Reimagining faculty development: A paradigm shift from content to transformative learning processes.

BACKGROUND: Faculty development programs in health professional education traditionally emphasise theories, principles, and effective teaching practices. However, the efficacy of these strategies in instigating meaningful changes in instructional practices has come under scrutiny. METHODS: This qualitative research aims to enhance our understanding and support of educators' ongoing learning and growth. Employing a transformative learning lens, the study explored the experiences, professional development practices, and responsibilities of clinical educators who participated in a faculty development course. Utilising Mezirow's transformative learning theory as a framework, this research investigated the transformative journey of educators, analysing reflective pieces from 144 participants. RESULTS: The study findings revealed shifts in pedagogical approaches, ranging from the recognition of a haphazard teaching style to the intentional integration of evidence-based methods and pedagogical philosophies. The thematic analysis identified key stages in the transformative process, illuminating educators' commitment to structured teaching, self-directed learning, and continuous improvement. CONCLUSION: This research has contributed valuable insights into how faculty development programs can stimulate reflective practices and transformative learning in health professional education. The article argues for the centrality of transformative learning processes in faculty development, presenting an intriguing perspective on sustainable and impactful professional growth. Trends across learning experiences are presented, accompanied by practical recommendations. The implications of the research for clinical educators, administrators, and developers of formal faculty professional development programs are also discussed.

Situated learning in community environments (SLICE): Systems design of an immersive and integrated curriculum for community-based learning.

PURPOSE: We sought to design a micro-curriculum to structure supervised clinical placements for junior medical students within a variety of community-based settings of differing clinical disciplines. Given the gaps in the literature, this paper reflects on the opportunities and challenges of our design, implementation, and evaluation strategies in constructing an integrated task-based micro-curriculum for interprofessional community-based learning in year 2 of a four-year graduate entry program. METHODS: The design was informed by a systems thinking framework and guided by contemporary curricular theories on self-directed and interprofessional learning. Extensive consultations with stakeholders were undertaken. Alignment with relevant national level documents and curricular frameworks was ensured. RESULTS: The systems thinking approach provided first, an experience of applying thinking tools for a deeper understanding of how various parts of this micro-curriculum and subsystems should be integrated. Second, applying the toolkit uncovered tension points on which leverage could optimise future enhancements. Eighteen types of health professions were recruited including 105 general practitioners and 253 healthcare practitioners from a range of disciplines. CONCLUSION: Systems thinking allows for the identification of various interacting elements within the curriculum to be considered as part of an integrated whole. Insights from this model could inform the design of similar innovative curricula.

Student perspectives on programmatic assessment in a large medical programme: A critical realist analysis.

BACKGROUND: Fundamental challenges exist in researching complex changes of assessment practice from traditional objective-focused 'assessments of learning' towards programmatic 'assessment for learning'. The latter emphasise both the subjective and social in collective judgements of student progress. Our context was a purposively designed programmatic assessment system implemented in the first year of a new graduate entry curriculum. We applied critical realist perspectives to unpack the underlying causes (mechanisms) that explained student experiences of programmatic assessment, to optimise assessment practice for future iterations. METHODS: Data came from 14 in-depth focus groups (N = 112/261 students). We applied a critical realist lens drawn from Bhasker's three domains of reality (the actual, empirical and real) and Archer's concept of structure and agency to understand the student experience of programmatic assessment. Analysis involved induction (pattern identification), abduction (theoretical interpretation) and retroduction (causal explanation). RESULTS: As a complex educational and social change, the assessment structures and culture systems within programmatic assessment provided conditions (constraints and enablements) and conditioning (acceptance or rejection of new 'non-traditional' assessment processes) for the actions of agents (students) to exercise their learning choices. The emergent underlying mechanism that most influenced students' experience of programmatic assessment was one of balancing the complex relationships between learner agency, assessment structures and the cultural system. CONCLUSIONS: Our study adds to debates on programmatic assessment by emphasising how the achievement of balance between learner agency, structure and culture suggests strategies to underpin sustained changes (elaboration) in assessment practice. These include; faculty and student learning development to promote collective reflexivity and agency, optimising assessment structures by enhancing integration of theory with practice, and changing learning culture by both enhancing existing and developing new social structures between faculty and the student body to gain acceptance and trust related to the new norms, beliefs and behaviours in assessing for and of learning.

