Are informants required to obtain valid ratings on the Positive and Negative Syndrome Scale (PANSS)?

Ratings on the Positive and Negative Syndrome Scale (PANSS) are ideally based on both a patient interview and an informant questionnaire. In research and clinical settings, however, the informant questionnaire is often omitted. This study investigated the consequences of omitting informant information by comparing PANSS ratings of patients with schizophrenia (n = 49 patients, 77 ratings) conducted with and without informant information, respectively. Additionally, changes in symptom severity over time based on ratings with and without informant information were also compared for the full PANSS and the six-item version of the PANSS (PANSS-6). PANSS ratings including informant information were higher than those without, both at the total score and individual item level. Additionally, the full PANSS appeared less "responsive" to baseline-to-endpoint changes for ratings without informant information compared to ratings including informant information, while no differences were found for the PANSS-6.

Patient-specific articulating spacer for two-stage shoulder arthroplasty exchange

OBJECTIVE

Two-stage exchange with an antibiotic-loaded polymethylmethacrylate (PMMA) spacer is standard treatment for chronic periprosthetic joint infection of the shoulder. We present a safe and simple technique for patient-specific spacer implants.

INDICATION

(Chronic) periprosthetic joint infection of the shoulder.

RELATIVE CONTRAINDICATIONS

Known allergy against components of PMMA bone cements. Inadequate compliance for two-stage exchange. Patient is unfit to undergo two-stage exchange.

SURGICAL TECHNIQUE

Hardware removal, histologic and microbiologic samples, and debridement. Preparation of targeted or calculated antibiotic-loaded PMMA. Tailoring of patient-specific spacer. Spacer implantation.

POSTOPERATIVE MANAGEMENT

Rehabilitation protocol. Antibiotic treatment. Reimplantation after successful eradication of infection.

Validation of ratings on the six-item Positive and Negative Syndrome Scale obtained via the Simplified Negative and Positive Symptoms Interview among outpatients with schizophrenia

BACKGROUND

The six-item Positive and Negative Syndrome Scale (PANSS-6) is a measure of the severity of core symptoms of schizophrenia, which can be administered via the brief Simplified Negative and Positive Symptoms Interview (SNAPSI). A recent study has confirmed the validity of PANSS-6 ratings as derived by SNAPSI (PANSS-6_SNAPSI) among inpatients with schizophrenia.

AIMS

We aimed to test the validity of PANSS-6_SNAPSI among outpatients with schizophrenia using PANSS-6 ratings extracted from the 30-item PANSS-30 as derived by the Structured Clinical Interview for the Positive and Negative Syndrome Scale (PANSS-6_SCI-PANSS) as a gold standard reference.

METHODS

PANSS-6_SNAPSI and PANSS-6_SCI-PANSS ratings were obtained at two time points by independent raters with established inter-rater reliability. Agreement between PANSS-6_SNAPSI and PANSS-6_SCI-PANSS ratings was estimated via intra-class coefficients (ICCs) and responsiveness over time was quantified using Spearman's rank correlation coefficients. Post hoc "leave-one-out" analyses were carried out, in which each rater in turn was excluded from the ICC calculations.

RESULTS

Seventy-three outpatients with schizophrenia participated in the study (mean age: 38.3 years; 56% males). The ICC for PANSS-6_SNAPSI versus PANSS-6_SCI-PANSS was 0.67 [95%CI = 0.56-0.76] and the Spearman's rank correlation coefficient for responsiveness was 0.40 (p = 0.004). When data from a specific outlying rater were excluded, the ICC for PANSS-6_SNAPSI versus PANSS-6_SCI-PANSS was 0.75 [95% CI = 0.63-0.83] and the Spearman's rank correlation coefficient for responsiveness was 0.55 (p = 0.018).

CONCLUSIONS

We found PANSS-6_SNAPSI ratings to have acceptable clinical validity, suggesting that PANSS-6_SNAPSI can be used for both inpatients and outpatients with schizophrenia.

Changes in telepsychiatry regulations during the COVID-19 pandemic: 17 countries and regions' approaches to an evolving healthcare landscape

BACKGROUND

During the COVID-19 pandemic, the use of telemedicine as a way to reduce COVID-19 infections was noted and consequently deregulated. However, the degree of telemedicine regulation varies from country to country, which may alter the widespread use of telemedicine. This study aimed to clarify the telepsychiatry regulations for each collaborating country/region before and during the COVID-19 pandemic.

METHODS

We used snowball sampling within a global network of international telepsychiatry experts. Thirty collaborators from 17 different countries/regions responded to a questionnaire on barriers to the use and implementation of telepsychiatric care, including policy factors such as regulations and reimbursement at the end of 2019 and as of May 2020.

RESULTS

Thirteen of 17 regions reported a relaxation of regulations due to the pandemic; consequently, all regions surveyed stated that telepsychiatry was now possible within their public healthcare systems. In some regions, restrictions on prescription medications allowed via telepsychiatry were eased, but in 11 of the 17 regions, there were still restrictions on prescribing medications via telepsychiatry. Lower insurance reimbursement amounts for telepsychiatry consultations v. in-person consultations were reevaluated in four regions, and consequently, in 15 regions telepsychiatry services were reimbursed at the same rate (or higher) than in-person consultations during the COVID-19 pandemic.

