Interrater reliability of physical examination tests in the acute phase of shoulder injuries.

BACKGROUND: The physical examination is one of the cornerstones of the diagnostic process in patients with acute shoulder injuries. The discriminative properties of a given examination test depend both on its validity and reliability. The aim of the present study was to assess the interrater reliability of 13 physical examination manoeuvres for acute rotator cuff tears in patients with acute soft tissue shoulder injuries. METHODS: In a large walk-in orthopaedic emergency department, 120 consecutive patients ≥40 years of age were included in a diagnostic study. Patients who had follow-up within three weeks of an acute shoulder injury without fracture on radiographs were eligible. Four emergency department physicians participated as examiners. In a subset of 48 patients, the physical examination tests were performed by two physicians, randomly chosen by their work rotation. The physicians were blinded to the findings of each other and the results of the ultrasound screening. The interrater reliability was assessed by Cohen's kappa, intraclass correlation coefficient (ICC), standard error of measurement (SEM) and Bland-Altman plots depending on whether the examination test result was registered as a binary, ordered categorical or continuous numerical variable. RESULTS: The median age was 55.5 years, 46% were female. Twenty-seven percent had a rotator cuff full-thickness tear on ultrasound screening; all but one involved the supraspinatus tendon. Cohen's kappa for binary tests ranged from excellent to fair. Excellent agreement (kappa > 0.8) was found for the inability to abduct above 90° and abduction strength. External rotation strength expressed substantial agreement (kappa 0.7). The lowest scores were registered for Hawkins` test and the external rotation lag sign (kappa 0.25 and 0.40, respectively). The ICCs for active range of abduction and external rotation were 0.93 (0.88-0.96) and 0.84 (0.72-0.91), whereas the SEM was 15 and 9, respectively. CONCLUSIONS: The results indicate that examination manoeuvres assessing abduction and external rotation range of motion and strength are more reliable than manoeuvres assessing pain in patients in the acute phase of traumatic shoulder injury. The poor agreement observed is likely to limit the validity in the present setting of two commonly used tests. TRIAL REGISTRATION: The Norwegian Regional Ethics Committee South East ( 2015/195 ).

Effect of structure and interlayer diffusion in organic position sensitive photodetectors based on complementary wedge donor/acceptor layers.

We have developed organic photodetectors based on two complementary wedge layers made of CuPc and C60 and observed a strong spatial dependence of the spectral response on the position of the incident light spot. Photocurrent measurements are correlated with atomic force microscopy (AFM), micro-Raman and ellipsometry maps in order to provide insights into the local donor/acceptor concentration, layer thickness and nature of the donor-acceptor interface along the direction of the thickness gradient. Deviations in spatial dependence between experimental photocurrent values and those predicted with a model assuming a sharp and well defined organic-organic interface are discussed in terms of inter-diffusion layers.

Diagnosis and management of gallbladder calculus disease.

BACKGROUND: The number and rate of cholecystectomy are increasing worldwide, although indications for operative treatment remain empirical, and several issues in the understanding of the condition are not concisely outlined. Our intention is to summarize and interpret current opinion regarding the indications and timing of cholecystectomy in calculous gallbladder disease. METHODS: Publications concerned with gallstone disease and related topics were searched for in MEDLINE using PubMed and summarized according to clinical scenarios with an emphasis on recent research. RESULTS: Only one randomized controlled trial has investigated the management (conservative vs. surgery) of patients with acute cholecystitis and several have compared early with deferred surgery. Two RCTs have examined treatment of uncomplicated, symptomatic gallstone disease. Apart from these, the overwhelming majority of publications are retrospective case series. CONCLUSIONS: Recent literature confirms that cholecystectomy for an asymptomatic or incidental gallstone is not justified. Symptomatic, uncomplicated gallstone disease may be classified into four severity groups based on severity and frequency of pain attacks, which may guide indication for cholecystectomy. Most patients below the age of 70 seem to prefer operative treatment. Acute cholecystitis may be treated with early operation if reduction of hospital days is an issue. Patients older than 70 years with significant comorbidities may forego surgical treatment without undue hazard. Symptoms following cholecystectomy remain in 25% or more and recent evidence suggest these are caused by a functional gastrointestinal disorder.

