Social media use by patients with hypermobile Ehlers-Danlos syndrome.

BACKGROUND: Patients with uncommon genetic conditions often face limited in-person resources for social and informational support. Hypermobile Ehlers-Danlos syndrome (hEDS) is a rare or underdiagnosed hereditary disorder of the connective tissue, and like those with similar diseases, patients with hEDS have begun to turn to social media in search of care and community. The aims of our study were to understand the usage habits and perceptions of utility of social media use for patients with hEDS in order to formulate suggestions for how clinicians may best engage these and similar patient populations about this topic. METHODS: We conducted both a quantitative survey and qualitative interviews with patients who had received a robust clinical diagnosis of hEDS. RESULTS: Twenty-four individuals completed the initial survey, and a subset of 21 of those participants completed an interview. Through thematic analysis, we identified four primary themes related to their experience with social media: (1) befriending others with their disease, (2) seeking and vetting information, (3) the risks and downsides of social media use, and (4) the desire for clinicians to discuss this topic with them. CONCLUSION: We conclude by proposing five suggestions that emerge empirically from our data. These proposals will help clinicians engage their patients regarding social media use in order to promote its potential benefits and circumvent its potential harms as they pursue support for their hereditary condition.

Defining Pseudoparalysis & Pseudoparesis - A Consensus Study.

PURPOSE: The purpose of this study was to establish consensus statements via a modified Delphi process on the definition of shoulder pseudoparalysis and pseudoparesis. METHODS: A consensus process on the definition of a diagnosis of pseudoparalysis utilizing a modified Delphi technique was conducted, and 26 shoulder/sports surgeons from 11 countries, selected based on their level of expertise in the field, participated in these consensus statements. Consensus was defined as achieving 80-89% agreement, whereas strong consensus was defined as 90-99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: Three statements regarding the diagnosis of pseudoparalysis reached strong (>89%) consensus: passive range of motion (ROM) should be unaffected, the passive range of abduction should not be considered and diagnosis should be excluded if lidocaine injection produces a substantial improvement in range of motion. Additionally, consensus (>79%) was reached that the active range of external rotation should not be considered for diagnosis, pain as a cause of restricted motion must be excluded, and that distinctions between restricted active flexion and external rotation should be made by ROM rather than tear characteristics. No consensus could be reached on statements regarding the size, number of tendons or chronicity of cuff tears. Nor was there agreement on the active range of flexion permitted or on the difference between pseudoparalysis and pseudoparesis. CONCLUSION: A modified Delphi process was utilized to establish consensus on the definition of shoulder pseudoparalysis and pseudoparesis. Unfortunately, almost half of the statements did not reach consensus, and agreement could not be reached across all domains for a unifying definition for the diagnosis of pseudoparalysis in the setting of RCTs. Furthermore, it was not agreed how or whether pseudoparalysis should be differentiated from pseudoparesis. Based on the lack of a consensus for these terms, studies should report explicitly how these terms are defined when they are used.

Risk Factors for Recurrence Following Arthroscopic Bankart Repair - A Systematic.