CONCLUSIONS

Our results confirm that, due to COVID-19, the majority of countries surveyed are altering telemedicine regulations that had previously restricted the spread of telemedicine. These findings provide information that could guide future policy and regulatory decisions, which facilitate greater scale and spread of telepsychiatry globally.

Clinical validation of the Aarhus Side effect Assessment Questionnaire(ASAQ)

BACKGROUND

Psychotropic medications are essential in the treatment of mental illness. Unfortunately, these medications are associated with side effects that may reduce adherence to treatment and quality of life. Therefore, systematic screening for side effects is fundamental to optimize treatment with psychotropic medications. Self-report of side effects is a practical alternative to time-consuming clinical assessments. We developed the Aarhus Side effect Assessment Questionnaire (ASAQ) in an attempt to strike the balance between extensive coverage of side effects and reasonable application time.

AIM

The aim of the study was to validate the ASAQ using the clinician-rated Udvalg for Kliniske Undersøgelser (UKU) Side Effect Scale as gold standard reference.

METHODS

A total of 122 inpatients and outpatients-mainly with psychotic (39%) and affective disorders (43%)-receiving treatment with psychotropic medication completed the ASAQ and the World Health Organization-Five Well-Being Index (WHO-5) and were subsequently rated on the UKU by trained raters.

RESULTS

Using the UKU as the gold standard reference, the ASAQ demonstrated sensitivity values >75% for 77% of its 30 items (ranging from 37% for cutaneous disturbances to 98% for increased sweating) and specificity values >75% for 47% of its 30 items (ranging from 28% for reduced sleep to 98% for micturition disturbances). While 17% of the participants considered discontinuing their medication, 24% had recently refrained from taking their medication as prescribed. A negative correlation was found between the ASAQ and the WHO-5 and total scores (Pearson's correlation coefficient = -0.44).

CONCLUSIONS

The self-reported ASAQ seems to be a sensitive tool for detecting side effects of psychotropic medications.

Application of Machine Learning Algorithms to Predict Clinically Meaningful Improvement After Arthroscopic Anterior Cruciate Ligament Reconstruction

Background:

Understanding specific risk profiles for each patient and their propensity to experience clinically meaningful improvement after anterior cruciate ligament reconstruction (ACLR) is important for preoperative patient counseling and management of expectations.

Purpose:

To develop machine learning algorithms to predict achievement of the minimal clinically important difference (MCID) on the International Knee Documentation Committee (IKDC) score at a minimum 2-year follow-up after ACLR.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

An ACLR registry of patients from 27 fellowship-trained sports medicine surgeons at a large academic institution was retrospectively analyzed. Thirty-six variables were tested for predictive value. The study population was randomly partitioned into training and independent testing sets using a 70:30 split. Six machine learning algorithms (stochastic gradient boosting, random forest, neural network, support vector machine, adaptive gradient boosting, and elastic-net penalized logistic regression [ENPLR]) were trained using 10-fold cross-validation 3 times and internally validated on the independent set of patients. Algorithm performance was assessed using discrimination, calibration, Brier score, and decision-curve analysis.

Results:

A total of 442 patients, of whom 39 (8.8%) did not achieve the MCID, were included. The 5 most predictive features of achieving the MCID were body mass index ≤27.4, grade 0 medial collateral ligament examination (compared with other grades), intratunnel femoral tunnel fixation (compared with suspensory), no history of previous contralateral knee surgery, and achieving full knee extension preoperatively. The ENPLR algorithm had the best relative performance (C-statistic, 0.82; calibration intercept, 0.10; calibration slope, 1.15; Brier score, 0.068), demonstrating excellent predictive ability in the study’s data set.

Conclusion:

Machine learning, specifically the ENPLR algorithm, demonstrated good performance for predicting a patient’s propensity to achieve the MCID for the IKDC score after ACLR based on preoperative and intraoperative factors. The femoral tunnel fixation method was the only significant intraoperative variable. Range of motion and medial collateral ligament integrity were found to be important physical examination parameters. Increased body mass index and prior contralateral surgery were also significantly predictive of outcome.

Clinical validation of ratings on the six-item Positive and Negative Syndrome Scale obtained via the Simplified Negative and Positive Symptoms Interview

BACKGROUND

The six-item version of the Positive and Negative Syndrome Scale (PANSS-6) has shown promise as a brief measure of the severity of core symptoms of schizophrenia. However, since all prior analyses of the PANSS-6 were based on data extracted from studies using the full 30-item PANSS (PANSS-30), it remains unknown whether it is possible to obtain valid information for the PANSS-6 ratings via a brief interview, such as the Simplified Negative and Positive Symptoms Interview (SNAPSI).

AIMS

We aimed to validate the PANSS-6 ratings obtained via the SNAPSI using the PANSS-6 scores extracted from the PANSS-30 ratings obtained via the comprehensive Structured Clinical Interview for PANSS (SCI-PANSS) as the gold-standard reference.

