Rotator cuff tear: A detailed update.

Rotator cuff tear has been a known entity for orthopaedic surgeons for more than two hundred years. Although the exact pathogenesis is controversial, a combination of intrinsic factors proposed by Codman and extrinsic factors theorized by Neer is likely responsible for most rotator cuff tears. Magnetic resonance imaging remains the gold standard for the diagnosis of rotator cuff tears, but the emergence of ultrasound has revolutionized the diagnostic capability. Even though mini-open rotator cuff repair is still commonly performed, and results are comparable to arthroscopic repair, all-arthroscopic repair of rotator cuff tear is now fast becoming a standard care for rotator cuff repair. Appropriate knowledge of pathology and healing pattern of cuff, strong and biological repair techniques, better suture anchors, and gradual rehabilitation of postcuff repair have led to good to excellent outcome after repair. As the healing of degenerative cuff tear remains unpredictable, the role of biological agents such as platelet-rich plasma and stem cells for postcuff repair augmentation is still under evaluation. The role of scaffolds in massive cuff tear is also being probed.

Costs and benefits of nitrogen for Europe and implications for mitigation.

Cost-benefit analysis can be used to provide guidance for emerging policy priorities in reducing nitrogen (N) pollution. This paper provides a critical and comprehensive assessment of costs and benefits of the various flows of N on human health, ecosystems and climate stability in order to identify major options for mitigation. The social cost of impacts of N in the EU27 in 2008 was estimated between €75-485 billion per year. A cost share of around 60% is related to emissions to air. The share of total impacts on human health is about 45% and may reflect the higher willingness to pay for human health than for ecosystems or climate stability. Air pollution by nitrogen also generates social benefits for climate by present cooling effects of N containing aerosol and C-sequestration driven by N deposition, amounting to an estimated net benefit of about €5 billion/yr. The economic benefit of N in primary agricultural production ranges between €20-80 billion/yr and is lower than the annual cost of pollution by agricultural N which is in the range of €35-230 billion/yr. Internalizing these environmental costs would lower the optimum annual N-fertilization rate in Northwestern Europe by about 50 kg/ha. Acknowledging the large uncertainties and conceptual issues of our cost-benefit estimates, the results support the priority for further reduction of NH3 and NOx emissions from transport and agriculture beyond commitments recently agreed in revision of the Gothenburg Protocol.

Is a single direct MR arthrography series in ABER position as accurate in detecting anteroinferior labroligamentous lesions as conventional MR arthography?

PURPOSE: The purpose of this study is to retrospectively compare accuracy of single magnetic resonance (MR) arthrography series in Abduction External Rotation (ABER) with conventional MR arthrography for detection and characterisation of anteroinferior labroligamentous lesions, with arthroscopy as reference standard. Inter-observer variability of both protocols was determined. METHODS AND MATERIALS: Institutional review board approval was obtained; informed consent was waived. MR arthrograms, including oblique axial fat suppressed T1-weighted images in ABER position and conventional imaging directions of 250 patients (170 men, 80 women; mean age, 36 years), were retrospectively and independently evaluated by three reviewers. Reviewers were blinded to clinical information and arthroscopic results. Labroligamentous lesions were registered in both ABER and MRa. The lesions were sub-classified (Bankart, Perthes, anterior labrum periosteal sleeve avulsion (ALPSA) or lesions not otherwise specified). Inter-observer agreement was assessed by Kappa statistics for all 250 patients. Ninety-two of 250 patients underwent arthroscopy. Sensitivity, specificity and accuracy of ABER versus conventional MR arthrography were calculated and compared using paired McNemar test. RESULTS: Kappa values of the ABER and conventional MR arthrography ranged from 0.44 to 0.56 and 0.44 to 0.62, respectively. According to arthroscopy, 45 of 92 patients had an intact anteroinferior labrum, and in 44 patients, a labroligamentous lesion (eight Bankart, seven Perthes, 29 ALPSA and three lesions not otherwise specified) was diagnosed. There were no statistically significant differences between ABER and conventional MR arthrography regarding sensitivity (85-89%, 89-96%), specificity (82-91%, 84-89%) and overall accuracy (50-62%, 53-63%). CONCLUSION: The results of a single MR arthrography series in ABER position are comparable with those of conventional MR arthrography for detecting anteroinferior labroligamentous lesions.