En Reumatología, ¿generamos los maestros que el siglo XXI necesita? / In Rheumatology, do we generate the teachers that the 21st century needs?

¿Quiénes deberían ser maestros de la Reumatología Argentina? Uno pensaría los mejores. ¿Son los mejores? ¿Cuál debería ser el criterio de selección para tan honroso y destacado sitio? Nuestra Sociedad exige: "Todos aquellos que hayan cumplido 65 años y que con su actividad académica mediante, formaron jóvenes reumatólogos". ¿Cómo los formaron? ¿Sabemos? ¿Técnicos o humanistas? La formación de un discípulo, en este caso en Reumatología, debe ser integral. No solo lo técnico, sino también de igual importancia en lo humano. Un maestro dialoga, mantiene un ideal, renuncia al enriquecimiento y muestras sus llagas.

Who should be the great educators and masters of Argentinian Rheumatology? One would think they should be the best ones! But are they the best ones? What ought to be the selection criteria for such a distinguished and honourable position? Our society demands: "All of those who have turned 65 years old and who, thanks to their academic work, have trained young rheumatologists". How the latter were trained? Do we know? As mere technicians or as humane professionals? The academic training of a pupil of Rheumatology, as in this case, must be comprehensive. Not only the technical but also the human aspect is of the utmost importance. An educator converses, is true to an ideal, gives up/sacrifices enrichment and reveals their weak points.

The Value of Supporting Education Research in the Academic Environment: The Hospital for Special Surgery Academy of Rheumatology Medical Educators.

PROBLEM: Medical education academies have been instrumental in providing greater recognition of and promotion for clinician-educators. However, producing education scholarship is essential for clinician-scholar-educator career advancement. Grant funding for education research and protected time to produce scholarship are still lacking for interested physicians, in part due to institutional budget constraints and competing priorities. APPROACH: The Hospital for Special Surgery Academy of Rheumatology Medical Educators was founded in 2011 to promote education scholarship through grants awarded to educators interested in research. Educators were asked to submit proposals aimed at the development of new teaching programs and curricular change. Selected applicants received up to $50,000 per year for one year. Grant money was obtained through directed fundraising from donors. Information from annual grant updates and survey responses from grant recipients in 2017 were used to assess the academy's effectiveness. OUTCOMES: Since 2012, 32 grants have been awarded, totaling $954,045 in funding. Recipients have produced national meeting abstracts, posters, oral presentations, and manuscripts and created unique curricula and electronic learning tools for medical students, residents, fellows, faculty, and patients. Four educators with demonstrated interest and research outcomes were identified during the pilot and received additional funding and support from a dedicated education research assistant. NEXT STEPS: The academy and the innovations grants program highlight the talents of under-supported and under-recognized teaching faculty by allowing them to distinguish themselves academically as clinician-scholar-educators. The success of these educators emphasizes the clear advantages of a formalized structure to achieve the hospital's education goals. Next steps include providing support for a rheumatology fellow to develop an education research career rather than one in bench, clinical, or translational research.

Knowledge gap about immune checkpoint inhibitors among rheumatologists and medical students: a survey.

Previous studies found that physicians working in developed countries in Europe and in the USA declared insufficient knowledge concerning immune-related adverse events (irAE) following use of immune checkpoint inhibitors (ICI) in cancer treatment. We determined this knowledge gap among rheumatologists and medical students (MS) in Brazil. A web-based structured survey or a direct interview was applied to 1428 board-certified Brazilian rheumatologists and an adapted questionnaire was sent to 840 undergraduate MS attending the last 2 years of Medical Schools in Fortaleza-CE, Brazil, in September 2019. 228 (15.9%) rheumatologists and 145 (17.2%) MS answered the survey; 136 (60%) rheumatologists worked at Institutions with Oncology service. Rheumatologists had 22.6 ± 12.6 years of medical practice, most [116 (50.9%)] worked in private practice and 9 (3.9%) were on training. Fifty-three (23.4%) declared being familiar [40 (17.6%)] or very familiar [13 (5.8%)] with irAE. Almost two-thirds declared having never managed irAE and about a third (38.6%) felt confident in managing such patients. Knowledge among rheumatologists was similar regardless of having more or less than 10 years of practice (P = 0.758). Less than 5% MS declared being familiar with ICI and most have never heard of irAE. There is a large gap concerning knowledge about ICI and irAE among rheumatologists and MS in Brazil. Continuing medical education strategies are needed to improve this knowledge.