METHODS

The PANSS-6 ratings based on the SNAPSI and the PANSS-30 ratings based on the SCI-PANSS were conducted by independent raters with established inter-rater reliability.

RESULTS

Seventy-seven inpatients with schizophrenia (M_age = 35.1 ± 11.7 years; males = 57%; paranoid schizophrenia = 75%) participated in the study. The intraclass correlation coefficient (ICC) of the PANSS-6 total scores obtained using the SNAPSI and the PANSS-30-derived PANSS-6 total scores via the SCI-PANSS was 0.77 (p < 0.001). The ICC for the PANSS-6 total score and the PANSS-30-derived PANSS-8 (Andreasen's remission criteria) was 0.75 (p < 0.001). Spearman's rank correlation coefficient for changes in PANSS-6 total scores via the SNAPSI and changes in PANSS-30-derived PANSS-6 total scores was 0.70 (p < 0.001).

CONCLUSIONS

Using the SNAPSI to rate the PANSS-6 enables a focused and brief assessment of the severity of core symptoms of schizophrenia, which facilitates measurement-based care and clinical decision making in the treatment of schizophrenia.

Return to Sport After Bone-Patellar Tendon-Bone Autograft ACL Reconstruction in High School-Aged Athletes

Background:

Anterior cruciate ligament (ACL) injuries are occurring with increasing frequency in the adolescent population. Outcomes after ACL reconstruction (ACLR) are inconsistently reported in homogeneous patient populations.

Purpose/Hypothesis:

To evaluate outcomes after bone–patellar tendon–bone (BTB) autograft ACLR in competitive high school–aged athletes by examining return to sport (RTS), patient satisfaction, and reinjury rates. Our hypothesis was that RTS rates and satisfaction will be high and reinjury rates will be low.

Study Design:

Case series; Level of evidence, 4.

Methods:

An institutional ACL registry was utilized to identify competitive high school–aged athletes (14-18 years old) who underwent primary ACLR using BTB autograft with a minimum 2-year follow-up. A postoperative questionnaire was administered to determine rates and types of RTS, quality of sports performance, reinjury, and satisfaction. Uni- and multivariable analyses were used to identify demographic, sport-specific, and clinical factors related to RTS.

Results:

A total of 53 patients were included (mean ± SD age at the time of surgery, 16.6 ± 1.34 years). Mean follow-up was 3.78 ± 0.70 years (range, 2.60-4.94 years). The overall ipsilateral ACL retear rate was 7.5% (n = 4). There were 10 subsequent ACL tears to the contralateral knee (19%). Forty-four (83%) patients successfully returned to at least their prior level of sport at a mean 10.5 ± 8.7 months (range, 3-48 months). Overall satisfaction was high, with 91% of patients very satisfied with the outcome. Higher confidence levels regarding performance of the reconstructed knee were associated with increased probability of RTS on multivariate analysis.

Conclusion:

BTB autograft ACLR results in high rates of RTS and satisfaction and low rates of subsequent ipsilateral ACL injuries in competitive high school–aged athletes. Patients with higher confidence in performance of the reconstructed knee are more likely to return to at least their prior level of sport.

Interval Return to Play Programs for the Tennis Athlete

PURPOSE OF REVIEW

General guidelines exist for return to sport after injury. The goal of these guidelines is to outline phases of recovery that will minimize the risk of reinjury and promote an optimal return to function for the athlete. This paper analyzes the current research pertaining to interval return to play programs with a special focus on the tennis athlete. The authors examine the different components of an interval tennis program and work to develop what they feel are the necessary elements of the optimal return to sport guidelines for tennis athletes. These criteria are based on the available literature, research, and preliminary data collection as well as the personal experiences and clinical observations of the authors.

RECENT FINDINGS

Interval sports programs are typically designed to guide the athlete back to competition after an injury. The current research reveals the obstacles present in implementing an appropriate interval sports program including a lack of consensus on which criteria is actually necessary and relevant. Limited research is present for interval tennis programs. Return to sport competition and sports science is continuously evolving. The authors highlight the necessary components in rehabilitation and performance principles for establishing a comprehensive interval tennis program. In addition, the role of technology in sports rehabilitation is assessed as it pertains to return to play. The authors proposed that interval sports program can help guide and direct future clinicians in their rehabilitation of the tennis athlete.

Standardized training in the rating of the six-item positive and negative syndrome scale (PANSS-6)

Introduction

The six-item Positive And Negative Syndrome Scale (PANSS-6) is short psychometric valid scale quantifying the severity of core schizophrenia symptoms. Using PANSS-6 to guide treatment decision-making requires that staff members’ ratings are valid and reliable.

Objectives

The objective of the study was to evaluate whether such valid and reliable PANSS-6 ratings can be obtained through a video-based training program.

Methods

One-hundred-and-four staff members from Aarhus University Hospital - Psychiatry, Denmark participated in the training. Participants conducted baseline PANSS-6 ratings based on a video of a patient being interviewed using the Simplified Positive And Negative Symptoms interview (SNAPSI). Subsequently, a theoretical introduction video was displayed followed by five SNAPSI patient interviews. After each SNAPSI video, individual ratings were performed before a video providing the gold standard scores was displayed. The validity of ratings was estimated by calculating the proportion of participants not deviating from the gold standard scores with >2 points on individual items or >6 points on the PANSS-6 total score. Reliability was evaluated after each step in the training by means of Gwet’s Agreement Coefficient (Gwet).

