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Ten years after the 1991 Persian Gulf War (GW I), a comprehensive evaluation of a national cohort of deployed veterans (DV) demonstrated a higher prevalence of several medical conditions, in comparison to a similarly identified cohort of nondeployed veterans (NDV). The present study determined the prevalence of medical conditions among nonveteran spouses of these GW I DV and NDV. A cohort of 490 spouses of GW I DV and 537 spouses of GW I NDV underwent comprehensive face-to-face examinations. No significant differences in health were detected except that spouses of DV were less likely to have one or more of a group of six common skin conditions. We conclude that, 10 years after GW I, the general physical health of spouses of GW I DV is similar to that of spouses of NDV. [ABSTRACT FROM AUTHOR]

Abstract: Health professions educators need knowledge, skills, and attitudes to provide high-quality education within dynamic clinical learning environments. Although postgraduate training opportunities in health professions education (HPE) have increased significantly, no shared competencies exist across the field. This article describes the systematic development of postgraduate HPE competencies for the Health Professions Education, Evaluation, and Research (HPEER) Advanced Fellowship, a 2-year, interprofessional, post-master's degree and postdoctoral HPE training program funded through the Department of Veterans Affairs' Office of Academic Affiliations. Using a modified RAND/University of California at Los Angeles Appropriateness Method, the authors developed competencies from March 2021 to August 2021 that were informed by current practices and standards in HPE. Literature reviews were conducted of published literature from November 2020 to February 2021 and gray literature from February to March 2021, identifying 78 and 274 HPE training competencies, respectively. These competencies were combined with 71 competencies submitted by program faculty from 6 HPEER fellowship sites, resulting in 423 initial competencies. Competencies were organized into 6 primary domains and condensed by deleting redundant items and combining overlapping concepts. Eight subject matter experts completed 3 Delphi surveys and met during 2 nominal group technique meetings. The final 25 competencies spanned 6 domains: teaching methods and learning theories; educational assessment and program evaluation; educational research methods; diversity, equity, and inclusion; interprofessional practice and team science; and leadership and management. In addition to informing the national HPEER curriculum, program evaluation, and learner assessment, these advanced competencies describe the knowledge, skills, and attitudes health professions educators need to provide high-quality education with an emphasis on the global and societal impact of HPE. These competencies represent a step toward leveraging HPE expertise to establish competencies to drive HPE program changes. Other programs should report their competencies and competency development processes to spur further dialog and progress., (Copyright © 2023 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Objective: This study seeks to assess rheumatology fellows' (RFs') and program directors' (PDs') interests in different educational tools and methods and to facilitate curriculum development for reproductive health related to rheumatic disease., Methods: Constructs were conceptualized in four dimensions: 1) RF and PD confidence in their current curriculum relating to the American College of Rheumatology (ACR) Reproductive Health Guidelines (RHGs), 2) personal interest in this topic, 3) opinions of the importance of this topic, and 4) interest in a range of learning materials and educational experiences. The final survey was distributed to 753 RFs and 179 PDs in the United States using the ACR Committee on Training and Workforce email list., Results: Response rates were 13% (n = 98) for RFs and 25% (n = 44) for PDs. Both groups indicated more interest in the topic than confidence in their curriculum and rated summary sheets, question banks, didactics, and online modules higher than nine other educational tools or methods. Despite interest in the topic, 38% of RF respondents and 24% of PD respondents were unaware of the recently published ACR RHGs., Conclusion: RFs and PDs consider reproductive health very important and report high personal interest in this topic. In contrast, both groups indicated lower confidence in current curricula, and substantial proportions of both groups were unaware of recently published guidelines. RFs' and PDs' interests in specific educational modalities are aligned. Curriculum development efforts should prioritize summary sheets, question banks, didactics, and online modules. Efforts are needed to address the educational needs of practicing rheumatologists and other professionals caring for patients with rheumatic disease., (© 2023 American College of Rheumatology. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Background: The US Department of Veterans Affairs has created a portfolio of educational programs to train primary care providers (PCPs) in the evaluation and management of common musculoskeletal (MSK) conditions. Appropriate resource utilization for evaluation of knee pain, including limiting unnecessary magnetic resonance imaging (MRI) studies, is an important theme of these initiatives. The objective of this study was to report the utilization of knee MRI by PCP providers before and after the MSK education program and to determine the appropriateness of these MRI orders., Methods: Twenty-six PCPs participated in the MSK Mini-Residency educational program held in Salt Lake City between April 2012 and October 2014. Knee MRI orders submitted by these providers 12 months before and 12 months after their participation were reviewed. Magnetic resonance imaging orders were categorized as "inappropriate," "probably inappropriate," or "possibly appropriate," based on accepted guidelines for knee MRI utilization. Differences in the numbers of precourse and postcourse MRI orders for each of these categories were compared using Student t test., Results: Following our program, MRI orders decreased from 130 (precourse) to 93 (postcourse), a reduction of 28% ( p = 0.04). This reduction was observed entirely within the "inappropriate" and "probably inappropriate" categories; the number of orders categorized as "possibly appropriate" increased, but not significantly., Conclusions: The MSK Mini-Residency training program was a successful educational intervention and was associated with a reduction in inappropriate knee MRI utilization for some participants, while keeping appropriate MRI utilization stable., (Copyright © 2022 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

