How well do workplace-based assessments support summative entrustment decisions? A multi-institutional generalisability study.

BACKGROUND: Assessment of the Core Entrustable Professional Activities for Entering Residency requires direct observation through workplace-based assessments (WBAs). Single-institution studies have demonstrated mixed findings regarding the reliability of WBAs developed to measure student progression towards entrustment. Factors such as faculty development, rater engagement and scale selection have been suggested to improve reliability. The purpose of this investigation was to conduct a multi-institutional generalisability study to determine the influence of specific factors on reliability of WBAs. METHODS: The authors analysed WBA data obtained for clerkship-level students across seven institutions from 2018 to 2020. Institutions implemented a variety of strategies including selection of designated assessors, altered scales and different EPAs. Data were aggregated by these factors. Generalisability theory was then used to examine the internal structure validity evidence of the data. An unbalanced cross-classified random-effects model was used to decompose variance components. A phi coefficient of >0.7 was used as threshold for acceptable reliability. RESULTS: Data from 53 565 WBAs were analysed, and a total of 77 generalisability studies were performed. Most data came from EPAs 1 (n = 17 118, 32%) 2 (n = 10 237, 19.1%), and 6 (n = 6000, 18.5%). Low variance attributed to the learner (<10%) was found for most (59/77, 76%) analyses, resulting in a relatively large number of observations required for reasonable reliability (range = 3 to >560, median = 60). Factors such as DA, scale or EPA were not consistently associated with improved reliability. CONCLUSION: The results from this study describe relatively low reliability in the WBAs obtained across seven sites. Generalisability for these instruments may be less dependent on factors such as faculty development, rater engagement or scale selection. When used for formative feedback, data from these instruments may be useful. However, such instruments do not consistently provide reasonable reliability to justify their use in high-stakes summative entrustment decisions.

What Are the Predictors for and Psychosocial Correlates of Chronic Headache After Moderate to Severe Traumatic Brain Injury?

OBJECTIVE: Although headache (HA) is a common sequela of traumatic brain injury (TBI), early predictors of chronic HA after moderate to severe TBI are not well established, and the relationship chronic HA has with psychosocial functioning is understudied. Thus, we sought to (1) determine demographic and injury predictors of chronic HA 1 or more years after moderate to severe TBI and (2) examine associations between chronic HA and psychosocial outcomes. SETTING: Community. PARTICIPANTS: Participants in the TBI Model System (TBIMS) with moderate to severe TBI who consented for additional chronic pain questionnaires at the time of TBIMS follow-up. DESIGN: Multisite, observational cohort study using LASSO (least absolute shrinkage and selection operator) regression for prediction modeling and independent t tests for psychosocial associations. MAIN OUTCOME MEASURES: Chronic HA after TBI at year 1 or 2 postinjury and more remotely (5 or more years). RESULTS: The LASSO model for chronic HA at 1 to 2 years achieved acceptable predictability (cross-validated area under the curve [AUC] = 0.70). At 5 or more years, predictability was nearly acceptable (cross-validated AUC = 0.68), but much more complex, with more than twice as many variables contributing. Injury characteristics had stronger predictive value at postinjury years 1 to 2 versus 5 or more years, especially sustained intracranial pressure elevation (odds ratio [OR] = 3.8) and skull fragments on head computed tomography (CT) (OR = 2.5). Additional TBI(s) was a risk factor at both time frames, as were multiple socioeconomic characteristics, including lower education level, younger age, female gender, and Black race. Lower education level was a particularly strong predictor at 5 or more years (OR up to 3.5). Emotional and participation outcomes were broadly poorer among persons with chronic HA after moderate to severe TBI. CONCLUSIONS: Among people with moderate to severe TBI, chronic HA is associated with significant psychosocial burden. The identified risk factors will enable targeted clinical screening and monitoring strategies to enhance clinical care pathways that could lead to better outcomes. They may also be useful as stratification or covariates in future clinical trial research on treatments.

Sleep duration and all-cause mortality among stroke survivors.