Diagnosis and management of connective tissue disease-associated interstitial lung disease in Australia and New Zealand: A position statement from the Thoracic Society of Australia and New Zealand.

Pulmonary complications in CTD are common and can involve the interstitium, airways, pleura and pulmonary vasculature. ILD can occur in all CTD (CTD-ILD), and may vary from limited, non-progressive lung involvement, to fulminant, life-threatening disease. Given the potential for major adverse outcomes in CTD-ILD, accurate diagnosis, assessment and careful consideration of therapeutic intervention are a priority. Limited data are available to guide management decisions in CTD-ILD. Autoimmune-mediated pulmonary inflammation is considered a key pathobiological pathway in these disorders, and immunosuppressive therapy is generally regarded the cornerstone of treatment for severe and/or progressive CTD-ILD. However, the natural history of CTD-ILD in individual patients can be difficult to predict, and deciding who to treat, when and with what agent can be challenging. Establishing realistic therapeutic goals from both the patient and clinician perspective requires considerable expertise. The document aims to provide a framework for clinicians to aid in the assessment and management of ILD in the major CTD. A suggested approach to diagnosis and monitoring of CTD-ILD and, where available, evidence-based, disease-specific approaches to treatment have been provided.

Baseline Characteristics and Survival of an Australian Interstitial Pneumonia with Autoimmune Features Cohort.

BACKGROUND AND OBJECTIVE: The research term "interstitial pneumonia with autoimmune features" (IPAF) encompasses interstitial lung disease (ILD) patients with autoimmune features not meeting diagnostic criteria for a defined connective tissue disease (CTD). It remains unclear if IPAF is a distinct disease entity with implications for management and prognosis. We describe an Australian IPAF population and compare their baseline characteristics and outcomes with distinct cohorts of idiopathic interstitial pneumonia (IIP), CTD-ILD, and unclassifiable ILD. METHODS: Review of 291 consecutive patients attending a specialist ILD clinic was performed. Patients with a diagnosis of IIP, CTD-ILD, and unclassifiable ILD by ILD-multidisciplinary meeting (ILD-MDM) were included. Patients meeting the IPAF criteria were identified. Baseline clinical data, survival, and progression were compared between ILD groups. RESULTS: 226 patients were included, 36 meeting the IPAF criteria. IPAF patients demonstrated a high prevalence of autoantibodies to tRNA synthetase (35.3%), Ro52 (27.8%), and neutrophilic cytoplasmic antigens (ANCA; 20.0%). IPAF and CTD-ILD patients demonstrated similar clinical characteristics (mean age 66.6 and 63.7 years, respectively, female predominant, frequent CTD-manifestations). Lung function did not differ between ILD groups. Disease severity, pulmonary hypertension (PH), and ILD-MDM diagnosis were strong predictors of worse transplant-free survival (TFS). Meeting the IPAF criteria was not associated with TFS. CONCLUSIONS: We identified IPAF as a heterogeneous phenotype that overlaps considerably with CTD-ILD. Disease severity, PH, and ILD-MDM diagnosis were more powerful predictors of survival outcomes than meeting the IPAF criteria.

Scaffolding medical student knowledge and skills: team-based learning (TBL) and case-based learning (CBL).