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., (© 2020 American College of Rheumatology.)

Background : Musculoskeletal (MSK) problems are common, yet many primary care (PC) providers feel inadequately trained to manage these conditions. Previous studies describe successful MSK educational innovations at single sites, but none have reported on subsequent attempts to replicate or adapt these innovations to new contexts. This article presents a study of a national Veterans Affairs MSK training program modified to fit an existing PC educational program. Objectives : (1) To evaluate the effectiveness and feasibility of an adapted MSK curriculum in a new context. (2) To provide a model for adaptation studies in health professions education. Design : A national MSK shoulder and knee curriculum was adapted for San Francisco VA PC trainees, which included a small-group workshop and workplace learning within a newly-created MSK clinic. Effectiveness was evaluated by assessments of trainee confidence in exam and injection skills (via 5-point Likert scale) and faculty-observed performance of knee and shoulder exams (reported as percent of maximum possible score). Feasibility was evaluated by determining acceptability of the program to PC trainees (via 5-point Likert scale) and ability to implement the curriculum using local resources. Results : 52 trainees completed the training during a 2-year period. Trainees' confidence in MSK exam skills improved from 3.3 to 4.5 for shoulder, and from 3.5 to 4.6 for knee. Confidence performing joint injections improved from 2.6 to 4.2 (shoulder) and 2.5 to 4.5 (knee) (p < 0.001 for all). Observed performance improved markedly - from 50% to 92% for shoulder, and 57% to 90% for knee. Feasibility was evident in high acceptability (5.0 for MSK clinic, and 4.9 for workshops), and successful and sustained implementation. Conclusions : Adapting an established MSK curriculum to a new context was effective and feasible. This may serve as a more efficient model for improving trainee education than de novo curriculum design at individual sites.

This article reviews several national programs in musculoskeletal education initiated by the Department of Veterans Affairs over the past decade. These programs have become sustained interprofessional opportunities for learners across disciplines and along the continuum of health professions education (HPE) and training pathways. This article also describes opportunities for leaders in rheumatology and other HPE programs to join these efforts and to collaborate in the scholarship that will be necessary in constructing educational programs fit for the purpose of ensuring a well-trained, competent workforce of health care providers., (Published by Elsevier Inc.)

A simulation-based training curricula applied to the primary care evaluation and management of shoulder and knee pain resulted in improved access to care for veterans and cost savings for the health care system., Competing Interests: Author disclosures The authors report no actual or potential conflicts of interest with regard to this article., (Copyright © 2020 Frontline Medical Communications Inc., Parsippany, NJ, USA.)