BACKGROUND: Post stroke sleep duration could increase the risk of death. This study tested the hypothesis that inadequate sleep duration is associated with increased mortality among stroke survivors. METHODS: The REasons for Geographic And Racial Differences in Stroke (REGARDS), a national population-based longitudinal study, was the data source. Sleep duration was ascertained between 2013 and 2016 among stroke survivors who were subsequently followed up until death or censored on December 31, 2022. Sleep duration was estimated as the difference between wake-up time and bedtime to which was subtracted the time spent in bed without sleep. Cox proportional hazards regression models were employed to investigate the association between sleep duration and all-cause mortality adjusting for demographic factors, socioeconomic factors, behavioral factors, and co-morbidities. RESULTS: A total of 468 non-Hispanic Black and White stroke survivors were included in this analysis. The mean age was 76.3 years, 52.6% were females and 56.0% were non-Hispanic White individuals. The distribution of short (≤6 h), adequate (7.0-8.9 h), and long sleep (≥9 h) was 30.3%, 44.7%, and 25%, respectively. Over a mean follow-up of 5.0 years, 190 (40.6%) deaths occurred. Compared to stroke survivors with adequate sleep (7.0-8.9 h), stroke survivors with long sleep (≥9 h) were at increased risk of all-cause mortality (HR=1.46, 95% CI=1.01, 2.12). However, short sleep (≤6 h) was not significantly associated with an increased risk of all-cause mortality (HR=1.31, 95% CI=0.90, 1.91). Subgroup analyses indicated higher risk in the age <75 years, females, non-Hispanic Black individuals, and those living in the Stroke Belt region, but those differences were not statistically significant. CONCLUSION: In this study of stroke survivors, 9 hours or more of sleep per day was associated with an increased risk of all-cause mortality. This finding suggests that excessive sleep duration may be a warning sign of poor life expectancy in stroke survivors.

Estimating rate of change for nonlinear trajectories in the framework of individual measurement occasions: A new perspective on growth curves.

Researchers are often interested in examining between-individual differences in within-individual processes. If the process under investigation is tracked for a long time, its trajectory may show a certain degree of nonlinearity, so that the rate of change is not constant. A fundamental goal of modeling such nonlinear processes is to estimate model parameters that reflect meaningful aspects of change, including the parameters related to change and other parameters that shed light on substantive hypotheses. However, if the measurement occasion is unstructured, existing models cannot simultaneously estimate these two types of parameters. This article has three goals. First, we view the change over time as the area under the curve (AUC) of the rate of change versus time ( r - t ) graph. Second, using the instantaneous rate of change midway through a time interval to approximate the average rate of change during that interval, we propose a new specification to describe longitudinal processes. In addition to obtaining the individual change-related parameters and other parameters related to specific research questions, the new specification allows for unequally spaced study waves and individual measurement occasions around each wave. Third, we derive the model-based interval-specific change and change from baseline, two common measures to evaluate change over time. We evaluate the proposed specification through a simulation study and a real-world data analysis. We also provide OpenMx and Mplus 8 code for each model with the novel specification.

Assessing mediational processes using piecewise linear growth curve models with individual measurement occasions.

Longitudinal processes often unfold concurrently where the growth patterns of two or more longitudinal outcomes are associated. Additionally, if the study under investigation is long, the growth curves may exhibit nonconstant change with respect to time. Multiple existing studies have developed multivariate growth models with nonlinear functional forms to explore joint development where two longitudinal records are correlated over time. However, the relationship between multiple longitudinal outcomes may also be unidirectional. Accordingly, it is of interest to estimate regression coefficients of such unidirectional paths. One statistical tool for such analyses is longitudinal mediation models. In this study, we develop two models to evaluate mediational processes where the linear-linear piecewise functional form is utilized to capture the change patterns. We define the mediational process as either the baseline covariate or the change in covariate influencing the change in the mediator, which, in turn, affects the change in the outcome. We present the proposed models through simulation studies and real-world data analyses. Our simulation studies demonstrate that the proposed mediational models can provide unbiased and accurate point estimates with target coverage probabilities with a 95% confidence interval. The empirical analyses demonstrate that the proposed models can estimate covariates' direct and indirect effects on the change in the outcome. We also provide the corresponding code for the proposed models.

