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Background: High-intensity therapy is recommended in current treatment guidelines for chronic poststroke aphasia. Yet, little is known about fatigue levels induced by treatment, which could interfere with rehabilitation outcomes. We analyzed fatigue experienced by people with chronic aphasia (>6 months) during high-dose interventions at 2 intensities., Methods: A retrospective observational analysis was conducted on self-rated fatigue levels of people with chronic aphasia (N=173) collected during a previously published large randomized controlled trial of 2 treatments: constraint-induced aphasia therapy plus and multi-modality aphasia therapy. Interventions were administered at a higher intensity (30 hours over 2 weeks) or lower intensity (30 hours over 5 weeks). Participants rated their fatigue on an 11-point scale before and after each day of therapy. Data were analyzed using Bayesian ordinal multilevel models. Specifically, we considered changes in self-rated participant fatigue across a therapy day and over the intervention period., Results: Data from 144 participants was analyzed. Participants were English speakers from Australia or New Zealand (mean age, 62 [range, 18-88] years) with 102 men and 42 women. Most had mild (n=115) or moderate (n=52) poststroke aphasia. Median ratings of the level of fatigue by people with aphasia were low (1 on a 0-10-point scale) at the beginning of the day. Ratings increased slightly (+1.0) each day after intervention, with marginally lower increases in the lower intensity schedule. There was no evidence of accumulating fatigue over the 2- or 5-week interventions., Conclusions: Findings suggest that intensive intervention was not associated with large increases in fatigue for people with chronic aphasia enrolled in the COMPARE trial (Constraint-Induced or Multimodality Personalised Aphasia Rehabilitation). Fatigue did not change across the course of the intervention. This study provides evidence that intensive treatment was minimally fatiguing for stroke survivors with chronic aphasia, suggesting that fatigue is not a barrier to high-intensity treatment., Competing Interests: Disclosures Dr Dickey reports compensation from La Trobe University for consultant services unrelated to this work. Dr Godecke reports service as the president of Aphasia WA. Drs Kim and Cadilhac report an educational grant from Moleac unrelated to this work paid to their institution. Dr Cadilhac reports an education grant from Boehringer Ingelheim and Amazon Web Services unrelated to this work paid to her institution. The other authors report no conflicts.

Competing Interests: The authors declare no conflicts of interest.

Background: Evidence from systematic reviews confirms that speech and language interventions for people with aphasia during the chronic phase after stroke (>6 months) improve word retrieval, functional communication, and communication-related quality of life. However, there is limited evidence of their cost-effectiveness. We aimed to estimate the cost per quality-adjusted life year gained from 2 speech and language therapies compared with usual care in people with aphasia during the chronic phase (median, 2.9 years) after stroke., Methods: A 3-arm, randomized controlled trial compared constraint-induced aphasia therapy plus (CIAT-Plus) and multimodality aphasia therapy (M-MAT) with usual care in 216 people with chronic aphasia. Participants were administered a standardized questionnaire before intervention and at 12 weeks after the 2-week intervention/control period to ascertain health service utilization, employment changes, and informal caregiver burden. Unit prices from Australian sources were used to estimate costs in 2020. Quality-adjusted life years were estimated using responses to the EuroQol-5 Dimension-3 Level questionnaire. To test uncertainty around the differences in costs and outcomes between groups, bootstrapping was used with the cohorts resampled 1000 times., Results: Overall 201/216 participants were included (mean age, 63 years, 29% moderate or severe aphasia, 61 usual care, 70 CIAT-Plus, 70 M-MAT). There were no statistically significant differences in mean total costs ($13 797 usual care, $17 478 CIAT-Plus, $11 113 M-MAT) and quality-adjusted life years (0.19 usual care, 0.20 CIAT-Plus, 0.20 M-MAT) between groups. In bootstrapped analysis of CIAT-Plus, 21.5% of iterations were likely to result in better outcomes and be cost saving (dominant) compared with usual care. In contrast, 72.4% of iterations were more favorable for M-MAT than usual care., Conclusions: We observed that both treatments, but especially M-MAT, may result in better outcomes at an acceptable additional cost, or potentially with cost savings. These findings are relevant in advocating for the use of these therapies for chronic aphasia after stroke., Competing Interests: Disclosures Drs Kim and Cadilhac report an educational grant from Moleac unrelated to this work paid to their institution. Dr Cadilhac reports education grant from Boehringer Ingelheim and Amazon Web Services unrelated to this work paid to her institution. Dr Godecke reports service as President for Aphasia WA

