Needs Assessment of Musculoskeletal Ultrasound Training in North American Pediatric Rheumatology Fellowship Programs.

OBJECTIVE: Musculoskeletal ultrasound (MSUS) is widely used in adult rheumatology practice for diagnosis of arthritis and procedural guidance; however, it is not yet common practice in pediatric rheumatology. MSUS is advantageous to the pediatric population because it lacks radiation and eliminates need for sedation. This study aims to assess interest in, access to, and barriers to MSUS training in pediatric rheumatology fellowship programs in North America. METHODS: A survey was developed by pediatric rheumatology providers with experience in medical and/or MSUS education and distributed via REDCap anonymously in March 2022 (Supplementary Material). Eligible participants included current and recently graduated (<1 year) pediatric rheumatology fellows at a North American program. Descriptive statistics and bivariate analyses using design-based Pearson chi-squared tests were performed. RESULTS: Overall response rate was 78% (88/113), and 75% reported some form of MSUS training during fellowship. Only 36% indicated their program had a formal MSUS curriculum. Of those with MSUS training, 23% reported adult-only MSUS education. Eighty-four percent felt MSUS would be beneficial to their career. Major barriers to MSUS training included lack of MSUS-trained faculty, lack of time, and lack of hands-on MSUS sessions. Those who had access to MSUS training were significantly more interested in MSUS than those without (P = 0.0036). CONCLUSION: This study demonstrates that North American pediatric rheumatology fellows have a strong interest in learning MSUS, but they face significant challenges in accessing MSUS training (lack of MSUS-trained faculty, time, and access to hands-on training). MSUS should be incorporated into fellowship curriculum; however, implementation remains a challenge.

The Sjögren's Working Group: The 2023 OMERACT meeting and provisional domain generation.

Sjögren's disease (SjD) is a systemic autoimmune exocrinopathy with key features of dryness, pain, and fatigue. SjD can affect any organ system with a variety of presentations across individuals. This heterogeneity is one of the major barriers for developing effective disease modifying treatments. Defining core disease domains comprising both specific clinical features and incorporating the patient experience is a critical first step to define this complex disease. The OMERACT SjD Working Group held its first international collaborative hybrid meeting in 2023, applying the OMERACT 2.2 filter toward identification of core domains. We accomplished our first goal, a scoping literature review that was presented at the Special Interest Group held in May 2023. Building on the domains identified in the scoping review, we uniquely deployed multidisciplinary experts as part of our collaborative team to generate a provisional domain list that captures SjD heterogeneity.

Standardization of interstitial lung disease assessment by ultrasound: results from a Delphi process and web-reliability exercise by the OMERACT ultrasound working group.

OBJECTIVES: Over the last years ultrasound has shown to be an important tool for evaluating lung involvement, including interstitial lung disease (ILD) a potentially severe systemic involvement in many rheumatic and musculoskeletal diseases (RMD). Despite the potential sensitivity of the technique the actual use is hampered by the lack of consensual definitions of elementary lesions to be assessed and of the scanning protocol to apply. Within the Outcome Measures in Rheumatology (OMERACT) Ultrasound Working Group we aimed at developing consensus-based definitions for ultrasound detected ILD findings in RMDs and assessing their reliability in dynamic images. METHODS: Based on the results from a systematic literature review, several findings were identified for defining the presence of ILD by ultrasound (i.e., Am-lines, B-lines, pleural cysts and pleural line irregularity). Therefore, a Delphi survey was conducted among 23 experts in sonography to agree on which findings should be included and on their definitions. Subsequently, a web-reliability exercise was performed to test the reliability of the agreed definitions on video-clips, by using kappa statistics. RESULTS: After three rounds of Delphi an agreement >75 % was obtained to include and define B-lines and pleural line irregularity as elementary lesions to assess. The reliability in the web-based exercise, consisting of 80 video-clips (30 for pleural line irregularity, 50 for B-lines), showed moderate inter-reader reliability for both B-lines (kappa = 0.51) and pleural line irregularity (kappa = 0.58), while intra-reader reliability was good for both B-lines (kappa = 0.72) and pleural line irregularity (kappa = 0.75). CONCLUSION: Consensus-based ultrasound definitions for B-lines and pleural line irregularity were obtained, with moderate to good reliability to detect these lesions using video-clips. The next step will be testing the reliability in patients with ILD linked to RMDs and to propose a consensual and standardized protocol to scan such patients.