Further exploration of the effects of time-varying covariate in growth mixture models with nonlinear trajectories.

Growth mixture modeling (GMM) is an analytical tool for identifying multiple unobserved sub-populations in longitudinal processes. In particular, it describes change patterns within each latent sub-population and investigates between-individual differences in within-individual change for each sub-group. A key research interest in using GMMs is examining how covariates influence the heterogeneity in change patterns. Liu & Perera (2022b) extended mixture-of-experts (MoE) models, which primarily focus on time-invariant covariates, to allow covariates to account for both within-group and between-group differences and investigate the heterogeneity in nonlinear trajectories. The present study further extends Liu & Perera, 2022b by examining the effects of time-varying covariates (TVCs) on trajectory heterogeneity. Specifically, we propose methods to decompose a TVC into an initial trait (the baseline value of the TVC) and a set of temporal states (interval-specific slopes or changes of the TVC). The initial trait is allowed to account for within-group differences in growth factors of trajectories (i.e., baseline effect), while the temporal states are allowed to impact observed values of a longitudinal process (i.e., temporal effects). We evaluate the proposed models using a simulation study and real-world data analysis. The simulation study demonstrates that the proposed models are capable of separating trajectories into several clusters and generally producing unbiased and accurate estimates with target coverage probabilities. The proposed models reveal the heterogeneity in initial trait and temporal states of reading ability across latent classes of students' mathematics performance. Additionally, the baseline and temporal effects on mathematics development of reading ability are also heterogeneous across the clusters of students.

Eating to cope: Advancing our understanding of the effects of exposure to racial discrimination on maladaptive eating behaviors.

OBJECTIVE: Racial discrimination is a stressor for young Black women that leads to poor health outcomes, including maladaptive eating. This study presents findings on racial discrimination and maladaptive eating behaviors (overeating, LOC eating) using ecological momentary assessment (EMA). METHODS: Black emerging adult women (N = 27) with overweight or obesity participated in a 14-day EMA study examining exposure to racial discrimination, eating behaviors, and racial identity. Frequencies and chi-square tests were used to characterize the type of racial discrimination experienced and frequency of overeating. Mixed effect ordinal logistic regression models were used to assess the relation between racial discrimination and maladaptive eating. Moderation analysis was conducted by creating interaction terms for discrimination and racial identity variables. RESULTS: 81.5% of participants reported experiencing racial discrimination. Young Black women reporting exposure to racial discrimination were more likely to endorse higher levels of both overeating and LOC eating compared to times when discrimination was not experienced (p < .0001). Racial identity moderated the link between racial discrimination and maladaptive eating (overeating, LOC) such that reporting greater levels of private regard buffered the deleterious effect of racial discrimination. Higher levels of public regard exacerbated the association between racial discrimination and both overeating, and LOC. Higher centrality worsened the relation between racial discrimination and LOC. CONCLUSION: Young Black women might use maladaptive eating to cope with exposure to racial discrimination, which underscores the importance of examining the link between racism and disordered eating, particularly among Black women submerged in a society that continuously exposes them to racial discrimination. PUBLIC SIGNIFICANCE: Emerging adult Black women are exposed to racial discrimination daily. In theory, exposure to racial discrimination could contribute to overeating and loss of control eating in this population. Using ecological momentary assessment, to capture experiences and eating behaviors in the moment they occur, this project quantified the magnitude of racial discrimination and how it was associated with maladaptive eating behaviors. Further, it examined ways in which racial identity was linked to this association.

Randomized trial of rTMS in traumatic brain injury: improved subjective neurobehavioral symptoms and increases in EEG delta activity.