Results

By the end of the training, 72% of the participants rated within the acceptable deviations of the gold standard, ranging from 60% (nurses) to 91% (medical doctors/psychologists). The reliability improved (Gwet baseline vs. endpoint) for all PANSS-6 items, except for Blunted affect.

Conclusions

The majority of the staff members conducted valid PANSS-6 ratings after a brief standardized training program, supporting the implementation of PANSS-6 in clinical settings to facilitate measurement-based care.

Conflict of interest

Dr. Opler is a full-time employee of MedAvante-ProPhase Inc. Dr. Correll has been a consultant and/or advisor to or have received honoraria from: Acadia, Alkermes, Allergan, Angelini, Axsome, Gedeon Richter, Gerson Lehrman Group, Indivior, IntraCellular T

Standardized training in the rating of the six-item Positive And Negative Syndrome Scale (PANSS-6)

The six-item Positive And Negative Syndrome Scale (PANSS-6) allows for a brief assessment of the severity of core symptoms of schizophrenia. However, implementing the PANSS-6 in clinical practice requires that staff members' ratings are accurate and reliable. We aimed to investigate whether such accuracy and reliability can be obtained via a brief video-based training program. One-hundred-and-four staff members from a psychiatric hospital in Denmark participated in the training. Participants performed a baseline PANSS-6 rating based on a video of a patient being interviewed using the Simplified positive And Negative Symptoms interview (SNAPSI). Subsequently, a theoretical introduction video was displayed followed by five successive videotaped SNAPSI patient interviews. After each SNAPSI video, individual ratings were conducted before a video providing the gold standard rating was displayed. The accuracy of ratings was estimated by calculating the proportion of participants not deviating from the gold standard rating with >2 points on individual items or >6 points on the PANSS-6 total score. Reliability was tested after each step in the training by means of Gwet's Agreement Coefficient (Gwet). By the end of the training, 72% of the participants rated within the acceptable deviations of the gold standard, ranging from 60% (nurses) to 91% (medical doctors & psychologists). The reliability improved (Gwet baseline vs. endpoint) for all PANSS-6 items, except for Blunted affect. In conclusion, the majority of the staff members conducted accurate PANSS-6 ratings after a brief standardized training program, supporting the implementation of PANSS-6 in clinical settings to facilitate measurement-based care.

Clinical validation of the self-reported Glasgow Antipsychotic Side-effect Scale using the clinician-rated UKU side-effect scale as gold standard reference

BACKGROUND

Antipsychotics are key for the treatment of psychotic and several non-psychotic disorders. Unfortunately, antipsychotic medications are associated with side effects, which may reduce quality of life and treatment adherence. Therefore, regular screening of antipsychotic side effects is essential. The Glasgow Antipsychotic Side-effect Scale is a patient self-report scale developed for this purpose. However, the Glasgow Antipsychotic Side-effect Scale has only been validated against another self-report side effect measure, which is suboptimal.

OBJECTIVE

We aimed to validate the Glasgow Antipsychotic Side-effect Scale using the clinician-rated Udvalg for Kliniske Undersøgelser side-effect rating scale as the gold standard reference.

RESULTS

81 antipsychotic-treated outpatients with schizophrenia-spectrum disorders (age = 42±13 years; males = 43%, schizophrenia = 77%, illness duration: median = 11 years) completed the Glasgow Antipsychotic Side-effect Scale and were subsequently scored on the Udvalg for Kliniske Undersøgelser by trained raters. Sensitivity, specificity, positive predictive value and negative predictive value were calculated for paired Glasgow Antipsychotic Side-effect Scale and Udvalg for Kliniske Undersøgelser items. Sensitivity of Glasgow Antipsychotic Side-effect Scale items ranged from 33-96%, with 19 (86%) having >75% sensitivity. Lowest sensitivity emerged for "nocturnal enuresis" (33%), "galactorrhea" (50%) and "hyperkinesia" 14-99%, with 14 items (64%) having >75% specificity, being lowest for "asthenia" (14%), "polyuria/polydipsia" (35%), "sedation" (41%), "akathisia" (53%), "dystonia" (65%), "hyperkinesia" (68%), "hypokinesia" (70%) and "accommodation" (70%). Positive predictive value ranged from 7-85%, with six items (27%) having a positive predictive value >75%. Negative predictive value ranged from 40-98%, with 21 items (95%) having a negative predictive value >75%. The mean time to complete the Glasgow Antipsychotic Side-effect Scale was 4±2 minutes.

CONCLUSION

The Glasgow Antipsychotic Side-effect Scale demonstrated satisfactory validity as a self-rated tool for antipsychotic side effects and may aid measurement-based care and decision-making.