BACKGROUND: Recurrent instability remains a major source of morbidity following arthroscopic Bankart repair. Many risk factors and predictive tools have been described, but there remains a lack of consensus surrounding individual risk factors and their contribution to outcomes. PURPOSE: To systematically review the literature to identify and quantify risk factors for recurrence following arthroscopic Bankart repair. METHODS: A literature search was performed using the PubMed/Medline databases based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies were included if they evaluated risk factors for recurrent instability following arthroscopic Bankart repair. RESULTS: Overall, 111 studies were included in the analysis, including a total of 19,307 patients and 2,750 episodes of recurrent instability with 45 risk factors described. Age at operation was reported by 60 studies, with 35 finding increased risk at younger ages. Meta-analysis showed a two-fold recurrence rate of 27.0% (171/634) for patients under 20 years old compared to 13.3% (197/1485) for older patients (p<0.001). Seventeen studies completed multivariable analysis, 13 of which were significant (Odds Ratio 1.3-14.0). Glenoid bone loss was evaluated by 39 studies, with 20 finding an increased risk. Multivariable analysis in 9 studies found OR ranging from 0.7-35.1; 6 were significant. Off-track Hill-Sachs lesions were evaluated in 21 studies (13 significant), with 3 of 4 studies that conducted multivariable analysis finding a significant association with odds ratio of 2.9-8.9 of recurrence. The number of anchors used in repair was reported by 25 studies, with 4 finding increased risk with fewer anchors. Pooled analysis demonstrated a 25.0% (29/156) risk of recurrence with 2 anchors compared to 18.1% (89/491) with 3 or more anchors (p=0.06). Other frequently described risk factors included glenohumeral joint hyperlaxity (46% of studies reporting a significant association), number of preoperative dislocations (31%), contact sport participation (20%), competitive sport participation (46%), patient sex (7%), and concomitant SLAP tear (0%). CONCLUSION: Younger age, glenoid bone loss, and off-track Hill-Sachs lesions, are established risk factors for recurrence following arthroscopic Bankart repair. Other commonly reported risk factors included contact and competitive sports participation, number of fixation devices, and patient sex.

Simultaneous bilateral total hip arthroplasty-a survey of Irish orthopaedic surgeons' practice.

BACKGROUND: Bilateral total hip arthroplasty may be performed simultaneously (SIMTHA) or in two staged operations. AIM: To assess attitudes towards and utilization of SIMTHA in Irish orthopaedic practice, and to assess patient and surgeon factors which are associated with the management of bilateral hip arthritis. METHODS: A 16-question electronic survey (Google Forms) was distributed via email to consultant Irish orthopaedic surgeons who perform total hip arthroplasty, followed by a reminder 1 month later. A p value < 0.05 was considered significant. RESULTS: There were 53 responses from arthroplasty surgeons, with 28% reporting they never perform SIMTHA, 26% have performed ≤ 5 SIMTHA, and 46% do ≥ 1 SIMTHA per year. Amongst the 15 surgeons who do not do SIMTHA, 60% reported a preference for staged arthroplasty, 20% felt it was not feasible in their institution, and a third reported a lack of experience with SIMTHA. There was a significant association between not performing SIMTHA and years of consultant experience (p = 0.002). There were no institutional guidelines on eligibility criteria for SIMTHA. The most common time interval for staged bilateral arthroplasty was 6-12 weeks (60%). Overall, 56% of surgeons felt SIMTHA is underutilised in the Irish healthcare system; this was associated with greater SIMTHA volume (p = 0.023). CONCLUSION: Half of the Irish arthroplasty surgeons report SIMTHA is a regular aspect of their practice. Performing SIMTHA is associated with greater arthroplasty volume, more recent consultant appointments, and a perception that the operation is underutilised.

Editorial Commentary: Latarjet for Anterior Shoulder Instability Literature Shows Limited Reporting of Outcomes in Female Patients: Female Patients Show Similar Outcomes but Greater Rate of Emergency Department Visits and Possible Greater of Complications.

It has been reported that use of the Latarjet procedure for anterior shoulder instability increased 250% from 2008 to 2019. With this increase in use, it is imperative to minimize complications. At present, most literature focuses on male patients, with scant evidence regarding female patients. Outcomes are similar when female with male patients are compared, but female patients have greater postoperative visits to the emergency department than male patients, which requires specific attention during the postoperative period. In addition, the literature reporting complications in female versus male patients after Latarjet is conflicting; some studies show similar rates of complications, whereas other studies show greater rates of adverse events in female patients. Previous consensus statements recommended (1) careful dissection; (2) identification of the musculocutaneous and axillary nerves; (3) prevention of overlateralization of the graft; (4) the use of tranexamic acid to reduce blood loss; (5) accurate screw placement; and (6) careful preparation of the glenoid neck and coracoid to reduce rates of nonunion or delayed union.

Posterior Shoulder Instability Part II - Glenoid Bone-Grafting, Glenoid Osteotomy, and Rehabilitation/Return to Play - An International Expert Delphi Consensus Statement.

