Increased vascularization during early healing after biologic augmentation in repair of chronic rotator cuff tears using autologous leukocyte- and platelet-rich fibrin (L-PRF): a prospective randomized controlled pilot trial

HYPOTHESIS We hypothesized that arthroscopic rotator cuff repairs using leukocyte- and platelet-rich fibrin (L-PRF) in a standardized, modified protocol is technically feasible and results in a higher vascularization response and watertight healing rate during early healing. METHODS Twenty patients with chronic rotator cuff tears were randomly assigned to 2 treatment groups. In the test group (N = 10), L-PRF was added in between the tendon and the bone during arthroscopic rotator cuff repair. The second group served as control (N = 10). They received the same arthroscopic treatment without the use of L-PRF. We used a double-row tension band technique. Clinical examinations including subjective shoulder value, visual analog scale, Constant, and Simple Shoulder Test scores and measurement of the vascularization with power Doppler ultrasonography were made at 6 and 12 weeks. RESULTS There have been no postoperative complications. At 6 and 12 weeks, there was no significant difference in the clinical scores between the test and the control groups. The mean vascularization index of the surgical tendon-to-bone insertions was always significantly higher in the L-PRF group than in the contralateral healthy shoulders at 6 and 12 weeks (P = .0001). Whereas the L-PRF group showed a higher vascularization compared with the control group at 6 weeks (P = .001), there was no difference after 12 weeks of follow-up (P = .889). Watertight healing was obtained in 89% of the repaired cuffs. DISCUSSION/CONCLUSIONS Arthroscopic rotator cuff repair with the application of L-PRF is technically feasible and yields higher early vascularization. Increased vascularization may potentially predispose to an increased and earlier cellular response and an increased healing rate.

Imported human rabies in Switzerland, 2012: a diagnostic conundrum

Human rabies is rare in Western Europe. It is not easily recognized in the absence of a history of exposure. We describe the clinical course, diagnosis and follow-up of an imported human rabies case in Switzerland. The patient, a U.S. citizen, presented at an outpatient clinic in Iraq with pain in his right shoulder on July 5, 2012. On July 8 he was transferred to a hospital in the United Arab Emirates, where he exhibited progressive encephalitis with coma. On July 29, he was transferred to a hospital in Switzerland, where he died on July 31, 2012. The autopsy showed severe encephalitis. Rabies was diagnosed by the rapid fluorescent focus inhibition test (RFFIT) and confirmed by fluorescence antibody testing (FAT) in brain smears and immunohistochemistry on paraffin-embedded brain sections. The viral strain was characterized by RT-PCR followed by sequencing and phylogenetic analysis as an American bat rabies strain associated with Tadarida brasiliensis. Close contacts and exposed health care workers received postexposure prophylaxis (PEP).

Effects of arm training with the robotic device ARMin I in chronic stroke: three single cases

BACKGROUND: Several clinical studies on chronic stroke conducted with end-effector-based robots showed improvement of the motor function in the affected arm. Compared to end-effector-based robots, exoskeleton robots provide improved guidance of the human limb and are better suited to train task-oriented movements with a large range of motions. OBJECTIVE: To test whether intensive arm training with the arm exoskeleton ARMin I is feasible with chronic-stroke patients and whether it improves motor function in the paretic arm. METHODS: Three single cases with chronic hemiparesis resulting from unilateral stroke (at least 14 months after stroke). A-B design with 2 weeks of multiple baseline measurements (A), 8 weeks of training (B) with repetitive measurements and a follow-up measurement 8 weeks after training. The training included shoulder and elbow movements with the robotic rehabilitation device ARMin I. Two subjects had three 1-hour sessions per week and 1 subject received five 1-hour sessions per week. The main outcome measurement was the upper-limb part of the Fugl-Meyer Assessment (FMA). RESULTS: The ARMin training was well tolerated by the patients, and the FMA showed moderate, but significant improvements for all 3 subjects (p < 0.05). Most improvements were maintained 8 weeks after discharge. CONCLUSIONS: This study indicates that intensive training with an arm exoskeleton is feasible with chronic-stroke patients. Moderate improvements were found in all 3 subjects, thus further clinical investigations are justified.