BACKGROUND: Two established small-group learning paradigms in medical education include Case-based learning (CBL) and Team-based learning (TBL). Characteristics common to both pedagogies include the use of an authentic clinical case, active small-group learning, activation of existing knowledge and application of newly acquired knowledge. However, there are also variances between the two teaching methods, and a paucity of studies that consider how these approaches fit with curriculum design principles. In this paper we explore student and facilitator perceptions of the two teaching methods within a medical curriculum, using Experience based learning (ExBL) as a conceptual lens. METHODS: A total of 34/255 (13%) Year 2 medical students completed four CBLs during the 2019 Renal and Urology teaching block, concurrent to their usual curriculum activities, which included weekly TBLs. Questionnaires were distributed to all students (n = 34) and CBL facilitators (n = 13). In addition, all students were invited to attend focus groups. Data were analysed using descriptive statistics and thematic analysis. RESULTS: In total, 23/34 (71%) of students and 11/13 (85%) of facilitators completed the questionnaires. Twelve students (35%) participated in focus groups. Findings indicate their experience in CBL to be positive, with many favourable aspects that built on and complemented their TBL experience that provided an emphasis on the basic sciences. The learning environment was enriched by the CBL framework that allowed application of knowledge to solve clinical problems within the small groups with consistent facilitator guidance and feedback, their capacity to focus discussion, and associated efficiencies in learning. CONCLUSION: While the TBL model was integral in developing students' knowledge and understanding of basic science concepts, the CBL model was integral in developing students' clinical reasoning skills. The strengths of CBL relative to TBL included the development of authentic clinical reasoning skills and guided facilitation of small group discussion. Our findings suggest that delivery of a medical curriculum may be enhanced through increased vertical integration, applying TBL in earlier phases of the medical program where the focus is on basic science principles, with CBL becoming more relevant as students move towards clinical immersion.

Peer review in team-based learning: influencing feedback literacy.

BACKGROUND: Peer review in Team-based learning (TBL) exists for three key reasons: to promote reflection on individual behaviours; provide opportunities to develop professional skills; and prevent 'free riders' who fail to contribute effectively to team discussions. A well-developed process that engages students is needed. However, evidence suggests it remains a difficult task to effectively incorporate into TBL. The purpose of this study was to assess medical students' ability to provide written feedback to their peers in TBL, and to explore students' perception of the process, using the conceptual framework of Biggs '3P model'. METHODS: Year 2 students (n = 255) participated in peer review twice during 2019. We evaluated the quality of feedback using a theoretically derived rubric, and undertook a qualitative analysis of focus group data to seek explanations for feedback behaviors. RESULTS: Students demonstrated reasonable ability to provide positive feedback, but were less prepared to identify areas for improvement. Their ability did not improve over time, and was influenced by the perceived task difficulty; social discomfort; and sense of responsibility in providing written feedback. CONCLUSIONS: To increase student engagement, we require a transparent process that incorporates verbal feedback and team discussion, with monitoring of outcomes by faculty and adequate training.

Team-based learning replaces problem-based learning at a large medical school.

ABSRACT: BACKGROUND: With increased student numbers in the Sydney Medical Program, and concerns regarding standardisation across cohorts, student satisfaction of the problem-based learning (PBL) model had decreased in recent years. In 2017, Team-based learning (TBL) replaced PBL in Years 1 and 2 of the medical program. This study sought to explore students' perceptions of their experience of TBL, and to consider resource implications. METHODS: In 2017, Years 1 and 2 medical students (n = 625) participated in weekly TBL sessions, with approximately 60 students per class, consisting of 11 teams of five or six students. Each class was facilitated by a consultant, a basic scientist and a medical registrar. Prior to each class, students were given pre-work, and completed an online Individual Readiness Assurance Test (IRAT). During face-to-face class, students completed the Team Readiness Assurance Test (TRAT), and received feedback with clarification from facilitators, followed by clinical problem-solving activities. Student feedback was collected by questionnaire, using closed and open-ended items. Data were analysed using descriptive statistics and thematic analysis. RESULTS: In total, 232/275 (84%) Year 1 and 258/350 (74%) Year 2 students responded to the questionnaire. Students found positive aspects of TBL included the small group dynamics, intra- and inter-team discussions, interactions with facilitators, provision of clinical contexts by clinicians, and the readiness assurance process. Suggested improvements included: better alignment of pre-reading tasks, shorter class time, increased opportunity for clinical reasoning, and additional feedback on the mechanistic flowchart. Resource efficiencies were identified, such as a reduction in the number of teaching sessions and required facilitators, and the ability to provide each classroom with clinical expertise. CONCLUSIONS: Our findings demonstrate that TBL, as a replacement for PBL in Years 1 and 2 of the medical curriculum, provided a standardised approach to small group learning on a large scale, and also provided resource efficiencies. Students perceived benefits related to the active learning strategy of TBL that encourage individual learning, consolidation of knowledge, retrieval practice, peer discussion and feedback. However, improvements are needed in terms of better alignment of pre-reading tasks with the TBL patient case, and greater facilitator interaction during the problem-solving activities. Additionally, consideration should be given to reducing class time, and providing TRAT scores.

