Developing a Pain Intensity Measure for Persons with Dementia: Initial Construction and Testing.

OBJECTIVE: The goal of this study was to identify a limited set of pain indicators that were most predicive of physical pain. We began with 140 items culled from existing pain observation tools and used a modified Delphi approach followed by statistical analyses to reduce the item pool. METHODS: Through the Delphi Method, we created a candidate item set of behavioral indicators. Next, trained staff observed nursing home residents and rated the items on scales of behavior intensity and frequency. We evaluated associations among the items and expert clinicians' assessment of pain intensity. SETTING: Four government-owned nursing homes and 12 community nursing homes in Alabama and Southeastern Pennsylvania. PARTICIPANTS: Ninety-five residents (mean age = 84.9 years) with moderate to severe cognitive impairment. RESULTS: Using the least absolute shrinkage and selection operator model, we identified seven items that best predicted clinicians' evaluations of pain intensity. These items were rigid/stiff body or body parts, bracing, complaining, expressive eyes, grimacing, frowning, and sighing. We also found that a model based on ratings of frequency of behaviors did not have better predictive ability than a model based on ratings of intensity of behaviors. CONCLUSIONS: We used two complementary approaches-expert opinion and statistical analysis-to reduce a large pool of behavioral indicators to a parsimonious set of items to predict pain intensity in persons with dementia. Future studies are needed to examine the psychometric properties of this scale, which is called the Pain Intensity Measure for Persons with Dementia.

Psychometric Evaluation of the MOBID Dementia Pain Scale in U.S. Nursing Homes.

PURPOSE: The Mobilization-Observation-Behavior-Intensity-Dementia (MOBID) Pain Scale is an observational tool in which raters estimate pain intensity on a 0-10 scale following five standardized movements. The tool has been shown to be valid and reliable in northern European samples and could be useful in the United States (US) for research and clinical purposes. The goal of this study was to examine the validity and reliability of the MOBID among English-speaking nursing home residents in the US. DESIGN: Cross-sectional study. SETTINGS: Sixteen nursing homes in Pennsylvania, New Jersey, Georgia and Alabama. PARTICIPANTS: One hundred thirty-eight older adults with dementia and moderate to severe cognitive impairment. METHODS: Validity was evaluated using Spearman correlations between the MOBID overall pain intensity score and 1) an expert clinician's pain intensity rating (ECPIR), 2) nursing staff surrogate pain intensity ratings, and 3) known correlates of pain. We assessed internal consistency by Cronbach's alpha. RESULTS: MOBID overall scores were significantly associated with expert clinician's rating of current and worst pain in the past week (rho = 0.54, and 0.57; p < .001, respectively). Statistically significant associations also were found between the MOBID overall score and nursing staff current and worst pain intensity ratings as well as the Cornell Scale for Depression in Dementia (rho = 0.29; p < .001). Internal consistency was acceptable (α = 0.83). CONCLUSIONS AND CLINICAL IMPLICATIONS: Result of this study support the use of the MOBID in English-speaking staff and residents in the US. Findings also suggest that the tool can be completed by trained, nonclinical staff.

Combining a symptom index, CA125 and HE4 (triple screen) to detect ovarian cancer in women with a pelvic mass.

OBJECTIVES: To assess a simple algorithm of CA125, HE4 and Symptom Index to predict ovarian cancer in women with a pelvic mass. METHODS: This was a prospective study of women referred to a gynecologic oncology clinic for surgical evaluation of a pelvic mass. Preoperatively, women completed a SI and had serum markers drawn. Results were correlated with pathology. A triple screen was considered positive if at least 2 of the 3 markers were abnormal (positive SI, CA125≥35U/mL, HE4≥140pmol/L). RESULTS: 218 patients enrolled in the study. 66 patients (30%) had ovarian or fallopian tube cancer (97% epithelial), 124 (57%) had benign masses, 17 (8%) had borderline tumors, and 11 (5%) had metastatic disease. The SI, CA125 and HE4 were positive in 87.9%, 74.2% and 60.6% of ovarian cancer patients, respectively. Of the 112 women with a positive SI 58 (52%) had ovarian cancer and 75 (67%) had non-benign masses. Excluding borderline and metastatic cancers the sensitivity of the triple screen was 79%; specificity 91%, PPV 83% and NPV 89%. CA125 alone had a sensitivity, specificity, PPV and NPV of 79%, 76%, 63% and 87% respectively. Requiring only one of the three tests to be abnormal resulted in a sensitivity of 97% but specificity dropped to 50%. CONCLUSIONS: An algorithm using SI, CA125 and HE4 has good performance statistics for predicting cancer in women with pelvic masses. The triple screen has higher specificity and PPV than CA125 alone but similar sensitivity and NPV for predicting ovarian cancer.

