Development of obstetric anesthesia core competencies for USA residency programs through a Delphi process.

PURPOSE: The standard for anesthesia residency training in the USA mainly relies on the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project, a framework that lacks specific directives for subspecialties including obstetric anesthesia. We aimed to identify core competencies in obstetric anesthesiology that can be adapted to different residency training programs to help improve the quality of training and accountability of the institutions within the USA. METHODS: We identified a preliminary list of competencies from review of existing competency-based obstetric anesthesia training curricula and practice guidelines. We used a modified Delphi methodology to achieve expert consensus among members of the Society for Obstetric Anesthesia and Perinatology education committee. The panellists were asked to evaluate the importance of each competency using a five-point Likert scale, with consensus after two rounds defined at 80% agreement. The responders were also asked at which level of training each competency should be attained. RESULTS: The Delphi rounds had 75% response rate and derived 94 competencies that were categorized under the six ACGME domains: patient care (38), medical knowledge (45), system-based practice (two), practice-based learning and improvement (five), interpersonal communication skills (two), and professionalism (two). CONCLUSION: We generated a residency training competency list for obstetric anesthesiology through expert consensus. This list can be used by residency training programs to develop a structured competency-based curriculum with tangible milestones, thereby reducing heterogeneity in the standard of training.

RéSUMé: OBJECTIF: La norme pour la formation en résidence en anesthésie aux États-Unis repose principalement sur le Projet de résultats (Outcome Project) de l'Accreditation Council for Graduate Medical Education (ACGME), un cadre qui ne dispose pas de directives spécifiques pour les surspécialités, notamment pour l'anesthésie obstétricale. Notre objectif était d'identifier les compétences de base en anesthésiologie obstétricale qui pourraient être adaptées aux différents programmes de formation en résidence afin d'améliorer la qualité de la formation et la responsabilisation des établissements aux États-Unis. MéTHODE: Nous avons dressé une liste préliminaire de compétences en passant en revue les programmes de formation axés sur les compétences et les lignes directrices de pratique existants en anesthésie obstétricale. Nous avons utilisé une méthodologie Delphi modifiée pour parvenir à un consensus d'expert·es parmi les membres du comité d'éducation de la Society for Obstetric Anesthesia and Perinatology. Les panélistes ont été invité·es à évaluer l'importance de chaque compétence à l'aide d'une échelle de Likert à cinq points, le consensus étant défini à 80 % d'accord après deux tours. On a également demandé aux répondant·es à quel niveau de formation chaque compétence devrait être atteinte. RéSULTATS: Les étapes du processus Delphi ont eu un taux de réponse de 75 % et ont permis de déterminer 94 compétences qui ont été classées dans les six domaines ACGME : soins aux patient·es (38), connaissances médicales (45), pratique systémique (deux), apprentissage et amélioration basés sur la pratique (cinq), compétences en communication interpersonnelle (deux) et professionnalisme (deux). CONCLUSION: Nous avons généré une liste de compétences pour la formation de résidence en anesthésiologie obstétricale grâce à un consensus d'expert·es. Cette liste peut être utilisée par les programmes de formation en résidence pour élaborer un programme structuré axé sur les compétences avec des jalons tangibles, réduisant ainsi l'hétérogénéité dans la norme de formation.

A survey of labour epidural practices at obstetric anesthesia fellowship programs in the United States.

PURPOSE: Labour epidural analgesia (LEA) is an evolving field. Various neuraxial techniques and dosing regimens are available to the modern obstetric anesthesia provider, allowing for significant practice variability. To begin a search for consensus on optimal care, we sought to query fellowship training practices for LEA. METHODS: We conducted an electronic survey of institutions with American Council for Graduate Medical Education-accredited obstetric anesthesiology fellowship programs. We studied the frequency of epidural initiation techniques, including combined spinal epidural (CSE), dural puncture epidural, and epidural bolus. For maintenance techniques, we appraised the use of continuous epidural infusion, programmed intermittent bolus (PIEB), and patient-controlled epidural analgesia (PCEA). RESULTS: Of 40 institutions surveyed, we received 32 responses (80% response rate). Twenty-eight of 40 (70%) were included in the analysis. A plurality of institutions (12/28; 43%) preferred CSE, and among those who used CSE, 23/27 (85%) included intrathecal opioids. A majority of institutions used protocols with PIEB (55%), while almost all (92%) used PCEA. Most participants (88%) reported using dilute concentration maintenance infusions of 0.1% bupivacaine/ropivacaine or less. CONCLUSION: Despite significant variability in LEA practice, some clear patterns emerged in our survey, including preference for opioid-containing CSE and maintenance with PIEB, PCEA, and dilute epidural solutions.