Effects of intensive arm training with the rehabilitation robot ARMin II in chronic stroke patients: four single-cases

BACKGROUND: Robot-assisted therapy offers a promising approach to neurorehabilitation, particularly for severely to moderately impaired stroke patients. The objective of this study was to investigate the effects of intensive arm training on motor performance in four chronic stroke patients using the robot ARMin II. METHODS: ARMin II is an exoskeleton robot with six degrees of freedom (DOF) moving shoulder, elbow and wrist joints. Four volunteers with chronic (>or= 12 months post-stroke) left side hemi-paresis and different levels of motor severity were enrolled in the study. They received robot-assisted therapy over a period of eight weeks, three to four therapy sessions per week, each session of one hour.Patients 1 and 4 had four one-hour training sessions per week and patients 2 and 3 had three one-hour training sessions per week. Primary outcome variable was the Fugl-Meyer Score of the upper extremity Assessment (FMA), secondary outcomes were the Wolf Motor Function Test (WMFT), the Catherine Bergego Scale (CBS), the Maximal Voluntary Torques (MVTs) and a questionnaire about ADL-tasks, progress, changes, motivation etc. RESULTS: Three out of four patients showed significant improvements (p < 0.05) in the main outcome. The improvements in the FMA scores were aligned with the objective results of MVTs. Most improvements were maintained or even increased from discharge to the six-month follow-up. CONCLUSION: Data clearly indicate that intensive arm therapy with the robot ARMin II can significantly improve motor function of the paretic arm in some stroke patients, even those in a chronic state. The findings of the study provide a basis for a subsequent controlled randomized clinical trial.

Precipitation over the past four centuries in the Dieshan Mountains as inferred from tree rings: An introduction to an HHT-based method

To improve our understanding of the Asian monsoon system, we developed a hydroclimate reconstruction in a marginal monsoon shoulder region for the period prior to the industrial era. Here, we present the first moisture sensitive tree-ring chronology, spanning 501 years for the Dieshan Mountain area, a boundary region of the Asian summer monsoon in the northeastern Tibetan Plateau. This reconstruction was derived from 101 cores of 68 old-growth Chinese pine (Pinus tabulaeformis) trees. We introduce a Hilbert–Huang Transform (HHT) based standardization method to develop the tree-ring chronology, which has the advantages of excluding non-climatic disturbances in individual tree-ring series. Based on the reliable portion of the chronology, we reconstructed the annual (prior July to current June) precipitation history since 1637 for the Dieshan Mountain area and were able to explain 41.3% of the variance. The extremely dry years in this reconstruction were also found in historical documents and are also associated with El Niño episodes. Dry periods were reconstructed for 1718–1725, 1766–1770 and 1920–1933, whereas 1782–1788 and 1979–1985 were wet periods. The spatial signatures of these events were supported by data from other marginal regions of the Asian summer monsoon. Over the past four centuries, out-of-phase relationships between hydroclimate variations in the Dieshan Mountain area and far western Mongolia were observed during the 1718–1725 and 1766–1770 dry periods and the 1979–1985 wet period.

Die Untersuchung der Schulter in der Praxis

Liegt die Ursache von Schmerzen oder Funktionseinbussen im Schulterbereich selbst, können diese mit einer präzisen klinischen Untersuchung in den meisten Fällen einer bestimmten anatomischen Struktur zugeordnet werden. Vorwiegend im Bild, mit nur knappem Text, werden die einzelnen Tests dargestellt. Dabei wurde zur besseren Merkfähigkeit die jeweils getestete Struktur mit eingezeichnet. Auch die häufigsten in der Praxis vorkommenden Trigger-Punkte mit der entsprechenden pseudoradikulären Symptomatik werden dargestellt. Ziel dieses Artikels ist die Erleichterung der täglichen Arbeit in der Praxis bei häufigen Schulterproblemen.