Prediction of pain outcomes in a randomized controlled trial of dose-response of spinal manipulation for the care of chronic low back pain.

BACKGROUND: No previous studies have created and validated prediction models for outcomes in patients receiving spinal manipulation for care of chronic low back pain (cLBP). We therefore conducted a secondary analysis alongside a dose-response, randomized controlled trial of spinal manipulation. METHODS: We investigated dose, pain and disability, sociodemographics, general health, psychosocial measures, and objective exam findings as potential predictors of pain outcomes utilizing 400 participants from a randomized controlled trial. Participants received 18 sessions of treatment over 6-weeks and were followed for a year. Spinal manipulation was performed by a chiropractor at 0, 6, 12, or 18 visits (dose), with a light-massage control at all remaining visits. Pain intensity was evaluated with the modified von Korff pain scale (0-100). Predictor variables evaluated came from several domains: condition-specific pain and disability, sociodemographics, general health status, psychosocial, and objective physical measures. Three-quarters of cases (training-set) were used to develop 4 longitudinal models with forward selection to predict individual "responders" (≥50% improvement from baseline) and future pain intensity using either pretreatment characteristics or post-treatment variables collected shortly after completion of care. The internal validity of the predictor models were then evaluated on the remaining 25% of cases (test-set) using area under the receiver operating curve (AUC), R(2), and root mean squared error (RMSE). RESULTS: The pretreatment responder model performed no better than chance in identifying participants who became responders (AUC = 0.479). Similarly, the pretreatment pain intensity model predicted future pain intensity poorly with low proportion of variance explained (R(2) = .065). The post-treatment predictor models performed better with AUC = 0.665 for the responder model and R(2) = 0.261 for the future pain model. Post-treatment pain alone actually predicted future pain better than the full post-treatment predictor model (R(2) = 0.350). The prediction errors (RMSE) were large (19.4 and 17.5 for the pre- and post-treatment predictor models, respectively). CONCLUSIONS: Internal validation of prediction models showed that participant characteristics preceding the start of care were poor predictors of at least 50% improvement and the individual's future pain intensity. Pain collected shortly after completion of 6 weeks of study intervention predicted future pain the best.

Evaluating the Cornell Scale for Depression in Dementia as a proxy measure in nursing home residents with and without dementia.

OBJECTIVES: We evaluated the use of the Cornell Scale for Depression in Dementia (CSDD) as a proxy measure. Study questions were: How do residents' self-reports on the CSDD compare with the nurse proxy CSDD ratings of the resident? How do characteristics of depression as rated by the resident CSDD and the nurse CSDD compare? To what extent are demographic and clinical variables associated with resident CSDD, nurse CSDD, and the discrepancy between resident and nurse CSDD scores? METHODS: Residents and nurse proxy pairs (n=395 pairs) from 28 nursing homes (NHs) participated. We calculated discrepancy scores for total and subscale CSDD scores, examined correlations between resident and nurse CSDD scores, and described rates of clinical depression using each of the scores. We conducted multivariate analyses to examine factors associated with resident and nurse CSDD and discrepancy scores. RESULTS: On average, participants had mild cognitive impairment, were White, and female. Associations between resident and nurse CSDD were low (r=0.16). The mean discrepancy score was -2.03 (SD=5.28, p<0.001), indicating that nurses evaluated residents as less depressed than residents evaluated themselves. Discrepancy scores were not associated with residents' cognitive status, but were associated with a measure of self-report reliability. Regression analyses indicated that depression diagnosis accounted for a small but significant association with resident CSDD, but was not significantly associated with nurse CSDD. CONCLUSION: These findings underscore the importance of obtaining resident input when assessing depression in NH residents with dementia, and educating NH nurses in the most effective ways to assess depression.