Background: Osteoporosis is inadequately treated in primary care settings. Under-recognition of the condition among male Veterans may contribute to this problem. In order to improve understanding of bone health in older male patients, we developed the "Musculoskeletal (MSK) Education Week", a multidisciplinary clinical training initiative within a primary care ambulatory rotation for internal medicine (IM) residents at the Salt Lake City VA Medical Center. The objective of this study was to evaluate the impact of this program on trainees' recognition of osteoporosis or treatment of this condition following the training experience., Methods: We examined several clinical behaviors of post-graduate year 1 (PGY-1) IM trainees following their participation in the MSK Education Week between July 1-April 30, 2014. To determine the prevalence of these clinical behaviors, we conducted an observational study of patients age 50 and older enrolled at the Salt Lake City VA Healthcare System from July 1, 2013 to May 31, 2014. We used time-dependent multivariable Cox proportional hazard models to evaluate the impact of the training program on 4 osteoporosis-related outcomes: (1) completion of dual energy X-ray absorptiometry (DXA) scan, (2) diagnosis of osteopenia, (3) diagnosis of osteoporosis, and (4) initiation of osteoporosis medications., Results: Twenty-six PGY-1 IM residents participated in the MSK Education Week, and 43,678 Veterans were identified over these periods of observation. In the Veterans cohort, 1154 had an encounter with a provider who had completed the training (and were therefore "exposed" to the training) and 42,524 Veterans did not. After adjusting for confounders, the effect of the provider training program was significant for DXA (HR = 1.78, 95% CI: 1.11, 2.87), osteoporosis diagnosis (HR = 3.90, 95% CI: 2.09, 7.29), and initiation of medications (HR = 2.87, 95% CI: 2.02, 4.09) outcomes., Conclusions: We have shown that IM residents' participation in the MSK Education Week was associated with significantly improvements in their completion of DXA scans, diagnosis of osteoporosis, and initiation of fracture-reducing medications in a population of US Veterans. Long-term follow up is needed to determine whether these initial results are followed by actual reductions in osteoporotic fractures.

Background: We developed two objective structured clinical examinations (OSCEs) to educate and evaluate trainees in the evaluation and management of shoulder and knee pain. Our objective was to examine the evidence for validity of these OSCEs., Methods: A multidisciplinary team of content experts developed checklists of exam maneuvers and criteria to guide rater observations. Content was proposed by faculty, supplemented by literature review, and finalized using a Delphi process. One faculty simulated the patient, another rated examinee performance. Two faculty independently rated a portion of cases. Percent agreement was calculated and Cohen's kappa corrected for chance agreement on binary outcomes. Examinees' self-assessment was explored by written surveys. Responses were stratified into 3 categories and compared with similarly stratified OSCE scores using Pearson's coefficient., Results: A multi-disciplinary cohort of 69 examinees participated. Examinees correctly identified rotator cuff and meniscal disease 88% and 89% of the time, respectively. Inter-rater agreement was moderate for the knee (87%; k = 0.61) and near perfect for the shoulder (97%; k = 0.88). No correlation between stratified self-assessment and OSCE scores were found for either shoulder (0.02) or knee (-0.07)., Conclusions: Validity evidence supports the continuing use of these OSCEs in educational programs addressing the evaluation and management of shoulder and knee pain. Evidence for validity includes the systematic development of content, rigorous control of the response process, and demonstration of acceptable interrater agreement. Lack of correlation with self-assessment suggests that these OSCEs measure a construct different from learners' self-confidence.

Introduction: A cost-effective professional development program enhancing musculoskeletal (MSK) skills of physicians and allied health providers working in primary care settings has been reported at a single site. This article describes the first 2 years of the national expansion and implementation of a 3-day "MSK Mini-residency.", Methods: Faculty from Veterans Affairs (VA) medical centers worked in partnership with national program faculty from the Salt Lake City VA to present an intensive, integrated, multidisciplinary program to strengthen the skills of primary care providers in evaluating and managing MSK conditions common in primary care. Course assessments included written surveys and a two-station observed structured clinical examination (OSCE) evaluating the physical examination of the shoulder and knee., Results: In the first 2 years of the program, 13 VA facilities participated. Two hundred twenty-seven health care providers, including 135 physicians, were trained. Two hundred seven participants (91 %) completed all pre- and post-course written assessments and the two-station OSCE., Discussion: The MSK Mini-residency program is an effective and well-received mixed-method educational initiative to strengthen the skills of primary care physicians and other health care providers in evaluating and managing patients with MSK complaints and to document their competence in performing physical examinations of the shoulder and knee. The 2-year experience in implementation suggests that this model of educational partnerships is a feasible approach to disseminating innovative educational programs in a way that preserves curricular consistency yet is adaptable to local needs., Competing Interests: All authors declare that they have no conflicts of interest and no competing interests.