Virtual learning environment in pediatric rheumatology for pediatric residents / Ambiente virtual de aprendizagem em reumatologia pediátrica para residentes em pediatria

ABSTRACT Objective: To develop, implement and evaluate an online virtual learning environment (VLE) on pediatric rheumatology, aimed at pediatric residents, analyzing its effectiveness and satisfaction rates. Methods: A total of 92 first and second year pediatric residents at two pediatric reference centers were invited to participate in the study. Residents were randomized into a case group (that answered the pre-course test, attended the six virtual pediatric rheumatology modules, and then responded to the post-course test and a satisfaction questionnaire) and a control group (that only answered the pre-course test and, after 4 weeks, the post-course test). Results: Forty-seven residents (51%) completed their participation. In the case group (n=24), the mean percentage of correct answers was 14% higher on the post-course test (p<0.001). The number of correct answers was larger in the case group than in the control one (n=23) in the post-course test (p=0.045). In the assessment of satisfaction with VLE use, residents considered the site easy to navigate (91%), suitable as a learning tool (91%), and attractive in design (79%). They reported poor prior knowledge in pediatric rheumatology (91%) and agreed that there was good learning with the methodology (75%). Conclusions: The virtual learning environment in pediatric rheumatology proved to be an effective teaching tool with high satisfaction rates, providing pediatrician residents with adequate knowledge regarding the initial assessment and management of children with rheumatic diseases.

RESUMO Objetivo: Elaborar, implementar e avaliar um ambiente virtual de aprendizagem online em reumatologia pediátrica, direcionado aos residentes em pediatria, analisando sua efetividade e seus índices de satisfação. Métodos: Foram convidados 92 residentes de pediatria do primeiro e segundo anos de dois centros de referência em pediatria. Os residentes foram divididos, de forma randomizada, em grupo caso (que respondeu ao teste pré-curso, assistiu aos seis módulos virtuais de reumatologia pediátrica e, ao término das aulas virtuais, respondeu ao teste pós-curso e ao questionário de satisfação) e grupo controle (que apenas respondeu ao teste pré-curso e, após quatro semanas, ao teste pós-curso). Resultados: Completaram a participação 47 (51%) residentes. No grupo caso (n=24), o percentual de acertos foi 14% maior no teste pós-curso (p<0,001). Houve um percentual de acertos maior no grupo caso em relação ao grupo controle (n=23) na comparação do resultado do teste pós-curso (p=0,045). Na avaliação da satisfação em relação ao uso do ambiente virtual, os residentes consideraram o site de fácil navegação (91%), adequado como ferramenta de aprendizagem (91%) e com design atrativo (79%). Eles relataram um conhecimento prévio ruim em reumatologia pediátrica (91%) e concordaram que houve um bom aprendizado por meio da metodologia (75%). Conclusões: O ambiente virtual de aprendizado em reumatologia pediátrica mostrou-se uma ferramenta de ensino eficaz e com altos índices de satisfação na sua utilização, fornecendo ao residente em pediatria um conhecimento adequado para avaliação e conduta inicial de pacientes com doenças reumáticas da infância.

Más allá del diagnóstico: comunicación, lenguaje y empatía / Beyond diagnosis: communication, language and empathy

La medicina actual, inmersa en una sociedad fría e individualista, se ha alejado de la buena comunicación con el enfermo. Es fundamental que en la formación médica más allá de entender la enfermedad, se comprenda al ser humano que la padece, lo que es parte del humanismo médico. La buena comunicación, más aún si es de una mala noticia para el enfermo y su entorno cercano, debe acompañarse de un lenguaje adecuado y un grado de empatía, que trasmitan una esperanza que no se aparte de la veracidad y la realidad.

Medicine today, immersed in a cold and individualistic society, has moved away from good communication with the patient. It is essential in medical training more beyond to understand disease, comprise the human suffering it, which is part of medical humanism. Good communication, even if it is bad news for the sick and their close environment, must accompanied by a suitable language and a degree of empathy, that convey hope to not depart from the truth and reality, accompanied by a suitable language and a degree of empathy, that convey hope to not depart from the truth and reality.

Development of rheumatology training in Brazil: the option for a medical residency program / Evolução da formação de reumatologistas no Brasil: a opção pela residência médica

Abstract Objective To describe the characteristics and progression of the supply of new rheumatologists in Brazil, from 2000 to 2015. Methods: Consultations to databases and official documents of institutions related to training and certification of rheumatologists in Brazil took place. The data were compared, summarized and presented descriptively. Results: From 2000 to 2015, Brazil qualified 1091 physicians as rheumatologists, of which 76.9% (n = 839) completed a medical residency program in rheumatology (MRPR); the others (n = 252) achieved this title without MRPR training. There was an expansion of MRPR positions. At the same time, there was a change in the profile of the newly qualified doctors. Early in the series, the fraction of new rheumatologists without MRPR, entering the market annually, was approaching 50%, dropping to about 15% in recent years. In 2015, Brazil offered 49 MRPR accredited programs, with 120 positions per year for access. There was an imbalance in the distribution of MRPR positions across the country, with a strong concentration in the southeast region, which in 2015 held 59.2% of the positions. Public institutions accounted for 94% (n = 789) of graduates in MRPR during the study period, while still maintaining 93.3% (n = 112) of seats for admission in 2015. Conclusions: In the last sixteen years, in parallel with the expansion of places of access, MRPR has established itself as the preferred route for rheumatology training in Brazil, mainly supported by public funds. Regional inequalities in the provision of MRPR positions still persist, as challenges that must be faced.