RéSUMé: OBJECTIF: L'analgésie péridurale obstétricale (APO) est un domaine en évolution. Diverses techniques neuraxiales et posologies sont disponibles pour le praticien en anesthésie obstétricale moderne, ce qui permet une variabilité significative de la pratique. Pour démarrer une recherche de consensus sur les soins optimaux, nous avons cherché à déterminer les pratiques d'APO dans le cadre de formation des fellows. MéTHODE: Nous avons réalisé une enquête électronique auprès d'établissements possédant des programmes de fellowship en anesthésiologie obstétricale accrédités par l'American Council for Graduate Medical Education. Nous avons étudié la fréquence des techniques de péridurale, notamment de rachi-péridurale combinée (RPC), de péridurale avec ponction durale et de bolus péridural. Pour les techniques de maintien, nous avons évalué l'utilisation de l'analgésie péridurale par perfusion continue, l'administration programmée de bolus périduraux (PIEB; programmed intermittent epidural bolus) et l'analgésie péridurale contrôlée par la patiente (APCP). RéSULTATS: Sur les 40 établissements sondés, nous avons reçu 32 réponses (taux de réponse de 80 %). Vingt-huit des 40 (70 %) établissements ont été inclus dans l'analyse. Plusieurs institutions (12/28; 43 %) ont répondu qu'elles préféraient la RPC, et parmi celles qui utilisaient la RPC, 23/27 (85 %) incluaient des opioïdes intrathécaux. La majorité des établissements utilisaient des protocoles avec le PIEB (55 %), tandis que presque tous (92 %) utilisaient l'APCP. La plupart des établissements participants (88 %) ont rapporté utiliser des perfusions de maintien à des concentrations diluées de bupivacaïne/ropivacaïne de 0,1 % ou moins. CONCLUSION: Malgré une variabilité significative dans la pratique de l'APO, certaines tendances claires ont émergé dans notre sondage, notamment une préférence pour les RPC contenant des opioïdes et le maintien avec un PIEB, une APCP et des solutions péridurales diluées.

DNAzymes for amine and peptide lysine acylation.

DNAzymes were previously identified by in vitro selection for a variety of chemical reactions, including several biologically relevant peptide modifications. However, finding DNAzymes for peptide lysine acylation is a substantial challenge. By using suitably reactive aryl ester acyl donors as the electrophiles, here we used in vitro selection to identify DNAzymes that acylate amines, including lysine side chains of DNA-anchored peptides. Some of the DNAzymes can transfer a small glutaryl group to an amino group. These results expand the scope of DNAzyme catalysis and suggest the future broader applicability of DNAzymes for sequence-selective lysine acylation of peptide and protein substrates.

Pediatric to Adult Transition in Sickle Cell Disease: Survey Results from Young Adult Patients.

BACKGROUND/AIMS: We surveyed sickle cell disease (SCD) patients who transitioned from pediatric care at Texas Children's Hematology Center (TCHC) to adult care to determine the characteristics of patients with an adult SCD provider, continuation rates of pre-transition therapies, and patient perceptions of the transition process. METHODS: A cross-sectional study was conducted by telephone survey of 44 young adults with SCD, aged 19-29 years, who transitioned from TCHC to adult care within the last 15 years. RESULTS: Findings of the 23-item questionnaire revealed that transitioned patients with current adult providers (68.2%) were more likely to have seen a provider within 6 months of transition (p = 0.023) and to have been on hydroxyurea and/or monthly blood transfusions pre-transition (p = 0.021) than transitioned patients without a provider; 83% of patients on pre-transition hydroxyurea reported continuing hydroxyurea after transition. Transition challenges included inadequate preparation, difficulty finding knowledgeable adult providers, and lack of healthcare insurance/coverage. CONCLUSION: Transition to adult providers is predicted by establishing care with an adult SCD provider within 6 months of transition and being on pre-transition disease-modifying therapy. Transition may be improved if pediatric hematology centers assist and verify adult provider contact within 6 months of transition and engage patients of all disease severity during transition.