Lupus nephritis and socioeconomic status: Findings from the Southern California lupus registry.

OBJECTIVE: Lupus nephritis (LN) is a major cause of morbidity and mortality in systemic lupus erythematosus (SLE). Despite multiple studies addressing healthcare disparities, disparate outcomes in LN persist. We investigate herein the association between socioeconomic status (SES) and LN as well as the association between SES, SLE disease activity index (SLEDAI), and treatment response. METHODS: Patients were selected from the Southern California Lupus Registry (SCOLR), a registry enrolling all-comers with SLE. Analysis was completed on individuals with public vs. private insurance. Insurance and ethnicity were used as surrogate variables for SES, and we tested differences in means. RESULTS: After adjusting for age and sex, public insurance was independently associated with the prevalence of LN. Analysis of 35 patients revealed greater proteinuria and mean SLEDAI in patients with public insurance at baseline and 6 months. Baseline, 6-, and 12-month SLEDAI means were significantly lower in Asian/Pacific Islanders (PI) compared to others. While non-Hispanic Whites demonstrated mean SLEDAI improvement over 6 months, Asians/PI, Blacks, and Hispanics demonstrated worsened disease activity on average. CONCLUSION: Low SES, when defined by insurance, is associated with greater adverse outcomes in SLE. This is the first regional study that compares differences in treatment response in LN patients with low SES as well as association of SES with long-term outcomes in SLE and LN in southern California.

Catastrophic Antiphospholipid Syndrome as a Complication of COVID-19 Infection.

COVID-19 infection has been found to precipitate hypercoagulability and transiently increase antiphospholipid antibodies. However, it is yet to be determined how likely these transient changes contribute to thrombotic events and antiphospholipid syndrome. We present a case in which antiphospholipid antibodies were detected in the presence of significant thromboses. The patient was subsequently treated for suspected catastrophic antiphospholipid syndrome following COVID-19 infection.

Cardiovascular disease and bone health in aging female rheumatic disease populations: A review.

Rheumatic diseases cover a wide spectrum of conditions, including primary and secondary degenerative joint diseases and autoimmune inflammatory rheumatic diseases. The risks of cardiovascular disease and osteoporosis and resultant fractures in aging female rheumatic disease populations, especially those with autoimmune rheumatic diseases, are increased. Changes in the immune system in aging populations need to be considered especially among patients with autoimmune rheumatic diseases. Immunosenescence is closely aligned to reduced adaptive immunity and increased non-specific innate immunity leading to chronic inflammation of inflammaging. The effective use of disease-modifying antirheumatic drugs to control autoimmune rheumatic diseases may also mitigate factors leading to cardiovascular disease and osteoporosis. Rheumatic diseases, which largely manifest as arthritis, predispose patients to premature joint degeneration and poor bone health and therefore have a higher risk of developing end-stage arthritis requiring joint arthroplasties sooner or more often than other patients without rheumatic disease.

The provisional OMERACT ultrasonography score for giant cell arteritis.

OBJECTIVES: To develop an Outcome Measures in Rheumatology (OMERACT) ultrasonography score for monitoring disease activity in giant cell arteritis (GCA) and evaluate its metric properties. METHODS: The OMERACT Instrument Selection Algorithm was followed. Forty-nine members of the OMERACT ultrasonography large vessel vasculitis working group were invited to seven Delphi rounds. An online reliability exercise was conducted using images of bilateral common temporal arteries, parietal and frontal branches as well as axillary arteries from 16 patients with GCA and 7 controls. Sensitivity to change and convergent construct validity were tested using data from a prospective cohort of patients with new GCA in which ultrasound-based intima-media thickness (IMT) measurements were conducted at weeks 1, 3, 6, 12 and 24. RESULTS: Agreement was obtained (92.7%) for the OMERACT GCA Ultrasonography Score (OGUS), calculated as follows: sum of IMT measured in every segment divided by the rounded cut-off values of IMTs in each segment. The resulting value is then divided by the number of segments available. Thirty-five members conducted the reliability exercise, the interrater intraclass correlation coefficient (ICC) for the OGUS was 0.72-0.84 and the median intrareader ICC was 0.91. The prospective cohort consisted of 52 patients. Sensitivity to change between baseline and each follow-up visit up to week 24 yielded standardised mean differences from -1.19 to -2.16, corresponding to large and very large magnitudes of change, respectively. OGUS correlated moderately with erythrocyte sedimentation rate, C reactive protein and Birmingham Vasculitis Activity Score (corrcoeff 0.37-0.48). CONCLUSION: We developed a provisional OGUS for potential use in clinical trials.