PRIMARY OBJECTIVE: While repetitive transcranial magnetic stimulation (rTMS) has shown efficacy for cognitive difficulties accompanying depression, it is unknown if it can improve cognition in persons with traumatic brain injury. RESEARCH DESIGN: Using a sham-controlled crossover design, we tested the capacity of high frequency rTMS of the prefrontal cortex to improve neuropsychological performance in attention, learning and memory, and executive function. METHODS: Twenty-six participants with cognitive complaints and a history of mild-to-moderate traumatic brain injury were randomly assigned to receive first either active or sham 10 Hz stimulation for 20 minutes (1200 pulses) per session for five consecutive days. After a one-week washout, the other condition (active or sham) was applied. Pre- and post-treatment measures included neuropsychological tests, cognitive and emotional symptoms, and EEG. MAIN OUTCOMES AND RESULTS: Results indicated no effect of treatment on cognitive function. Subjective measures of depression, sleep dysfunction, post-concussive symptoms (PCS), and executive function showed significant improvement with stimulation, retaining improved levels at two-week follow-up. EEG delta power exhibited elevation one week after stimulation cessation. CONCLUSIONS: While there is no indication that rTMS is beneficial for neuropsychological performance, it may improve PCS and subjective cognitive dysfunction. Long-term alterations in cortical oscillations may underlie the therapeutic effects of rTMS.

Physical Therapy Use, Costs, and Value for Latent Classes of Good vs Poor Outcome in Patients Who Catastrophize About Their Pain Prior to Knee Arthroplasty.

OBJECTIVE: To examine use, costs, and value of physical therapy (PT) among subgroups. DESIGN: We conducted an observational study of data from a randomized trial of a pain coping skills intervention. Good and poor outcome subgroups were determined based on Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) Pain and Physical Function scores. The use and costs of PT care as well as changes in WOMAC Pain and Physical Function scores over 4 time periods during a 1-year follow-up were reported. We compared the number of PT visits, total PT costs, and cost per 1-unit improvement in WOMAC scores for the 2 latent subgroups. SETTING: Five academic medical centers. PARTICIPANTS: Patients who catastrophized about their pain prior to knee arthroplasty (N=384). INTERVENTIONS: Pain coping skills training, arthritis education, and usual care. MAIN OUTCOME MEASURES: The WOMAC Pain Scale was the primary outcome. RESULTS: The value of PT was lower and the cost of PT was higher for poor vs good outcome subgroups beginning 2 months after knee arthroplasty. For example, during the 2- to 6-month period, participants in the poor outcome subgroup incurred a PT cost of $5181.22 per 1-unit improvement in WOMAC Pain compared with $437.87 per 1-unit improvement in WOMAC Pain for the good outcome subgroup (P<.001). From the 6- to 12-month period, WOMAC scores worsened for the poor outcome subgroup, indicating no benefit from PT. CONCLUSIONS: Patients in 2 latent classes demonstrated clinically important differences in value of PT. Future research should identify rehabilitation-based interventions that reduce utilization and enhance effectiveness for patients at high risk for poor outcome.

Building reliable and generalizable clerkship competency assessments: Impact of 'hawk-dove' correction.

PURPOSE: Systematic differences among raters' approaches to student assessment may result in leniency or stringency of assessment scores. This study examines the generalizability of medical student workplace-based competency assessments including the impact of rater-adjusted scores for leniency and stringency. METHODS: Data were collected from summative clerkship assessments completed for 204 students during 2017-2018 the clerkship at a single institution. Generalizability theory was used to explore variance attributed to different facets (rater, learner, item, and competency domain) through three unbalanced random-effects models by clerkship including applying assessor stringency-leniency adjustments. RESULTS: In the original assessments, only 4-8% of the variance was attributed to the student with the remainder being rater variance and error. Aggregating items to create a composite score increased variability attributable to the student (5-13% of variance). Applying a stringency-leniency ('hawk-dove') correction substantially increased the variance attributed to the student (14.8-17.8%) and reliability. Controlling for assessor leniency/stringency reduced measurement error, decreasing the number of assessments required for generalizability from 16-50 to 11-14. CONCLUSIONS: Similar to prior research, most of the variance in competency assessment scores was attributable to raters, with only a small proportion attributed to the student. Making stringency-leniency corrections using rater-adjusted scores improved the psychometric characteristics of assessment scores.