Clinical characteristics and patient-reported outcomes of total shoulder arthroplasty after anterior stabilization: a retrospective matched control study

BACKGROUND

Instability arthropathy is a known cause of glenohumeral osteoarthritis (OA) among patients with and without prior shoulder stabilization. This study aims to compare the clinical, radiographic, and patient-reported outcome measure (PROM) scores among total shoulder arthroplasty (TSA) patients with and without a history of shoulder stabilization.

METHODS

A case-control study was performed comparing 20 patients with a history of anterior shoulder stabilization (11 open, 9 arthroscopic) who underwent TSA to a matched cohort of 20 TSA patients without a history of shoulder surgery (mean follow-up = 2.8 years). Patients were matched by sex, age, and baseline American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score within 10 points (mean age 59.6 ± 9.6 years). Patient characteristics, operative findings, and preoperative and postoperative radiographic characteristics for both groups were reported. Comparisons were made regarding PROM scores (ASES, 12-Item Short Form Health Survey (SF-12), Shoulder Activity Scale [SAS], numeric rating scale for pain) at baseline, 2 years, and 5 years and patient satisfaction at 2 years.

RESULTS

Intraoperative findings of subscapularis scarring or attenuation was common among patients with prior anterior stabilization. The instability cohort did have a higher percentage of B2/B3 glenoid types than the OA cohort (45% vs. 15%), but this was not significantly different possibly because of the small sample size. At 2 years, both instability and OA groups reported significant improvement in pain, function, and activity level. There was no difference between groups on any PROMs or patient satisfaction level. At 5 years, instability patients had significantly lower scores on the ASES and the SF-12 PCS than the OA group.

CONCLUSION

There was notable alterations in both soft tissue and bony morphology among patients with prior anterior stabilization. After TSA, both instability and primary OA groups showed significant improvements at 2 years. However, PROMs for instability patients deteriorated at 5 years compared with the control group. Complex bony and soft tissue imbalances may contribute to more unpredictable long-term PROM scores. Thoughtful preoperative consideration of these factors should influence decision making regarding selection of TSA for management of OA in this complex patient cohort.

M35. CLINICAL VALIDATION OF THE SIX-ITEM POSITIVE AND NEGATIVE SYNDROME SCALE (PANSS-6)

Background

The development of the brief and psychometrically valid, six-item Positive and Negative Syndrome Scale (PANSS-6) holds promise to improve the treatment of schizophrenia by paving the way for implementation of measurement-based care. However, an important limitation to the existing studies of PANSS-6 is that PANSS-6 was extracted from studies in which the 30-item PANSS ratings were obtained through the Structured Clinical Interview (SCI-PANSS). Therefore, it remains unknown whether it is possible to extract sufficient and equally valid information for PANSS-6 rating via a brief and focused interview, which is a prerequisite for the utility of PANSS-6 in clinical practise. The Simplified Negative And Positive Symptoms Interview (SNAPSI) is a brief semi-structured interview, which focuses specifically on extracting information on the PANSS-6. The aim of the present study was to perform a clinical validation study of PANSS-6 ratings obtained via the SNAPSI using PANSS-30 ratings obtained via SCI-PANSS as a gold standard reference.

Methods

Participants were ≥18 years old, had a diagnosis of schizophrenia (ICD-10: F20.x) and were undergoing inpatient treatment at the Department for Psychosis, Aarhus University Hospital - Psychiatry, Denmark. The SNAPSI and the SCI-PANSS were conducted by trained and reliable independent interviewers, which was followed by independent PANSS-6 and PANSS-30 ratings at two time-points: as soon as possible after admission and as close to discharge as possible. The degree to which the PANSS-6 (rated independently using the SNAPSI) corresponds to PANSS-6 extracted from PANSS-30 (rated using the SCI-PANSS) was tested by means of intra-class correlation coefficient (ICC) analysis. The sensitivity to change was tested by comparing the endpoint-baseline change in the PANSS-6 total scores to the endpoint-baseline change in the PANSS-6 total scores extracted from the PANSS-30 ratings via Spearman correlation analysis.

Results

A total of 77 inpatients with schizophrenia (age=35.3, SD=11.8 years; males=56%, paranoid schizophrenia=79%) were included. Of these 65% (n=50) were rated at two time-points. Time to complete the SNAPSI was 18.1, SD=6.9 minutes. The mean score of PANSS-30 at baseline and at follow-up was 81.0, SD=15.9 and 71.8, SD=12.5, respectively. The mean score of PANSS-6 at baseline and follow-up was 18.8, SD=4.6 and 18.1, SD=4.0, respectively. The ICC between the PANSS-6 total scores obtained by the SNAPSI and the PANSS-6 total scores extracted from the PANSS-30 ratings was 0.77 [95% CI 0.62–0.85]. The absolute mean deviation between PANSS-6 ratings and PANSS-6 derived from PANSS-30 ratings was 0.7, SD=0.9. Three percent (n=4) of the PANSS-6 ratings deviated by more than a mean of 1 point i.e. >6 points on the PANSS-6 total score compared to the PANSS-6 derived from PANSS-30 ratings. The Spearman correlation coefficient for changes in endpoint-baseline PANSS-6 and PANSS-30 derived PANSS-6 total scores was 0.67, p<0.001. The full results of the study will be presented at the SIRS 2020 conference.