Background: Growth assessment, which relies on a combination of radiographic and clinical markers, is an integral part of clinical decision-making in pediatric orthopaedics. The aim of this study is to evaluate the accuracy and reliability of the Diméglio skeletal age system using a modern cohort of pediatric patients., Methods: A retrospective review was undertaken of all patients at a large tertiary pediatric hospital who had lateral forearm radiographs (before the age of 14 y for females and before 16 y for males). In addition, all of these patients had height measurements within 60 days of their forearm x-ray and a final height listed in their medical records. The x-rays were graded by 5 reviewers according to the Diméglio skeletal age system. Inter and intraobserver reliability was tested., Results: One hundred forty-seven patients with complete radiographs and height data were evaluated by 5 observers ranging in experience from medical students to senior pediatric orthopaedic surgeons. The Diméglio system demonstrated excellent reliability across levels of training with an intraobserver correlation coefficient of 0.995 (95% CI, 0.991-0.997) and an interobserver correlation coefficient of 0.906 (95% CI, 0.857-0.943). When the Diméglio stage was paired with age and sex in a multivariable linear regression model predicting the percent of final height, the adjusted R2 was 78.7% (model P value <0.001), suggesting a strong relationship between the Diméglio stage (plus age and sex) and percent of final height., Conclusion: This unique approach to maturity assessment demonstrates that the Diméglio staging system can be used effectively in a modern, diverse patient population., Level of Evidence: Level II; retrospective cohort study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Amyloid elastosis is an exceedingly rare form of amyloidosis characterized by amyloid material deposited on dermal elastic fibers. Most reported cases have been associated with systemic amyloid light-chain amyloidosis. A single previously reported case of amyloid elastosis showed evidence that the amyloid material was derived from light-chain proteins and was associated with a monoclonal plasma cell infiltrate but failed to demonstrate systemic involvement. As a result, the case was felt to represent localized cutaneous amyloid elastosis. We present a case of localized cutaneous amyloid elastosis that is not associated with a definitive monotypic plasma cell population or with systemic amyloidosis. We also review the clinical and histopathologic features of reported cases of amyloid elastosis and discuss possible etiologic considerations. Because amyloid elastosis can be either localized to the skin or associated with systemic involvement, additional workup to exclude an underlying plasma cell dyscrasia or hematologic malignancy is warranted., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: A systematic review with meta-analysis., Objective: The aim of this study was to conduct a systematic review and meta-analysis of current evidence evaluating the effectiveness of rehabilitation following lumbar fusion surgery (LFS)., Summary of Background Data: LFS for the management of lower back pain, with(out) neurogenic leg pain, is increasing as the population ages. Clinical outcomes commonly lag behind surgical outcomes and 40% of patients experience significant back-related disability 12 months after LFS. Identifying rehabilitation strategies to improve function and quality of life following LFS is important., Methods: A systematic review of databases were searched, including MEDLINE, CINAHL, and grey literature. Studies identified were screened for inclusion by title and abstract. Full text of eligible/potentially eligible studies was evaluated against predetermined eligibility criteria. Included studies were subjected to critical appraisal and risk of bias evaluation. The GRADE approach to quality of evidence was utilized. A meta-analysis comparing usual care with "complex rehabilitation," comprising exercise and cognitive behavioral therapy, for outcomes relating to pain, disability, fear of movement, and mental health was conducted at short and longer term (<3 and >12 months postsurgery) time points., Results: Three studies were identified for the systematic review and 2 included in the meta-analysis (n = 237, female = 62%, mean age = 55). Low-quality evidence suggests that "complex rehabilitation" provides short-term improvement in disability [effect size, -0.85, 95% confidence interval (95% CI), -1.41 to -0.29] and fear avoidance behavior (-1.07, 95% CI -1.33, -0.80), compared with usual care. Low-quality evidence exists favoring "complex rehabilitation" over usual care for longer term disability (-0.84, 95% CI -1.11 to -0.58) and fear avoidance behavior (-1.40, 95% CI -1.69 to -1.12)., Conclusions: A small number of low-quality studies suggest that "complex rehabilitation" reduces short and long-term disability and fear avoidance behavior following LFS. More, high-quality research is required to confirm the effectiveness of "complex rehabilitation" programs.