Addressing Competency in Rheumatology Telehealth Care Delivery.

OBJECTIVE: Telehealth is an essential facet of care delivery for patients with rheumatic diseases. The Association of American Medical College's (AAMC) telehealth competencies (TCs) define the skills required for delivering general telehealth care across the range of clinician experience. In this study, the American College of Rheumatology's (ACR) TCs working group aimed to adapt the AAMC TCs to rheumatology, outlining the skills acquisition unique to rheumatology with a focus on knowledge, skills, and behaviors expected of recent rheumatology fellowship graduates. METHODS: Through a collaborative process, the working group adapted the AAMC TCs to the training structure and practice of rheumatology. The rheumatology TCs underwent peer review among recipients of the Clinician Scholar Educator Award and attendees at the ACR 2021 Convergence conference. RESULTS: The rheumatology TCs define 24 essential skills required for synchronous telehealth care of patients with rheumatic diseases. The working group adapted the AAMC's 20 TCs organized within 6 domains, added 2 skills to the AAMC's domains of patient safety and appropriate use, and data collection and assessment, and created a novel domain of systems-based requirements with 2 competencies. The rheumatology TCs define expected skill levels for recent rheumatology fellowship graduates and experienced rheumatology clinicians. CONCLUSION: The rheumatology TCs represent the first adaptation of the AAMC TCs to subspecialty care, expanding the scope to include rheumatology fellowship graduates and additional domains of rheumatology practice. These competencies can guide curricular innovations and measurements of proficiency in telehealth care delivery among rheumatology trainees and experienced clinicians, enhancing the care provided to patients with rheumatic diseases.

North American musculoskeletal ultrasound scanning protocol of the shoulder, elbow, wrist, and hand: update of a Delphi Consensus Study.

INTRODUCTION/OBJECTIVES: There has been an increase in the proficiency and utilization of ultrasound among North American rheumatologists over the past decade. This study aims to create an updated upper extremity scanning protocol to inform ultrasound curriculum development for the American College of Rheumatology affiliated fellowship programs and guide clinical practice patterns in North America. METHOD: Three Delphi survey rounds were used to reach consensus on tiered-mastery designations for scan views of the shoulder, elbow, wrist, and hand joints. The survey was disseminated by Qualtrics™ to 101 potential participants with ultrasound experience. High agreement was defined as having ≥ 85% consensus and final tier designation as > 50% agreement for a preferred tier. Changes in responses were evaluated by McNemar's chi-square test. RESULTS: Consensus was achieved for 70% of scan views of the upper extremity joints. Two views-ulnar transverse view of the wrist and the radial/ulnar orthogonal views over metacarpophalangeal joints 2 and 5 of the hand-were upgraded from tier 2 to tier 1. The suprascapular transverse and the axillary longitudinal views of the shoulder were downgraded from tier 2 to tier 3. A new anterior transverse view of the elbow was added to the protocol with tier 1 designation. CONCLUSIONS: This study reflects the current opinions of North American rheumatologists for scanning upper extremity joints and provides support for the updated protocol and guidance for educators in rheumatology ultrasound. Key Points • Ultrasound scan views of the metacarpophalangeal, wrist, elbow, and glenohumeral joint recesses and views of the biceps and rotator cuff tendons at the shoulder were perceived as essential views of the upper extremity scanning protocol for rheumatologists to master and perform routinely. • A targeted scanning approach of the upper extremity joints may be considered when focal symptoms are present. • The North American Musculoskeletal Ultrasound Scanning Protocol shares some similarities with existing musculoskeletal ultrasound protocols of other specialties and worldwide rheumatology societies but varies in the extent of examination and emphasis on certain specialty-specific focuses.