Applying the theory of planned behavior to examine adjuvant endocrine therapy adherence intentions.

OBJECTIVE: Adherence to adjuvant endocrine therapy (AET) in breast cancer survivors is suboptimal. Using the theory of planned behavior (TPB), this study aimed to identify the strongest predictors from the TPB of AET intentions and past behavior and assessed whether ambivalence and anticipatory emotions increased the predictive capacity of TPB. METHODS: Two hundred eighty women diagnosed with hormone positive (HR+) breast cancer who filled at least one prescription of AET responded to a survey measuring TPB constructs, attitudinal ambivalence, and anticipatory emotions. The outcomes were intentions to adhere to AET and past medication adherence (previous 2 weeks). RESULTS: The TPB explained 66% of intentions to adhere to AET (P < 0.001). Ambivalence did not improve the TPB model's predictive value. When emotions were included with TPB, the model explained 70% of adherence intentions F11,226  = 52.84, P < 0.001 (R2c  = .70). This increase of 4% in predictability was statistically significant (ΔR2  = 0.04), F6, 226  = 7.90, P < 0.001. Women who self-reported nonadherence in the past 2 weeks differed significantly in the TPB variables, ambivalence, and anticipatory emotions from adherent women. Nonadherent participants reported lower-future intentions to adhere F1, 236  = 5.63, P = 0.018. CONCLUSIONS: Results suggest key concepts, such as anticipatory positive emotions that should be addressed in future interventions to enhance AET adherence and survivorship.

Workplace support and breastfeeding duration: The mediating effect of breastfeeding intention and self-efficacy.

BACKGROUND: Given the large proportion of mothers in the United States work force, understanding the implications of workplace support on breastfeeding outcomes is an important public health priority. The current study investigates if (a) workplace support directly influences the working mothers' breastfeeding intention, self-efficacy, and duration, and (b) workplace support indirectly influences breastfeeding duration through the mediating effect of breastfeeding intention and self-efficacy. METHODS: Data from the longitudinal Infant Feeding Practices Survey II were analyzed. The main predictor variable, workplace support, was based on a Likert scale from "not at all supportive" to "very supportive." Both mediators, exclusive breastfeeding intention and self-efficacy, were dichotomized (yes; no) while the study outcome, breastfeeding duration, was continuous. Structural equation modeling was used to obtain direct and indirect effects of breastfeeding intention and confidence in attaining breastfeeding goals. RESULTS: After adjusting for confounders, there was a statistically significant direct effect between self-efficacy, breastfeeding intention, and breastfeeding duration. A statistically significant indirect effect of workplace support on breastfeeding duration through self-efficacy in attaining breastfeeding goals was also observed. The mediation ratios of the indirect effects showed that self-efficacy in attaining breastfeeding goals accounted for 40.8% (P-value=0.032) of the total effect; however, all other mediation ratios did not show statistical significance. CONCLUSIONS: Self-efficacy is an important predictor for breastfeeding duration. Workplaces may help bolster women's self-efficacy by providing environments that are supportive to breastfeeding working mothers. Future research is needed to identify breastfeeding policies that boost self-efficacy.

Identifying Attrition Phases in Survey Data: Applicability and Assessment Study.