Discussion

We found an excellent level of correlation between the PANSS-6 total scores obtained via SNAPSI and the PANSS-6 total scores extracted from the PANSS-30 ratings obtained via SCI-PANSS. Also, the sensitivity to change reached a good level of agreement. In conclusion, the combination of SNAPSI and PANSS-6 allows for a brief and valid assessment of the severity of core symptoms of schizophrenia. These results hold promise for the implementation of measurement-based care in the treatment of schizophrenia.

Inter-rater reliability of ratings on the six-item Positive and Negative Syndrome Scale (PANSS-6) obtained using the Simplified Negative and Positive Symptoms Interview (SNAPSI)

PURPOSE

The six-item version of the Positive And Negative Syndrome Scale (PANSS-6) is a brief rating scale focusing on core symptoms of schizophrenia. In order to facilitate rating of PANSS-6 and selected items from other common psychiatric rating scales, we recently developed the Simplified Negative and Positive Symptoms Interview (SNAPSI). The objective of the present study was to test the inter-rater reliability of PANSS-6 ratings obtained using the SNAPSI.

MATERIALS AND METHODS

Using the SNAPSI, seven raters (psychiatrists, first-year psychiatry residents and psychologists) performed a total of 56 PANSS-6 ratings of 12 in- or outpatients with schizophrenia. As a measure of inter-rater reliability, we calculated the intra-class correlation coefficient (ICC, ≥0.75 = excellent, 0.40-0.74 = fair to good, <0.40 = poor) for the PANSS-6 total score and individual item scores. Furthermore, for the PANSS-6 total scores obtained by the six noncertified PANSS raters, we calculated the median deviation from the PANSS-6 total scores obtained by the only certified PANSS rater.

RESULTS

The ICC for the PANSS-6 total score was 0.74 (F = 2.84, p = .03). The ICCs for the six individual PANSS-6 items ranged from 0.45 (N6 - Lack of spontaneity & flow of conversation) to 0.76 (P3 - Hallucinatory behavior). The PANSS-6 total scores obtained by the six noncertified PANSS raters deviated by a median of 12.7% (interquartile range: 6.2-20.0) from the PANSS-6 total scores obtained by the certified PANSS rater.

CONCLUSIONS

We found a good level of inter-rater reliability of PANSS-6 ratings obtained using the SNAPSI for seven raters with varying levels of clinical and research experience.

Neutral glenoid alignment in reverse shoulder arthroplasty does not guarantee decreased risk of impingement

Reverse Shoulder Arthroplasty (RSA) has gained popularity over the recent years, but impingement concerns are still present. Surgeons aim to correct pre-operative glenoid deformities to reduce impingement but it can be challenging without assistance like patient specific guides. However, it is unclear how accurate glenoid correction affects the impingement. The main objective of this study was to determine whether accurate glenoid correction to neutral version and tilt can reduce the risk of impingement. Two types of virtual surgeries were performed on 22 pre-operative arthritic shoulders: (i) "Interactive," the glenoid baseplate could be placed with accuracy, and (ii) "Blind," surgeons placed the RSA baseplate while they could only visualize the glenoid. The virtual models were then used in an RSA biomechanical model which recorded impingement for (i) four Range of Motion (ROM) tasks, (ii) ten Activities of Daily Living (ADL). The "Blind" method resulted in more variable glenoid placement (version and tilt) than the "Interactive" method (p = 0.001). However, both methods showed similar ROM and impingement occurrence in ADLs. The results suggest it is challenging for surgeons to accurately correct version and tilt on arthritic glenoids when only referencing off of the face of the glenoid. However, the variable glenosphere placement observed in the "Blind" method did not result in worse impingement compared to the accurate "Interactive" method. This was because both methods had similar inferior baseplate positioning which is more important than correcting version or tilt. Implantation accuracy remains important in RSA, but pre-operative planning should not just target at correcting version and tilt. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1213-1219, 2018.

'Batter's shoulder': can athletes return to play at the same level after operative treatment?

BACKGROUND

Batter's shoulder has been defined as posterior subluxation of the lead shoulder during the baseball swing. However, it is unclear whether or how frequently patients may return to play after treatment of this uncommon condition.

QUESTIONS/PURPOSES

We therefore determined the rate of return to play after operative treatment for Batter's shoulder and whether ROM was restored.

METHODS

We retrospectively reviewed the records of 14 baseball players diagnosed with Batter's shoulder. Four played professionally, six were in college, and four were in varsity high school. The average age was 20.3 years (range, 16-33 years). All had physical examinations and MRI findings consistent with posterior labral tears involving the lead shoulder. Treatment involved arthroscopic posterior labral repair (n = 10), débridement (n = 2), or rehabilitation (n = 2). The minimum followup was 18 months (average, 2.8 years; range, 18-64 months).

RESULTS

Eleven of 12 surgically treated patients returned to their previous level of batting at an average of 5.9 months after surgery. The one patient who was unable to return to play also had an osteochondral lesion of the glenoid identified at surgery. Players typically returned to hitting off a tee at 3 months and to facing live pitching at 6 months postoperatively. All patients regained full internal and external ROM as compared with preoperative data.