PURPOSE: The purpose of this study was to establish consensus statements on glenoid bone-grafting, glenoid osteotomy, rehabilitation, return to play, and follow-up for posterior shoulder instability. METHODS: A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating based on their level of expertise in the field. Experts were assigned to one of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80-89% agreement, whereas strong consensus was defined as 90-99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: All of the statements relating to rehabilitation, return to play, and follow-up achieved consensus. There was unanimous consensus that the following criteria should be considered: restoration of strength, range of motion, proprioception, and sport-specific skills, with a lack of symptoms. There is no minimum time point required to return to play. Collision athletes and military athletes may take longer to return because of their higher risk for recurrent instability, and more caution should be exercised in clearing them to return to play, with elite athletes potentially having different considerations in returning to play. The relative indications for revision surgery are symptomatic apprehension, multiple recurrent instability episodes, further intra-articular pathologies, hardware failure, and pain. CONCLUSION: The study group achieved strong or unanimous consensus on 59% of statements. Unanimous consensus was reached regarding the criteria for return to play, collision/elite athletes having different considerations in return to play, indications for revision surgery, and imaging only required as routine for those with glenoid bone-grafting/osteotomies at subsequent follow-ups. There was no consensus on optimal fixation method for a glenoid bone-block, the relative indications for glenoid osteotomy, whether fluoroscopy is required or if the labrum should be concomitantly repaired. LEVEL OF EVIDENCE: Level V Expert Opinion.

Posterior Shoulder Instability, Part I-Diagnosis, Nonoperative Management, and Labral Repair for Posterior Shoulder Instability-An International Expert Delphi Consensus Statement.

PURPOSE: To establish consensus statements on the diagnosis, nonoperative management, and labral repair for posterior shoulder instability. METHODS: A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating on the basis of their level of expertise in the field. Experts were assigned to 1 of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. RESULTS: Unanimous agreement was reached on the indications for nonoperative management and labral repair, which include whether patients had primary or recurrent instability, with symptoms/functional limitations, and whether there was other underlying pathology, or patient's preference to avoid or delay surgery. In addition, there was unanimous agreement that recurrence rates can be diminished by attention to detail, appropriate indication and assessment of risk factors, recognition of abnormalities in glenohumeral morphology, careful capsulolabral debridement and reattachment, small anchors with inferior placement and multiple fixation points that create a bumper with the labrum, treatment of concomitant pathologies, and a well-defined rehabilitation protocol with strict postoperative immobilization. CONCLUSIONS: The study group achieved strong or unanimous consensus on 63% of statements related to the diagnosis, nonoperative treatment, and labrum repair for posterior shoulder instability. The statements that achieved unanimous consensus were the relative indications for nonoperative management, and the relative indications for labral repair, as well as the steps to minimize complications for labral repair. There was no consensus on whether an arthrogram is needed when performing advanced imaging, the role of corticosteroids/orthobiologics in nonoperative management, whether a posteroinferior portal is required. LEVEL OF EVIDENCE: Level V, expert opinion.

Patient interest in the development of a center for Ehlers-Danlos syndrome/hypermobility spectrum disorder in the Chicagoland region.

BACKGROUND: The Ehlers-Danlos Syndromes (EDS) are a group of connective tissue disorders that are hereditary in nature and characterized by joint hypermobility and tissue fragility. The complex nature of this unique patient population requires multidisciplinary care, but appropriate centers for such care do not exist in large portions of the country. Need for more integrated services has been identified in Chicagoland, or Chicago and its suburbs. In order to explore and begin to address barriers to seeking appropriate care facing EDS patients in this region, we developed an online survey which we circulated through EDS social media groups for Chicagoland patients. RESULTS: Three hundred and nine unique respondents participated. We found that there exists a strong medical need for and interest in the development of a center in the region, and participants reported that, if made available to them, they would make extensive and regular use of such a facility. CONCLUSIONS: We conclude that the establishment of a collaborative medical center specializing in the diagnosis and treatment of EDS, Hypermobility Spectrum Disorder, and related disorders in the Chicagoland area would greatly benefit patients by providing comprehensive care, alleviate the burden on overworked healthcare providers, and contribute to the sustainability of medical facilities.

