Rheumatology Fellows Research Articles

Prologue: 2014 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)

The 2014 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) was held in New York, New York, USA, and attended by rheumatologists, dermatologists, and representatives of biopharmaceutical companies and patient groups. Summaries of presentations at that meeting are introduced, including the GRAPPA-organized Fellows Symposium adjacent to the 2014 Swiss Psoriasis Day in Geneva. At the GRAPPA meeting itself, a Trainees Symposium was organized for rheumatology fellows and dermatology residents to present their research work; several patient research partners (PRP) organized Building Bridges, a session of interactive dialogue regarding the roles and responsibilities of PRP and researchers participating in working groups at GRAPPA and elsewhere; and 5 dermatology sessions were held to report on the international dermatology outcome measures group. Among the meeting topics were dermatologists’ management of psoriatic arthritis (PsA); the unmet need for a comprehensive assessment tool for psoriasis; the Psoriasis Symptom Inventory; and the importance of treat-to-target strategies for managing psoriasis. Other presentations included an update of GRAPPA’s research initiative to develop evidence-based criteria to identify inflammatory arthritis, enthesitis, dactylitis, and spondylitis; the utility of magnetic resonance imaging in PsA; a review of the PsA working group at OMERACT (Outcome Measures in Rheumatology); and updates on several GRAPPA educational projects. Considerable time was allotted to discussions of GRAPPA’s efforts to update its treatment guidelines for PsA.

Editorial introductions

Editorial introductions

Tribute to Stephen M. Krane.

Tribute to Stephen M. Krane.

Prologue: 2013 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

The 2013 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) was held in July 2013 in Toronto, Canada, and attended by rheumatologists, dermatologists, and representatives of biopharmaceutical companies and patient groups. We introduce the articles that summarize the meeting: A summary of a GRAPPA-organized Fellows Symposium adjacent to the 2013 European Academy of Dermatology and Venereology meeting in Istanbul; at the GRAPPA meeting proper, proceedings of a trainee symposium, where rheumatology fellows and dermatology residents presented their research; a summary of experiences and perspectives of psoriasis and psoriatic arthritis (PsA) research of 8 patient research partners with PsA who were invited to participate as delegates. Other presentations and discussions included an interactive session on composite measures of disease severity and response, including voting by GRAPPA members; a 3 part update of basic/translational/clinical science, including new bone formation, enthesitis pathophysiology, and comorbidity monitoring; a 3 part dermatology update on psoriasis outcome measures, the Brigham Scalp Nail Inverse Palmoplantar Psoriasis Composite Index, and large-scale databases; a short summary of the ongoing GRAPPA effort to update treatment guidelines for PsA; updates on several GRAPPA educational and rheumatology-related projects; and a discussion of clinical criteria to identify inflammatory arthritis, enthesitis, dactylitis, and spondylitis as distinguished from non-inflammatory conditions.

SAT0585 Evaluation of Wikipedia Rheumatology Articles as A Learning Resource for Medical Students

BackgroundDespite concerns regarding its accuracy and reliability, Wikipedia is increasingly being used by medical students as a source of medical information (1,2).ObjectivesAim of our study was to evaluate whether Wikipedia...

GRAPPA Trainees Symposium 2013: a report from the GRAPPA 2013 Annual Meeting.

At the 2013 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) in Toronto, Ontario, Canada, 26 dermatology and rheumatology fellows engaged in psoriasis or psoriatic arthritis research were invited to present their work at the Trainees Symposium, which preceded the annual meeting and was also attended by GRAPPA members from around the world. Herein, we provide a brief overview of the 6 oral presentations and 25 posters presented, which reflect the focus and diversity of current basic and clinical research in psoriatic disease.