Clinical Academic Rheumatology: A Boon for Health Systems.

OBJECTIVE: Finding a balance between clinical and scholarly productivity is a challenge for many academic clinician-educator rheumatologists. An examination of workload and downstream revenue determines if the financial value generated by services rendered by rheumatologists are proportionate to the financial value created for a health system. A 2005 study found that academic rheumatologists generate $10.02 for every $1.00 they receive for an office visit. METHODS: A retrospective analysis of ordering and billing practices of 5 full-time clinician-educator rheumatologists from August 2017 to February 2019 was conducted. Individual workload is defined as averaged full-time equivalent workload based on time spent on clinical and academic duties. Academic productivity was reviewed. Revenue-generating activities that benefited the division directly and downstream revenue were collected. Revenue was extrapolated based on volumes of referrals, publicly available drug costs, and estimated Medicare reimbursement values (average sales price) of representative drugs. RESULTS: The total revenue by physician that benefited the division directly was $597,203, with evaluation and management codes accounting for $174,456. Downstream revenue by physician totaled $2,119,437. The largest contributor was from referrals to the hospital-based infusion center, at $1,287,496. The downstream revenue generated by rheumatologist per dollar of evaluation and management services was found to be $12.14 ($9.37 in 2005 dollars). CONCLUSION: For every $1 generated though office visits by 5 practicing academic rheumatologists at our institution, $12.14 was generated through downstream revenue, which, when adjusted for inflation, shows stability in the value generated by academic rheumatologists ($10.02 versus $9.37).

Rheumatology Milestones 2.0: A Roadmap for Competency-Based Medical Training of Rheumatology Fellows in the 21st Century.

OBJECTIVE: Since 2014, rheumatology fellows have been assessed not only based on their ability to provide patient care and possession of medical knowledge but also on their skill in serving as patient advocates, navigators of health systems, and members of a health care team. Such assessments have been carried out through the use of competency-based milestones from the Accreditation Council of Graduate Medical Education (ACGME). However, a needs assessment has demonstrated interest in more context validity and subspecialty relevance since the development of the ACGME internal medicine (IM) subspecialty reporting milestones. The ACGME thus created a milestones working group, and the present study was undertaken to develop Rheumatology Milestones 2.0 as well as a supplemental guide to assist with implementation. METHODS: The working group, consisting of 7 rheumatology program directors, 2 division directors, a community practice rheumatologist, a rheumatology fellow in training, and a public member who is a rheumatology patient, was overseen by the ACGME vice president for milestones development and met through three 12-hour, in-person meetings to compose the rheumatology specialty milestones and supplemental guide within the ACGME Milestones 2.0 project. RESULTS: Informed by the needs assessment data and stakeholders, the working group revised and adapted the ACGME IM subspecialty reporting milestones to create a rheumatology-specific set of milestones and a supplemental guide for their implementation. CONCLUSION: The Rheumatology Milestones 2.0 provides a specialty-specific, competency-based evaluation tool that can be used by program directors, clinical competency committees, and others to assess the competencies of rheumatology fellows during training and help measure readiness for independent practice.

Does hydroxychloroquine improve patient reported outcomes in patients with lupus?

BACKGROUND: Hydroxychloroquine (HCQ) use is associated with less disease activity, flares, damage and improved survival in Systemic Lupus Erythematosus (SLE). However, its effect on patient reported health outcomes (PROs) such as quality of life (QOL) is not known. METHODS: International data from Study on Outcomes of Lupus (SOUL) from 2,161 SLE patients were compared by HCQ use. Disease activity and damage were assessed using SELENA-SLEDAI and SLICC-ACR/SDI. QOL was evaluated using LupusPRO and Lupus Impact Tracker (LIT). Linear regression analyses were performed with LupusPRO summary scores health related HRQOL, non-health related NHRQOL and LIT as dependent and HCQ use as independent variable. Analyses were undertaken to test mediation of effects of HCQ use on QOL through disease activity. RESULTS: Mean age was 40.5 ± 12.8 years, 93% were women. Sixty-three (1363/2161) percent were on HCQ. On univariate analysis, HCQ use was associated with (a) better QOL (LupusPRO-HRQOL: ß 6.19, 95% CI 4.15, 8.24, P ≤ 0.001, LupusPRO NHRQOL: ß 5.83, 95% CI 4.02, 7.64, P ≤ 0.001) and less impact on daily life (LIT: ß -9.37, 95% CI -12.24, -6.50, P ≤ 0.001). On multivariate and mediational analyses, the effects of HCQ on QOL were indirectly and completely mediated through disease activity. CONCLUSIONS: HCQ use in SLE is associated with better patient reported health outcomes (LupusPRO-HRQOL and NHRQOL and impact on daily life), and the effects are mediated through disease activity. This information can facilitate patients and physician's communication with decision-making regarding the use of HCQ for SLE management.