Midterm outcomes of primary reverse shoulder arthroplasty: a systematic review of studies with minimum 5-year follow-up.

Background: Excellent short-term outcomes after reverse shoulder arthroplasty (RSA) have been reported, but longer term outcomes in the existing literature are sparse and vary widely. The purpose of this study is to systematically assess the existing literature to quantify functional outcomes and complication rates after RSA at a minimum of five years of follow-up. Methods: A Preferred Reporting Items for Systematic Reviews and Meta-analyses-compliant systematic literature search of the PubMed and Embase databases was undertaken. Studies reporting outcomes after primary RSA for nontrauma-related indications with a minimum of 5-year follow-up were included. Results: Overall, 20 studies satisfied all inclusion criteria. This represented 1591 shoulders in 1556 patients (32.1% males), with a mean age of 70.2 ± 5.0 years and mean follow-up of 8.8 years, or 106.2 ± 30.1 months (60-243). At final follow-up, the mean reported Constant Murley score was 62.1 ± 5.0 (49.0-83.0). The mean adjusted Constant Murley score was 83.5 ± 12.5 (58-111.9). The mean American Shoulder and Elbow Surgeons score was 81.8 ± 4.6, while the mean subjective shoulder value was 74.6 ± 6.4. Overall, 88% of patients rated their satisfaction as either good or very good. The range of active forward flexion, abduction, external, and internal rotation were respectively, 126° ± 13°, 106° ± 11°, 22° ± 11°, and 6° ± 2°. The overall rate of revision surgery was 4.9% (0%-45.5%). Regarding complications, the rate of prosthetic joint infection was 4.3% (0%-26.7%), shoulder dislocation was 3.7% (0%-20.4%), and acromial fracture was 2.0% (0%-8.8%). At final follow-up, 30.9% of shoulders had some degree of scapular notching. Conclusion: This systematic review shows that RSA results in high satisfaction rates, good clinical outcomes, as well as modest complication and revision rates at minimum 5-year follow-up.

Patients' strategies for numeric pain assessment: a qualitative interview study of individuals with hypermobile Ehlers-Danlos Syndrome.

PURPOSE: Chronic pain is a common feature of hypermobile Ehlers-Danlos Syndrome (hEDS), yet how patients assess and communicate their pain remains poorly understood. The objective of the present study was to explore the use of numeric pain assessment in individuals with hEDS, from a patient-centered perspective. MATERIALS AND METHODS: Our analysis is based on in-depth qualitative interviews. The interviews were conducted over the phone. Our participants were patients living with hEDS (N = 35). Interviews were recorded, transcribed, and analyzed to identify factors related to their use of these pain assessment instruments. RESULTS: Three primary themes emerged from these data, namely, (1) confusion around the quantification of multidimensional pain, (2) the subjectivity of pain experience, and (3) a strategic use of assessments for practical purposes beyond the accurate representation of pain.These results demonstrate the need for caution in relying exclusively on numeric pain assessment instruments. We conclude with a brief proposal for a clinical communication strategy that may help to address the limitations of numeric pain assessment that were identified in our interviews.

Chronic pain is a common feature of hypermobile Ehlers­Danlos Syndrome (hEDS), yet how patients assess and communicate their pain remains poorly understood.Clinicians should be aware that patients have difficulties with the Numeric Rating Scale (NRS) for at least three reasons: (1) confusion around the quantification of multidimensional pain, (2) the subjectivity of pain experience, and (3) a strategic use of assessments for practical purposes beyond the accurate representation of pain.Clinicians should use caution in relying exclusively on NRS instruments.Clinicians may benefit from using clinical communication strategies outlined in our paper, which may help to address the limitations of the NRS that were identified in our interviews.