Editorial introductions

Editorial introductions

Editorial introductions

Editorial introductions

Noncompletion in Pediatric Rheumatology Fellowships

One challenge facing the health care workforce is a paucity of pediatrics subspecialists. No prior studies have investigated fellowship noncompletion as an influence of the subspecialty workforce. We sought to determine the noncompletion rate for pediatric rheumatology fellowships and to identify demographic characteristics associated with noncompletion. A retrospective cohort study of all trainees entering US pediatric rheumatology fellowship programs between 1997 and 2007 was performed. American Board of Pediatrics tracking data were used to determine completion status (completer or noncompleter) for each trainee. Completers were compared with noncompleters, using the independent variables sex, medical school location, and age. The noncompletion rate was calculated overall and individually. Program size was examined as a predictor of nonompletion rate. Data analysis used χ(2) tests, Kruskal-Wallis tests, and Spearman correlation. The cohort included 182 trainees from 28 pediatric rheumatology fellowship programs. Program size ranged from 1 to 18 trainees. The overall noncompletion rate was 16%. Male fellows, especially male international medical graduates, were more likely to be noncompleters. Noncompletion rates varied among programs: 15 programs had noncompletion rates of 0% and 4 programs had noncompletion rates of 50% or higher. Program size was not associated with noncompletion rate. During the study period, 1 of 6 pediatric rheumatology fellows did not complete training. Noncompletion was concentrated in a small number of programs. Further research should investigate noncompletion across specialties, identifying the causes of noncompletion at the individual, program, and specialty levels to inform future interventions to improve fellowship completion.

A177: Program Evaluation of the ACR/CARRA Inter‐Institutional Mentoring Program (AMIGO) in Pediatric Rheumatology

Background/Purpose:In pediatric rheumatology, the small size of many academic programs translates into limited mentoring options for early career physicians. To address this “mentorship gap,” in 2011 the American College of Rheumatology (ACR) and the Childhood Arthritis and Rheumatology Research Alliance (CARRA) joined together to develop AMIGO, the ACR/CARRA Mentoring Interest Group, that now includes greater than half of pediatric rheumatology fellows and junior faculty in the US and Canada. We report ongoing program evaluation encompassing pilot (2011) and full roll‐out (2012, 2013) phases of the AMIGO project.Methods:Mentees and mentors participating in the AMIGO project were surveyed via online questionnaire to determine dynamics of contact and perceived benefit. The entire pediatric rheumatology community was surveyed in 2011 to determine the state of mentoring and career development, with a repeat survey planned for early 2014. We tabulated the active dyads as of January 2014.Results:As recently reported, detailed evaluation of the pilot phase 17 months after initial roll‐out found that 19 of 20 pilot AMIGO dyads were still functioning, with substantial benefit noted by mentees in career guidance, scholarship, and job satisfaction. Benefits reported by mentors included improvement of their mentoring skills and development of their academic portfolios. Both mentees and mentors reported improved connectedness to the wider pediatric rheumatology community. 83 additional dyads were matched prior to 2012 and 2013 ACR meetings. Comparison of these 17‐month pilot results to a December 2013/January 2014 survey of all active AMIGO participants is ongoing. A questionnaire administered to the whole pediatric rheumatology community in 2011 (n = 135 respondents, including an estimated 64–70% response rate among fellows and junior faculty) found that approximately 60% of fellows and junior faculty had a career development mentor. We will assess whether the AMIGO program has had a global impact upon the mentoring culture in pediatric rheumatology by collecting community‐wide survey data in 2014 and then comparing to 2011 data.Conclusion:The 2011 AMIGO pilot program has confirmed the feasibility of a North American inter‐institutional mentoring program in pediatric rheumatology. Participants identified benefits to both mentees and mentors in multiple domains, most prominently in career guidance, a core goal of the program. Ongoing program evaluation will determine how much of this benefit has been sustained after participation was opened to the whole community, and whether the program has had a measureable impact on the overall state of mentoring in pediatric rheumatology.

Current pediatric rheumatology fellowship training in the United States: what fellows actually do

