Demystifying the Complexity of Aphasia Treatment: Application of the Rehabilitation Treatment Specification Systemx

A considerable body of research supports the use of behavioral communication treatment as the standard of care for aphasia. In spite of robust progress in clinical aphasiology, many questions regarding optimal care remain unanswered. One of the major challenges to progress in the field is the lack of a common framework to adequately describe individual treatments, which, if available, would allow comparisons across studies as well as improved communication among researchers, clinicians, and other stakeholders. Here, we describe how aphasia treatment approaches can be systematically characterized using the Rehabilitation Treatment Specification System (RTSS). At the core of the RTSS is a tripartite structure that focuses on targets (the behavior that is expected to change as a result of treatment), ingredients (what a clinician does to affect change in the target), and mechanism(s) of action (why a given treatment works by linking the ingredients to the target). Three separate articles in the current issue specifically describe how the RTSS can be used to describe different kinds of aphasia treatment approaches: functional approaches, cognitive-linguistic approaches, and biological approaches. It is our hope that the application of the RTSS in clinical aphasiology will improve communication in published studies, grant proposals, and in the clinical care of persons with aphasia.     

Surgical excision versus observation as initial management of desmoid tumors: A population based study

SynopsisDesmoid tumors can be safely managed with watchful waiting, including either observation alone or tamoxifen/NSAIDs. Surgery at first presentation can be associated with significant treatment burden.BackgroundImmediate surgery was historically recommended for desmoid tumors. Recently, watchful waiting, (tamoxifen/NSAIDs or observation alone), has been advocated.MethodsAll diagnoses of desmoid tumor within the Alberta Cancer Registry from August 2004 to September 2015 were identified. Patients with FAP were excluded. Demographics, tumor characteristics and treatment and outcome data were collected. Outcomes were compared between immediate surgery and watchful waiting. The effect of abdominal wall site on progression and recurrence and the effect of microscopic margin on recurrence were assessed with Fisher's exact test.ResultsWe identified 111 non-FAP patients. Median follow-up was 35 months from diagnosis. 74% were female. Mean age was 42. Fifty (45%) underwent watchful waiting, of whom 21(42%) progressed, with median PFS of 10 months. Fifty-three (48%) underwent resection at presentation, of whom 8 (15%) recurred, with median disease-free survival of 22 months.Abdominal wall lesions were equally represented in both groups, and equally likely to progress on watchful waiting (50% vs 39%, p = 0.53), but there was a trend toward decreased recurrence after surgery. (5% vs 23%, p = 0.08).Microscopic margin had no effect on recurrence (14% of margin negative vs 20% of margin positive, p = 1.0).ConclusionsWatchful waiting was successful in 58% of patients, and a further 28% only required one aggressive treatment thereafter, for a total of 86%. Surgery had a favorable recurrence rate (15%), but some recurrences were associated with significant treatment burden. Treatment should be tailored to individual patients in a multidisciplinary setting. A trial of observation appears warranted in most patients.Recurrence rate was not affected by positive margins.     

The Limited Reliability of Physical Examination and Imaging for Diagnosis of Iliopsoas Tendinitis

PurposeTo determine if any association exists between physical examination, imaging findings [ultrasound (US) and magnetic resonance imaging (MRI)], and iliopsoas tendinitis (IPT) to characterize the reliability of these diagnostic modalities.MethodsPatients who had undergone US-guided iliopsoas tendon sheath injection (of lidocaine and a corticosteroid agent) as well as MRI performed within 1 year of injection from 2014 to 2019 were retrospectively reviewed. Demographic data, response to physical exam maneuvers, and response to injection were queried from patient records. US and MRI were reviewed by 2 independent musculoskeletal-trained radiologists. Response to injection was considered positive if the patient improved by >2 points on a 0- to 10-point VAS score. Chi-squared and Fisher exact testing were used to assess for any associations. Sensitivities, specificities, positive predictive values, and negative predictive values were calculated.ResultsSixty-three patients, age 52.3 ± 17.3 years (mean ± standard deviation), body mass index 27.4 ± 4.3 kg/m², and follow-up 33.6 ± 20.6 months, met inclusion criteria. No physical exam maneuvers, sonographic features, or MRI findings were significantly associated with response to iliopsoas tendon injection (P > .05). Groin pain had a sensitivity of 100% but a specificity of 7%. Snapping hip had a specificity of 82% but a sensitivity of 24%. Pain with resisted straight leg raise (SLR) (sensitivity 62%, specificity 25%) and weakness with resisted SLR (sensitivity 15%, specificity 71%) both were nonreliable. Sonographic bursal distension and tendinosis had low sensitivities (67% and 63%, respectively) and specificities (35% and 32%). Bursal distension on MRI had sensitivity and specificity of 64% and 45%, respectively. Tendon thickening had sensitivity and specificity of 55% and 60%, respectively, and heterogeneity had sensitivity and specificity of 52% and 65%.ConclusionNeither physical examination nor US or MRI findings were associated with a positive response to peritendinous iliopsoas corticosteroid injections in patients with suspected IPT.Level of EvidenceIII, retrospective comparative trial limited by lack of a reference standard for iliopsoas tendonitis diagnosis.     