The statistical fragility of the management options for reverse shoulder arthroplasty: a systematic review of randomized control trial with fragility analysis.

Reverse shoulder arthroplasty (RSA) is used in the treatment of traumatic and arthritic pathologies, with expanding clinical indications and as a result there has been an increase in clinical research on the topic. The purpose of this study was to examine the statistical fragility of randomized control trials (RCTs) reporting outcomes from RSA. A systematic search was undertaken to find RCTs investigating RSA. The Fragility Index (FI) was calculated using Fisher's exact test, by sequentially altering the number of events until there was a reversal of significance. The Fragility Quotient (FQ) was calculated by dividing the FI by the trial population. Each trial was assigned an overall FI and FQ calculated as the median result of its reported findings. Overall, 19 RCTs warranted inclusion in the review, representing 1146 patients, of which 41.2% were male, with a mean age of 74.2 ± 4.3 years and mean follow-up of 22.1 ± 9.9 months. The median RCT population was 59, with a median of 9 patients lost to follow-up. The median FI was 4.5, and median FQ was 0.083, indicating more patients did not complete the trial than the number of outcomes which would have to change to reverse the finding of significance. This review found that the RCT evidence for RSA management may be vulnerable to statistical fragility, with a handful of events required to reverse a finding of significance.

Battle of the titans: Survivorship analysis of the 3 most common types of uncemented femoral stems used across national registries.

Background: Although many institutions utilize uncemented stems as routine in performing total hip arthroplasty (THA), many surgeons continue to rely on outcomes reported in the literature in the form of small cohorts and patient series when analyzing survivorship for specific implants. The purpose of this study was to identify and analyze the survivorship of the 3 most common uncemented stem types (as opposed to brands) used across multiple national joint registries. Methods: A review of data available from all national joint registries was carried out in July 2022. Analysis of each individual registry and classified uncemented implants into the seven different uncemented stem types. The 3 most common stem types were identified, and average cumulative revision rates calculated. Metal on metal bearings surface implants were excluded from this study due to high revision rates across all implant types. Results: Our detailed review identified 6 out of 13 (NJR, AOANJRR, LROI, EPRD, MARCQI and the NZJR) international registries reporting implant specific survivorship on uncemented femoral stems; including 960,328 uncemented stems across all registries. The most common type of stem used was type 3c, accounting for 61% (583,724), followed by type 1 stems with 23% (217,897) and type 2 stems with 8% (79,257). Cumulative revision rates at 13 years follow-up for these stems ranged from 6.9% to 7.9%. Conclusion: Although all stem types have comparable revision rates across all registries, the most common uncemented stem reported was the type 3c, tapered rectangular fully coated stem. Furthermore, out of all type 3c, the Müller design philosophy with full hydroxyapatite coating seems to be the most sought after worldwide. In this study we can conclude, thus far, that there does not appear to clinical or statistical differences in revision rates between the different stem types. Level of evidence: III.

Patient understanding of pharmacogenomic test results in clinical care.

OBJECTIVE: Previous research has not objectively assessed patients' comprehension of their pharmacogenomic test results. In this study we assessed understanding of patients who had undergone cytochrome P450 2C19 (CYP2C19) pharmacogenomic testing. METHODS: 31 semi-structured interviews with patients who underwent CYP2C19 testing after cardiac catheterization and had been sent a brochure, letter, and wallet card explaining their results. Answers to Likert and binary questions were summarized with descriptive statistics. Qualitative data were analyzed using a grounded theory approach, with particular focus on categorization. RESULTS: No participants knew the name of the gene tested or their metabolizer status. Seven participants (23%) knew whether the testing identified any medications that would have lower effectiveness or increased adverse effects for them at standard doses ("Adequate Understanding"). Four participants (13%) read their results from the letter or wallet card they received but had no independent understanding ("Reliant on Written Materials"). Ten participants remembered receiving the written materials (32%). CONCLUSION: A majority of participants who had undergone CYP2C19 PGx testing did not understand their results at even a minimal level and would be unable to communicate them to future providers. PRACTICE IMPLICATIONS: Further research is necessary to improve patient understanding of PGx testing and their results, potentially through improving patient-provider communication.