Increased cancer incidence in some gallstone diseases, and equivocal effect of cholecystectomy: a long-term analysis of cancer and mortality.

BACKGROUND: Our aim was to investigate cancer incidence and the cause of long-term mortality in different gallstone diseases and conditions. STUDY DESIGN: The study population consisted of 2034 subjects: 224 persons diagnosed with asymptomatic gallstones in 1983, 254 patients who underwent cholecystectomy in 1983, and 513 patients with symptomatic uncomplicated gallstones (SGS, n = 337) or acute cholecystitis (AC, n = 176) between 1992 and 1994. One thousand and forty-three people who participated in a population study in 1983 were controls. RESULTS: An overall increased risk of cancer, as well as higher mortality, was found among persons with asymptomatic gallstones compared to controls (HR 1.46, 95% CI: 1.06-2.00 and HR 1.39, 95% CI: 1.08-1.78), whereas patients who underwent cholecystectomy in 1983 showed a slightly higher risk (not significant) for both cancer and death than controls. Among patients with SGS from 1992 to 1994 there was a significantly higher risk of contracting cancer in patients who had undergone surgery (HR = 2.56, 95% CI: 1.13-5.83). For patients with AC, there was no significant difference between surgically treated and non-surgically treated subjects, but there was a higher risk of cancer in all AC compared to SGS patients (HR 2.03, 95% CI: 1.20-3.43). Mortality did not differ significantly between surgically treated and non-surgically treated patients with SGS or AC. CONCLUSION: Gallstone patients had a greater risk than the general population for developing cancer, but this was dependent on the type of gallstone condition and treatment. The effect of cholecystectomy seemed dubious.

Long-term follow-up of a randomized controlled trial of observation versus surgery for acute cholecystitis: non-operative management is an option in some patients.

BACKGROUND: Cholecystectomy is routinely recommended to prevent recurrent disease after an initial episode of acute cholecystitis. Therefore, randomized controlled trials have mainly focused on the timing of surgery, but many patients scheduled for cholecystectomy have deferred surgery with long periods of symptom-free intervals. Our present aim is to examine the long-term feasibility and safety of observation compared with surgery. METHODS: Trial of 64 patients with acute cholecystitis previously randomized to observation or cholecystectomy, which examined outcome in terms of completed randomized treatment and appearance of further symptoms and the need for surgical treatment. Thirty-three patients were randomized to observation and 31 patients to cholecystectomy. Median follow-up was 14 years. RESULTS: Of the 33 patients randomized to observation, 11 (33%) experienced a new event of gallstone-related disease (eight (24.2%) had acute cholecystitis) and 11 (33%) were operated. No significant difference (p = 0.565) was found between the two randomized groups with regard to recurrent disease or complications. Virtually no surgery took place after 5 years of follow-up. The difference in completed randomized treatment between the groups was not significant (p = 0.077). Long-term mortality was equal in those operated and in those observed. CONCLUSIONS: Twenty-four percent of the patients experienced recurrent cholecystitis, but escalation of disease severity or increased mortality was not observed. Long-term observation after acute cholecystitis was feasible in two-thirds of the patients as the risk for recurrent disease was negligible after 5 years.

A 24-year controlled follow-up of patients with silent gallstones showed no long-term risk of symptoms or adverse events leading to cholecystectomy.