The Effect of Pectoral Nerve Blocks on Opioid Use and Postoperative Pain in Masculinizing Mastectomy: A Randomized Controlled Trial.

BACKGROUND: Bilateral masculinizing mastectomy is the most common gender-affirmation operation performed. Currently, there is lack of data regarding intraoperative and postoperative pain control for this population. It is the authors' aim to study the effects of the pectoral nerve (Pecs) I and II regional nerve blocks in patients undergoing masculinizing mastectomy. METHODS: A randomized, double-blind, placebo-controlled trial was performed. Patients undergoing bilateral gender-affirmation mastectomy were randomized to receive either a Pecs block with ropivacaine or placebo injection. The patient, surgeon, and anesthesia team were blinded to the allocation. Intraoperative and postoperative opioid requirements were collected and recorded as morphine milligram equivalents (MME). Participants recorded postoperative pain scores at specific time points on the day of surgery through postoperative day 7. RESULTS: Fifty patients were enrolled between July of 2020 and February of 2022. Twenty-seven were randomized to the intervention group and 23 to the control group, with 43 patients undergoing analysis. There was no significant difference in intraoperative MME between the Pecs block group and the control group (9.8 versus 11.1; P = 0.29). In addition, there was no difference in postoperative MME between the groups (37.5 versus 40.0; P = 0.72). Postoperative pain scores were also similar between the groups at each specified time point. CONCLUSIONS: There was no significant reduction in opioid consumption or postoperative pain scores in patients undergoing bilateral gender-affirmation mastectomy who received a regional anesthetic when compared with placebo. In addition, a postoperative opioid-sparing approach may be appropriate for patients undergoing bilateral masculinizing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Medical Concerns in Orthobiologics Procedures.

Orthobiologics have shown immense treatment potential in many medical fields including sports medicine, musculoskeletal disorders, and pain management. As with the case of any medical procedures and treatments, there are potential side effects or caveats that physicians and patients should be cognizant of. Nevertheless, the use of orthobiologics does not seem to have consistent severe side effects and do not have increased risks with transmissible disease, immune-modulated reactions, or oncologic processes.

Anti-gal antibodies in α1,3-galactosyltransferase gene-knockout pigs.

Serum anti-galactose-α1,3-galactose (Gal) IgM and IgG antibody levels were measured by ELISA in α1,3-galactosyltransferase gene-knockout (GTKO) pigs (78 estimations in 47 pigs). A low level of anti-Gal IgM was present soon after birth, and rose to a peak at 4-6 m, which was maintained thereafter even in the oldest pigs tested (at >2 yr). Anti-Gal IgG was also present at birth, peaked at 3 m, and after 6 m steadily decreased until almost undetectable at 20 m. No differences in this pattern were seen between pigs of different gender. Total IgM followed a similar pattern as anti-Gal IgM, but total IgG did not decrease after 6m. The data provide useful baseline data for future experimental studies in GTKO pigs, e.g., relating to the antibody response to WT pig allografts.

Postarthroscopic glenohumeral chondrolysis.

Postarthroscopic glenohumeral chondrolysis (PAGCL) is a rare complication in which the articular cartilage of the shoulder undergoes rapid, degenerative changes shortly after arthroscopic surgery. Patients with PAGCL are often young (eg, aged 10 to 40 years) and develop deep shoulder pain with progressive loss of motion that begins months after the initial arthroscopic surgery. PAGCL should be considered in the differential diagnosis in the patient with deep, unexplained shoulder pain following arthroscopic surgery. Although the etiology of PAGCL is not yet fully understood, the pathophysiology is likely multifactorial. Inherent patient factors and risk factors for PAGCL have been identified, but it is unclear how these factors interact. Current surgical practices need to be examined and new practices developed to prevent PAGCL. Proud placement of nonabsorbable suture anchors during surgery to correct instability, as well as the use of thermal devices and intra-articular pain pumps, should be avoided.