Carotid artery atherosclerosis: effect of intensive lipid therapy on the vasa vasorum--evaluation by using dynamic contrast-enhanced MR imaging.

PURPOSE: To investigate whether short-term, intensive lipid therapy leads to changes in microvascular characteristics, as measured by using dynamic contrast material-enhanced (DCE) magnetic resonance (MR) imaging. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained for this HIPAA-compatible study. Subjects with established coronary artery disease or carotid artery stenosis of 15% or greater determined by using ultrasonography and with levels of apolipoprotein B of 120 mg/dL (1.2 g/L) or greater were enrolled in an ongoing study (clinical trial NCT00715273). All received intensive lipid therapy to achieve targeted high- and low-density lipoprotein cholesterol levels and underwent serial serum monitoring including high-sensitivity C-reactive protein (HsCRP) level measurements. Carotid artery MR imaging examinations including morphologic and DCE MR images were obtained at baseline and 1 year after treatment. In subjects with advanced lesions (>2 mm thick), MR image analysis was performed, including measurement of lipid-rich necrotic core size and kinetic modeling of DCE MR images to assess changes in the transfer constant (K(trans)). The differences in K(trans) between baseline and 1-year follow-up were compared by using the Wilcoxon signed rank test, and associations were assessed by using the Spearman rank correlation coefficient. RESULTS: Twenty-eight subjects with interpretable DCE MR imaging results at both baseline and 1-year follow-up were included. After 1 year of treatment, a significant reduction was found in mean K(trans) (0.085 min(-1) ± 0.037 [standard deviation] to 0.067 min(-1) ± 0.028, P = .02). Reduction in K(trans) was not significantly correlated with observed reductions in lipid-rich necrotic core size or reductions in HsCRP level. CONCLUSION: These findings suggest that DCE MR imaging may be a useful imaging method for the assessment of the therapeutic response of the vasa vasorum in patients with atherosclerotic plaque.

A reproducible and practical method for documenting the position of the humeral head center relative to the scapula on standardized plain radiographs.

BACKGROUND: Recent articles in this journal showed the clinical importance of the position of the humeral head center in relation to the glenoid. However, the precision, reproducibility, and sensitivity of this and other methods of documenting the head center position have not been evaluated in detail. MATERIALS AND METHODS: We used templates to fit a coordinate system to the scapular anatomy visible on standardized radiographs. Two observers then used these templates to measure the position of the head center relative to this coordinate system on 25 normal shoulder radiographs and on 25 radiographs of shoulders with cuff tear arthropathy (CTA). RESULTS: Head center measurements had excellent precision. Normal shoulder radiographs showed a consistent head center position (0.7 ± 1.7 mm medial and 0.6 ± 1.3 mm inferior to the coordinate origin on the anteroposterior view and 0.1 ± 1.3 mm medial and 0.0 ± 1.3 mm anterior to the coordinate origin on the axillary view). The head center of CTA shoulder radiographs was 10.18 ± 5.16 mm above the coordinate origin on the anteroposterior view, significantly different from that for the normal shoulder radiographs (P < .001). DISCUSSION: The relative position of the humeral head center to the scapula determines the resting length and the moment arms of the scapulohumeral muscles. Correlation of shoulder function with the head center position may provide insights into both shoulder pathomechanics and the optimization of shoulder arthroplasty. CONCLUSION: This practical technique showed a high degree of precision and reproducibility for normal and CTA shoulder radiographs as well as a high level of discrimination between these two groups.