BackgroundPediatric Rheumatology (PR) training in the US has existed since the 1970’s. In the early 1990’s, the training was formalized into a three year training program by the American College of Graduate Medical Education (ACGME) and American Board of Pediatrics (ABP). Programs have been evaluated every 5 years by the ACGME to remain credentialed and graduates had to pass a written exam to be certified. There has been no report yet that details not just what training fellows should receive in the 32 US PR training programs but what training the trainees are actually receiving.MethodsAfter a literature search, a survey was constructed by the authors, then reviewed and revised with the help members of the Executive Committee of the Rheumatology Section of the American Academy of Pediatrics (AAP) using the Delphi technique. IRB approval was obtained from the AAP and Nationwide Children’s Hospital. The list of fellows was obtained from the ABP and the survey sent out to 81 current fellows or fellows just having finished. One repeat e-mail was sent out.ResultsForty-seven fellows returned the survey by e-mail (58%) with the majority being 3rd year fellows or fellows who had completed their training. The demographics were as expected with females > males and Caucasians> > non-Caucasians. Training appeared quite appropriate in the number of ½ day continuity clinics per week (1–2, 71%), number of patients per clinic (4–5, 60%), inpatient exposure (2–4 inpatients per week, 40%; 5 or greater, 33%), and weekday/weekend call. Fellows attended more didactic activities than required, had ample time for research (54% 21-60/hours per week), and had multiple teaching opportunities. Seventy-seven percent of the trainees presented abstracts at national meetings, 41% had publication. Disease exposure was excellent and joint injection experience sufficient.ConclusionsMost US PR training programs as a whole provide an appropriate training by current ACGME, American College of Rheumatology (ACR), and ABP standards in: 1) number of continuity clinics; 2) sufficient on-call activities for weekday nights and weekends; 3) joint interdisciplinary conferences; 4) electives 5) didactic activities; 6) scholarly activities; and 7) exposure to diverse rheumatology diseases. Areas of concern were uniformity & standardization of training, need for a customized PR training curriculum, more mentorship, free electives, training in musculoskeletal ultrasound, need for a hands-on OSCE certification exam and more exposure to ACGME competencies.

Preworkshop Knowledge of Musculoskeletal Anatomy of Rheumatology Fellows and Rheumatologists of Seven North, Central, and South American Countries

To report the baseline knowledge of clinical anatomy of rheumatology fellows and rheumatologists from Argentina, Chile, Ecuador, El Salvador, Mexico, the US, and Uruguay. The invitation to attend a workshop in clinical anatomy was an open call by national rheumatology societies in 4 countries or by invitation from teaching program directors in 3 countries. Prior to the workshop, a practical test of anatomic structures commonly involved in rheumatic diseases was administered. The test consisted of the demonstration of these structures or their function in the participant's or instructor's body. At one site, a postworkshop practical test was administered immediately after the workshop. There were 170 participants (84 rheumatology fellows, 61 rheumatologists, and 25 nonrheumatologists). The overall mean ± SD number of correct answers was 46.6% ± 19.9% and ranged from 32.5-67.0% by country. Rheumatology fellows scored significantly higher than nonrheumatologists. Questions related to anatomy of the hand scored the lowest of the regions surveyed. Rheumatology fellows and rheumatologists showed a deficit in knowledge of musculoskeletal anatomy that is of central importance in rheumatologic assessment and diagnosis. This gap may hinder accurate and cost-effective rheumatologic diagnosis, particularly in the area of regional pain syndromes. Presently, widespread use of musculoskeletal ultrasound (MSUS) by rheumatologists may be premature, since a key component of expert-level MSUS is the integration of an accurate knowledge of anatomy with the views obtained with the ultrasound probe.

Intérêt de l’échographie ostéo-articulaire dans les rhumatismes inflammatoires chroniques et les connectivites

Musculoskeletal ultrasonography is now widely used by almost all rheumatologists thanks to an improvement in the quality of ultrasound unit and probe and to the systematic teaching of this imaging technique to the rheumatology fellows. Applications have broadened from the study of degenerative and mechanical diseases to inflammatory rheumatic diseases. Ultrasound is more sensitive than clinical examination. Power Doppler allows the direct visualisation of inflammation within the tissues. Finally, it is a prognostic tool helping the physician in the management of the disease. This review will focus on the value and applications of ultrasonography in the 2 most frequent rheumatic diseases: rheumatoid arthritis and spondyloarthritis. We will also give some recent data on the usefulness of this imaging technique in the study of musculoskeletal manifestations associated with connective tissue disease.

Editorial introductions

Editorial introductions

Musculoskeletal Ultrasound Objective Structured Clinical Examination: An Assessment of the Test