BACKGROUND: The fate of asymptomatic gallstones has not been investigated in many studies with a long-term follow-up. We wanted to examine the subsequent rate of cholecystectomy and gallstone-related symptoms in a population examined in 1983. METHODS: Among the persons examined in 1983, unknown (perceived as silent) gallstones were discovered in 20.1% (285/1417) persons. Owing to technical reasons, only 89.9% (1274 persons) of the original study population was retrieved for the present study. Of these, 19.2% (245 persons) had gallstones in 1983 [135 women (55.1%) and 110 men (44.9%), mean age in 1983: 49.9 and 51.3 years, respectively]. RESULTS: Of the 154 still living persons with gallstones from 1983, 134 were traced for follow-up. Of these, 89 underwent a clinical examination and 45 answered a mail or telephone questionnaire. Ultrasonography revealed gallstones in 28.1% (25/89) and 6.7% (9/134) had had the gallbladder removed. 5.5% (5/91) of the deceased patients had had a cholecystectomy. Overall cholecystectomy rate was 6.2%. No link could be shown between the number and the size of gallstones in 1983 and the ultrasonographic demonstration of gallstones in 2007. 43.8% had abdominal pain, and 29.2% had functional abdominal complaints. CONCLUSIONS: Unexpectedly, only a minority of persons examined with ultrasonography had present day gallstones without any obvious explanation for this low figure. The rate of cholecystectomy was low in a conservative setting and no adverse events could be ascertained from such a policy.

A randomized controlled study of uncomplicated gallstone disease with a 14-year follow-up showed that operation was the preferred treatment.

BACKGROUND/AIMS: Cholecystectomy is considered the treatment of choice for symptomatic gallstone disease. Some patients abstain from surgery and provide the opportunity to study the natural history of cholelithiasis. The aim of the present study was to examine the feasibility and safety of observation after extended long-term follow-up in a randomized controlled trial. METHODS: A total of 137 patients (40.5% of those assessed) were randomized to observation or cholecystectomy and followed up for 14 years. The prevalence of symptomatic events or major complications after treatment was the primary end point. A secondary end point was completion of randomized treatment. RESULTS: There were no differences in outcome between the observation group and the surgical group (p = 0.298). Virtually no cholecystectomy was performed after 5 years of follow-up, and no clear escalation in the severity of the disease was observed. A total of 50.7% of patients from the observation group and 88.2% from the surgical group underwent surgery. The group randomized to surgery completed their designated treatment significantly more often (p < 0.001), especially among patients younger than 70 years of age (p = 0.005). CONCLUSION: Cholecystectomy was the preferred treatment after extended long-term follow-up, but conservative management for symptomatic gallstone disease is an alternative to surgery in the elderly.

In-Line Observation of Laser Cladding Processes via Atomic Emission Spectroscopy.

Direct metal deposition (DMD) can be used for the cladding of surfaces as well as repairing and additive manufacturing of parts and features. Process monitoring and control methods ensure a consistent quality during manufacturing. Monitoring by optical emission spectroscopy of the process radiation can provide information on process conditions and the deposition layer. The object of this work is to measure optical emissions from the process using a spectrometer and identify element lines within the spectra. Single spectra have been recorded from the process. Single tracks of Co-based powder (MetcoClad21) were clad on an S235 base material. The influence of varying process parameters on the incidence and intensity of element lines has been investigated. Moreover, the interactions between the laser beam, powder jet, and substrate with regard to spectral emissions have been examined individually. The results showed that element lines do not occur regularly. Therefore, single spectra are sorted into spectra including element lines (type A) and those not including element lines (type B). Furthermore, only non-ionised elements could be detected, with chromium appearing frequently. It was shown that increasing the laser power increases the incidence of type A spectra and the intensity of specific Cr I lines. Moreover, element lines only occurred frequently during the interaction of the laser beam with the melt pool of the deposition layer.

Rotational Path of Insertion in Fixed Prosthodontics when Abutment Axes Do Not Match: A Case History Report.

Fixed dental prostheses are the standard treatment option for replacing missing teeth when adjacent teeth require crowns or are already restored with crowns. Divergent abutment teeth axes may require invasive teeth preparation to achieve a common path of insertion, which substantially weakens residual tooth structure and increases the risk of pulpal problems. In selected cases with divergent abutment teeth in the buccal-lingual direction, the use of a rotational path of insertion might overcome these problems. This concept is presented via a clinical case history report.