Comparing the psychometric properties of the Checklist of Nonverbal Pain Behaviors (CNPI) and the Pain Assessment in Advanced Dementia (PAIN-AD) instruments.

OBJECTIVE: To examine and compare the psychometric properties of two common observational pain assessment tools used in persons with dementia. DESIGN: In a cross-sectional descriptive study nursing home (NH) residents were videotaped at rest and during a structured movement procedure. Following one training session and one practice session, two trained graduate nursing research assistants independently scored the tapes using the two pain observation tools. SETTING: Fourteen NHs in Western Washington State participating in a randomized controlled trial of an intervention to enhance pain assessment and management. PARTICIPANTS: Sixty participants with moderate to severe pain were identified by nursing staff or chosen based on the pain items from the most recent Minimum Data Set assessment. MEASURES: Checklist of Nonverbal Pain Indicators (CNPI) and the Pain Assessment in Advanced Dementia (PAINAD), demographic and pain-related data (Minimum Data Set), nursing assistant reports of participants' usual pain intensity, and Pittsburgh Agitation Scale. RESULTS: Internal consistency for both tools was good except for the CNPI at rest for one rater. Inter-rater reliability for pain presence was fair (K = 0.25 for CNPI with movement; K = 0.31 for PAINAD at rest) to moderate (K = 0.43 for CNPI at rest; K = 0.54 for PAINAD with movement). There were significant differences in mean CNPI and PAINAD scores at rest and during movement, providing support for construct validity. However, both tools demonstrated marked floor effects, particularly when participants were at rest. CONCLUSIONS: Despite earlier studies supporting the reliability and validity of the CNPI and the PAINAD, findings from the current study indicate that these measures warrant further study with clinical users, should be used cautiously both in research and clinical settings and only as part of a comprehensive approach to pain assessment.

Patient-derived determinants for participation in placebo-controlled clinical trials for fibromyalgia.

Perspectives of patients with fibromyalgia influence their likelihood of participating in randomized placebo-controlled trials and potentially clash with current, well-established methodology of randomized controlled trial design. Mandates to use only acetaminophen for breakthrough pain and that require discontinuation of concomitant medications, especially in studies lacking an active comparator arm, could bias a trial cohort to thereby reduce the generalizability of study findings and conclusions. This study evaluates factors affecting willingness to participate in such clinical trials, including the impact of altruism, payment, study duration, forced discontinuation of specific medications, and subject demographics for patients seen by rheumatologists proficient and avidly interested in treating fibromyalgia.

The validation of a new scoring method for assessing ego development based on three dimensions of language.

We describe research on the validity of a new theoretical framework and scoring methodology, called STAGES, for sentence completion tests of meaning-making maturity or complexity (also called ego development or perspective-taking capacity). STAGES builds upon research on the substantially validated Washington University Sentence Completion Test of Jane Loevinger as updated by Susanne Cook-Greuter. STAGES proposes an underlying structural explanation for the Cook-Greuter system based on three dimensions. Two of these are polar factors: individual/collective, and passive/active; and the third is a categorization of the sophistication of the types of objects referred to (i.e. as concrete, subtle/abstract, or "metaware"). We describe two validation studies for the STAGES scoring method and model. The first is a replication study of concurrent validity, using 73 inventories to test the hypothesis that the STAGES scoring method replicates the Cook-Greuter scoring method. Using the weighted Kappa statistic, we demonstrate a very strong match between the two methods, confirming the first hypothesis. This study includes levels up to and including Strategist (i.e. a substantial percentage of test-takers from most populations). Levels above Strategist were validated using another method because (1) there is less Cook-Greuter data available at these levels, and (2) the two scoring methods diverge sufficiently, making comparison difficult. The second study, of 71 inventories, attempts to validate the STAGES scoring method at levels above Strategist by testing the inter-rater reliability among four scorers. The inter-rater reliability above Strategist, using the weighted Kappa statistic, was found to be moderate to substantial, indicating that the instrument and scoring method has internal validity for these four, rare higher levels. Additionally, the inter-rater reliability over all STAGES levels were found to be very strong.

