltrated brain with a 1064-nm laser. This is the first study to characterize early MR imaging changes after MR imaging-guided laser-assisted cingulotomy by using a 980-nm laser. It is important for neuroradiologists and neurosurgeons to understand expected imaging findings as laser ablation cingulotomy re-emerges to treat intractable pain.