Missing data in randomised controlled trials of rheumatoid arthritis drug therapy are substantial and handled inappropriately.

OBJECTIVES: To analyse the amount, reporting and handling of missing data, approach to intention-to-treat (ITT) principle application and sensitivity analysis utilisation in randomised clinical trials (RCTs) of rheumatoid arthritis (RA). To assess the trend in such reporting 10 years apart (2006 and 2016). METHODS: Parallel group drug therapy RA RCTs with a clinical primary endpoint. RESULTS: 176 studies enrolling a median of 160 (IQR 62-339) patients were eligible. In terms of actual analysis: 81 (46%) RCTs conducted ITT, 42 (23.9%) conducted modified ITT while 53 (30.1%) conducted non-ITT analysis. Only 58 of 97 (59.8%) RCTs reporting an ITT analysis actually performed it. The median (IQR) numbers of participants completing the trial and included in analysis for primary outcome were 86% (74%-91%) and 100% (97.1%-100%), respectively. 53 (32.7%) and 65 (40.1%) RCTs had >20% and 10%-20% missing primary outcome data, respectively. Missing data handling was unreported by 58 of 171 (33.9%) RCTs. When reported, vast majority used simple imputation methods. No significant trend towards improved reporting was seen between 2006 and 2016. Sensitivity analysis numerically improved from 2006 to 2016 (14.7% vs 21.4%). CONCLUSIONS: There is significant discrepancy in the reported and the actual performed analysis in RA drug therapy RCTs. Nearly one-third of RCTs had >20% missing data. The reporting and methods of missing data handling remain inadequate with high usage of non-preferred simple imputation methods. Sensitivity analysis utilisation was low. No trend towards better missing data reporting and handling was seen.

North American musculoskeletal ultrasound scanning protocol of the hip, knee, ankle, and foot: update of a Delphi consensus study.

BACKGROUND/OBJECTIVE: A North American rheumatology consensus on tiered-mastery designation for anatomic views was developed in 2011 for course and fellowship teaching. This study updates the lower extremity joint scanning protocols aiming to inform musculoskeletal ultrasound curriculum development for the American College of Rheumatology affiliated Fellowship Programs. METHODS: Three Delphi rounds were conducted to reach consensus for tiered-level mastery designation for hip, knee, ankle, and foot scanning views. The survey was disseminated (Qualtrics™) to 101 potential participants with ultrasound teaching experience. High agreement was defined as ≥ 85% consensus and final tier designation as having >50% agreement for the preferred tier. Response changes were evaluated by McNemar's chi-square test. RESULTS: Consensus regarding tier designations was reached for 80% of the views. Three knee views (anterior transverse suprapatellar, medial, and lateral longitudinal) and 2 ankle views (anterior and posterior transverse) achieved upgrades to tier 1 from 2. The transverse sacroiliac hip joint was downgraded from tier 2 to 3. The lateral longitudinal hip view was added with a tier 1 designation. CONCLUSION: Updated scanning protocols support modifications reflecting current scanning methods delivered by North American rheumatologists performing point of care ultrasound that may inform educators involved in rheumatology ultrasound. Key Points • The anterior transverse suprapatellar, medial, and lateral longitudinal knee views; the anterior and posterior transverse ankle views; and the lateral longitudinal view hip view were perceived as important to master and perform routinely. • The transverse sacroiliac joint view was suggested to be performed based on practice focus.

Novel gene-specific translation mechanism of dysregulated, chronic inflammation reveals promising, multifaceted COVID-19 therapeutics.