Accuracy of prenatal diagnosis and prediction of lethality for fetal skeletal dysplasias.

OBJECTIVES: We reviewed all cases with fetal skeletal dysplasia and correlated the accuracy of prenatal diagnoses with the final post-mortem, radiological, or molecular diagnoses. The accuracy of prenatal prediction of lethality was also reviewed. METHODS: All cases of fetal skeletal dysplasia referred between October 2002 and August 2010 were reviewed. Perinatal outcome, the accuracy of prenatal diagnosis, and prediction of lethality were ascertained. Lethality was suspected when significant thoracic narrowing, severe micromelia, multiple fractures, or long bone bowing was present. RESULTS: There were 40 cases of skeletal dysplasia. Thirty-nine (97.5%) were singletons and one (2.5%) was a dichorionic twin pregnancy. Twenty-eight (70%) pregnancies were terminated, five (12.5%) were stillborn, and only seven (17.5%) cases were live born. A final diagnosis was established in 28 (70%) cases. In 29 cases with a presumptive prenatal diagnosis, this was confirmed in 23 (79.3%) cases postnatally. Lethality was predicted with 100% certainty. CONCLUSION: We report higher prenatal/postnatal concordance rates in this series. A precise prenatal diagnosis is frequently difficult and often inaccurate. Prediction of lethality is much easier and often possible with accuracy. Parents need to be aware that the outcome of many skeletal dysplasias is poor.

Assessing Physical Medicine and Rehabilitation Residency Education Using the Neurological Assessment Competency Evaluation System.

ABSTRACT: Competent neurologic examination and clinical skills are essential components in the care for patients in acute hospital and rehabilitation settings. To enhance the evaluation and education of Physical Medicine and Rehabilitation residents, the authors developed an educational objective structured clinical examination, the Neurological Exam Assessment Competency Evaluation System, and gathered 2 yrs of baseline data. The Neurological Exam Assessment Competency Evaluation System consisted of nine 9-min examination stations, seven with written clinical scenario with instructions for junior residents to complete the appropriate examination (stations: Altered Mental Status, Mild Traumatic Brain Injury, Dementia, Stroke, Falls, and the International Standards for Neurological Classification of Spinal Cord Injury Sensory and Motor Examinations). Examinees provided written responses to posed questions for the other two stations-Modified Ashworth Scale and brachial plexus. The assessment tools for this examination were designed for residency programs to evaluate the basic competencies as outlined by the Accreditation Council for Graduate Medical Education and Physical Medicine and Rehabilitation milestones. Based on the feedback received from the examinees and examiners, the Neurological Exam Assessment Competency Evaluation System can serve as an educational objective structured clinical examination for the improvement of trainee core competencies.

Novel assessment of leukocyte-rich platelet-rich plasma on functional and patient-reported outcomes in knee osteoarthritis: a pilot study.

Background: Leukocyte-rich platelet-rich plasma (LR-PRP) has demonstrated to be beneficial for patients with knee osteoarthritis (KOA); however, reliable objective end points to accurately assess its therapeutic effects is lacking. Aim: To investigate the efficacy of LR-PRP as assessed by functional and patient-reported outcomes at early time points (6 weeks). Materials & methods: We conducted a prospective cohort study in 12 patients with diagnosed KOA (Kellgren Lawrence score of II-III), who underwent a single ultrasound-guided LR-PRP injection. Results: There was significant improvement in timed up and go, pain and quality of life scales and balance parameters. There were nonsignificant improvements in range of motion and gait parameters. Conclusion: LR-PRP demonstrates efficacy in meaningful end points for functional and patient-reported outcomes at early time points in patients with KOA.

Investigation of potential carbohydrate antigen targets for human and baboon antibodies.