BACKGROUND: Although Web-based questionnaires are an efficient, increasingly popular mode of data collection, their utility is often challenged by high participant dropout. Researchers can gain insight into potential causes of high participant dropout by analyzing the dropout patterns. OBJECTIVE: This study proposed the application of and assessed the use of user-specified and existing hypothesis testing methods in a novel setting-survey dropout data-to identify phases of higher or lower survey dropout. METHODS: First, we proposed the application of user-specified thresholds to identify abrupt differences in the dropout rate. Second, we proposed the application of 2 existing hypothesis testing methods to detect significant differences in participant dropout. We assessed these methods through a simulation study and through application to a case study, featuring a questionnaire addressing decision-making surrounding cancer screening. RESULTS: The user-specified method set to a low threshold performed best at accurately detecting phases of high attrition in both the simulation study and test case application, although all proposed methods were too sensitive. CONCLUSIONS: The user-specified method set to a low threshold correctly identified the attrition phases. Hypothesis testing methods, although sensitive at times, were unable to accurately identify the attrition phases. These results strengthen the case for further development of and research surrounding the science of attrition.

Do Pain Coping and Pain Beliefs Associate With Outcome Measures Before Knee Arthroplasty in Patients Who Catastrophize About Pain? A Cross-sectional Analysis From a Randomized Clinical Trial.

BACKGROUND: Pain-coping strategies and appraisals are responses to the pain experience. They can influence patient-reported and physical performance outcome measures in a variety of disorders, but the associations between a comprehensive profile of pain-coping responses and preoperative pain/function and physical performance measures in patients scheduled for knee arthroplasty have not been examined. Patients with moderate to high pain catastrophizing (a pain appraisal approach associated with an exaggerated focus on the threat value of pain) may represent an excellent study population in which to address this knowledge gap. QUESTIONS/PURPOSES: We asked the following questions among patients with high levels of pain catastrophizing who were scheduled for TKA: (1) Do maladaptive pain responses correlate with worse self-reported pain intensity and function and physical performance? (2) Do adaptive pain-coping responses show the opposite pattern? As an exploratory hypothesis, we also asked: (3) Do maladaptive responses show more consistent associations with measures of pain, function, and performance as compared with adaptive responses? METHODS: A total of 384 persons identified with moderate to high levels of pain catastrophizing and who consented to have knee arthroplasty were recruited. The sample was 67% (257 of 384) women and the mean age was 63 years. Subjects were consented between 1 and 8 weeks before scheduled surgery. All subjects completed the WOMAC pain and function scales in addition to a comprehensive profile of pain coping and appraisal measures and psychologic health measures. Subjects also completed the Short Physical Performance Battery and the 6-minute walk test. For the current study, all measures were obtained at a single point in time at the preoperative visit with no followup. Multilevel multivariate multiple regression was used to test the hypotheses and potential confounders were adjusted for in the models. RESULTS: Maladaptive pain responses were associated with worse preoperative pain and function measures. For example, the maladaptive pain-coping strategy of guarding and the pain catastrophizing appraisal measures were associated with WOMAC pain scores such that higher guarding scores (ß = 0.12, p = 0.007) and higher pain catastrophizing (ß = 0.31, p < 0.001) were associated with worse WOMAC pain; no adaptive responses were associated with better WOMAC pain or physical performance scores. Maladaptive responses were also more consistently associated with worse self-reported and performance-based measure scores (six of 16 associations were significant in the hypothesized direction), whereas adaptive responses did not associate with better scores (zero of 16 scores were significant in the hypothesized direction). CONCLUSIONS: The maladaptive responses of guarding, resting, and pain catastrophizing were associated with worse scores on preoperative pain and performance measures. These are pain-related responses surgeons should consider when assessing patients before knee arthroplasty. TKA candidates found to have these pain responses may be targets for treatments that may improve postoperative outcome given that these responses are modifiable. Future intervention-based research should target this trio of maladaptive pain responses to determine if intervention leads to improvements in postsurgical health outcomes. LEVEL OF EVIDENCE: Level I, prognostic study.

Sex Disparities in Adverse Childhood Experiences and HIV/STIs: Mediation of Psychopathology and Sexual Behaviors.

