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Emily C Somers,1–3 Seetha U Monrad,1 Jeffrey S Warren,4 Maritsa Solano,5 Lourdes Schnaas,6 Mauricio Hernandez-Avila,5 Martha Maria Tellez-Rojo,5 Howard Hu7 1Divison of Rheumatology, Department of Internal Medicine, 2Department of Environmental Health Sciences, 3Department of Obstetrics & Gynecology, 4Division of Clinical Pathology, Department of Pathology, University of Michigan, Ann Arbor, MI, USA; 5Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Morelos, 6Department of Developmental Neurobiology, National Institute of Perinatology, Mexico City, Mexico; 7Occupational and Environmental Health, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada Objective: To characterize antinuclear antibody (ANA) prevalence according to distinct assay methodologies in a pediatric cohort from Mexico City, and to further examine associations with age and sex.Methods: Serum ANA were measured by indirect immunofluorescence assay (IFA) and multiplex immunoassay in 114 children aged 9–17 years. IFA was considered positive at a cutoff titer of ≥1:80. Agreement between assay methods was assessed by kappa statistic. Sensitivity, specificity, and 95% confidence intervals (CIs) of the multiplex were computed with IFA as the reference standard.Results: Of the 114 children (mean age 14.7 [standard deviation 2.1] years; 54 [47%] female), 18 of 114 (15.8%) were ANA positive by IFA, and 11 of 114 (9.6%) by 11-antigen multiplex assay. ANA prevalence was higher in females compared with males by both of the methods (ratios 1.6–1.9 to 1). Agreement between tests was classified as slight by kappa (κ=0.177 [95% CI −0.051, 0.406]). The multiplex immunoassay had sensitivity of 22.2% (95% CI 6.4, 47.6) and specificity of 92.7% (95% CI 85.6, 97.0), and failed to capture 3 of 4 (75%) of the high-titer (≥1:1280) IFA-positives.Conclusion: Up to 15% of children in this general population cohort were ANA positive, with a higher rate of positivity among females according to both assay methods. Substantial discordance in ANA results was found between IFA and multiplex methods, even for high-titer IFA positives. These findings underscore the need to sufficiently account for assay characteristics when interpreting ANA test results, and support IFA as the more appropriate assay for studies of subclinical autoimmunity. Keywords: Autoreactivity, biomarker, immune dysfunction, preclinical, subclinical autoimmunity, autoantibodies, pediatric, epidemiology

Abstract: Although most students complete Step 1 before clerkships, some institutions delay the exam until after clerkships. The change to pass/fail grading adds additional complexity that should be considered when deciding about exam timing. Both early and late administration may affect learning outcomes, learner behavior, student well-being, and residency match success. Step 1 completion before clerkships promotes learning outcomes (e.g., integration and mastery of foundational material), may encourage students to focus on the curriculum, and may better prepare students for clinical science exams (CSEs). However, delaying the exam ensures that students maintain foundational knowledge and may encourage clinical educators to demonstrate basic science illustrations. An early Step 1 may affect learner behavior by allowing clerkship students to focus on clinical learning. The associated National Board of Medical Examiners performance report may also be used for Step 2 and CSE preparation. However, delaying Step 1 allows greater scheduling flexibility based on developmental milestones. Administration of Step 1 before clerkships removes a significant stressor from the clinical year and decompresses the residency application period. However, a delayed Step 1 reduces the pressure on students to engage in numerous extracurricular and research activities to distinguish themselves due to the pass/fail change. An early Step 1 exam may also lead to improved CSE performance, which is often linked to clerkship honors criteria, an increasingly valuable distinction for residency match success after the change to pass/fail. In contrast, delaying Step 1 is associated with higher first-time pass rates, which may be especially important for students at risk for failure. Medical educators and students should collaboratively approach the question of Step 1 timing, considering these factors within the context of the medical school program, curricular constraints and priorities, and students' individual needs and goals., (Copyright © 2024 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.)