Risk adjustment in aging societies

Background In Switzerland, age is the predominant driver of solidarity transfers in risk adjustment (RA). Concerns have been voiced regarding growing imbalances in cost sharing between young and old insured due to demographic changes (larger fraction of elderly >65 years and rise in average age). Particularly young adults aged 19–25 with limited incomes have to shoulder increasing solidarity burdens. Between 1996 and 2011, monthly intergenerational solidarity payments for young adults have doubled from CHF 87 to CHF 182, which corresponds to the highest absolute transfer increase of all age groups. Results By constructing models for age-specific RA growth and for calculating the lifetime sum of RA transfers we investigated the causes and consequences of demographic changes on RA payments. The models suggest that the main driver for RA increases in the past was below average health care expenditure (HCE) growth in young adults, which was only half as high (average 2% per year) compared with older adults (average 4% per year). Shifts in age group distributions were only accountable for 2% of the CHF 95 rise in RA payments. Despite rising risk adjustment debts for young insured the balance of lifetime transfers remains positive as long as HCE growth rates are greater than the discount rate used in this model (3%). Moreover, the life-cycle model predicts that the lifetime rate of return on RA payments may even be further increased by demographic changes. Nevertheless, continued growth of RA contributions may overwhelm vulnerable age groups such as young adults. We therefore propose methods to limit the burden of social health insurance for specific age groups (e.g. young adults in Switzerland) by capping solidarity payments. Conclusions Taken together, our mathematical modelling framework helps to gain a better understanding of how demographic changes interact with risk adjustment and how redistribution of funds between age groups can be controlled without inducing further selection incentives. Those methods can help to construct more equitable systems of health financing in light of population aging.

Extracorporeal shockwave therapy in a dog with chronic bicipital tenosynovitis

A 15-month-old, spayed female, Bernese mountain dog was presented to the Institute of Small Animal Surgery at the University of Zurich because of chronic left forelimb lameness. The referring veterinarian diagnosed pain in the left shoulder region and had treated the dog with systemic non-steroidal anti-inflammatory drugs and restricted exercise for a two-week period. The follow-up examination revealed only minimal improvement and therefore, the dog was referred for further diagnostic evaluation. Chronic bicipital tenosynovitis and tendinitis of the infraspinatus muscle was diagnosed based on survey radiographs, arthrography, ultrasound, computed tomography (CT), and synovial fluid cytology. The dog underwent three sessions of extracorporeal shockwave therapy and substantial clinical improvement was observed. On follow-up examinations, only mild left forelimb lameness was evident following exercise, and changes in the intertubercular groove and at the supraglenoid tuberosity appeared less active on radiographs and CT. However, six months following treatment, mild degenerative joint disease was apparent.

Radiographic bone level changes of implant-supported restorations in edentulous and partially dentate patients: 5-year results.