HIV and other sexually transmitted infections (STIs) are important public health challenges in the US. Adverse childhood experiences (ACEs), including abuse (emotional, physical or sexual), witnessing violence among household members, may have an effect on sexual behaviors, which increase the risk of HIV/STIs. The aim of this study was to examine the sex differences in the role of posttraumatic stress disorder (PTSD), major depression (MD), substance use disorders (SUDs), early sexual debut, and intimate partner violence (IPV) perpetration as mediators in the association between ACEs and HIV/STIs. Data were obtained from Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions. Structural equation modeling was used to determine the role of PTSD, MD, SUDs, early sexual debut, and IPV perpetration as mediators in the relationships between ACEs and HIV/STIs. Differences and similarities existed in the mediational roles of psychopathology and sexual behaviors. For example, among men, MD fully mediated physical/psychological abuse (ß = 0.0002; p = 0.012) and sexual abuse (ß = 0.0002; p = 0.006), and HIV/STIs while among women, MD fully mediated physical/psychological abuse (ß = 0.0005; p < 0.001) and parental violence (ß = -0.0002; p = 0.012). Among men, IPV perpetration fully mediated sexual abuse (ß = -0.0005; p = 0.012) and HIV/STIs while among women, IPV perpetration was not a statistically significant mediator. HIV/STI prevention and intervention programs should use a life course approach by addressing adverse childhood events among men and women and consider the sex differences in the roles of psychopathology and sexual behaviors.

Construct validation and correlates of preoperative expectations of postsurgical recovery in persons undergoing knee replacement: baseline findings from a randomized clinical trial.

BACKGROUND: A patient's recovery expectations prior to knee arthroplasty influence postsurgical outcome and satisfaction but a unidimensional measure of expectation has not been reported in the literature. Our primary purpose was to determine the extent to which a patient expectations scale reflects a unidimensional construct. Our second purpose was to identify pre-operative variables associated with patients' expectations. We hypothesized that previously identified predictors of the latent expectation scale score would be associated with expectations and that previously unexplored variables of pain catastrophizing, depressive and anxiety symptoms, self-efficacy and number of painful body regions would also associate with pre-operative expectations. METHODS: Our randomized clinical trial had 384 patients assessed prior to knee replacement surgery. The expectations scale along with several predictor variables including WOMAC, psychological distress, and sociodemographic variables were obtained. Confirmatory factor analysis tested the unidimensionality of the measure and structural equation modeling identified predictors of the latent expectations measure. RESULTS: The expectations scale was found to be unidimensional with superior model fit (χ2 = 1.481; df = 2; p = 0.224; RMSEA = 0.035; 90% CI = [0-0.146]; CFI = 0.999; TLI = 0.993). The only variable significantly associated with expectations in the multivariate model was self-efficacy. CONCLUSIONS: The expectations scale used in our study demonstrated unidimensionality and has strong potential for clinical application. Poor self-efficacy is a potential target for intervention given its independent association with expectation. Addressing expectations directly and indirectly through self-efficacy assessment may assist in better aligning patient's expectations with likely outcome. TRIAL REGISTRATION: ClinicalTrials.gov NCT01620983 .

External Validation of a Prognostic Model for Predicting Nonresponse Following Knee Arthroplasty.

BACKGROUND: Instruments designed to predict the extent of pain and function following knee arthroplasty (KA) recovery has strong potential to guide patients and clinicians in shared decision making. Our purpose was to test the external validity of a recently developed prognostic instrument designed to estimate the probability of nonresponse following KA. METHODS: We used data from the Osteoarthritis Initiative (OAI), a 9-year multisite National Institutes of Health study designed to examine the natural history of knee osteoarthritis in 4796 subjects. A total of 427 subjects underwent KA over the study period. Dowsey et al examined the prognostic role of obesity, general mental health, pain and function, and Kellgren and Lawrence knee osteoarthritis grades. Calibration of the prognostic model was determined using a calibration curve. The c-statistic was used to indicate discrimination of the model. RESULTS: In the primary analysis, 63 (19.3%) of 326 subjects in OAI were classified as nonresponders. The calibration curve generated from OAI data indicated poor calibration relative to the recently developed instrument. Discrimination as measured by the c-statistic was 0.76. CONCLUSION: The external validity of the prognostic instrument was partially supported. While discrimination of the model was very similar to the recently developed instrument, calibration was poor indicating poor agreement between actual vs predicted probabilities of nonresponse. Western Ontario and McMaster Universities Arthritis Index and Kellgren and Lawrence grades show strong potential for use in future prognostic model development. Measurements of general mental health and obesity were not prognostic for nonresponse.