Resumo Objetivo: Descrever as características e a evolução da oferta de novos reumatologistas no Brasil, de 2000 a 2015. Métodos: Fizeram-se consultas a bases de dados e a documentos oficiais de instituições relacionadas à formação e à certificação de reumatologistas no país. Os dados foram cruzados, sumarizados e apresentados de forma descritiva. Resultados: De 2000 até 2015, o Brasil habilitou 1.091 médicos à condição de reumatologistas, dentre os quais 76,9% (n = 839) concluíram residência médica em reumatologia (RMR); os demais (n = 252) obtiveram o título sem cursar RMR. Houve expansão das vagas de RMR. Paralelamente, ocorreu uma modificação no perfil dos recém-habilitados. No início da série, a fração de novos reumatologistas sem RMR, ingressantes no mercado anualmente, aproximava-se dos 50%, reduziu-se para cerca de 15%, em anos recentes. Em 2015, havia no país 49 programas de RMR credenciados, com 120 vagas anuais de acesso. Observou-se desequilíbrio na distribuição de vagas de RMR pelo país, com forte concentração na Região Sudeste, que em 2015 detinha 59,2% das vagas. Instituições públicas responderam por 94% (n = 789) dos concluintes de RMR no período estudado, mantiveram ainda 93,3% (n = 112) das vagas para ingresso em 2015. Conclusões: Nos últimos 16 anos, paralelamente à expansão das vagas de acesso, a RMR consolidou-se como via preferencial para formação em reumatologia no Brasil, eminentemente suportada por recursos públicos. Desigualdades regionais na oferta de vagas de RMR persistem como desafios a serem enfrentados.

Interventional rheumatology: the competence of Brazilian rheumatologists / Reumatologia intervencionista: competência dos reumatologistas brasileiros

Abstract Objectives: Describe Brazilian rheumatologists's competence in interventional rheumatology; assess the association between this ability and demographic and training variables. Methods: A cross-sectional study with 500 Brazilian rheumatologists. Participants were assessed by self-administered questionnaire consisting of demographics, training, practice in office and knowledge in interventional rheumatology data. Results: 463 participants had their data analyzed. The mean age was 40.2 years (±11.2). 70% had performed periarticular injections and 78% had performed intra-articular injections. The sample was divided into three groups: non-interventionist, little interventionist and very interventionist. The non-interventionist group showed (p < 0.001-0.04) higher mean age, lower proportion of university bond, lower training history, higher proportion of graduates in the Southeast country, and higher proportion of graduates in the 1980s to 1989. The very interventionist group showed higher (p < 0.001-0.018) proportion of adult rheumatologists, higher proportion of university bond, longer training time with greater practice of complex procedures, and higher proportion of graduates, trained and with private practice in the South country. Variables most associated with the very interventionist subgroup are performing axial intra-articular injections (OR: 7.4, p < 0.001), synovial biopsy (OR: 5.75, p = 0.043), image-guided IAI (OR: 4.16, p < 0.001), viscosupplementation (OR = 3.41, p < 0.001), joint lavage (OR = 3.22, p = 0.019), salivary gland biopsy (OR = 2.16, p = 0.034) and over 6-month training (OR: 2.16, p = 0.008). Conclusions: Performing more complex invasive procedures and over 6-month training in interventional rheumatology were variables associated with enhanced interventional profile.

