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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.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 having50% agreement for the preferred tier. Response changes were evaluated by McNemar's chi-square test.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.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.

Systemic lupus erythematosus (SLE) is characterized by the over-production of high affinity autoantibodies. However, it is not clear how these autoantibodies are generated and selected. VH replacement is originally considered as a receptor editing process to change unwanted non-functional immunoglobulin heavy chain (IgH) genes or IgH genes encoding self reactive BCRs. Our sequence analysis shows that VH replacement products are highly enriched in IgH genes derived from different autoimmune diseases, including SLE. In this study, we performed single cell RT-PCR to study the functional antibody repertoires in active SLE patients. Analysis of 180 recombinant antibodies derived from SLE patients showed that 19.0% of the antibodies derived from naïve B cells and 56.9% of the antibodies derived from plasmablasts are autoreactive. In contrast, only 7.7% and 17.4% of the antibodies derived from naïve B cells and plasmablast B cells are autoreactive in healthy donors. The VH replacement products are significantly increased in IgH genes obtained from SLE patients (20%) compared to that in healthy controls (10%). Importantly, the accumulated VH replacement products in SLE patients have long CDR3 regions enriched with positively charged amino acids; 74% of them directly encode anti-nuclear antigen or polyreactive antibodies. Based on these results, we conclude that the accumulated VH replacement products in SLE patients contribute to the generation of auto/polyreactive antibodies in SLE.