Objective: The Rheumatology Research Foundation's Clinician Scholar Educator (CSE) award is a 3-year career development award supporting medical education research while providing opportunities for mentorship and collaboration. Our objective was to document the individual and institutional impact of the award since its inception, as well as its promise to strengthen the subspecialty of rheumatology., Methods: All 60 CSE Award recipients were surveyed periodically. Fifty-six of those 60 awardees (90%) responded to requests for survey information that included post-award activities, promotions, and further funding. Data were also collected from yearly written progress reports for each grant., Results: Of the total CSE recipients to date, 48 of 60 (80%) are adult rheumatologists, 11 of 60 (18%) are pediatric rheumatologists, and 1 is an adult and pediatric rheumatologist. Two-thirds of survey respondents spend up to 30% of their total time in educational activities, and one-third spend greater than 30%. Thirty-one of the 60 CSE recipients (52%) have published a total of 86 medical education papers. Twenty-six of 52 (50%) had received an academic promotion following the award. Eleven awardees earned advanced degrees., Conclusion: We describe the creation and evolution of a grant program from a medical subspecialty society foundation and the impact on producing education research, individual identity formation, and ongoing support for educators. This community of rheumatology scholar educators now serves as an important resource at the national level for the American College of Rheumatology and its membership. We believe that this grant may serve as a model for other medical societies that want to promote education scholarship and leadership within their specialties., (© 2016, American College of Rheumatology.)

Background: Musculoskeletal (MSK) problems are common, and a recent US Bone and Joint Initiative calls for new models of education and professional collaboration. Evidence of feasibility and acceptability of innovative methods are needed., Objective: We assessed if an experimental immersion interdisciplinary MSK curriculum would be acceptable to residents from different specialties, be feasible within existing rotations, and be effective in strengthening clinical skills., Methods: Through funding from the Veterans Affairs Office of Academic Affiliations and the Office of Specialty Care, we developed a Center of Excellence in MSK Care and Education. A core element is the monthly MSK Education Week, which teaches skills and provides opportunities to apply these in clinical settings. Participants include internal medicine, physical medicine and rehabilitation, and orthopaedic surgery residents, as well as students and residents from other health professions programs. All were assigned to the MSK week in lieu of other clinical experiences. Faculty encompassed primary care, rheumatology, endocrinology, orthopaedics, and physical medicine and rehabilitation. Assessments include surveys and a 2-station objective structured clinical examination (OSCE)., Results: Since 2012, a total of 176 trainees have participated. Percentage of trainees reporting ability to evaluate and manage MSK complaints increased (9% to 87% for shoulder; 18% to 86% for knee), and confidence performing MSK injections increased from 10% to 70%. Competency in evaluation of shoulder and knee pain was confirmed by OSCEs., Conclusions: The MSK week program was accepted by residents from the 3 specialties, with learners reporting improved ability to perform shoulder and knee examinations, as demonstrated by OSCEs.

Objective: A structured educational effort to train primary care providers (PCPs) to perform joint injections has been projected to be cost effective. The US Department of Veterans Affairs (VA) is developing a national continuing professional development program to train PCPs in the evaluation and management of patients with common musculoskeletal conditions. The objective of this pilot project was to confirm initial projections of cost effectiveness and to inform further efforts to develop this program on a national scale., Methods: The Salt Lake City VA served as the national hub for this pilot project. The initial phase included 19 providers, who participated in a weeklong mixed-methods course. Evaluation was conducted by the VA Employee Education System. Assessments included anonymous surveys, structured telephone interviews, and a review of de-identified procedure codes., Results: The survey response rate was 100%, with uniformly positive results. All participants recommended the expansion of this program. The mean number of joint injections performed each month increased from 0.3 (precourse) to 3.5 (postcourse), congruent with prior analyses projecting program cost effectiveness., Conclusion: The musculoskeletal mini-residency is a well-received program, with early evidence of cost effectiveness and impact aligned with course objectives. This pilot program is a foundation for efforts in the national dissemination of this initiative., (© 2016, American College of Rheumatology.)