Resumo Objetivos: Descrever a competência dos reumatologistas brasileiros na reumatologia intervencionista (RI); avaliar a associação entre essa capacidade e variáveis demográficas e de treinamento. Métodos: Fez-se um estudo transversal com 500 reumatologistas brasileiros. Os participantes foram avaliados por questionário autoadministrado, constituído por dados demográficos, treinamento, prática em consultório e conhecimento em dados de RI. Resultados: Analisaram-se os dados de 463 participantes. A média foi de 40,2 anos (± 11,2). Desses, 70% fizeram injeções periarticulares (IPA) e 78% intra-articulares (IIA). A amostra foi dividida em três grupos: não intervencionista, pouco intervencionista e muito intervencionista. O grupo não intervencionista apresentou (p < 0,001 - 0,04) maior média de idade, menor proporção de vínculo universitário, menor história de treinamento, maior proporção de graduados na Região Sudeste do país e maior proporção de graduados nas décadas de 1980 a 1989. O grupo muito intervencionista apresentou (p < 0,001 - 0,018) maior proporção de reumatologias que atendem pacientes adultos, maior proporção de vínculo universitário, maior tempo de treinamento de prática de procedimentos complexos, maior proporção de graduados no sul do país, treinados e com consultório particular nessa região. As variáveis mais frequentemente associadas ao subgrupo muito intervencionista foram realização de IIA axial (OR: 7,4, p < 0,001), biópsia sinovial (OR: 5,75, p = 0,043), IIA guiada por imagem (OR: 4,16, p < 0,001), viscossuplementação (OR = 3,41, p < 0,001), lavagem articular (OR = 3,22, p = 0,019), biópsia da glândula salivar (OR = 2,16, p = 0,034) e mais de seis meses de treinamento (OR: 2,16; p = 0,008). Conclusões: Fazer procedimentos invasivos mais complexos e ter mais de seis meses de treinamento em RI foram as variáveis associadas a um maior perfil intervencionista.

Pain management in rheumatology research, training, and practice.

The Pain Management Task Force of the American College of Rheumatology published a report in 2010 highlighting pain management as a fundamental aspect of clinical practice, training and research. In the interim, the consideration of pain as a focus of attention of rheumatologists and rheumatology health professionals has become even more challenging than in 2010 because of the epidemic of opiate addiction and overdose death. The characterisation of categories of pain by mechanism (e.g., inflammation, joint degeneration, abnormalities of central pain processing) can help guide treatment. However, such categorisation can overlook the overlap of these processes and their interaction to create mixed pain states. Further complicating the assessment of pain, outcome measures in rheumatic disease often assess the degree of pain indirectly while concentrating on the quantification of inflammation. Non-inflammatory pain often persists despite treatment, highlighting the need for alternative analgesic therapies. Recommended therapies include acetaminophen, nonsteroidal anti-inflammatory drugs, and stimulators of the pain inhibitory pathway. Each of these non-opioid therapies has incomplete efficacy and potential toxicities that can limit their utility. Non-pharmacologic therapies can show efficacy that rivals or surpasses pharmacologic therapies in the control of pain and improving function in a variety of rheumatic disorders including chronic low back pain and fibromyalgia. A limitation of the use of these therapies is inadequate training and appreciation of their benefits. Furthermore, the supply of trained practitioners to provide non-pharmacological care and support patient efforts for self-management is often limited. Together, these considerations suggest the importance of a renewed effort to implement task force recommendations.

Interventional rheumatology: the competence of Brazilian rheumatologists.

OBJECTIVES: Describe Brazilian rheumatologists's competence in interventional rheumatology; assess the association between this ability and demographic and training variables. METHODS: A cross-sectional study with 500 Brazilian rheumatologists. Participants were assessed by self-administered questionnaire consisting of demographics, training, practice in office and knowledge in interventional rheumatology data. RESULTS: 463 participants had their data analyzed. The mean age was 40.2 years (±11.2). 70% had performed periarticular injections and 78% had performed intra-articular injections. The sample was divided into three groups: non-interventionist, little interventionist and very interventionist. The non-interventionist group showed (p<0.001-0.04) higher mean age, lower proportion of university bond, lower training history, higher proportion of graduates in the Southeast country, and higher proportion of graduates in the 1980s to 1989. The very interventionist group showed higher (p<0.001-0.018) proportion of adult rheumatologists, higher proportion of university bond, longer training time with greater practice of complex procedures, and higher proportion of graduates, trained and with private practice in the South country. Variables most associated with the very interventionist subgroup are performing axial intra-articular injections (OR: 7.4, p<0.001), synovial biopsy (OR: 5.75, p=0.043), image-guided IAI (OR: 4.16, p<0.001), viscosupplementation (OR=3.41, p<0.001), joint lavage (OR=3.22, p=0.019), salivary gland biopsy (OR=2.16, p=0.034) and over 6-month training (OR: 2.16, p=0.008). CONCLUSIONS: Performing more complex invasive procedures and over 6-month training in interventional rheumatology were variables associated with enhanced interventional profile.