Hyperinflammation and lymphopenia provoked by SARS-CoV-2-activated macrophages contribute to the high mortality of Coronavirus Disease 2019 (COVID-19) patients. Thus, defining host pathways aberrantly activated in patient macrophages is critical for developing effective therapeutics. We discovered that G9a, a histone methyltransferase that is overexpressed in COVID-19 patients with high viral load, activates translation of specific genes that induce hyperinflammation and impairment of T cell function or lymphopenia. This noncanonical, pro-translation activity of G9a contrasts with its canonical epigenetic function. In endotoxin-tolerant (ET) macrophages that mimic conditions which render patients with pre-existing chronic inflammatory diseases vulnerable to severe symptoms, our chemoproteomic approach with a biotinylated inhibitor of G9a identified multiple G9a-associated translation regulatory pathways that were upregulated by SARS-CoV-2 infection. Further, quantitative translatome analysis of ET macrophages treated progressively with the G9a inhibitor profiled G9a-translated proteins that unite the networks associated with viral replication and the SARS-CoV-2-induced host response in severe patients. Accordingly, inhibition of G9a-associated pathways produced multifaceted, systematic effects, namely, restoration of T cell function, mitigation of hyperinflammation, and suppression of viral replication. Importantly, as a host-directed mechanism, this G9a-targeted, combined therapeutics is refractory to emerging antiviral-resistant mutants of SARS-CoV-2, or any virus, that hijacks host responses.

Ultrasound Doppler and tenosynovial fluid analysis in tenosynovitis.

OBJECTIVE: To assess Doppler ultrasound (US) and tenosynovial fluid (TSF) characteristics in tenosynovitis within common rheumatic conditions, as well as their diagnostic utility. METHODS: Subjects with tenosynovitis underwent Doppler US and US-guided TSF aspiration for white cell count (WCC) and crystal analysis. Tenosynovial Doppler scores (DS) were semiquantitatively graded. TSF WCC and DS were compared using Kruskal-Wallis tests and logistic regression between non-inflammatory conditions (NIC), inflammatory conditions (IC) and crystal-related conditions (CRC). Receiver operating curves, sensitivity and specificity assessed the ability of WCC and DS to discriminate IC from NIC. RESULTS: We analysed 100 subjects from 14 sites. The mean age was 62 years, 65% were female, and the mean TSF volume was 1.2 mL. Doppler signal was present in 93.7% of the IC group and was more frequent in IC than in NIC group (OR 6.82, 95% CI 1.41 to 32.97). The TSF median WCC per 109/L was significantly higher in the IC (2.58, p<0.001) and CRC (1.07, p<0.01) groups versus the NIC group (0.38). A TSF cut-off of ≥0.67 WCC per 109/L optimally discriminated IC versus NIC with a sensitivity and specificity each of 81.3%. In the IC group, 20 of 48 (41.7%) subjects had a TSF WCC <2.00 per 109/L. CONCLUSIONS: A negative DS helps rule out IC in tenosynovitis, but a positive DS is non-specific and merits TSF testing. Unlike synovial fluid, a lower TSF WCC better discriminates IC from NIC. US guidance facilitates aspiration of minute TSF volume, which is critical for diagnosing tenosynovial CRC.

Screening for acquired latent tuberculosis in rheumatoid arthritis patients on tumor necrosis factor inhibition therapy in Southern California.