Unlabelled: This is a cost-effectiveness analysis of training rural providers to identify and treat osteoporosis. Results showed a slight cost savings, increase in life years, increase in treatment rates, and decrease in fracture incidence. However, the results were sensitive to small differences in effectiveness, being cost-effective in 70 % of simulations during probabilistic sensitivity analysis., Introduction: We evaluated the cost-effectiveness of training rural providers to identify and treat veterans at risk for fragility fractures relative to referring these patients to an urban medical center for specialist care. The model evaluated the impact of training on patient life years, quality-adjusted life years (QALYs), treatment rates, fracture incidence, and costs from the perspective of the Department of Veterans Affairs., Methods: We constructed a Markov microsimulation model to compare costs and outcomes of a hypothetical cohort of veterans seen by rural providers. Parameter estimates were derived from previously published studies, and we conducted one-way and probabilistic sensitivity analyses on the parameter inputs., Results: Base-case analysis showed that training resulted in no additional costs and an extra 0.083 life years (0.054 QALYs). Our model projected that as a result of training, more patients with osteoporosis would receive treatment (81.3 vs. 12.2 %), and all patients would have a lower incidence of fractures per 1,000 patient years (hip, 1.628 vs. 1.913; clinical vertebral, 0.566 vs. 1.037) when seen by a trained provider compared to an untrained provider. Results remained consistent in one-way sensitivity analysis and in probabilistic sensitivity analyses, training rural providers was cost-effective (less than $50,000/QALY) in 70 % of the simulations., Conclusions: Training rural providers to identify and treat veterans at risk for fragility fractures has a potential to be cost-effective, but the results are sensitive to small differences in effectiveness. It appears that provider education alone is not enough to make a significant difference in fragility fracture rates among veterans.

Objective: Community-based outpatient clinics (CBOCs) have been established by the Department of Veterans Affairs (VA) to provide primary care services to veterans living in remote and rural regions. The objective of this study was to evaluate the cost effectiveness of training rural primary care providers to perform knee injections in CBOCs, thereby avoiding referring the patient to an urban medical center for an injection by rheumatology or orthopedic specialists., Methods: We developed a decision-analysis model to compare costs and outcomes between rural providers who are trained to perform knee injections versus those who are not trained, therefore requiring a referral to a specialist to provide the injections. The model was run separately using costs from the perspective of the VA as well from the patient's perspective. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analyses were performed using 10,000 second-order Monte Carlo simulations., Results: In our base-case analyses, the incremental cost-effectiveness ratio for trained rural providers was $21,190/QALY using costs from the perspective of the VA and $205/QALY using costs from the patient's perspective. Training rural providers was cost effective in 74.4% and 93.6% of 10,000 Monte Carlo simulations at a willingness-to-pay threshold of $50,000/QALY from the perspectives of the VA and the patient, respectively., Conclusion: Training rural providers to perform knee injections for patients with knee pain secondary to osteoarthritis appears cost effective using the commonly used threshold of $50,000/QALY if more than 20 such patients per year are seen at rural primary care clinics. These results provide support for our ongoing efforts to implement such a training program., (Copyright © 2014 by the American College of Rheumatology.)