CONCLUSIONS

Batter's shoulder is an uncommon form of posterior instability in hitters affecting their lead shoulder. Most athletes are able to return to play at the same level after arthroscopic treatment of posterior capsulolabral lesions.

LEVEL OF EVIDENCE

Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

In vitro analysis of an rhGDF-5 suture coating process and the effects of rhGDF-5 on rat tendon fibroblasts

We describe a dipcoating method of coating 4-0 VICRYL sutures with recombinant human growth and differentiation factor-5 (rhGDF-5), and analyze the in vitro effects of rhGDF-5 on rat tendon fibroblasts (RTFs). Part I: Eight 4-0 VICRYL sutures were coated in a dipcoat solution using rhGDF-5 solutions at concentrations of 0, 40, 200, and 1000 μg/ml (n=32). ELISA was performed to determine the amount of rhGDF-5 that was transferred on the suture. Part II: Using a dipcoat solution of 200 μg/ml, four sutures were passed through rat tendon, and quantified ELISA was again performed. Cell proliferation, collagen synthesis, and RTF cell migration were also analyzed. The differences in the amount rhGDF-5 transferred on the suture between the different concentration groups were statistically significant. Furthermore, rhGDF-5-stimulated RTF cell migration, cell proliferation, and collagen synthesis at dipcoat concentrations of rhGDF-5 of at least 200 μg/ml.

Prevalence of peripheral neurologic injuries in rotator cuff tears with atrophy

The purpose of this study is to define the prevalence of peripheral nerve injury associated with full-thickness tears of the rotator cuff presenting with shoulder muscle atrophy. Twenty-five patients with the diagnosis of full-thickness rotator cuff tear were included. Electrodiagnostic testing, including nerve conduction studies and needle examination, was performed on all patients. There were 7 abnormal electromyographic examinations. The most common diagnosis was upper trunk brachial plexopathy severely affecting the axillary nerve (4/7), followed by suprascapular neuropathy (2/7) and cervical radiculopathy (1/7). The prevalence of associated peripheral neuropathy was found to be 28%. Greater degrees of atrophy were significantly associated with the presence of neuropathy in these patients. Careful neurologic screening in all patients and electromyographic examination in clinically suspicious groups are recommended in patients with full-thickness cuff tears before surgical repair.

Stem cells as platforms for delivery of genes to enhance cartilage repair

BACKGROUND

The long-held axiom put forth by Hunter in 1743, that cartilage once injured is incapable of healing, has been challenged by the technique of autologous chondrocyte transplantation. This conceptual change in the way in which orthopaedists are approaching the problem of cartilage repair has spawned a myriad of new and innovative treatment modalities. This review will focus on the new techniques and directions that our facility and other investigators are exploring to restore functional articular cartilage.

METHODS

To show the usefulness and effectiveness of local tissue-engineered gene therapy, we transduced periosteal stem cells known to have osteochondral potential with either bone morphogenetic protein-7 (BMP-7) or sonic hedgehog (Shh) gene. These cells were cultured to increase the number of cells and then were seeded onto bioresorbable polymer scaffolds. Full-thickness osteochondral defects were created in the mid-trochlear region of eighty New Zealand White rabbits, and the implants containing the transduced cells were placed in the defects. Animals were killed at six, eight, twelve, and twenty-six weeks postoperatively and were examined macroscopically and histologically.

RESULTS

Periosteal-derived cambium-layer cells proliferated rapidly and were easily used for transfection of both the bone morphogenic protein-7 (BMP-7) and sonic hedgehog (Shh) genes. The control defects became filled with a mixture of fibrous and fibrocartilaginous tissue. The addition of either the BMP-7 or the Shh gene significantly enhanced the quality of the repair tissue, resulting in a much smoother surface and more hyaline-appearing cartilage. There was, however, a noticeable difference in the persistence of the cartilage phase between the group that received the Shh gene and the group that received the BMP-7 gene, with the subchondral compartment in the latter group seeming to remodel with bone much faster.

CONCLUSION AND CLINICAL RELEVANCE

The results of these experiments clearly demonstrate the utility of tissue-engineering strategies in which gene therapy is used to locally influence the repair environment. It is interesting to note the relative differences in the two different gene responses with regard to skeletal development and the repair process. These differences could be related to the genes' temporal patterns in skeletal development.

Hip and shoulder internal rotation range of motion deficits in professional tennis players

One hundred tennis players were recruited from the professional men's tennis tour to investigate the correlation between hip internal rotation deficits and low back pain (LBP), as well as shoulder internal rotation deficits and shoulder pain. A statistically significant correlation was observed between dominant shoulder internal rotation deficits and shoulder pain. Also observed was a statistically significant correlation between lead hip internal rotation deficits and lumbar extension deficits with LBP. We conclude that due to repetitive demands on the dominant shoulder and repetitive pivoting at the lead hip, the cycle of microtrauma and scar formation leads to capsular contracture and subsequent reduction in internal range of motion. It is likely that the limitation in lumbar extension in the symptomatic group is not only due to decreased flexibility from an increased load on the spine, but also due to a protective mechanism to prevent further exacerbation of the LBP. Physical conditioning that includes shoulder as well as hip internal rotation stretching programs should therefore be essential aspects in the treatment of tennis players with shoulder pain and LBP respectively.