Patient Interest in the Development of a Center for Ehlers-Danlos Syndrome/Hypermobility Spectrum Disorder in the Chicagoland Region.

Background: The Ehlers-Danlos Syndromes (EDS) are a set of connective tissue disorders that are hereditary in nature and characterized by joint hypermobility and tissue fragility. The complex nature of this unique patient population requires multidisciplinary care, but appropriate centers for such care do not exist in large portions of the country. Need for more integrated services has been identified in the Chicagoland region. In order to explore and begin to address barriers to seeking out appropriate care facing EDS patients in this region, we developed an online survey which we circulated through EDS social media groups for Chicagoland patients. Results: Three hundred and nine unique respondents participated. We found that there exists a strong medical need for and interest in the development of a center in the region, and participants reported that, if made available to them, that they would make extensive and regular use of such a facility. Conclusions: We conclude that the establishment of a collaborative medical center specializing in the diagnosis and treatment of EDS, HSD, and related disorders in the Chicagoland area would greatly benefit patients by providing comprehensive care, alleviate the burden on overworked healthcare providers, and generate revenue for medical facilities.

Helping Cancer Patients Through Difficult Decisions.

A patient with cancer faces a choice between radiation and chemotherapy without the resources he needs to guide him.

The Fragility Index of Statistically Significant Findings From Randomized Controlled Trials Comparing the Management Strategies of Anterior Shoulder Instability.

BACKGROUND: Debate centering on the management of anterior shoulder instability (ASI) in recent years has led to many randomized controlled trials (RCTs) being published on the topic. The fragility index (FI) has subsequently emerged as a novel method of assessing significant findings reported in RCTs, particularly those with small sample sizes. PURPOSE: To evaluate the FI of statistically significant findings in RCTs that reported the outcomes of management strategies of patients with ASI. STUDY DESIGN: Systematic review; Level of evidence, 1. METHODS: Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent reviewers performed a systematic review of RCTs focusing on the outcomes of management strategies of patients with ASI. There were 3 main categories of RCTs included: (1) nonoperative management in internal rotation (IR) versus external rotation (ER), (2) nonoperative management versus a surgical intervention, and (3) surgical management with arthroscopic Bankart repair versus open Bankart repair. The Fisher exact test was utilized to calculate the FI for the reversal of statistical significance in all statistically significant dichotomous outcomes. RESULTS: A total of 21 RCTs were included, including 1589 shoulders (mean age, 29.4 years) with a mean follow-up of 26.8 months. There were 10 RCTs (831 shoulders) that reported outcomes after the nonoperative management of ASI in IR versus ER, with a mean FI of 6.8. There were 5 RCTs (324 shoulders) that reported outcomes comparing the nonoperative and operative management of ASI, with a mean FI of 3.5. There were 6 RCTs (434 shoulders) that reported outcomes after the operative management of ASI with either arthroscopic Bankart repair or open Bankart repair, with a mean FI of 9.6. CONCLUSION: The overall FI of RCTs reporting the outcomes of management strategies for patients with ASI was high, suggesting a moderate fragility of statistically significant outcomes including recurrence, revision stabilization, and return to play.

The Statistical Fragility of Management Options for Acute Achilles Tendon Ruptures - A Systematic Review of Randomized Control Trial with Fragility Analysis.