BACKGROUND: The continued presence of a primate antibody-mediated response to cells and organs from alpha1,3-galactosyltransferase gene-knockout (GTKO) pigs indicates that there may be antigens other than Gal alpha 1,3Gal (alpha Gal) against which primates have xenoreactive antibodies. Human and baboon sera were tested for reactivity against a panel of saccharides that might be potential antigen targets for natural anti-non-alpha Gal antibodies. METHODS: Human sera (n = 16) and baboon sera (n = 15) of all ABO blood types were tested using an enzyme-linked immunoadsorbent assay for binding of IgM and IgG to a panel of synthetic polyacrylamide-linked saccharides (n = 15). Human sera were also tested after adsorption on alpha Gal immunoaffinity beads. Sera from healthy wild-type (WT, n = 6) and GTKO (n = 6) pigs and from baboons (n = 4) sensitized to GTKO pig organ or artery transplants (of blood type O) were also tested. Forssman antigen expression on baboon and pig tissues was investigated by immunohistochemistry. RESULTS: Both human and baboon sera showed high IgM and IgG binding to alpha Gal saccharides, alpha-lactosamine, and Forssman disaccharide. Human sera also demonstrated modest binding to N-glycolylneuraminic acid (Neu5Gc). When human sera were adsorbed on alpha Gal oligosaccharides, there was a reduction in binding to alpha Gal and alpha-lactosamine, but not to Forssman. WT and GTKO pig sera showed high binding to Forssman, and GTKO pig sera showed high binding to alpha Gal saccharides. Baboon sera sensitized to GTKO pigs showed no significant increased binding to any specific saccharide. Staining for Forssman was negative on baboon and pig tissues. CONCLUSIONS: We were unable to identify definitively any saccharides from the selected panel that may be targets for primate anti-non-alpha Gal antibodies. The high level of anti-Forssman antibodies in humans, baboons, and pigs, and the absence of Forssman expression on pig tissues, suggest that the Forssman antigen does not play a role in the primate immune response to pigs.

An in vitro model of pig liver xenotransplantation--pig complement is associated with reduced lysis of wild-type and genetically modified pig cells.

BACKGROUND: After pig liver transplantation in humans, the graft will produce pig complement (C). We investigated in vitro the lysis of wild-type (WT), α1,3-galactosyltransferase gene-knockout (GTKO), and CD46 transgenic (CD46) pig peripheral blood mononuclear cells (PBMC) caused by human anti-pig antibodies (Abs) + pig C. METHODS: Human serum IgM/IgG binding to WT and GTKO PBMC was determined by flow cytometry, and lysis of pig PBMC by a C-dependent cytotoxicity assay using (i) human serum (human Abs + C), (ii) GTKO pig serum (anti-Gal Abs + pig C), (iii) heat-inactivated human serum (human Abs) + rabbit C, or (iv) human Abs + pig C (serum). RESULTS: Binding of human IgM and IgG to GTKO PBMC was less than to WT PBMC (P < 0.05). In the presence of human Abs, lysis of WT and GTKO PBMC by rabbit C was 87 and 13%, respectively (WT vs. GTKO, P < 0.01), but was only 37 and 0.4% in the presence of pig C (WT vs. GTKO, P < 0.05). Human/rabbit C-induced lysis was greater than pig C-induced lysis for both WT and GTKO PBMC. CD46 pig PBMC reduced rabbit/human C- and pig C-mediated lysis (P < 0.05). CONCLUSIONS: Pig livers, particularly from GTKO and CD46 pigs, are likely to have an immunologic advantage over other organs after transplantation into humans. In the absence of pig antibodies directed to human tissues, pig complement is unlikely to cause problems after liver xenotransplantation, especially if GTKO/CD46 pigs are used as the source of the livers.

Distal triceps rupture.

Distal triceps rupture is an uncommon injury. It is most often associated with anabolic steroid use, weight lifting, and laceration. Other local and systemic risk factors include local steroid injection, olecranon bursitis, and hyperparathyroidism. Distal triceps rupture is usually caused by a fall on an outstretched hand or a direct blow. Eccentric loading of a contracting triceps has been implicated, particularly in professional athletes. Initial diagnosis may be difficult because a palpable defect is not always present. Pain and swelling may limit the ability to evaluate strength and elbow range of motion. Although plain radiographs are helpful in ruling out other elbow pathology, MRI is used to confirm the diagnosis, classify the injury, and guide management. Incomplete tears with active elbow extension against resistance are managed nonsurgically. Surgical repair is indicated in active persons with complete tears and for incomplete tears with concomitant loss of strength. Good to excellent results have been reported with surgical repair, and very good results have been achieved even for chronic tears.