Introduction: After the United States Medical Licensing Examination (USMLE) shifted the Step 1 licensure exam to pass/fail, there have been limited studies to analyze changes in student study strategies., Material and Methods: Surveys were distributed to third- and fourth-year medical students at the University of Michigan Medical School (UMMS). The response rate was 66%., Results: The largest proportion (18.81%) of students chose 8 weeks of study time. 40.59% of students increased the length of their study period. To determine time allocated for dedicated study, 37.26% of respondents consulted near-peers who had already taken Step 1. Students also considered prior experiences with standardized tests (15.57%), personal reasons (14.62%), and conversations with school advisors (13.21%). 44.55% of students studied for 9-11 h a day, and 42.57% studied for 5-8 h a day. 52.69% of students scored between 70 and 80% on their final practice NBME test before their Step 1 exam. One hundred percent of respondents passed the exam. Exam non-extenders achieved higher end average practice test scores with shorter study periods. No differences in Step 1 study time or intensity were found when comparing students by intended specialty competitiveness., Conclusion: Our results demonstrated patterns in study strategies for the new pass/fail Step 1 exam that may prove useful for curriculum design and schedule plan for future cohorts., Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-024-02072-2., Competing Interests: Competing InterestsThe authors declare no competing interests., (© The Author(s) under exclusive licence to International Association of Medical Science Educators 2024. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Purpose: Learner development and promotion rely heavily on narrative assessment comments, but narrative assessment quality is rarely evaluated in medical education. Educators have developed tools such as the Quality of Assessment for Learning (QuAL) tool to evaluate the quality of narrative assessment comments; however, scoring the comments generated in medical education assessment programs is time intensive. The authors developed a natural language processing (NLP) model for applying the QuAL score to narrative supervisor comments., Method: Samples of 2,500 Entrustable Professional Activities assessments were randomly extracted and deidentified from the McMaster (1,250 comments) and Saskatchewan (1,250 comments) emergency medicine (EM) residency training programs during the 2019-2020 academic year. Comments were rated using the QuAL score by 25 EM faculty members and 25 EM residents. The results were used to develop and test an NLP model to predict the overall QuAL score and QuAL subscores., Results: All 50 raters completed the rating exercise. Approximately 50% of the comments had perfect agreement on the QuAL score, with the remaining resolved by the study authors. Creating a meaningful suggestion for improvement was the key differentiator between high- and moderate-quality feedback. The overall QuAL model predicted the exact human-rated score or 1 point above or below it in 87% of instances. Overall model performance was excellent, especially regarding the subtasks on suggestions for improvement and the link between resident performance and improvement suggestions, which achieved 85% and 82% balanced accuracies, respectively., Conclusions: This model could save considerable time for programs that want to rate the quality of supervisor comments, with the potential to automatically score a large volume of comments. This model could be used to provide faculty with real-time feedback or as a tool to quantify and track the quality of assessment comments at faculty, rotation, program, or institution levels., (Copyright © 2024 the Association of American Medical Colleges.)

Background: Interns must recognize urgent clinical situations and know when to seek assistance. However, assessing this skill is challenging., Objective: We explored whether graduating medical students could determine urgency of medical cross-cover scenarios and what factors were associated with this ability., Methods: Sixty senior medical students enrolled in an internal medicine residency preparation course, and 28 experts were invited to take an assessment using 4 clinical vignette handoffs, each with 5 to 6 cross-cover scenarios. Respondents were asked whether they would evaluate the patient at bedside and notify their supervising resident. They were asked to rate their comfort managing the scenario, rate the urgency (1=low, 2=moderate, 3=high), and take a medical knowledge quiz. Student performance was categorized based on stratification of clinical urgency-those who underestimated (fourth quartile), accurately estimated (second and third quartile), and overestimated (first quartile) urgency. We examined differences between groups in medical knowledge, action, and confidence using analysis of variance and post-hoc Tukey Honestly Significant Difference test., Results: Fifty-eight students (96.7%) and 22 experts (78.6%) participated. Clear differentiation emerged between students' ability to estimate urgency on the 3-point urgency scale (lowest quartile: 2.15±0.11; mid-quartiles: 2.38±0.07; upper quartile: 2.61±0.10, respectively). Students who underestimated urgency were less likely to notify their supervising resident ( P =.001) and less likely to evaluate a patient at bedside ( P =.01). There was no difference in quiz score or comfort level., Conclusions: Incoming interns vary in their abilities to recognize urgent scenarios, independent of medical knowledge and confidence., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Objective: To describe the character and composition of the 2015 pediatric rheumatology workforce in the US, evaluate current workforce trends, and project future supply and demand of the pediatric rheumatology workforce through 2030., Methods: The American College of Rheumatology created the workforce study group to study the rheumatology workforce. The workforce study group used primary and secondary data to create a representative workforce model. Pediatric rheumatology supply and demand was projected through 2030 using an integrated data-driven framework to capture a more realistic clinical full-time equivalent (FTE) and produce a better picture of access to care issues in pediatric rheumatology., Results: The 2015 pediatric rheumatology workforce was estimated at 287 FTEs (300 providers), while the estimated excess demand was 95 (33%). The projected demand will continue to increase to almost 100% (n = 230) by 2030 if no changes occur in succession planning, new graduate entrants into the profession, and other factors associated with the workforce., Conclusion: This study projects that the pediatric rheumatology workforce gap will continue to worsen significantly from the 2015 baseline, and by 2030 the demand for pediatric rheumatologists will be twice the supply. Innovative strategies are needed to increase the workforce supply and to improve access to care., (© 2020 American College of Rheumatology.)