Pain Management Algorithms for Implementing Best Practices in Nursing Homes: Results of a Randomized Controlled Trial.

OBJECTIVE: To enhance pain practices in nursing homes (NHs) using pain assessment and management algorithms and intense diffusion strategies. DESIGN: A cluster, randomized controlled trial. The intervention consisted of intensive training and support for the use of recommended pain assessment and management practices using algorithms (ALGs). Control facilities received pain education (EDU) only. SETTING: Twenty-seven NHs in the greater Puget Sound area participated. Facilities were diverse in terms of size, quality, and ownership. PARTICIPANTS: Data were collected from 485 NH residents; 259 for the intervention and 226 for the control group. MEASUREMENTS: Resident outcomes were nursing assistant (proxy) report and self-reported resident pain intensity. Process outcomes were adherence to recommended pain practices. Outcomes were measured at baseline, completion of the intervention (ALG) or training (EDU), and again 6 months later. RESULTS: Among 8 comparisons of outcome measures between ALG and EDU (changes in 4 primary pain measures compared at 2 postintervention time points) there was only 1 statistically significant but small treatment difference in proxy- or self-reported pain intensity. Resident-reported worst pain decreased by an average of 0.8 points from baseline to 6 months among the EDU group and increased by 0.2 points among the ALG (P = .005), a clinically nonsignificant difference. There were no statistically significant differences in adherence to clinical guideline practice recommendations between ALG and EDU following the intervention. CONCLUSIONS: Future research needs to identify and test effective implementation methods for changing complex clinical practices in NHs, including those to reduce pain.

Rotator cuff repair: published evidence on factors associated with repair integrity and clinical outcome.

BACKGROUND: Rotator cuff tears are common, and rotator cuff repair represents a major health care expense. While patients often benefit from rotator cuff repair, anatomic failure of the repair is not unusual. PURPOSE: To identify the published evidence on the factors associated with retears and with suboptimal clinical outcomes of rotator cuff repairs. STUDY DESIGN: Systematic review and meta-analysis of articles with evidence levels 1-4. METHODS: A total of 2383 articles on rotator cuff repairs published between 1980 and 2012 were identified. Only 108 of these articles, reporting on over 8011 shoulders, met the inclusion criteria of reporting quantitative data on both imaging and clinical outcomes after rotator cuff repair. Factors related to the patients, their shoulders, the procedures, and the results were systematically categorized and submitted for meta-analysis. RESULTS: While the number of relevant articles published per year increased dramatically over the period of the study, the clinical and anatomic results did not show improvement over this period. The weighted mean retear rate was 26.6% at a mean of 23.7 months after surgery. Retears were associated with more fatty infiltration, larger tear size, advanced age, and double-row repairs. Clinical improvement averaged 72% of the maximum possible improvement. Patient-reported outcomes were generally improved whether or not the repair restored the integrity of the rotator cuff. The inconsistent and incomplete data in the published articles limited the meta-analysis of factors affecting the outcome of rotator cuff repair. CONCLUSION: In spite of a dramatic increase in the number of publications per year, there is little evidence that the results of rotator cuff repair are improving. The information needed to guide the management of this commonly treated and costly condition is seriously deficient. To accumulate the evidence necessary to inform practice, future clinical studies on the outcome of rotator cuff repair must report important data relating to each patient's condition, the surgical technique, the outcome in terms of integrity, and the change in patient self-assessed comfort and function.

Demographics of disclosure of conflicts of interest at the 2011 annual meeting of the American Academy of Orthopaedic Surgeons.