Background: The cricothyroid membrane (CTM) is the recommended site of access to the airway during cricothyroidotomy to provide emergency oxygenation. Despite the apparent simplicity of the technique, this rescue maneuver frequently fails to achieve its goals and complications are numerous. The reasons for this failure are unclear. We sought to determine the ability of physicians to correctly identify the CTM in female patients., Methods: Using fluorescent "invisible" ink, the physician was asked to mark the CTM with the patient in the supine neutral position and then with the head extended. The actual level was identified using ultrasound and the distance between the actual and estimated margin of the CTM was measured. A correct estimation was defined as a mark made between the upper and lower limits of the membrane and within 5 mm of midline. Participants were also asked to assess the ease of CTM palpation using a 10-cm visual analog scoring (VAS) scale., Results: Fifty-six patients participated of whom 15 were obese. In the supine neutral neck position, the CTM was identified in 10/41 vs 0/15 (P = 0.048) in nonobese versus obese, respectively. Of the 46 incorrectly identified CTMs in this position, 24 were above (maximum 3 cm) and 22 below (maximum 3 cm) the actual level. Similar results were observed when the patients were placed with the neck in the extended position; the CTM was identified correctly in 12/41 vs 1/15 nonobese and obese patients, respectively. The range of values was also extensive; the estimation of the position of the membrane was as high as 2.5 cm above and 4 cm below the actual level, and up to 1.6 cm laterally. Participating doctors found palpation of the CTM subjectively more difficult in the obese than nonobese groups; VAS score for palpation difficulty was 5.25 ± 2.5 vs 3.3 ± 2.5, respectively, P = 0.005. Using multiple linear regression, VAS scores for palpation correlated negatively with increased patient height (P < 0.001) and greater thyromental distance (P = 0.006), and correlated positively with increased sternomental distance (P = 0.011) and neck circumference (P = 0.001)., Conclusions: Misidentification of the CTM in female patients is common and its localization is less precise in those who are obese. This has implications for the likely success of invasive airway access via the CTM.

Purpose: Impaired quadriceps strength and joint position sense (JPS) have been linked with knee osteoarthritis (OA) cross-sectionally. Although neither has been independently associated with incident radiographic OA, their combination may mediate risk. The purpose of this study was to determine whether better sensorimotor function protects against the development of incident radiographic or symptomatic knee OA., Methods: The Multicenter Osteoarthritis study is a longitudinal study of adults aged 50–79 yr at high risk for knee OA. Participants underwent bilateral, weight-bearing, fixed-flexion radiographs, JPS acuity tests, and isokinetic quadriceps strength tests. The relationships between combinations of the tertiles of sex-specific baseline peak strength and mean JPS and development of incident radiographic (Kellgren–Lawrence (KL) grade Q2) or symptomatic knee OA (KL grade Q2 and frequent knee pain or stiffness) at a 30-month follow-up were evaluated. Secondary analyses defined JPS as the variance during the 10 JPS trials and also assessed the interaction of strength and JPS in predicting each outcome., Results: The study of incident radiographic knee OA included 1390 participants (age = 61.2 ± 7 .9 yr and body mass index = 29.4 ± 5.1 kg·m−²), and the study of incident symptomatic knee OA included 1829 participants (age = 62.2 ± 8.0 yr and body mass index = 30.0 ± 5.4 kg·m−²). Greater strength at baseline protected against incident symptomatic but not radiographic knee OA regardless of JPS tertile. There was no significant relationship between the strength–JPS interaction and the development of radiographic or symptomatic knee OA., Conclusions: The finding that quadriceps strength protected against incident symptomatic but not radiographic knee OA regardless of JPS tertile suggests that strength may be more important than JPS in mediating risk for knee OA.