Prologue: 2015 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

The 2015 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) was held in Stockholm, Sweden, and attended by rheumatologists, dermatologists, and representatives of biopharmaceutical companies and patient groups. In this prologue, we introduce the articles that summarize that meeting. As in previous years, GRAPPA members held a Trainees Symposium, providing an opportunity for trainees to discuss their research in psoriatic disease with experts in the field. Two dermatology sessions were held: an update on the International Dermatology Outcome Measures group; and a description of a new tool, the Comprehensive Assessment of the Psoriasis Patient, to more accurately assess the full burden of plaque psoriasis and its subtypes. Four distinct plenary sessions were held to update members on the status of the Outcome Measures in Rheumatology (OMERACT) initiative. GRAPPA's patient research partners discussed their 2 years of involvement in GRAPPA activities and were active in several sessions before and during the 2015 annual meeting. New work was presented toward developing a patient-reported instrument to measure flare in psoriatic disease, and the status of GRAPPA's multiple research and continuing education programs in psoriasis and PsA was summarized. Finally, a Presidential Round Table was held in which the past, current, and incoming presidents reflected on GRAPPA's history and provided insights about its future.

Fellow use of medical jargon correlates inversely with patient and observer perceptions of professionalism: results of a rheumatology OSCE (ROSCE) using challenging patient scenarios.

The NYC Rheumatology Objective Structured Clinical Examination (NYC-ROSCE) is held annually to assess fellow competencies. We recently redesigned our OSCE to better assess subspecialty trainee communication skills and professionalism by developing scenarios in which the patients encountered were psychosocially or medically complex. The objective of this study is to identify which types of verbal and non-verbal skills are most important in the perception of professionalism in the patient-physician interaction. The 2012-2013 NYC-ROSCEs included a total of 53 fellows: 55 MD evaluators from 7 NYC rheumatology training programs (Hospital for Special Surgery-Weill Cornell (HSS), SUNY/Downstate, NYU, Einstein, Columbia, Mount Sinai, and North Shore/Long Island Jewish (NSLIJ)), and 55 professional actors/standardized patients participated in 5 stations. Quantitative fellow performance assessments were made on the following: maintaining composure; partnering with the patient; honesty; professionalism; empathy; and accountability. Free-text comments were solicited regarding specific strengths and weaknesses. A total of 53/53 eligible (100 %) fellows were evaluated. MD evaluators rated fellows lower for professionalism than did the standardized patients (6.8 ± 0.6 vs. 7.4 ± 0.8, p = 0.05), suggesting that physicians and patients view professionalism somewhat differently. Fellow self-evaluations for professionalism (6.6 ± 1.2) were concordant with those of the MD evaluators. Ratings of empathy by fellows themselves (6.6 ± 1.0), MD evaluators (6.6 ± 0.7), and standardized patients (6.6 ± 1.1) agreed closely. Jargon use, frequently cited by evaluators, showed a moderate association with lower professionalism ratings by both MD evaluators and patients. Psychosocially challenging patient encounters in the NYC-ROSCE permitted critical assessment of the patient-centered traits contributing to impressions of professionalism and indicate that limiting medical jargon is an important component of the competency of professionalism.

The inadequacy of musculoskeletal knowledge in graduating medical students in the United Kingdom.

BACKGROUND: Musculoskeletal symptoms are common reasons for patients seeking medical attention. Basic competency in musculoskeletal medicine is therefore essential for all clinicians. To our knowledge, this is the first assessment of the competency in musculoskeletal medicine of medical students in the United Kingdom. METHODS: Medical students were enrolled after passing final university examinations and being awarded degrees of Bachelor of Medicine, Bachelor of Surgery (MBBS) or Medicinae Baccalaureus, Baccalaureus Chirurgiae (MBChB) in 2013 and were assessed with use of the Freedman and Bernstein musculoskeletal cognitive examination tool. RESULTS: Two hundred and thirty students were recruited, of whom 210 were suitable for inclusion. Only 21% (forty-four students) passed the assessment. Mandatory exposure to musculoskeletal medicine during medical school consisted of orthopaedics for 100% of participants for a mean duration of 2.65 weeks, rheumatology for 96% of participants for a mean duration of 2.5 weeks, and sports medicine for 1% of participants for a mean duration of two weeks. There was a significant difference (p = 0.002) in scores between those with career interests in musculoskeletal specialties (69.3%) and the rest of the cohort (54.9%). There was also a significant difference (p = 0.001) in scores between participants with career interests in general practice (42%) and the rest of the cohort (56%). Only 40% of participants considered themselves competent in musculoskeletal medicine. Fifty-five percent thought that musculoskeletal conditions would be an important component of their future practice. CONCLUSIONS: Our findings suggest that medical schools may be currently failing to ensure that medical students have a basic competence in musculoskeletal medicine. Further investigation is warranted to fully assess the current training provided by U.K. medical schools in musculoskeletal medicine, and appropriate steps must be taken to improve the quantity and quality of training in musculoskeletal medicine in the United Kingdom.

Psoriasis and psoriatic arthritis educational initiatives: an update from the 2013 GRAPPA Annual Meeting.