We performed bedside testing for peripheral neuropathy in our systemic sclerosis (SSc) population to determine whether foot care guidelines should be developed for SSc. Twenty consecutive SSc patients and 20 healthy control (HC) patients were evaluated for peripheral neuropathy in both feet using the 10-g Semmes-Weinstein monofilament examination (SWME) and 128 Hz vibration sensation using the on-off method. Independent, blinded, vibratory sensation, and SWME evaluations were performed on each subject by two investigators who had completed a training session to standardize each exam. An additional consecutive 20 patients with type 2 diabetes mellitus (DM) were examined by a diabetologist to compare with peripheral neuropathy prevalence in SSc patients. We examined the inter-rater variability using Cohen's kappa. We compared SWME and vibratory sensation in SSc to HC using Fisher's exact. The t test was used to compare duration of disease and modified Rodnan skin score (mRSS) for those with abnormal SWME or vibratory sensation. Two of 20 SSc patients reported sensory foot symptoms consistent with peripheral neuropathy prior to the examination. Inter-rater agreement for both SWME and vibratory sensation was strong (kappa: 0.72 and 0.83, respectively). Two HC and 12 SSc patients demonstrated abnormal vibratory sense (one-sided Fishers' exact, p < 0.002). No HC and four SSc patients had abnormal monofilament exams (one-sided Fisher's exact, p = 0.053). Neither mRSS (p = 0.28) nor duration of non-Raynauds (p = 0.07) symptoms differed between those with peripheral neuropathy and those without. Duration of Raynaud's symptoms were clinically significantly associated with presence of peripheral neuropathy (p = 0.04). The prevalence of sensory loss to monofilament in SSc was identical to DM patients (4/20). SSc patients have a considerable prevalence of pedal peripheral neuropathy as detected by loss of vibratory sensation or inability to sense the 10-g SWME. Further studies are indicated to determine if routine screening for neuropathy and subsequent podiatric care for SSc patients with abnormalities can reduce pedal complications.

Introduction. Accurate blood pressure (BP) measurement is essential to the diagnosis and management of hypertension in patients with systemic sclerosis (SSc) to help prevent renal and cardiovascular complications. The presence of an auscultatory gap during manual BP measurement-the temporary disappearance of the Korotkoff sounds during cuff deflation-leads to a potentially important underestimate of systolic BP if undetected. Objectives. Since the presence of an auscultatory gap is frequently associated with increased vascular stiffness, we investigated its presence and correlates in 50 consecutive SSc patients. Methods. For each patient, BP was measured sequentially using three different approaches performed in the same order. Results. Sixteen of 50 patients (32%) had an auscultatory gap which if undetected would have resulted in clinically important underestimates of systolic BP in 4 patients. The presence of an auscultatory gap was statistically associated with the presence of antibodies to RNA polymerase III (P<0.0068) and SSc diagnosis type (P<0.01). Conclusions. Our study demonstrates that auscultatory gaps are relatively common in SSc and correlate with markers for SSc vasculopathy. If undetected auscultatory gaps may result in clinically important underestimation of BP. Thus, electronic oscillometric BP may be preferred in SSc patients.

Background: Whether attending physicians, residents, nurses, and medical students agree on what constitutes medical student abuse, its severity, or influencing factors is unknown., Method: We surveyed 237 internal medicine attending physicians, residents, medical students, and nurses at 13 medical schools after viewing five vignettes depicting potentially abusive behaviors., Results: The majority of each group felt the belittlement, ethnic insensitivity, and sexual harassment scenarios represented abuse but that excluding a student from participating in a procedure did not. Only a majority of attending physicians considered the negative feedback scenario as abuse. Medical students rated abuse severity significantly lower than other groups in the belittlement scenario (p<.05). Respondents who felt abused as students were more likely to rate behaviors as abusive (p<.05)., Conclusions: The groups generally agree on what constitutes abuse, but attending physicians and those abused as students may perceive more behaviors as abusive.