PURPOSE To evaluate and compare crestal bone level changes and peri-implant status of implant-supported reconstructions in edentulous and partially dentate patients after a minimum of 5 years of loading. MATERIALS AND METHODS All patients who received a self-tapping implant with a microstructured surface during the years 2003 and 2004 at the Department of Prosthodontics, University of Bern, were included in this study. The implant restorations comprised fixed and removable prostheses for partially and completely edentulous patients. Radiographs were taken immediately after surgery, at impression making, and 1 and 5 years after loading. Crestal bone level (BIC) was measured from the implant shoulder to the first bone contact, and changes were calculated over time (ΔBIC). The associations between pocket depth, bleeding on probing (BOP), and ΔBIC were assessed. RESULTS Sixty-one implants were placed in 20 patients (mean age, 62 ± 7 years). At the 5-year follow-up, 19 patients with 58 implants were available. Implant survival was 98.4% (one early failure; one patient died). The average ΔBIC between surgery and 5-year follow-up was 1.5 ± 0.9 mm and 1.1 ± 0.6 mm for edentulous and partially dentate patients, respectively. Most bone resorption (50%, 0.7 mm) occurred during the first 3 months (osseointegration) and within the first year of loading (21%, 0.3 mm). Mean annual bone loss during the 5 years of loading was < 0.12 mm. Mean pocket depth was 2.6 ± 0.7 mm. Seventeen percent of the implant sites displayed BOP; the frequency was significantly higher in women. None of the variables were significantly associated with crestal bone loss. CONCLUSION Crestal bone loss after 5 years was within the normal range, without a significant difference between edentulous and partially dentate patients. In the short term, this implant system can be used successfully for various prosthetic indications.

Relationship of individual scapular anatomy and degenerative rotator cuff tears.

BACKGROUND The etiology of rotator cuff disease is age related, as documented by prevalence data. Despite conflicting results, growing evidence suggests that distinct scapular morphologies may accelerate the underlying degenerative process. The purpose of the present study was to evaluate the predictive power of 5 commonly used radiologic parameters of scapular morphology to discriminate between patients with intact rotator cuff tendons and those with torn rotator cuff tendons. METHODS A pre hoc power analysis was performed to determine the sample size. Two independent readers measured the acromion index, lateral acromion angle, and critical shoulder angle on standardized anteroposterior radiographs. In addition, the acromial morphology according to Bigliani and the acromial slope were determined on true outlet views. Measurements were performed in 51 consecutive patients with documented degenerative rotator cuff tears and in an age- and sex-matched control group of 51 patients with intact rotator cuff tendons. Receiver operating characteristic analyses were performed to determine cutoff values and to assess the sensitivity and specificity of each parameter. RESULTS Patients with degenerative rotator cuff tears demonstrated significantly higher acromion indices, smaller lateral acromion angles, and larger critical shoulder angles than patients with intact rotator cuffs. However, no difference was found between the acromial morphology according to Bigliani and the acromial slope. With an area under the receiver operating characteristic curve of 0.855 and an odds ratio of 10.8, the critical shoulder angle represented the strongest predictor for the presence of a rotator cuff tear. CONCLUSION The acromion index, lateral acromion angle, and critical shoulder angle accurately predict the presence of degenerative rotator cuff tears.

Bone loss after ridge expansion with or without reflection of the periosteum.

OBJECTIVE To evaluate the role of the periosteum in preserving the buccal bone after ridge splitting and expansion with simultaneous implant placement. MATERIAL AND METHODS In 12 miniature pigs, the mandibular premolars and first molars were removed together with the interdental bone septa and the buccal bone. Three months later, ridge splitting and expansion of the buccal plate was performed with simultaneous placement of two titanium implants per quadrant. Access by a mucosal flap (MF) was prepared on test sides, while a mucoperiosteal flap (MPF) with complete denudation of the buccal bone was increased on control sides. After healing periods of six and 12 weeks, the animals were sacrificed for histologic and histometric evaluation. RESULTS In the MF group, all 16 implants were osseointegrated, while in the MPF group, four of 16 implants were lost. Noticeable differences of bone levels on the implant surface and of the bone crest (BC) were found between the MF and the MPF group. Buccally after 6 weeks, the median distance between the implant shoulder (IS) and the coronal-most bone on the implant (cBIC) was for the MF group -1.42 ± 0.42 mm and for the MPF group -4.80 ± 2.72 mm (P = 0.15). The median distance between the IS and the buccal BC was -1.24 ± 0.51 mm and -2.78 ± 1.98 mm (P = 0.12) for the MF and MPF group, respectively. After 12 weeks, median IS-cBIC was -2.12 ± 0.84 mm for MF and -7.19 mm for MPF, while IS-BC was -2.08 ± 0.79 mm for MF and -5.96 mm for MPF. After 6 weeks, the median buccal bone thickness for MF and MPF was 0.01 and 0 mm (P < 0.001) at IS, 1.48 ± 0.97 mm and 0 ± 0.77 mm (P = 0.07) at 2 mm apical to IS, and 2.12 ± 1.19 mm and 1.72 ± 01.50 mm (P = 0.86) at 4 mm apical to IS, respectively. After 12 weeks, buccal bone thickness in the MF group was 0 mm at IS, 0.21 mm at 2 mm apical to IS, and 2.56 mm at 4 mm apical to IS, whereas complete loss of buccal bone was measured from IS to 4 mm apical to IS for the MPF group. CONCLUSIONS In this ridge expansion model in miniature pigs, buccal bone volume was significantly better preserved when the periosteum remained attached to the bone.