Many challenges could occur that result in the need to handle an increase in the number of medical student clinical placements, such as curricular transformations or viral pandemics, such as COVID 19. Here, we describe four different institutions' approaches to addressing the impact of curricular transformation on clerkships using an implementation science lens. Specifically, we explore four different approaches to managing the 'bulge' as classes overlap in clerkships Curriculum leaders at four medical schools report on managing the bulge of core clinical placements resulting from reducing the duration of the foundational sciences curriculum and calendar shifts for the respective clerkship curriculum. These changes, which occurred between 2014 and 2018, led to more students being enrolled in core clinical rotations at the same time than occurred previously. Schools provided respective metrics used to evaluate the effectiveness of their bulge management technique. These data typically included number of students affected in each phase of their curricular transformation, performance on standardized examinations, and student and faculty feedback. Not all data were available from all schools, as some schools are still working through their 'bulge' or are affected by COVID-19. There is much to be learned about managing curricular transformations. Working on such endeavors in a learning collaborative such as the AMA Accelerating Change in Medical Education Initiative provided support and insights about how to survive, thrive and identifying lessons learned during curricular transformation.

In 2010, several key works in medical education predicted the changes necessary to train modern physicians to meet current and future challenges in health care, including the standardization of learning outcomes paired with individualized learning processes. The reframing of a medical expert as a flexible, adaptive team member and change agent, effective within a larger system and responsive to the community's needs, requires a new approach to education: competency-based medical education (CBME). CBME is an outcomes-based developmental approach to ensuring each trainee's readiness to advance through stages of training and continue to grow in unsupervised practice. Implementation of CBME with fidelity is a complex and challenging endeavor, demanding a fundamental shift in organizational culture and investment in appropriate infrastructure. This paper outlines how member schools of the American Medical Association Accelerating Change in Medical Education Consortium developed and implemented CBME, including common challenges and successes. Critical supporting factors include adoption of the master adaptive learner construct, longitudinal views of learner development, coaching, and a supportive learning environment.

Introduction: As educators seek to improve medical student well-being, it is essential to understand the interplay between distress and important outcomes. Performance on Step 1 of the United States Medical Licensing Examination has played a significant role in selection for postgraduate residency positions in the United States and consequently has been a source of great stress for medical students. The purpose of this study was to examine whether student well-being correlates with performance on a high stakes licensing examination., Methods: Between 2014 and 2016, three sequential cohorts of medical students at the University of Michigan Medical School completed the Medical Student Well-Being Index (MSWBI) at the end of their 2nd-year curriculum, shortly before taking Step 1. Associations between well-being and Step 1 scores were investigated while adjusting for MCAT scores and cumulative second-year course scores., Results: In total, 354 students were included in the analysis (68.1% of potential responders). On bivariate analysis, poor student well-being (0 = low distress [high well-being], 7 = high distress [poor well-being]) was associated with lower Step 1 examination scores (slope = -2.10, P < .01), and well-being accounted for 5% of overall Step 1 score variability (R 2  = .05). However, after adjustment for MCAT scores and cumulative GPA (full model R 2  = .51), the relationship between well-being and Step 1 score was no longer significant (slope = -0.70, P-value = .06)., Conclusions: When controlling for metrics of academic performance, student well-being prior to taking Step 1 was not associated with how well students performed on Step 1 for the study sample., (© 2021 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Background: Using revised Bloom's taxonomy, some medical educators assume they can write multiple choice questions (MCQs) that specifically assess higher (analyze, apply) versus lower-order (recall) learning. The purpose of this study was to determine whether three key stakeholder groups (students, faculty, and education assessment experts) assign MCQs the same higher- or lower-order level., Methods: In Phase 1, stakeholders' groups assigned 90 MCQs to Bloom's levels. In Phase 2, faculty wrote 25 MCQs specifically intended as higher- or lower-order. Then, 10 students assigned these questions to Bloom's levels., Results: In Phase 1, there was low interrater reliability within the student group (Krippendorf's alpha = 0.37), the faculty group (alpha = 0.37), and among three groups (alpha = 0.34) when assigning questions as higher- or lower-order. The assessment team alone had high interrater reliability (alpha = 0.90). In Phase 2, 63% of students agreed with the faculty as to whether the MCQs were higher- or lower-order. There was low agreement between paired faculty and student ratings (Cohen's Kappa range .098-.448, mean .256)., Discussion: For many questions, faculty and students did not agree whether the questions were lower- or higher-order. While faculty may try to target specific levels of knowledge or clinical reasoning, students may approach the questions differently than intended.