Interprofessional team-based learning (TBL): how do students engage?

BACKGROUND: Although challenging to integrate within university curricula, evidence suggests that interprofessional education (IPE) positively impacts communication and teamwork skills in the workplace. The nature of Team-based learning (TBL) lends itself to interprofessional education, with the capacity to foster a culture of collaboration among health professional students. Our study was designed to pilot an interprofessional 'back pain' TBL module for physiotherapy and medical students, and to explore their experience of the TBL process, using the conceptual framework of 'knowledge reconsolidation' to discuss our finding. METHODS: Three hundred and eleven students participated in the TBL session: 222/277 (80%) of Year 1 medical students and 89/89 (100%) of Year 2 physiotherapy students. Students completed one interprofessional Musculoskeletal Sciences TBL session on the topic of 'back pain'. A questionnaire including closed and open-ended items, was distributed to students immediately following completion of the TBL session. Descriptive statistics were used to analyse the quantitative data. Thematic analysis was used to code and categorise qualitative data into themes. Pre-class quiz scores were compared between the groups using a one-way between groups Analysis of Variance (ANOVA) test with Tukeys Post Hoc test. RESULTS: In total, 117/311 (38%) of participants completed the questionnaire. Both medicine and physiotherapy students appreciated the opportunity to learn about the curriculum of another healthcare discipline, and their scope of practice; gain multiple perspectives on a patient case from different disciplines; and recognised the importance of multidisciplinary teams in patient care. Students felt having an interprofessional team of facilitators who provided immediate feedback helped to consolidate student learning and promoted clinical reasoning. An analysis of variance revealed no difference between Physiotherapy and Medical students' pre-class quiz scores. CONCLUSION: Our study demonstrated that the small group and task-focused characteristics of TBL provided a student-centred teaching strategy to support the achievement of interprofessional learning goals. Students valued their interactions with other students from a different professional degree, the opportunity to problem solve together, and learn different perspectives on a patient case. The pre-class quiz results demonstrate that both groups of students had a comparative level of prior knowledge to be able to work together on the in-class activities.

Medical students: what educational resources are they using?

BACKGROUND: The number of resources available to medical students studying a degree in medicine is growing exponentially. In addition to traditional learning resources such as lectures and textbooks, students are increasingly using e-learning tools like commercially available question banks to supplement their learning. Student preference for learning resources has not been described in detail, and a better understanding of the tools perceived to be useful could provide essential information to medical educators when designing and implementing medical curricula. METHODS: We invited 1083 undergraduate and postgraduate medical students from two major Australian universities to complete an online survey. Questions asked students to indicate the frequency with which they use various types of resources when learning new material or when revising previous content. RESULTS: Approximately one third (32.3%, N = 350) of invited participants completed the survey, and of those who responded, the gender distribution was even with a median age of 25 years. Making written notes and reading textbooks were the most frequently utilized resources for learning new material. Online or downloaded question banks were the most frequently used resource for revision. In addition to the use of traditional learning tools, the majority of students report using a variety of e-learning tools including online teaching videos (92%, n = 322) and question banks (90.6%, n = 317). CONCLUSION: Despite the trend towards e-learning, traditional resources like attendance at face-to-face lectures remain the most popular for learning new material. The increasing use of question banks raises potential issues of poor alignment to medical school curricula. With the advantages of exam technique practice, time efficiency and multiplatform availability, their popularity is likely to continue. Evaluation of existing question banks is required to facilitate appropriate integration into the curricula, with equitable access for all students.

Team-based learning (TBL): a community of practice.