BACKGROUND: There are no studies assessing the development of latent tuberculosis infection (LTBI) in patients on tumor necrosis factor inhibitors (TNFα-I) in high TB prevalence areas of the USA. Our objective was to assess the rate of LTBI development in rheumatoid arthritis (RA) patients on TNFα-I therapies in San Bernardino and Riverside Counties of California, high TB prevalence areas in the US. METHODS: Data were extracted from the electronic health record for 217 adult RA patients across three health centers from January 2010 to January 2017 who have had at least 1 year of TNFα-I use and negative initial QuantiFERON Gold status. Demographics, TNFα-I type, duration of use, TB risk factors, QuantiFERON results, rates of re-screening, TB test seroconversion, and its association with drug use and other factors were assessed. RESULTS: Of the 217 patients, 115 (53%) received baseline and annual screening for LTBI. LTBI was diagnosed in 9.4% (10) of patients. Four patients were on infliximab, three on golimumab, two on adalimumab, and one on etanercept. Hispanic patients tended to have a greater than 200% increase in odds of seroconversion compared to non-Hispanic patients. Infliximab and golimumab were associated with a 92% and 400% increase in odds of seroconversion, respectively. CONCLUSION: The LTBI developed in 9.4% of the patients. This is higher than what is reported for previous US studies. Screening for LTBI in the US should take into consideration TB prevalence, ethnicity, drug type, and duration of use. For our local population and similar populations, annual screening should be practiced. Key Points • Although patients on TNFα inhibitor (TNFα-I) therapy are at high risk of latent tuberculosis infection (LTBI), few studies report the rate of LTBI in patients living in high prevalence areas of the US. • The rate of LTBI was 9.4% in patients on TNFα-I therapy in Southern California. The risk of seroconversion was higher in patients of Hispanic ethnicity and also higher for those on infliximab and golimumab compared to those on other TNFα-I therapies. • Screening guidelines for LTBI screening on TNFα-I should consider local TB prevalence, drugs used, duration of use and ethnicity for cost efficient, and optimal healthcare.

Competency-based medical education for the clinician-educator: the coming of Milestones version 2.

Competency-based medical education is emphasized by institutions overseeing medical school and postgraduate training worldwide. The high rate of preventable errors in medicine underscores this need. Expanding physician competency beyond the domains of patient care and medical knowledge towards goals that emphasize a more holistic view of the healthcare system is one aspect of this emphasis. The Accreditation Council on Graduate Medical Education (ACGME), which oversees postgraduate training programs in the USA, has recently expanded to oversee training programs internationally. The original ACGME Milestones effort unveiled in 2013 was met with skepticism. Nevertheless, other outcomes-based education programs worldwide, including the CanMEDS framework (Canada), Tomorrow's Doctor (UK), and Scottish Doctor (Scotland), have suggested that milestones do offer advantages. Missing from the milestone rollout, however, was collaborative buy-in from multiple stakeholders such as from clinician-educators. Consequently, Milestones version 2 is in development. Specifically, these will address the need for specialty-specific milestones, and the usage of harmonized milestones. A concise history of the push towards outcomes-based medical education is presented and contextualized for physicians who must embrace the transition from teacher-based to learner-based outcomes.

Psychological safety, the hidden curriculum, and ambiguity in medicine.

Psychological safety is a feeling that individuals are comfortable expressing and being themselves, as well as comfortable sharing concerns and mistakes without fear of embarrassment, shame, ridicule, or retribution. It has long been recognized as part of successful patient safety and quality improvement processes. However, in the realm of medical education, psychological safety is a relatively unknown concept to many educators and learners alike. Learners, whether students or postgraduate trainees, are in a phase of cognitive apprenticeship whereby they learn not only skills and knowledge from teachers as part of an explicit and formal curriculum. At the same time, a hidden curriculum is also part of the learning environment in the form of norms, values, and behaviors exhibited by teachers. These norms, values, and behaviors become part of the culture of the clinical learning environment. The vulnerability of learners in this environment is magnified by the hierarchal nature of medicine, and the complexity, uncertainty, and the ambiguity inherent to medical conditions. This is especially true of cognitive specialties such as rheumatology. Educators who engage in unprofessional behaviors that result in learner humiliation and shame may serve to dampen productive discourse and scientific dialog. Therefore, educators must embrace psychological safety to foster learning and facilitate high-performing teams in the clinical learning environment.Key Points• Psychological safety improves communication and teamwork by allowing individuals to be comfortable expressing and being themselves, as well as comfortable sharing concerns and mistakes without fear of embarrassment, shame, ridicule, or retribution.• Commonly studied in the context of patient safety and quality improvement, psychological safety should extend towards medical education particularly in the context of allowing medical students and postgraduate trainees to be able to voice clinical reasoning in the face of ambiguity.• Educators take on a leadership role when having learners under their supervision; as leaders, educators are the prime movers of psychological safety• Learners in the process of developing their self-identity in the context of their chosen profession adopt not only knowledge and skills within the framework of an explicit and formal curriculum but also norms and values from daily behavior and language educators present in the clinical learning environment of learners; these norms and values are collectively part of the hidden curriculum.