Leukocyte-rich platelet-rich plasma application in post-traumatic osteoarthritis with popliteal cyst: a case report.

Aim: To describe the successful treatment of a Baker's cyst in the setting of post-traumatic osteoarthritis using ultrasound-guided injection of platelet-rich plasma. Setting: Outpatient sports clinic. Patient: 29-year old male basketball player. Case description: The patient presented with 2-months history of right knee pain, 17 months after undergoing right knee anterior cruciate ligament reconstruction surgery. Exam revealed medial joint line and medial collateral ligament tenderness with posterior knee swelling. After aspiration, a corticosteroid injection was administered with temporary symptom relief. Diagnostic ultrasound examination confirmed the Baker's cyst. The patient then underwent two serial leukocyte-rich platelet-rich plasma injections into his right knee. Results: The patient reported complete resolution of pain and cyst size. Conclusion: Leukocyte-rich platelet-rich plasma may be considered as a treatment option for patients with Baker's cysts in the setting of post-traumatic osteoarthritis.

Systemic manifestations of Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome (EDS) is a multifaceted debilitating disease. Affected patients are at risk for complications such as joint hypermobility and cardiac disease, but the prevalence, course, and management of these conditions are not well understood. The objective of this retrospective cohort study was to investigate the demographic characteristics and systemic manifestations in EDS. We performed a retrospective analysis of 98 EDS patients seen in a physical medicine and rehabilitation clinic between January 2015 and April 2019. Charts were reviewed for demographic information, subtype of EDS, characteristics of musculoskeletal pain, and presence of certain systemic comorbid diagnoses: autonomic dysfunction, headaches/migraines, gastrointestinal conditions, cardiovascular anomalies, mast cell activation syndrome, and temporomandibular joint dysfunction. Of 98 patients, 75 were diagnosed with EDS-hypermobile type (EDS-HT); 94 patients were women, and the mean age was 36.7 years. On average, each patient reported involvement of 5.4 joints, with the shoulder, knee, and lumbar spine as the most common. The average number of comorbid systemic conditions was 2.8, of which autonomic dysfunction was the most common. This study aims to provide a better understanding of this disease to promote earlier and more accurate diagnoses to guide treatment and prevent complications.

Effects of Antiplatelet and Nonsteroidal Anti-inflammatory Medications on Platelet-Rich Plasma: A Systematic Review.

BACKGROUND: Platelet-rich plasma (PRP) has wide applications in orthopaedic care. Its beneficial effects are attributed to the growth factor profile from the platelet secretome. In theory, these effects would be diminished by medications that inhibit platelet activation and/or the subsequent release of growth factors. PURPOSE: To determine whether commonly used antiplatelets, nonsteroidal anti-inflammatory drugs (NSAIDs), or anticoagulant medications affect platelet growth factor release in PRP. STUDY DESIGN: Systematic review; Level of evidence, 2. METHOD: A systematic review of the literature related to antiplatelet, anti-inflammatory, and anticoagulant drugs was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We used the Downs and Black objective quality scoring system. The literature search consisted of PubMed and Cochrane Library databases. Search terms consisted of 1 item selected from "platelet-rich plasma," "platelet-derived growth factor," and "platelet-rich plasma AND growth factor" combined with 1 item from "antiplatelet," "aspirin," "anticoagulant," and "NSAID." Only studies published within the past 25 years were included. RESULTS: A total of 15 studies met the inclusion criteria: 7 studies detected no significant decrease in growth factors or mitogenesis, whereas 6 detected a decrease with antiplatelet agents, 1 detected mixed results with an antiplatelet agent, and 1 had mixed results with an antiplatelet agent/vasodilator. In terms of PRP activation, all 3 studies assessing collagen, the 2 studies analyzing adenosine diphosphate alone, and the 1 study investigating arachidonic acid found a decrease in growth factor concentration. CONCLUSION: Antiplatelet medications may decrease the growth factor release profile in a cyclooxygenase 1- and cyclooxygenase 2-dependent manner. Eight of 15 studies found a decrease in growth factors or mitogenesis. However, more studies are needed to comprehensively understand antiplatelet effects on the PRP secretome.