BACKGROUND: Rapid changes in medical practice have a large impact on the demands faced by educators in preparing students for future participation in a multifaceted healthcare workforce. Competencies required by today's medical graduates encompass the ability to effectively collaborate, communicate and problem solve. The learning needs of medical students have also changed over time. Today's medical students are highly interconnected, enjoying teamwork and collaborative practice, and desire continuous, explicit feedback. They want structured learning activities, with clear expectations, and enjoy a sense of accomplishment on their achievements. The conflation of these issues has seen many medical schools adopt the model of Team-based learning (TBL). Using the conceptual framework of communities of practice, we sought to qualitatively explore students' and teachers' experience of TBL in Year 1 of a graduate entry medical program. METHODS: Convenience sampling was used to select 169/350 (48%) Year 1 students who completed three TBL sessions. Each TBL session was facilitated by three senior clinicians. Following participation in the TBLs, students were invited to attend focus groups, and all facilitators (n = 9) were invited to attend interviews. A coding framework was developed to code the entire dataset, using the theoretical lens of communities of practice. RESULTS: 34/169 (20%) of students attended focus groups. Three facilitators (3/9, 33%) were interviewed. Students and facilitators felt the structure and organisation of TBL made students accountable for their learning and team contributions. The combined expertise and clinical experience of facilitators, with immediate feedback helped groups to work both independently and collaboratively. Facilitators found working with their peers in the TBLs to be a rewarding experience. CONCLUSIONS: The community of practice found in the TBL classes, provided an enriching and rewarding learning environment that motivated students to build on their basic knowledge and apply what had been learnt. The interactions of experienced, senior clinicians as facilitators, sharing their expertise within a clinical context, prompted effective student engagement in learning and understanding. Our change in curriculum design and pedagogy will assist in preparing medical students for demands of the increasingly complex healthcare systems in which they will work.

Diagnosis and management of idiopathic pulmonary fibrosis: Thoracic Society of Australia and New Zealand and Lung Foundation Australia position statements summary.

INTRODUCTION: Idiopathic pulmonary fibrosis (IPF) is a fibrosing interstitial lung disease associated with debilitating symptoms of dyspnoea and cough, resulting in respiratory failure, impaired quality of life and ultimately death. Diagnosing IPF can be challenging, as it often shares many features with other interstitial lung diseases. In this article, we summarise recent joint position statements on the diagnosis and management of IPF from the Thoracic Society of Australia and New Zealand and Lung Foundation Australia, specifically tailored for physicians across Australia and New Zealand. Main suggestions: A comprehensive multidisciplinary team meeting is suggested to establish a prompt and precise IPF diagnosis. Antifibrotic therapies should be considered to slow disease progression. However, enthusiasm should be tempered by the lack of evidence in many IPF subgroups, particularly the broader disease severity spectrum. Non-pharmacological interventions including pulmonary rehabilitation, supplemental oxygen, appropriate treatment of comorbidities and disease-related symptoms remain crucial to optimal management. Despite recent advances, IPF remains a fatal disease and suitable patients should be referred for lung transplantation assessment.

The interstitial lung disease multidisciplinary meeting: A position statement from the Thoracic Society of Australia and New Zealand and the Lung Foundation Australia.

Interstitial lung diseases (ILD) are a diverse group of pulmonary diseases for which accurate diagnosis is critical for optimal treatment outcomes. Diagnosis of ILD can be challenging and a multidisciplinary approach is recommended in international guidelines. The purpose of this position paper is to review the evidence for the use of the multidisciplinary meeting (MDM) in ILD and suggest an approach to its governance and constitution, in an attempt to provide a standard methodology that could be applied across Australia and New Zealand. This position paper is endorsed by the Thoracic Society of Australia and New Zealand (TSANZ) and the Lung Foundation Australia (LFA).

Team-based learning (TBL) in the medical curriculum: better than PBL?