Background: United States military personnel reported various symptoms after deployment to the Persian Gulf during the 1991 Gulf War. However, the symptoms' long-term prevalence and association with deployment remain controversial., Objective: To assess and compare the prevalence of selected medical conditions in a national cohort of deployed and nondeployed Gulf War veterans who were evaluated by direct medical and teledermatologic examinations., Design: A cross-sectional prevalence study performed 10 years after the 1991 Gulf War., Setting: Veterans were examined at 1 of 16 Veterans Affairs medical centers., Participants: Deployed (n = 1061) and nondeployed (n = 1128) veterans of the 1991 Gulf War., Measurements: Primary outcome measures included fibromyalgia, the chronic fatigue syndrome, dermatologic conditions, dyspepsia, physical health-related quality of life (Short Form-36 [SF-36]), hypertension, obstructive lung disease, arthralgias, and peripheral neuropathy., Results: Of 12 conditions, only 4 conditions were more prevalent among deployed than nondeployed veterans: fibromyalgia (deployed, 2.0%; nondeployed, 1.2%; odds ratio, 2.32 [95% CI, 1.02 to 5.27]); the chronic fatigue syndrome (deployed, 1.6%; nondeployed 0.1%; odds ratio, 40.6 [CI, 10.2 to 161]); dermatologic conditions (deployed, 34.6%; nondeployed, 26.8%; odds ratio, 1.38 [CI, 1.06 to 1.80]), and dyspepsia (deployed, 9.1%; nondeployed, 6.0%; odds ratio, 1.87 [CI, 1.16 to 2.99]). The mean physical component summary score of the SF-36 for deployed and nondeployed veterans was 49.3 and 50.8, respectively., Limitations: Relatively low participation rates introduce potential participation bias, and deployment-related illnesses that resolved before the research examination could not, by design, be detected., Conclusions: Ten years after the Gulf War, the physical health of deployed and nondeployed veterans is similar. However, Gulf War deployment is associated with an increased risk for fibromyalgia, the chronic fatigue syndrome, skin conditions, dyspepsia, and a clinically insignificant decrease in the SF-36 physical component score.

Background: A systematized approach to descriptive evaluation of clinical performance using a vocabulary of global descriptors in the setting of formal evaluation and feedback sessions has been shown to be reliable and valid. The feasibility of this method beyond the institution at which it was developed has not been studied., Purpose: To determine the feasibility and acceptability of implementing formal evaluation and feedback sessions, using a vocabulary of global descriptors, in a third-year core clinical clerkship., Methods: In 1997, the University of Utah internal medicine clerkship introduced an evaluation method in which student performance was discussed at formal sessions, using a taxonomy of global terms describing progressive development from "reporter" to "interpreter" to "manager/educator" (R-I-M-E). The sessions were face-to-face meetings between the clinical teachers and a clerkship director, at three-week intervals through the twelve-week clerkship at the inpatient teaching sites. Following the evaluation session students met individually with the clerkship director for feedback. To determine feasibility, the authors estimated the time and resources necessary to administer the system and recorded actual teacher attendance over 2 academic years (1997-99). Anonymous surveys, using a four-point, Likert-type scale, were used to determine acceptance of the method by faculty, residents, and students., Results: Attendance was high for residents (79%) and faculty (72%). Mean survey responses from residents and faculty rated the descriptive system "more valid" than the previous method. A majority of the students rated the method as either "helpful" (30%) or "very helpful" (50%). Time requirement for eight to ten students at each teaching site, for evaluation and feedback sessions was one-half day per week of the clerkship director, every three weeks., Conclusion: Our experience establishes the feasibility of implementing this system of formal evaluation and feedback, using descriptive vocabulary, beyond the institution at which it was developed. Students, residents, and faculty endorsed this evaluation system and the survey results suggest substantial utility and face validity.

Purpose: To characterize the responsibilities, activities, and scholarly productivity of internal medicine clerkship directors (CDs)., Methods: In 1999, internal medicine CDs from 122 U.S. medical schools and one Canadian medical school were surveyed. The instrument asked about the CDs' demo-graphics, workloads, clerkship characteristics, and scholarly productivity., Results: The response rate was 89%; 72% of the respondents were men. Mean age was 45 years, mean time as CD was 6.5 years, and 58% of the CDs had completed fellowship training. The CDs spent 28% of their professional time on the clerkship, three half days weekly in clinic, and three months on inpatient services. The CDs had published a mean of 2.2 (range 0-20) articles and received a mean of 0.7 (range 0-4) grants. Similar factors were associated with publishing articles and receiving grants; gender (men), < or = three clinic half days weekly, fellowship training, having a faculty development program, teaching other courses, and discussing expectations with their department chairs. In a multivariate analysis, fellowship training, clinic half days, teaching other courses, and discussing expectations explained 22% of the variance for papers published. For grants received, a model with gender, clinic half days, a faculty development program, discussing expectations, and teaching other courses explained 35% of the variance., Conclusions: An internal medicine CD invests significant effort administering the clerkship and contributing to clinical and educational activities. The factors associated with successful scholarship may be useful for fostering CDs' academic careers.