At the 2013 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), members were updated on educational areas in psoriasis and psoriatic arthritis (PsA). Discussions included (1) the psoriasis and PsA GRAPPA video project, comprising a set of educational online videos that provide standardized psoriatic disease endpoint training to clinicians and researchers; (2) the GRAPPA Educational Outreach Project, focused on cross-disciplinary education for rheumatologists and dermatologists and including several collaborations to expand educational sessions globally; (3) the Dermatology and Rheumatology Trainee Educational Initiative, that provides psoriatic disease education to medical students, residents, and fellows training in dermatology and/or rheumatology; and (4) the GRAPPA Educational Slide Library, developed as a resource for GRAPPA members for their own educational presentations.

Inequalidade na distribuição de reumatologistas no Brasil: correlação com local de residência médica, Produto Interno Bruto e Índice de Desenvolvimento Humano / Inequality in the distribution of rheumatologists in Brazil: correlation with local of medical residency, Gross Domestic Product and Human Development Index

Objetivo: Avaliar a distribuição dos reumatologistas no Brasil e sua correlação com oferta de residência médica (RM) especializada, Produto Interno Bruto (PIB) e Índice De Desenvolvimento Humano Municipal (IDH-M) das unidades da federação (UFs). Métodos: Consulta a várias bases de dados oficiais, sumarização de dados por técnicas estatísticas descritivas e cruzamento de informações. Para análise de correlação, utilizou-se o coeficiente de Spearman (r). Resultados: Foram encontrados 1.229 reumatologistas registrados regularmente no país. A região Norte reunia apenas 3,6% desse contingente (n = 44), enquanto o Sudeste, 42,2% (n = 519). As capitais somadas aos cinco maiores municípios de cada UF concentraram 75,8% desses especialistas (n = 931). No total, 49,9% dos reumatologistas prestavam atendimento pelo Sistema Único de Saúde (SUS). Achou-se razão geral de 157.809 habitantes para cada reumatologista no Brasil, porém com grande variação entre as UF quanto a essa proporção. Entre 2000 e 2012, houve 593 concluintes de RM em reumatologia no Brasil. Achou-se correlação positiva do número de reumatologistas ante o PIB (r = 0,94), o IDH-M da capital (r = 0,77) e o número de concluintes de RM em reumatologia (r = 0,79) das UF. Conclusões: Observou-se forte concentração de reumatologistas nas capitais e maiores municípios brasileiros, com inequalidades perceptíveis também entre as UF e as regiões do país. A distribuição desses profissionais acompanhou o PIB, o IDH-M da capital e o número de concluintes de RM em reumatologia das UF, sugerindo que fatores relacionados a oportunidades de renda e desenvolvimento humano e ao local de formação especializada podem influir na fixação geográfica ...

Objective: To assess the distribution of rheumatologists in Brazil and their correlation with Medical Residency specialization offer, Gross Domestic Product (Gdp) And Municipal Human Development Index (HDI-M) of units of the federation (UFs). Methods: Query to various official databases, data summarization by techniques for descriptive statistics and cross-referenced information. For correlation analysis, we used the Spearman correlation coefficient (r). Results: There were 1229 rheumatologists regularly registered in the country. The Northern region had only 3.6% of the total (n = 44), while the Southeast had 42.2% (n = 519). The State capitals, added to the five largest municipalities in each UF, concentrated 75.8% of these specialists (n = 931). In total, 49.9% of rheumatologists offered treatment at SUS. A general ratio of 157,809 inhabitants per rheumatologist in Brazil was determined, but with wide variation among UFs with respect to this ratio. In the years 2000-2012, there were 593 Rheumatology Residency graduated physicians in Brazil. We observed a positive correlation among number of rheumatologists compared with GDP (r = 0.94), HDI-M of the State capitals (r = 0.77) and number of Rheumatology Residency graduated physicians (r = 0.79) in UFs. Conclusions: We noted a strong concentration of rheumatologists in State capitals and larger municipalities, with noticeable inequalities also between UFs and country regions. The distribution of these professionals accompanied GDP, HDI-M of the State capital and number of Rheumatology Residency graduated physicians, suggesting that factors related to income opportunities and human development and the place of speciality training may influence the geographical fixation of rheumatologists.

The adherence to ASAS classification criteria and to ASAS recommendations for the use of anti-TNH-alpha agents in axial spondyloarthritis.