BACKGROUND: Internationally, medical schools have long used a variety of approaches to develop hybrid Problem based learning (PBL) curricula. However, Team-based learning (TBL), has gained recent popularity in medical education. TBL maintains the advantages of small group teaching and learning, but in contrast to Problem-based learning (PBL), does not require large numbers of tutors. In 2016, TBL was introduced to Year 1 of the Sydney Medical Program (SMP).This study sought to compare students' perceptions of using TBL in place of PBL. METHODS: Year 1 students (n = 169) completed three PBL and three TBL sessions during one of the following teaching blocks: Musculoskeletal (n = 56), Respiratory (n = 59) or Cardiovascular (n = 54). Student feedback following completion of each block of teaching was collected by questionnaire, using closed and open ended items. Data were analysed using descriptive statistics and thematic analysis. RESULTS: In total, 144/169 (85%) of participants completed a questionnaire regarding PBL, and 152/169 (90%) completed a similar questionnaire regarding TBL. The students found positive aspects of their TBL experience to include the smaller group size, the use of readiness assurance tests, immediate feedback from senior clinicians, and time efficiency. In PBL, students reported that variable expertise of tutors; limited direction; and large group size hindered their learning. CONCLUSIONS: Overwhelmingly, students preferred TBL over PBL, as the optimal teaching strategy. Students found the structure and format of the TBL sessions more conducive to learning, engagement and participation than PBL sessions. Although the use of TBL required an instructional approach, needing direction from the tutor, it remained student-centred, generating a range of positive outcomes. Study results provide confidence to change from PBL to TBL within Year 1 and Year 2 of the SMP in 2017.

Feedback using an ePortfolio for medicine long cases: quality not quantity.

BACKGROUND: The evidence for the positive impact of an electronic Portfolio (ePortfolio) on feedback in medicine is mixed. An ePortfolio for medical long cases in a Graduate Medical Program was developed. The purpose of this study was to explore the perceptions of medical students and faculty of the impact of the ePortfolio on the feedback process. METHODS: In total, 130 Year 3 medical students, and six faculty participated in the study. This is a mixed methods study, using a combination of both quantitative and qualitative approaches. Quantitative methods were used to quantify the number of long cases performed. Qualitative methods were used to explore the relationship between quantity and quality of feedback, and provide a rich understanding of both students' and faculty's experience and perceptions of the ePortfolio. RESULTS: Students received a variable quantity of feedback at each of the three studied clinical schools, with an average of between 4 - 5.4 feedback episodes per student. Feedback that was constructive, specific and timely and delivered by a senior academic was important. Quantity was not an essential factor, with two episodes of detailed feedback reported to be adequate. The barriers to the use of the ePortfolio were technical aspects of the platform that interfered with student engagement. CONCLUSIONS: Feedback using the ePortfolio for medical long cases is a valuable tool providing a senior clinician delivers detailed, constructive and personalized feedback in a timely fashion. The ePortfolio system needs to be user-friendly to engage students.

A Composite Serum Biomarker Index for the Diagnosis of Systemic Sclerosis-Associated Interstitial Lung Disease: A Multicenter, Observational Cohort Study.

OBJECTIVE: In patients with systemic sclerosis (SSc), we investigated composite serum biomarker panels for the diagnosis and risk stratification of SSc-associated interstitial lung disease (SSc-ILD). METHODS: We analyzed 28 biomarkers in 640 participants: 259 patients with SSc-ILD and 179 SSc patients without ILD (Australian Scleroderma Cohort Study), 172 patients with idiopathic pulmonary fibrosis (IPF-controls) (Australian IPF Registry), and 30 healthy controls. A composite index was developed from biomarkers associated with ILD in multivariable analysis derived at empirical thresholds. We evaluated the performance of the index to identify ILD, and specifically SSc-ILD, and its association with lung function, disease extent on radiography, and patient health-related quality of life in derivation and validation cohorts. Biomarkers to distinguish SSc-ILD from IPF-controls were identified. RESULTS: A composite biomarker index, comprising surfactant protein D (SP-D), Ca15-3, and intercellular adhesion molecule 1 (ICAM-1), was strongly associated with SSc-ILD diagnosis, independent of age, sex, smoking history, and lung function (for biomarker index score 3, pooled adjusted odds ratio was 12.72 (95% confidence interval 4.59-35.21) (P < 0.001). The composite index strengthened the performance of individual biomarkers for SSc-ILD identification. In SSc patients, a higher index was associated with worse baseline disease severity (for biomarker index score 3 relative to biomarker index score 0, the adjusted absolute change in forced vital capacity percent predicted was -17.84% and the diffusing capacity for carbon monoxide percent predicted was -20.16%; both P < 0.001). CONCLUSION: A composite serum biomarker index, comprising SP-D, Ca15-3, and ICAM-1, may improve the identification and risk stratification of ILD in SSc patients at baseline.