Rosai-Dorfman disease or sinus histiocytosis with massive lymphadenopathy is a rare disease. A third of patients with this disease have extranodal involvement affecting the skin. Of these individuals, only around 3% will have purely cutaneous Rosai-Dorfman disease, which is limited to skin manifestations without systemic involvement. Cutaneous (localized) scleroderma or morphea, on the other hand, is a more common disease that most often affects women of all ages. Both conditions have unknown etiologies. Presented here is a case of a 60-year-old white woman with cutaneous Rosai-Dorfman disease and coexisting morphea. Representative biopsies from both areas were performed: one showing a dermal S-100+ histiocytic infiltrate with emperipolesis and the other showing a deep perivascular and interstitial plasma cell infiltrate with dermal sclerosis and loss of perieccrine fat. A laboratory and radiologic workup revealed no evidence of systemic involvement by either entity. The diagnosis of coexisting cutaneous Rosai-Dorfman disease and morphea was established. To our knowledge, this is the first report of these 2 entities found simultaneously in 1 patient.

Objective: The major aim of this study was to determine whether a combination of hand preference inventories and hand performance measures identifies distinct handedness groups. If distinct groups are identified, then these subgroupings can be used in future studies to learn more about the neurobiology of these distinct handedness groups., Background: Although most individuals classify themselves as right- or left-handed, it is not entirely clear whether handedness should be determined based on preference inventories, hand performance tasks, or a combination of these measures. Given that hand preference is linked in part to hemispheric specialization of language, it is important to clearly define hand preference groups if lateralized differences between right- and left-handers are to be explored. Healthy adult right- and left-handers were examined from a multivariate perspective in an attempt to determine whether handedness subgroups exist within performance data., Method: Hand preference of 62 right- and left-handed male and female adults was assessed using items from Briggs and Nebes' and Oldfield's handedness inventories. Individuals were assigned to right- and left-hand preference groups, both by visually inspecting the distribution of preference scores and via cluster analysis. Asymmetries in performance of unimanual motor tasks (grooved pegboard, finger-tapping, and grip strength) were then examined using a multivariate approach., Results: Sixteen items from the two-handedness inventories were used to determine preference-based handedness groups. Two non-overlapping groups, right- and left-hand preference, were identified. Writing hand was highly correlated with hand-preference group, as only three individuals in the entire sample wrote with the non-preferred hand. The expected unimodal distributions of performance asymmetry scores, known as laterality quotients (LQs), were seen. However, when those LQs were viewed from a multivariate perspective, distinct performance-based groups emerged. In more than 90% of the observed cases, the performance-based groups corresponded to preference-based groups. No sex differences were found; the relationship between preference and performance measures was not significantly different for men and women., Conclusions: Writing hand was highly correlated with scores from a hand preference inventory. In contrast, the use of a single hand performance measure, finger tapping or pegboard, did not always correctly classify an individual as right- or left-handed. However, when both of these hand performance measures were used together. individuals were correctly classified as right- or left-handed. Using this approach, two approximately non-overlapping groups, right- and left-handers, emerged. Thus, handedness is probably not a one-dimensional trait or behavior, and must be defined using multiple measures that assess different aspects of hand preference and performance. The implications for hemispheric specialization of language and neural asymmetry research are discussed.