OBJECTIVES: To determine the adherence of practicing rheumatologists, before and after an educational project, to Assessment of SpondyloArthritis international Society (ASAS) classification criteria and to ASAS recommendations for the use of anti-tumor necrosis factor (TNF)-alpha agents in patients with axial spondyloarthritis (SpA). METHODS: The project involved 53 rheumatologists attending 2 educational meetings on an update of SpA. Each meeting included interactive sessions on 1) clinical cases, 2) clinimetric evaluation, including ASAS core set for daily practice and 3) imaging. Diagnostic and therapeutic approach of each participant was tested using short clinical cases, obtained from real-life rheumatology settings, at the beginning and at the end of this educational project. Each case for diagnostic (n=10) or therapeutic purpose (n=10) had 10 possible choices. Each participant gave a score from 0 (total disagreement) to 10 (total agreement) for each choice. RESULTS: At baseline, the rheumatologists had an excellent agreement with ASAS classification criteria for axial SpA and anti-TNF-alpha treatment according to ASAS recommendations with a further significant improvement after the educational programme. In axial SpA cases with acute anterior uveitis (AU) or Crohn's disease, anti-TNF-alpha treatment was indicated mainly as monoclonal anti-TNF antibody. In presence of elevated levels of CRP, anti-TNF option has been considered useful. CONCLUSIONS: Practicing rheumatologists had a satisfying adherence to ASAS classification criteria and to ASAS recommendations for the use of anti-TNF-alpha agents for patients with axial SpA. Extra-articular manifestations and other variables might play a role in the decision-process of the management of axial SpA.

Educational quality of YouTube videos on knee arthrocentesis.

BACKGROUND: Knee arthrocentesis is a commonly performed diagnostic and therapeutic procedure in rheumatology and orthopedic surgery. Classic teaching of arthrocentesis skills relies on hands-on practice under supervision. Video-based online teaching is an increasingly utilized educational tool in higher and clinical education. YouTube is a popular video-sharing Web site that can be accessed as a teaching source. OBJECTIVE: The objective of this study was to assess the educational value of YouTube videos on knee arthrocentesis posted by health professionals and institutions during the period from 2008 to 2012. METHODS: The YouTube video database was systematically searched using 5 search terms related to knee arthrocentesis. Two independent clinical reviewers assessed videos for procedural technique and educational value using a 5-point global score, ranging from 1 = poor quality to 5 = excellent educational quality. As validated international guidelines are lacking, we used the guidelines of the Swiss Society of Rheumatology as criterion standard for the procedure. RESULTS: Of more than thousand findings, 13 videos met the inclusion criteria. Of those, 2 contained additional animated video material: one was purely animated, and one was a check list. The average length was 3.31 ± 2.28 minutes. The most popular video had 1388 hits per month. Our mean global score for educational value was 3.1 ± 1.0. Eight videos (62 %) were considered useful for teaching purposes. Use of a "no-touch" procedure, meaning that once disinfected the skin remains untouched before needle penetration, was present in all videos. Six videos (46%) demonstrated full sterile conditions. There was no clear preference of a medial (n = 8) versus lateral (n = 5) approach. CONCLUSIONS: A discreet number of YouTube videos on knee arthrocentesis appeared to be suitable for application in a Web-based format for medical students, fellows, and residents. The low-average mean global score for overall educational value suggests an improvement of future video-based instructional materials on YouTube would be necessary before regular use for teaching could be recommended.

National survey of knowledge, attitude and practice of fibromyalgia among rheumatologists in China.

AIM: Fibromyalgia (FM) is a chronic disorder characterized by widespread musculoskeletal pain and fatigue. It is a less frequently diagnosed disease in China, thus Chinese rheumatologists may have lower awareness of FM compared with colleagues in Western countries. The aim of this study is to investigate the perceptions of FM in Chinese rheumatologists and analyze their therapeutic approach in clinical practice. METHOD: An anonymous questionnaire survey was conducted among a nationwide sample of Chinese rheumatologists at the 15th National Rheumatology Conference in 2010. The 20-question survey included questions regarding background, work experience, perceptions of diagnosis and behaviors of treatment related to FM. Continuing medical education (CME) information was also collected in the survey. RESULTS: Seven hundred and seven rheumatologists responded to the questionnaire, a response rate of 60%. Less than one-fifth of the respondents were experienced in dealing with FM. Although most of the respondents regarded FM as a distinct pathological entity, nearly 30% of Chinese rheumatologists believed that FM was only a psychological disorder. The respondents recognized some of the FM-related symptoms, but had limited knowledge on the diagnostic criteria. Eighty percent of the respondents declared they had difficulties in treating FM patients. However, nearly all (90.8%) respondents believed that the prognosis of FM patients was usually benign. Our data also showed that most Chinese rheumatologists were eager for CME on FM. CONCLUSION: The awareness and perception of FM are still low among Chinese rheumatologists. CME on FM is needed for improving the quality of health care in China.

Patient experiences, attitudes and expectations towards receiving information about anti-TNF medication--"It could give me two heads and I'd still try it!".