Balanced Adjustable Mirrored Current Source with Common Mode Feedback and Output Measurement for Bioimpedance Applications.

Bioimpedance methods are used in a variety of applications such as impedance tomography, electrodermal activity detection and vascular disease assessment. Recent developments in portable and unobtrusive biosignal acquisition systems facilitate the integration of wearable bioimpedance applications including sleep monitoring, respiration estimation and fluid monitoring. However, the less stable measurement situation in a wearable scenario increases the requirements for the system's accuracy and adaptability. The current source of a bioimpedance system needs to drive large complex loads subject to vast variations over time while maintaining a high level of accuracy. The widely used improved Howland current source suffers from multiple disadvantages when considered for an adaptive bioimpedance system. We propose an optimized mirrored architecture which allows for a simple output current adjustment and current measurement without an additional shunt resistor in the load path. The system implements a common mode feedback system which includes balancing of the mirrored sources. Our design is validated by calculation, SPICE simulation and complex load measurements. We achieved output impedances in excess of 3 MΩ and derived a simplified transconductance function valid for frequencies up to 1 MHz. We conclude that the presented architecture is an important step forward towards accurate wearable bioimpedance acquisition. Employing generalized impedance converters, the output impedance could be further optimized.

Methacrylated gelatin/hyaluronan-based hydrogels for soft tissue engineering.

In vitro-generated soft tissue could provide alternate therapies for soft tissue defects. The aim of this study was to evaluate methacrylated gelatin/hyaluronan as scaffolds for soft tissue engineering and their interaction with human adipose-derived stem cells (hASCs). ASCs were incorporated into methacrylated gelatin/hyaluronan hydrogels. The gels were photocrosslinked with a lithium phenyl-2,4,6-trimethylbenzoylphosphinate photoinitiator and analyzed for cell viability and adipogenic differentiation of ASCs over a period of 30 days. Additionally, an angiogenesis assay was performed to assess their angiogenic potential. After 24 h, ASCs showed increased viability on composite hydrogels. These results were consistent over 21 days of culture. By induction of adipogenic differentiation, the mature adipocytes were observed after 7 days of culture, their number significantly increased until day 28 as well as expression of fatty acid binding protein 4 and adiponectin. Our scaffolds are promising as building blocks for adipose tissue engineering and allowed long viability, proliferation, and differentiation of ASCs.

Post-cholecystectomy symptoms were caused by persistence of a functional gastrointestinal disorder.

AIM: To classify gallstone disease as a basis for assessment of post-cholecystectomy symptoms. METHODS: One hundred and fifty three patients with a clinical and ultrasonographic diagnosis of gallstones filled out a structured questionnaire on abdominal pain symptoms and functional gastrointestinal disorder (FGID) before and at six months after cholecystectomy. Symptom frequency groups (SFG) were categorized according to frequency of pain attacks. According to certain pain characteristics in gallstone patients, a gallstone symptom score was accorded on a scale from one to ten. A visual analogue scale was used to quantify pain. Operative specimens were examined for size and magnitude of stone contents as well as presence of bacteria. Follow-up took place after six months with either a consultation or via a mailed questionnaire. Results were compared with those obtained pre-operatively to describe and analyze symptomatic outcome. RESULTS: SFG groups were categorized as severe (24.2%), moderate (38.6%), and mild (22.2%) attack frequency, and a chronic pain condition (15%). Pain was cured or improved in about 90% of patients and two-thirds of patients obtained complete symptom relief. Patients with the most frequent pain episodes were less likely to obtain symptom relief. FGID was present in 88% of patients pre-operatively and in 57% post-operatively (P = 0.244). Those that became asymptomatic or improved with regard to pain also had most relief from FGID (P = 0.001). No pre-operative FGID meant almost complete cure. CONCLUSION: Only one third of patients with FGID experienced postoperative relief, indicating that FGID was a dominant cause of post-cholecystectomy symptoms.