Ehlers-Danlos Syndrome: An Analysis of the Current Treatment Options.

BACKGROUND: Ehlers-Danlos syndrome (EDS) is a multifaceted disease that can present with a variety of types of pain. Unfortunately, both the mechanisms and treatments for pain are poorly understood. The proposed treatments for the various musculoskeletal pain syndromes in EDS have had variable success, and it becomes much more imperative to better define and evaluate the current treatment modalities in treating this debilitating disease. OBJECTIVES: The purpose of this study was to investigate the currently available treatment modalities for patients with EDS and their efficacies in pain and symptom relief. STUDY DESIGN: Retrospective cohort study. SETTING: Institutional physical medicine and rehabilitation primary care clinic. METHODS: All patients were seen between January 2015 and April 2019, in which 98 patients with EDS were identified through retrospective chart review. Institutional review board approval was obtained, and all patients provided written consent to be included in the study. We reviewed various treatment modalities, including complimentary/alternative treatments, opioids/opioid-like medications, nonsteroidal antiinflammatory drugs, physical therapy, occupational therapy, muscle relaxants, neuropathic modulators, steroids, surgery/procedures, and acetaminophen. Treatment methods were extracted from individual patient charts, and efficacy was grouped into 3 categories: improvement, no effect, or worsened symptoms. RESULTS: The most common treatments used were complimentary/alternative treatments (n = 88). Occupational therapy and bracing were the most effective options with 70% of patients reporting improvement. Neuropathic modulators were the least well tolerated with 47% of patients reporting adverse effects. LIMITATIONS: Men were a small percentage of the study. Patients were not randomized, and pain score reporting was subjective. Patient data were extracted from a single practice setting. Timing and symptom onset were not measured. CONCLUSIONS: There is a relative paucity of published literature regarding the various treatment methods for EDS. Although our study is able to identify positive and negative trends with certain modalities, it is vital to understand that EDS is not a uniform diagnosis among patients, and that a combination of several different treatments usually is needed for optimal symptom control. Further research and investigation are necessary to develop a comprehensive treatment database for this complex condition. KEY WORDS: Ehlers-Danlos syndrome, pain, hypermobility, arthralgia, subluxation, genetic, physical therapy, interventional pain.

Content Evaluation of Physical Medicine and Rehabilitation Residency Websites.

BACKGROUND: Prospective Physical Medicine and Rehabilitation (PM&R) applicants commonly view residency program websites to make informed decisions about where to submit their applications. To our knowledge, this is the first comprehensive review of the availability and accessibility of online content for PM&R residency programs. OBJECTIVE: To evaluate the comprehensiveness of PM&R residency websites to inform prospective applicants about the information readily available to them and identify deficient areas for program directors to address. DESIGN: Cross-sectional analysis of residency program websites using quantitative and descriptive statistics. SETTING: World Wide Web (Internet). SUBJECTS: 87 PM&R civilian residency program websites listed on the Fellowship and Residency Electronic Interactive Database (FREIDA). MAIN OUTCOME MEASUREMENTS: The presence or absence of 25 predetermined criteria on residency program websites. RESULTS: The individual residency program websites had a mean ± SD of 12.3 ± 4.3 (49.1%) of the 25 criteria sought. The programs ranged from having as few as one to as many as 19 of the 25 criteria. Twenty programs had 9 or fewer criteria, 35 programs had 10 to 14 criteria, 31 programs had 15 to 18 criteria, and one program had 19 criteria available online. No PM&R residency website had all 25 criteria. There was a significant association between a program's Doximity ranking as top 20 or not and the citation of published research projects by faculty on a PM&R website (P = .026), but the other 24 criteria had no significant associations. CONCLUSIONS: Most PM&R residency websites currently do not include comprehensive information about their programs for prospective applicants.