Localization of the brachial plexus: Sonography versus anatomic landmarks.

PURPOSE: Interscalene brachial plexus blocks are performed for perioperative management of surgeries involving the shoulder. Historically, these procedures employed anatomic landmarks (AL) to determine the location of the brachial plexus as it passes between the anterior and middle scalene muscles in the neck. In this study, we compared the actual location of the brachial plexus as found with sonography (US) to the anticipated location using AL. METHODS: The location of the brachial plexus was evaluated using US and AL in 96 subjects. The distance between the two locations was measured. A multivariate analysis of variance was used to determine the significance of the difference and a 2 × 2 analysis of variance was used to compare differences in gender, height, and body mass index. RESULTS: The brachial plexus was located on average 1.8 cm inferior (p = 0.0001) and 0.2 cm lateral (p = 0.09) to the location determined with AL. A significant difference was also associated with gender (p = 0.03), but not with height or body mass index. CONCLUSIONS: US is a reliable method that accurately pinpoints the roots of the brachial plexus. The brachial plexus is often located inferior to the location anticipated using AL. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:411-415, 2016.

What Is the Relationship Between Depressive Symptoms and Pain During Functional Tasks in Persons Undergoing TKA? A 6-year Perioperative Cohort Study.

BACKGROUND: Preoperative depressive symptoms have been shown in some but not all studies to be associated with poor self-reported pain and function outcomes. In addition, depressive symptoms after surgery have been shown to improve relative to preoperative levels. QUESTIONS/PURPOSES: We hypothesized that (1) preoperative depressive symptoms would predict postoperative pain; (2) depressive symptoms would decrease after surgery; and (3) preoperative depressive symptoms would increase as the scheduled surgery date approached. METHODS: Data from the Osteoarthritis Initiative, a National Institutes of Health-funded prospective multiyear cohort study, were used in this retrospective analysis. Persons from four communities were eligible if they had radiographic knee osteoarthritis or were at risk for developing knee osteoarthritis based on occupational, medical history, or body weight risk factors. A total of 4796 persons participated and rates of followup were 80% or greater over the course of the study. Participants completed a validated depressive symptom scale and the Knee Injury and Osteoarthritis Outcome Scale pain scale each year for 3 years before and 3 years after TKA. Latent growth curve modeling was used to model intercepts and slopes of pre- and postoperative depression and pain. Preoperative trajectories and intercepts were then used to predict postoperative pain and depressive symptoms adjusting for confounding variables. RESULTS: After adjustment for potential confounding, we found no evidence that preoperative depressive symptoms predicted postoperative pain with function (estimate, 0.1; 95% confidence interval, -0.31 to 0.50; p = 0.64) or that depressive symptoms were reduced after surgery (z = 0.06, p = 0.80). We also found no evidence to indicate that preoperative depressive symptoms increased as the date of surgery approached (linear slope = 0.28, SE = 0.19, p = 0.15). CONCLUSIONS: Preoperative and postoperative depressive symptoms in patients before and after TKA did not appreciably change over a 6-year perioperative period. Patient depressive symptoms were not reduced after surgery and did not appear to be related to less pain postoperatively. Our findings of no association between preoperative depressive symptom severity and postoperative pain and no reduction in postoperative depressive symptoms run counter to other available evidence, potentially attributable, in part, to a data collection process that occurred outside of orthopaedic surgeons' offices. Future research is needed to more fully explore the potential role of social desirability, the concept that patients respond in a way that they think the researcher or clinician wants them to respond in lieu of responding in a way that truly reflects the patient's status. Social desirability may influence a TKA patient's pain and function outcome assessment. LEVEL OF EVIDENCE: Level I, prognostic study.