BACKGROUND: There is growing concern regarding conflicts of interest in orthopaedic research and education. Because of their potential influence on orthopaedic practice, conflicts of interest among participants in the educational programs of the American Academy of Orthopaedic Surgeons (AAOS) are of particular interest. METHODS: We analyzed the voluntarily disclosed conflicts of interest listed in the Final Program of the 2011 Annual Meeting of the AAOS for the relevant program committees as well as for presentations in the disciplines of pediatric orthopaedic surgery, spine, and sports medicine/arthroscopy. RESULTS: Conflicts of interest were disclosed by participants for each of the program committees and for over 75% of the presentations. Conflicts of interest were disclosed for 100% of the featured symposia, 80% of the scientific exhibits, 76% of the podium presentations, and 75% of the posters. Over half (53%) of the disclosures were for paid consultancy, 51% were for research support for the principal investigator, 41% were for paid presentations, 39% were for royalties, and 39% were for stock. The highest number of disclosures for an individual author was thirty-seven. The number of disclosures per author was significantly (p < 0.001) correlated to the number of presentations per author. Disclosures were associated with 379 different companies; relationships with a relatively small number (twenty-six, 7%) of these companies were listed in the disclosures for 67% of the presentations. CONCLUSIONS: Voluntarily disclosed conflicts of interest were common at the 2011 AAOS Annual Meeting, especially for the featured symposia. In view of the previously documented frequency of undisclosed conflicts of interest, as well as the previously documented effects of conflicts of interest on research design, conduct, and conclusion, it may be time to consider improved strategies for ensuring the accuracy and completeness of disclosure and for managing the biasing effects of conflicts of interest.

Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012.

BACKGROUND: Although glenoid component failure is one of the most common complications of anatomic total shoulder arthroplasty, substantial evidence from the recent published literature is lacking regarding the temporal trend in the rate of this complication and the risk factors for its occurrence. METHODS: We conducted a systematic review and identified twenty-seven articles presenting data on glenoid component failure rates that met the inclusion criteria. These articles represented data from 3853 total shoulder arthroplasties performed from 1976 to 2007. RESULTS: Asymptomatic radiolucent lines occurred at a rate of 7.3% per year after the primary shoulder replacement. Symptomatic glenoid loosening occurred at 1.2% per year, and surgical revision occurred at 0.8% per year. There was no significant evidence that the rate of symptomatic loosening has diminished over time. Keeled components had greater rates of asymptomatic radiolucent lines compared with pegged components in side-by-side comparison studies. However, as a result of wide variability in outcomes reporting, only sex, Walch class, and diagnosis were significantly associated with the risk of glenoid component failure in the overall analysis. CONCLUSIONS: This is the first systematic review of the published evidence on glenoid component failure. Although the authors of individual articles proposed various risk factors for glenoid component failure, many of these relationships were not significant in the present study. A consistent methodological approach to future investigations is likely to improve the quality of the evidence on which patients, techniques, and prostheses are selected for total shoulder arthroplasty.

An inter-laboratory retrospective analysis of immunotoxicological endpoints in non-human primates: flow cytometry immunophenotyping.

Non-human primates may be the only relevant species for pharmacology or toxicology studies of certain biologics, due to lack of activity in other species. Flow cytometry immunophenotyping is often included as a minimally invasive adjunct to standard toxicity testing. A retrospective inter-laboratory analysis was conducted to assess counts and variability of the main cell types monitored in toxicity studies, and to provide guidance for conduct and interpretation of immunophenotyping assessments in cynomolgus monkeys. Univariate and multivariate models were developed. Study design factors influencing cell counts and variability were identified and a power analysis was performed. Pre-study and on-study counts were generally similar; longitudinal analysis showed little drift in mean counts or within-animal variability over time. Within-animal variability was lower than inter-animal variability. Gender was associated with small but significant differences in mean counts and variability. Age was associated with significant differences in variability. Immunophenotype definitions were associated with significant differences in mean counts and within-animal variability for most cell types. Power analysis for groups of 6-8 animals showed that differences of ≈50% in counts of T-cells, T-cell subsets, and B-cells compared to pre-treatment values may be detected; for NK cells and monocytes, differences of ≈60-90% may be detected. This review yields some general points to consider for immunophenotyping studies, i.e. (a) analysis of log-transformed cell count data and comparisons using each animal as its own reference will improve ability to detect changes, (b) the magnitude of change detectable given study group size should be considered, (c) multiplication of sampling timepoints during a study seems unnecessary, (d) consideration should be given to using only one gender, when applicable, to increase power while minimizing animal usage, and (e) the choice of immunophenotype has impacts on cell counts and variability.

Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening.

BACKGROUND: Propionibacterium acnes has been grown on culture in half of the reported cases of chronic infection associated with shoulder arthroplasty. The presence of this organism can be overlooked because its subtle presentation may not suggest the need for culture or because, in contrast to many orthopaedic infections, multiple tissue samples and weeks of culture incubation are often necessary to recover this organism. Surgical decisions regarding implant revision and antibiotic therapy must be made before the results of intraoperative cultures are known. In the present study, we sought clinically relevant prognostic evidence that could help to guide treatment decisions. METHODS: We statistically correlated preoperative and intraoperative observations on 193 shoulder arthroplasty revisions that were performed because of pain, loosening, or stiffness with the results of a Propionibacterium acnes-specific culture protocol. Regression models were used to identify factors predictive of a positive culture for Propionibacterium acnes. RESULTS: One hundred and eight of the 193 revision arthroplasties were associated with positive cultures; 70% of the positive cultures demonstrated growth of Propionibacterium acnes. The rate of positive cultures per shoulder increased with the number of culture specimens obtained from each shoulder. Fifty-five percent of the positive cultures required observation for more than one week. Male sex, humeral osteolysis, and cloudy fluid were each associated with significant increases of ≥ 600% in the likelihood of obtaining a positive Propionibacterium acnes culture. Humeral loosening, glenoid wear, and membrane formation were associated with significant increases of >300% in the likelihood of obtaining a positive Propionibacterium acnes culture. CONCLUSIONS: Preoperative and intraoperative factors can be used to help to predict the risk of a positive culture for Propionibacterium acnes. This evidence is clinically relevant to decisions regarding prosthesis removal or retention and the need for immediate antibiotic therapy at the time of revision shoulder arthroplasty before the culture results become available. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Development of a composite pain measure for persons with advanced dementia: exploratory analyses in self-reporting nursing home residents.

CONTEXT: Experts agree that pain assessment in noncommunicative persons requires data from sources that do not rely on self-report, including proxy reports, health history, and observation of pain behaviors. However, there is little empirical evidence to guide clinicians in weighting or combining these sources to best approximate the person's experience. OBJECTIVES: The aim of this exploratory study was to identify a combination of observer-dependent pain indicators that would be significantly more predictive of self-reported pain intensity than any single indicator. Because self-reported pain is usually viewed as the criterion measure for pain, self-reported usual and worst pains were the dependent variables. METHODS: The sample consisted of 326 residents (mean age: 83.2 years; 69% female) living in one of 24 nursing homes. Independent variables did not rely on self-report: surrogate reports from certified nursing assistants (CNAs) using the Iowa Pain Thermometer (IPT), Checklist of Nonverbal Pain Indicators (CNPI), Cornell Scale for Depression in Dementia (CSDD), Pittsburgh Agitation Scale (PAS), number of painful diagnoses, and Minimum Data Set (MDS) pain variables. RESULTS: In univariate analyses, the CNA IPT scores were correlated most highly with self-reported pain. The final multivariate model for self-reported usual pain included CNA IPT, CSDD, PAS, and education; this model accounted for only 14% of the variance. The more extensive of the two final models for worst pain included MDS pain frequency, CSDD, CNA IPT, CNPI, and age (R(2)=0.14). CONCLUSION: Additional research is needed to develop a predictive pain model for nonverbal persons.

Risk factors for chondrolysis of the glenohumeral joint: a study of three hundred and seventy-five shoulder arthroscopic procedures in the practice of an individual community surgeon.