To determine the reliability and validity of an objective structured clinical examination (OSCE) for musculoskeletal ultrasound (MSUS). A 9-station OSCE was administered to 35 rheumatology fellows trained in MSUS and to 3 expert faculty (controls). Participants were unaware of joint health (5 diseased/4 healthy). Faculty assessors (n = 9) graded image quality with predefined checklists and a 0-5 global rating, blinded to who performed the study. Interrater reliability, correlation between a written multiple choice question examination (MCQ) and OSCE performance, and comparison of fellow OSCE results with those of the faculty were measured to determine OSCE reliability, concurrent validity, and construct validity. Assessors' interrater reliability was good (intraclass correlation coefficient [ICC] 0.7). Score reliability was good in the normal wrist and ankle stations (ICC 0.7) and moderate in the abnormal wrist and ankle stations (ICC 0.4). MCQ grades significantly correlated with OSCE grades (r = 0.52, P < 0.01). The fellows in the bottom quartile of the MCQ scored 3.07 on the OSCE, significantly worse than the top quartile fellows (3.32) and the faculty (3.29; P < 0.01). Scores also significantly discriminated bottom quartile fellows from faculty in the normal wrist and ankle stations (3.38 versus 3.78; P < 0.01), but not in the abnormal stations (3.37 versus 3.49; P = 0.08). MSUS OSCE is a reliable and valid method for evaluation of MSUS skill. Normal joint assessment stations are more reliable than abnormal joint assessment stations and better discriminate poorly performing fellows from faculty. Therefore, MSUS OSCE with normal joints can be used for the assessment of MSUS skill competency.

Musculoskeletal Ultrasound Training and Competency Assessment Program for Rheumatology Fellows

The purpose of this study was to establish standards for musculoskeletal ultrasound competency through knowledge and skills testing using criterion-referenced methods. Two groups of rheumatology fellows trained in musculoskeletal ultrasound through a standardized curriculum, which required submission of ultrasound studies for review over 8 months. Both groups then completed written and practical examinations in musculoskeletal ultrasound. Instructors, advanced users, and intermediate users of musculoskeletal ultrasound served as comparison groups. A passing score (competency) was established for the written examination by the Angoff procedure and for the practical examination by the borderline method. Thirty-eight fellows (19 in each group) took the final examination. Five fellows failed the written examination, and 1 failed the practical examination, whereas none of the advanced users failed. Written examination scores did not differ between the two fellow groups (74% versus 70%; P > .05), were reliable, and were able to discriminate between the intermediate and advanced groups. Practical and written examination results correlated in both groups (first group, r = 0.70; P = .0008; second group, r = 0.59; P = .009). Criterion-referenced methods were used for the first time to determine fellow musculoskeletal ultrasound competency. The examination used to determine competency was reproducible, was reliable, and could differentiate musculoskeletal ultrasound users with different levels of experience. Most rheumatology fellows completing our program passed the written and practical examinations, suggesting achievement of basic musculoskeletal ultrasound competency.

Prologue: 2012 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)

The 2012 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) was held in June 2012 in Stockholm, Sweden, and attended by rheumatologists, dermatologists, and representatives of biopharmaceutical companies and patient groups from around the world. In this Prologue we introduce discussions that were held among meeting attendees. Prior to the 2012 meeting, 2 GRAPPA members organized a Fellows Symposium adjacent to the European Academy of Dermatology and Venerology meeting in Verona, where they discussed comorbidities and treatments of patients with psoriasis. The 2012 GRAPPA meeting began with a trainee symposium, where 30 rheumatology fellows and dermatology residents presented their research work. Other presentations and discussions included a review of arthritis mutilans; dermatology issues including screening tools for psoriatic arthritis (PsA) and the instruments to measure psoriasis severity; cardiovascular and other comorbidities of psoriasis and PsA; development of criteria to define inflammatory arthritis, enthesitis, dactylitis, and spondylitis; distinctions between peripheral spondyloarthritis and PsA; the status of an ultrasound outcome measure for dactylitis; and updates on several GRAPPA projects, including a study of biomarkers to predict structural damage in PsA, the ongoing video project, and several education initiatives.

AB1408 Knowledge of clinical anatomy by rheumatology fellows and rheumatologists in latin america

BackgroundIt is generally agreed that knowledge of musculoskeletal anatomy is a prerequisite to performing an adequate rheumatologic physical examination. However, little information is available regarding the level of anatomical knowledge...

AB1118 Prevalence of musculoskeletal complaints in 6-17 years old children from india: A school based population study

BackgroundMusculoskeletal complaints are common in children in the developed countries. (1) However, most of these are non-inflammatory, and prevalence of juvenile idiopathic arthritis is 7-220 per 100,000. (2) There is...

THU0279 Absence of radiographic progression of hip arthritis in patients with ankylosing spondylitis treated with infliximab for 6 years

BackgroundHip involvement is the most frequent extraspinal arthritic manifestation of Ankylosing Spondylitis (AS) and a common cause of disability. In contrast to the classical changes in the spine, hip joint...