Immunoglobulin heavy chain variable region gene replacement As a mechanism for receptor revision in rheumatoid arthritis synovial tissue B lymphocytes

Mature B cells can alter their antibody repertoires by several mechanisms, including immunoglobulin heavy chain variable region (V(H)) replacement. This process changes the antigen combining site by replacing a portion of the original V(H)/diversity/heavy chain joining region (V(H)DJ(H)) rearrangement with a corresponding portion of a new V(H) segment. This exchange can involve cryptic heptamer-like sequences embedded in the coding regions of V(H) genes. While studying the B lymphocytes that expand in the synovial tissues of patients with rheumatoid arthritis (RA), clones with V(H)DJ(H) variants that were apparently generated by V(H) replacement were identified with surprising frequency (approximately 8%). Examples of multiple independent V(H) replacement events occurring in distinct progeny clones were also identified. These secondary V(H) rearrangements were documented at both the cDNA and genomic DNA levels and involved several heptamer-like sequences at four distinct locations within V(H) (three sites in framework region 3 and one in complementarity determining region 2). The identification of blunt-ended double-stranded DNA breaks at the embedded heptamers and the demonstration of recombinase activating gene (RAG) expression suggested that these rearrangements could occur in the synovial tissues, presumably in pseudo-germinal centers, and that they could be mediated by RAG in a recognition signal sequence-specific manner. The presence of V(H) mutations in the clones that had undergone replacement indicated that these B cells were immunocompetent and could receive and respond to diversification signals. A relationship between these secondary V(H) gene rearrangements and the autoimmunity characteristic of RA should be considered.

Dissociation of modular humeral head components: a biomechanical and implant retrieval study

In vivo dissociation of the Morse-taper of shoulder arthroplasty modular humeral components has been reported. The incidence of this complication appears to be approximately 1:1000. The objective of this study was to identify conditions that might affect the Morse-taper interface strength in humeral components. Mechanical tests were performed to load and dissociate humeral heads from the humeral stems (titanium). The effect of loading rate, load amplitude, and number of impactions was investigated. Dissociation force was measured after the taper was contaminated with water, oil, blood, and bone cement particles. The mean dissociation force after two impactions with a mallet was 2926 +/- 955 N. Dissociation force was linearly proportional to impaction force. Repetitive loading beyond two impactions did not significantly increase taper strength. Contamination of the taper with as little as 0.4 ml of fluid could prevent fixation of the taper.

Arthroscopic assisted rotator cuff repair: results using a mini-open deltoid splitting approach

Out of 78 patients identified who underwent mini-open cuff repair, 64 were interviewed and returned a detailed questionnaire and 47 returned for a physical examination. Their average age was 64 years (31 to 85 years); and the average follow-up was 29.2 months (range, 12 to 65 months). The average tear size was 8 cm2. Preoperatively, all patients complained of pain and weakness. Ninety-six percent of patients displayed positive impingement signs preoperatively compared with 16% postoperatively. Active elevation increased significantly (P < .05) from 129 degrees to 166 degrees. At the time of follow-up there was no significant difference between active elevation in the operative and contralateral shoulders (P > .05). Weakness was detectable by physical examination in 83% of patients initially, and in 22% at the time of the final examination. The average pain and function scores improved significantly. Eighty-nine percent were satisfied with the results of their surgery. Three patients required further surgery on their shoulder. We found no correlation between cuff tear size and final Hospital for Special Surgery shoulder score.

Surgical treatment of lesions of the long head of the biceps

A follow-up study was carried out on 20 patients with a Hitchcock type of biceps tenodesis performed during the past seven years at the Hospital for Special Surgery. Thirteen cases were diagnosed as biceps tendinitis and seven as biceps instability. At follow-up, there was a 30% failure rate; the failures were related to misdiagnosing biceps instability, not identifying an impingement syndrome, or glenohumeral instability. Those patients who were relieved of symptoms had in addition to biceps tenodesis, an excision of a portion of the coracoacromial ligament. In four of the six failures, the coracoacromial ligament was not released. Two patients had a fixed dislocation of the biceps tendon noted preoperatively by arthrography and confirmed at surgery, and were successfully treated by biceps tenodesis. Two other patients who had unsuccessful biceps tenodesis and coracoacromial ligament excision were subsequently shown to have humeral head impingement with the coracoid process. Coracoid osteotomy relieved their pain. The role of the biceps tendon in the production of shoulder pain is difficult to assess and is easily overestimated, The biceps tendon inflammation may be a secondary manifestation of an impingement syndrome and unless treated as such, surgery will not be successful. Conversely, biceps lesions secondary to disorders of the bicipital groove can be treated by tenodesis. Instability of the biceps tendon can be difficult to evaluate preoperatively. Arthrography was noted to be diagnostic in dislocation of the biceps tendon.