BACKGROUND: Glenohumeral chondrolysis is a complication of arthroscopic shoulder surgery characterized by the dissolution of the articular cartilage of the glenoid and the humeral head. An analysis of 375 intra-articular shoulder arthroscopic surgical procedures by an individual community orthopaedic surgeon was performed to explore which factors or combinations of factors might be associated with glenohumeral chondrolysis. METHODS: The occurrence of chondrolysis was correlated with several demographic and surgical variables with use of hazard ratios from Cox proportional hazards models and Kaplan-Meier survivorship curves. Sensitivity analysis was used to examine the effect of two different definitions of the date of the onset of chondrolysis. RESULTS: In this cohort, each case of documented chondrolysis was associated with the intra-articular post-arthroscopic infusion of a local anesthetic, either Marcaine (bupivacaine) or lidocaine. In an analysis of the group that received an intra-articular postoperative infusion of a local anesthetic, the risk of chondrolysis was found to be greater for those with one or more suture anchors placed in the glenoid, for younger patients, and for those who had the surgery near the end of the ten-year study period. CONCLUSIONS: To our knowledge, this is the first Level-II retrospective cohort study of the factors associated with the development of post-arthroscopic glenohumeral chondrolysis. In this cohort of intra-articular shoulder arthroscopic procedures, chondrolysis was observed only in cases in which either Marcaine or lidocaine had been infused into the joint during the postoperative period. Avoiding such a postoperative infusion may reduce the risk of chondrolysis.

Can magnetic resonance imaging predict posterior drawer laxity at the time of surgery in patients with knee dislocation or multiple-ligament knee injury?

BACKGROUND: Previous studies indicate that isolated posterior cruciate ligament injuries demonstrate magnetic resonance imaging (MRI) and clinical evidence of healing when treated nonoperatively; however, the authors are unaware of any other study that has looked at whether initial MRI can predict posterior cruciate ligament stability at the time of surgery in patients with knee dislocation. HYPOTHESIS: An MRI grading system will predict laxity on posterior drawer testing at the time of surgery in patients with knee dislocations. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: Forty-two consecutive patients with knee dislocation or multiple-ligament knee injury evaluated by MRI were included in the study. An assignment of grade 0 (intact), grade I (injured/fibers intact), grade II (partial tearing of ligament), or grade III (complete tear) was made after each reading on 2 separate occasions by 3 surgeons. Posterior laxity of the knee was graded by the magnitude of excursion on the posterior drawer test by the senior author at the time of surgery. Interobserver and intraobserver reliability of the MRI grading scheme expressed by the kappa statistic κ, as well as the predictive value of MRI grade in determining stability of the posterior cruciate ligament at the time of surgery, was assessed. RESULTS: The posterior cruciate ligament injury grading scheme tested demonstrated moderate to substantial intraobserver agreement (κ = 0.66, κ = 0.53, and κ = 0.52, respectively, for all raters). Interobserver reliability demonstrated only moderate agreement (κ = 0.49). If the grading scheme was changed to group both grades 0 and I (intact) and grades II and III (disrupted), intraobserver reliability demonstrated substantial to almost perfect agreement (κ = 0.83, κ = 0.80, and κ = 0.75), and interobserver reliability demonstrated substantial agreement (κ = 0.70). If the posterior cruciate ligament was classified as intact (grade 0 [intact] or grade I [injured]) on initial MRI, the injured knee was judged clinically stable (tibia anterior to or flush with the femoral condyles on posterior drawer testing) at the time of surgery 98.5% (95% confidence interval, 93%-100%) of the time. When the posterior cruciate ligament was classified as disrupted (grade II [partial tear] or grade III [complete tear]), the injured knee was judged unstable (tibia posterior to the femoral condyles on posterior drawer testing) 57.5% (95% confidence interval, 40%-73%) of the time. CONCLUSION: The presented system of grading posterior cruciate ligament injury in patients with knee dislocation on initial MRI demonstrates moderate to substantial interobserver and intraobserver reliability that increases if the grading scheme is modified. An initial MRI scan read as grade I may predict stability to posterior drawer at the time of surgery. Even with MRI evidence of disruption in the posterior cruciate ligament (grade II and grade III injuries), posterior cruciate ligament reconstruction may not be clinically indicated at the time of reconstruction and/or repair of other associated injuries.