Nailfold capillaroscopy by smartphone-dermatoscope for connective tissue disease diagnosis in interstitial lung disease: a prospective observational study.

Nailfold capillaroscopy (NFC) is a non-invasive tool validated for systemic sclerosis diagnosis. The role and interpretation of NFC in interstitial lung disease (ILD) patients for the diagnosis of connective tissue disease associated ILD (CTD-ILD) remains undefined. In a prospective study, quantitative and qualitative NFC by smartphone-dermatoscope (3M Dermlite-DL4ΤΜ attached to iPhone-6plusΤΜ) was performed in 96 patients with well-defined CTD-ILD (n=27) and non-CTD ILD (n=69; idiopathic interstitial pneumonia n=42, interstitial pneumonia with autoimmune features n=27) by ILD-multidisciplinary meeting. NFC scoring was performed by two independent, blinded specialist rheumatologists. Comprehensive baseline clinical, serological, physiological and radiological data were included. Multivariable models for CTD diagnosis in ILD, comprising nailfold characteristics at empirical thresholds determined by receiver operating characteristic curve analysis and clinical variables, were explored. In 94 patients with complete NFC data (total 687 images, median eight images per patient from eight digits), low capillary density (<6 capillaries/millimetre), increased giant capillaries (≥3), avascular areas (≥2) and microhaemorrhages all strongly enhanced the discrimination of CTD-ILD from non-CTD ILD (OR 5.00-7.47) independent of clinical covariates. In multivariable analysis, low capillary density and microhaemorrhages were independent predictors of CTD in ILD additional to the risk conferred by serology and radiology. Microhaemorrhages were also a strong predictor of CTD (adjusted OR 13.45, p=0.006) independent of clinical manifestations. All pre-specified qualitative NFC classification schemes identified CTD-ILD (OR range 3.27-8.47). NFC performed by smartphone-dermatoscope is an accessible, clinically feasible tool that may improve the identification of CTD further to routine clinical assessment of the ILD patient.

Diagnosis of myositis-associated interstitial lung disease: Utility of the myositis autoantibody line immunoassay.

OBJECTIVES: The detection of myositis autoantibodies (MA) in patients with interstitial lung disease (ILD) has major implications for diagnosis and management, especially amyopathic and forme frustes of idiopathic inflammatory myositis-associated ILD (IIM-ILD). Use of the MA line immunoblot assay (MA-LIA) in non-rheumatological cohorts remains unvalidated. We assessed the diagnostic performance of the MA-LIA and explored combined models with clinical variables to improve identification of patients with IIM-ILD. METHODS: Consecutive patients referred to a specialist ILD clinic, with ILD-diagnosis confirmed at multidisciplinary meeting, and MA-LIA performed within six months of baseline were included. Pre-specified MA-LIA thresholds were evaluated for IIM-ILD diagnosis. RESULTS: A total 247 ILD patients were included (IIM-ILD n = 12, non-IIM connective tissue disease-associated ILD [CTD-ILD] n = 52, idiopathic interstitial pneumonia [IIP] n = 115, other-ILD n = 68). Mean age was 64.8 years, with 45.3% female, mean FVC 75.5% and DLCO 59.2% predicted. MA were present in 13.8% overall and 83.3% of IIM-ILD patients. The most common MA in IIM-ILD and non-IIM ILD patients were anti-Jo-1 (prevalence 40%) and anti-PMScl (29.2%) autoantibodies respectively. The pre-specified low-positive threshold (>10 signal intensity) had the highest discriminative capacity for IIM-ILD (AUC 0.86). Combining MA-LIA with age, gender, clinical CTD-manifestations and an overlap non-specific interstitial pneumonia/organising pneumonia pattern on HRCT improved discrimination for IIM-ILD (AUC 0.96). CONCLUSION: The MA-LIA is useful to support a diagnosis of IIM-ILD as a complement to multi-disciplinary ILD assessment. Clinical interpretation is optimised by consideration of the strength of the MA-LIA result together with clinical and radiological features of IIM-ILD.