Phosphoglycerate dehydrogenase promotes proliferation and bortezomib resistance through increasing reduced glutathione synthesis in multiple myeloma

The serine synthesis pathway (SSP) is active in multiple cancers. Previous study has shown that bortezomib (BTZ) resistance is associated with an increase in the SSP in multiple myeloma (MM) cells; however, the underlying mechanisms of SSP-induced BTZ resistance remain unclear. In this study, we found that phosphoglycerate dehydrogenase (PHGDH), the first rate-limiting enzyme in the SSP, was significantly elevated in CD138⁺ cells derived from patients with relapsed MM. Moreover, high PHGDH conferred inferior survival in MM. We also found that overexpression of PHDGH in MM cells led to increased cell growth, tumour formation, and resistance to BTZ in vitro and in vivo, while inhibition of PHGDH by short hairpin RNA or NCT-503, a specific inhibitor of PHGDH, inhibited cell growth and BTZ resistance in MM cells. Subsequent mechanistic studies demonstrated PHGDH decreased reactive oxygen species (ROS) through increasing reduced glutathione (GSH) synthesis, thereby promoting cell growth and BTZ resistance in MM cells. Furthermore, adding GSH to PHGDH silenced MM cells reversed S phase arrest and BTZ-induced cell death. These findings support a mechanism in which PHGDH promotes proliferation and BTZ resistance through increasing GSH synthesis in MM cells. Therefore, targeting PHGDH is a promising strategy for MM therapy.     

A comparison of kinematic demands placed on the knee and hip during two ACL return-to-sport screening maneuvers and an agility test

ObjectivesThis study's purpose was to compare the kinematic demands placed on the knee and the hip during various biomechanical tests.DesignRetrospective cross-sectional design.SettingA university research laboratory.ParticipantsThe study sample consisted of 70 NCAA Division I female athletes.Main outcome measuresDuring the performance of three test maneuvers, a drop vertical jump (DVJ), single leg cross over hop (COH) and modified T-test (AT), the hip and knee joint angles at maximum knee valgus were obtained from marker displacement data collected using a 20-camera motion analysis system. A linear mixed model was used to compare the effect of test on joint angle.ResultsA significant difference (p < 0.001) in the frontal and sagittal plane position of the knee and hip was noted between the DVJ, COH, and AT tests at maximum knee valgus.ConclusionsThe DVJ, COH, and AT maneuvers do not appear to place the same kinematic stress on the knee, supporting the need for the development of return to sport tests that mimic on field demands.     

Editorial Commentary: Early Operative Management of “Stable” Osteochondritis Dissecans Lesions Confers Greater Value in Skeletally Immature Patients

The ideal treatment of juvenile osteochondritis dissecans (OCD) varies according to the chronicity of symptoms and radiographic classification. Traditionally, “stable” OCD lesions of the knee are managed conservatively with limited weight bearing and nonoperative care. However, this can require up to 6 to 12 months of observation, and success rates are estimated at only 59%. By contrast, recent data suggest that early subchondral drilling of OCD lesions may more consistently facilitate new vascular channels and remodeling of the compromised osteochondral unit. When considering overarching health care costs and probabilistic modeling, contemporary treatment paradigms may preferentially suggest early surgical treatment of OCD lesions for greater cost-effectiveness and an optimized timeline for a return to full activity. Additionally, surgery may be prioritized for larger lesions, atypical locations, closing physes, and/or the presence of mechanical symptoms.