Material culture entanglements of early wetland sites in central Switzerland (4300-3850 BC)

In central Switzerland, the earliest wetland settlements with definitely attested finds and features date into the second half of the 5th millennium BC. Combining the information they have yielded with that from dryland sites, we can construct a detailed picture of material culture at the turn of the 5th to the 4th millennium. On this basis, the definition of clearly delimited archaeological cultures seems questionable, not only from a theoretical point of view. Similiarities and differences in the pottery show small-scale regional units defined via vessel forms as well as stylistic and technological aspects. Yet there are also inter-regional connections: roundbased vessels with opposing handles are typical for Lake Zurich, central and western Switzerland, the Valais and the central Rhône valley. In turn, ‘foreign‘ types such as shoulder-band beakers indicate regular connections between groups living in central Switzerland and those in Alsace and southern Germany. Are these beakers ‘imports‘ or locally produced items (‘imitations‘) indicating the adoption of ‘foreign‘ vessel types and concepts? This and similar material culture phenomena result in a picture of many material entanglements and problematise the kinds of relationships and mobility which might have existed. Our paper addresses these questions and discusses how and whether these interwoven connections changed in the early 4th millennium.

New osseous soft markers for trisomy 13, 18 and 21

INTRODUCTION For ultrasonographic diagnosis of a fetal trisomy so-called "soft markers" (=ultrasonographically detectable morphological variants) are used. Detection of a certain number of them increases the diagnostic certainty of a fetal trisomy. Up to now there are very few diagnostically accepted osseous soft markers for trisomy. Hence potential osseous soft markers applicable for first and second trimester ultrasound screening for trisomy 21, 18 or 13 were studied. METHODS Postmortal fetal X-rays (ap, lateral) of 358 fetuses (trisomy 21: n = 109, trisomy 18: n = 46; trisomy 13: n = 38, control group: n = 165). RESULTS Not yet described but with trisomy 21 statistically associated soft markers were un-timely os sternale ossification, delayed os sacrum ossification, shortened os maxillare, reduced os maxillare-jaw-corner distance, augmented orbita height, premature os calcaneus ossification, bell-shaped thorax, coronal clefts, trend to wider binocular as well as wider intraocular distances; for trisomy 18: elevated clavicula slope, reduced number of ribs, bell-shaped thorax, coronal clefts, reduced os maxillare-jaw-corner distance, shortened ramus mandibulare, shortened os metacarpale IV and V, augmented ratio between biparietal diameter and (osseus and soft-tissue) shoulder width; for trisomy 13: longer os nasale, elevated clavicula slope, premature sternum, delayed os sacrum ossification, delayed/premature cranium ossification, reduced number of ribs, coronal clefts, reduced os maxillare-jaw-corner distance, shortened ramus mandibulare, augmented orbita height, shortened os metacarpale V and a tendency for a shortened os metacarpale IV. CONCLUSION We found several not yet published osseous soft markers statistically associated with trisomy 21, 18 and 13, which can help to ensure sonographically these aneuploidy diagnoses.