BACKGROUND: Anti-tumour necrosis factor (anti-TNF) therapies are an important recent development in the treatment of autoimmune disease. Despite important side effects relating to immune suppression, there is lack of research into patient experiences, attitudes and expectations about the information they receive prior to starting anti-TNF therapy. METHODS: In May 2011 participants were purposively sampled to form two focus groups varying in age, anti-TNF agent and pre-therapy disease activity. A semi-structured topic guide was used to explore patients' experiences regarding the information they received prior to commencing anti-TNF therapy. The focus groups were audio-taped and transcribed verbatim. Data were analysed using content analysis. RESULTS: Four key themes were identified.Firstly, weighing the risks and benefits of anti-TNF therapy. However, most participants attached limited importance to side effects, saying their strong desire for RA symptom control was overriding. Two reported deliberately concealing illness in order to continue their medication. Secondly, the desire for information. They suggested that counselling should occur at an early stage and not during a severe RA flare-up. Thirdly, the process of starting anti-TNF. Many identified that their biggest worry was whether they would be eligible for the new medication. They remembered little about the investigations they underwent, and none said they would have objected to being tested for blood borne viruses. Finally, the experience of being on anti-TNF. Most were positive, describing effects on quality of life as well as symptoms. CONCLUSIONS: The use of qualitative methodology in this study has enabled an understanding of patients' attitudes towards receiving information about anti-TNF therapy. The results may be useful to health professionals in terms of the timing and content of the information given to patients prior to commencing anti-TNF therapy.

Rheumatology practice profiles in teaching and community settings in Puerto Rico: implications to subspecialty training.

BACKGROUND: University-based fellowship training programs may not always provide the required experience to manage common and less complex medical conditions usually seen at the community setting. Few studies have addressed this concern. OBJECTIVE: The purpose of this study was to compare the demographic features, diagnoses, and rheumatologic procedures in patients seen at the University of Puerto Rico Medical Sciences Campus Adult Rheumatology Training Program practice and 3 community-based rheumatology practices in Puerto Rico. METHODS: Claim forms submitted to health care insurance companies in 2007 from the university and community practices were evaluated. Demographic parameters, primary diagnoses (per International Classification of Diseases, Ninth Revision), medical visits, and rheumatologic procedures (per Current Procedural Terminology 4) were examined. Variables were analyzed by χ and Student t tests. RESULTS: A total of 11,373 claim forms were reviewed: 1952 from the university setting and 9421 from the community-based practices. Younger age and female sex were more common in visits from the university-based setting. Autoimmune diseases were reported more commonly at the university setting (65.3% vs 37.6%, P < 0.001). Conversely, osteoarthritis (24.4% vs 9.8%, P < 0.001), fibromyalgia syndrome (7.4% vs 1.9, P < 0.001), and regional rheumatic pain syndromes (7.2% vs 1.4%, P < 0.001) were seen more frequently at community practices. Hospital/emergency room visits (11.8% vs 0.3%, P < 0.001) were more frequent at the university setting, whereas joint (13.3% vs 2.9%, P < 0.001) and periarticular injections (6.2% vs 1.7%, P < 0.001) were performed more frequently at the community practices. CONCLUSIONS: Several differences were found in the profile of demographic parameters, diagnoses, medical visits, and rheumatologic procedures between patients seen at the University of Puerto Rico Medical Sciences Campus rheumatology practice and 3 community-based practices. Efforts may be required to diversify and increase the exposure of rheumatology fellows to patients with conditions commonly seen at the community setting.

Psoriasis and psoriatic arthritis video project: an update from the GRAPPA 2011 annual meeting.

Numerous physical examination instruments are used to assess and measure severity of psoriasis and psoriatic arthritis (PsA) in practice and in clinical trials. The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) has developed several online training modules used by GRAPPA members and investigators participating in psoriasis and PsA research. At the 2011 GRAPPA meeting, attendees were updated on the ongoing development of the training modules. Several Internet-based multimedia presentations for psoriasis and PsA assessments have been completed. Available psoriasis modules include the Psoriasis Area and Severity Index (PASI) and Body Surface Area, one 5-point and two 6-point Physician Global Assessments, the original and modified Nail Psoriasis Severity Index, the Palmar-Plantar Pustular Psoriasis Area and Severity Index, the Psoriasis Scalp Severity Index, and the Total Plaque Severity Score. Rheumatology modules that demonstrate evaluation of swollen and tender joints, enthesitis, and dactylitis are now available, and an axial disease evaluation module is near completion. Each video includes the background and rationale for each measure, demonstration videos of select examinations, diagrams, and photographs to emphasize teaching points, and for most dermatology modules, an optional test to assess competence. Preliminary data generated by a pilot study of pre- and post-education PASI scoring by experienced and naive physicians and patient assessors were presented, revealing improved accuracy of scoring after viewing the PASI video. Attendees agreed that additional patient examples with more diverse skin types and psoriasis phenotypes, translation to languages other than English, and further validation studies are needed.