IMPORTANCE: In the treatment of acute Achille's tendon rupture, there is no uniform consensus on which of the many treatment modalities for this common injury is superior with respect to all possible complications. This review is to assess the statistical quality of the available evidence. OBJECTIVES: The P value is the common method to determine the significance of a finding, but it does not convey statistical robustness. The reversal of a small number of outcome events can be enough to change a finding of significance; this is known as statistical fragility, which can be measured with the fragility index (FI) and fragility quotient (FQ). The purpose of this study was to examine the statistical fragility of randomised control trials (RCTs) reporting outcomes of acute Achille's tendon rupture (AATR) management. EVIDENCE REVIEW: A systematic search strategy was used to find RCTs published since 1990 investigating AATR management. The FI was calculated using Fisher's exact test by sequentially altering the number of events until there was a reversal of significance. The FQ was calculated by dividing the FI by the sample size. Each trial was assigned an overall FI and FQ calculated as the median result of its reported findings. FINDINGS: Overall, 55 RCTs met the inclusion criteria, including 4,205 patients, 82.7% of which were male, there was a mean age of 41 and follow-up of 21 months; 60% of RCTs either did not report a statistical power analysis or were statistically underpowered. The overall FI was 4, indicating the reversal of just four outcomes would change the significance finding. The overall FQ was 0.082, suggesting that reversing eight patients out of every 100 would alter significance. In 22/55 (40%) RCTs, the number of patients lost to follow-up was greater than or equal to the FI of the trial. CONCLUSION: This review indicates the RCT literature for AATR management may be vulnerable to statistical fragility, with a handful of events required to reverse a finding of significance. We recommend that future trials in this area report the FI, FQ, and P value, to aid readers in assessing the evidence, therefore impacting clinical decision making. LEVEL OF EVIDENCE: I; Systematic Review of Randomised Control Trials.

Use of complementary and alternative medicine by patients with hypermobile Ehlers-Danlos Syndrome: A qualitative study.

Background: Patients with hypermobile Ehlers-Danlos Syndrome (hEDS) often make use of complementary and alternative medical (CAM) techniques to manage their chronic pain and other symptoms. Nevertheless, how they use CAM, which techniques they favor, and how CAM use affects their allopathic care remain unclear. The purpose of this qualitative study was to understand patients' personal experiences with CAM and its role in their symptom management. Materials and methods: Thirty individuals living with hEDS completed a brief online survey related to their CAM use. Thereafter, in-depth interviews were conducted with 24 of the survey respondents, qualitatively investigating their experiences with CAM. Data were analyzed using thematic analysis. Results: Participants described massage therapy (N = 21), medical cannabis (N = 12), and mindfulness (N = 13) as some of the most useful CAM modalities for managing symptoms related to hEDS, but they expressed a general interest in pursuing any treatment that could potentially reduce their chronic pain. They suggested an overall trust in CAM modalities and practitioners and ascribed greater empathy to CAM practitioners than to conventional medical providers. However, they also described a critical skepticism of CAM (and conventional) therapies and recounted instances of injury from such treatments. Conclusion: Participants made extensive use of CAM therapies. They described both critical benefits as well as harms from the use of these non-conventional modalities. These results underscore the importance of clinicians maintaining communicative and compassionate relationships with their patients, and of an openness to the discussion and use of CAM treatments.

Microplastics in the Arctic: A case study with sub-surface water and fish samples off Northeast Greenland.

The Arctic is a unique and fragile ecosystem that needs to be preserved and protected. Despite its remoteness, plastic pollution has been documented in this region. In the coming years, it is likely to worsen since, with climate changes and the opening of new shipping routes, the human presence is going to increase in the whole area. Here, we investigated the presence of microplastics (MPs) in sub-surface water and in two mid-trophic level Arctic fishes collected off Northeast Greenland: the demersal bigeye sculpin, Triglops nybelini, and the pelagic polar cod, Boreogadus saida. Plastics debris were found in the water samples at a concentration of 2.4 items/m3 ±0.8 SD which is higher than in most seas at lower latitudes. Both fish species had eaten MPs with different proportion among the species, 34% for T. nybelini (n = 71) and 18% for B. saida (n = 85). The significant difference in the occurrence of MPs between the two species is likely a consequence of their feeding behavior and habitat. Polyethylene was the main plastic polymer for water samples (41%, n = 17) and polyester (34%, n = 156) for fish samples as analyzed by Fourier Transformed Infrared (FT-IR) spectroscopy. Our data underscore that the Arctic regions are turning into a hotspot for plastic pollution, and this calls urgently for precautionary measures.