Objective: To determine the prevalence of radiographic evidence of sacroiliitis in a large population of patients with psoriatic arthritis., Patients and Design: Patients were recruited from 15 clinical centers. This was part of a large, multicenter study of patients with an established diagnosis of ankylosing spondylitis, psoriatic arthritis, or reactive arthritis. For this cohort, an established diagnosis of psoriatic arthritis was required, with cutaneous manifestations and involvement of at least three appendicular joints. At entry, patients were not selected for the presence of axial involvement. Radiographs - one anteroposterior view of the pelvis and one oblique view of each sacroiliac joint - were graded using the New York classification scale by a musculoskeletal radiologist masked to the specific diagnosis and clinical symptoms. Re-evaluation of 10% of the films 3 years later quantified intraobserver variability., Results: Two hundred and two patients with psoriatic arthritis were studied. Duration of the disease averaged 12 years; all patients had psoriasis and peripheral arthritis. The prevalence of radiographic evidence of sacroiliitis (grade 2 or higher) was 78%; 71% of these had grade 3 disease., Conclusions: Previously reported prevalence of sacroiliitis in patients with psoriatic arthritis ranges from 30% to 50%. The prevalence of radiographic evidence of sacroiliitis in this large multicenter cohort of patients with appendicular psoriatic arthritis was substantially higher.

Objective: To determine whether detailed oblique radiographs of the sacroiliac (SI) joints provide significant diagnostic advantage to a single AP projection of the pelvis in establishing the presence and severity of sacroiliitis., Methods: Radiographs (both AP pelvis and detailed oblique projections) of 445 right SI joints and 442 left SI joints were obtained from patients with an established diagnosis of a seronegative spondyloarthropathy, and interpreted for severity. Data for the right and left SI joints were analyzed, comparing interpretations of severity based on AP pelvis projections with oblique views., Results: Analysis of these data showed an agreement rate between AP views and SI views of 89.7% for the right SI joint radiographs and 86.4% for the left SI joint. There was no instance in which a patient with "unequivocal abnormalities"of the SI joints on the AP pelvis was read as having "normal" SI views. Similarly, there were no cases in which "normal" SI joints on AP pelvis films were read as having unequivocal abnormalities on SI views., Conclusion: In this group of patients with seronegative spondyloarthropathies, there was very close agreement between severity score of sacroiliitis from AP pelvis radiographs and SI joint views. We conclude that in most circumstances, the AP pelvis film will yield the diagnosis of sacroiliitis without the additional radiation exposure and expense related to specific SI joint radiographs.

Androgen-independent Dunning R3327-AT3 rat prostate tumors are considered an appropriate model of advanced prostate cancer in humans. We recently reported that the progestational steroid melengestrol acetate (MGA) inhibited growth of these tumors on oral administration but also induced a marked involution of adrenals and androgen target organs (prostate, seminal vesicles, and testes). We report herein that the 1-dehydro derivative of melengestrol acetate (dMGA) fed to rats for 21 days also inhibited the growth of Dunning AT3 tumors by approximately 55% without causing a significant regression of adrenals or androgen-dependent tissues. Thus, tumor-growth inhibition was induced by dMGA in the absence of glucocorticoid activity. Cytosolic AT3 tumor fractions obtained by diethylaminoethyl (DEAE)-Sephacel batch chromatography were assayed for lipid- and Ca(2+)-dependent (PKC) and -independent protein kinase activities. Prostatic cytosols had equivalent activity levels of both types of kinases (approximately 2 nmol gamma-[32P]-adenosine 5'-triphosphate (ATP) incorporated mg protein-1 min-1. The PKC activity recovered from the cytosol of untreated AT3 tumors was approximately 4 times higher. Oral administration of dMGA reduced this activity by > 95%. The relationship between protein-kinase activity levels and dMGA-induced growth inhibition of androgen-independent tumors in this animal model is discussed.