Phenomenon: Because of its importance in residency selection, the United States Medical Licensing Examination Step 1 occupies a critical position in medical education, stimulating national debate about appropriate score use, equitable selection criteria, and the goals of undergraduate medical education. Yet, student perspectives on these issues and their implications for engagement with health systems science-related curricular content are relatively underexplored. Approach: We conducted an online survey of medical students at 19 American allopathic medical schools from March-July, 2019. Survey items were designed to elicit student opinions on the Step 1 examination and the impact of the examination on their engagement with new, non-test curricular content related to health systems science. Findings: A total of 2856 students participated in the survey, representing 23.5% of those invited. While 87% of students agreed that doing well on the Step 1 exam was their top priority, 56% disagreed that studying for Step 1 had a positive impact on engagement in the medical school curriculum. Eighty-two percent of students disagreed that Step 1 scores should be the top item residency programs use to offer interviews. When asked whether Step 1 results should be reported pass/fail with no numeric score, 55% of students agreed, while 33% disagreed. The majority of medical students agreed that health systems science topics were important but disagreed that studying for Step 1 helped learn this content. Students reported being more motivated to study a topic if it was on the exam, part of a course grade, prioritized by residency program directors, or if it would make them a better physician in the future. Insights: These results confirm the primacy of the United States Medical Licensing Examination Step 1 exam in preclinical medical education and demonstrate the need to balance the objectives of medical licensure and residency selection with the goals of the broader medical profession. The survey responses suggest several potential solutions to increase student engagement in health systems science curricula which may be especially important after Step 1 examination results are reported as pass/fail.

Introduction: Multiple-choice question (MCQ) creation is an infrequently used active-learning strategy. Previous studies demonstrated that medical students find value in the process, but have minimal training, which may limit potential learning benefits. We therefore developed a process for question-creation that required students to complete in-depth training, in addition to collaborative question-writing and editing., Methods: We created a question-writing workshop consisting of three components: (1) training in MCQ writing utilizing NBME online modules, a practice MCQ-writing session, and a training session, (2) writing MCQs independently after choosing topics from an institutionally generated blueprint, and (3) reviewing and editing MCQs via an in-person session. To understand students' perceptions, we held two four-student focus groups and recorded/transcribed the data. We iteratively reviewed the transcripts to generate a codebook and corresponding themes. We used the focus group data to generate a survey with Likert-scale questions, which we sent to the remaining 10 students and analyzed using Microsoft Excel., Results: Eighteen second-year medical students participated in this workshop. Students perceived that question-writing training (3.7/5.0±0.5) and question writing (3.9/5.0±0.3) benefitted their learning. Students perceived that MCQ writing required concept integration (4.1/5.0±0.6). Students described how question writing allowed them to recognize subtle distinctions between therapies and diagnoses. Each MCQ required about 1.5 hours to write and collaboratively edit., Discussion: Our results demonstrated that students perceived question writing to benefit their learning. More importantly, students felt that question writing actively engaged them to integrate content and compare concepts; students' engagement suggests that they learned from this question-writing activity., (© 2020 Kurtz et al.)

Implementing competency-based medical education in undergraduate medical education (UME) poses similar and unique challenges to doing so in graduate medical education (GME). To ensure that all medical students achieve competency, educators must make certain that the structures and processes to assess that competency are systematic and rigorous. In GME, one such key structure is the clinical competency committee. In this Perspective, the authors describe the University of Michigan Medical School's (UMMS's) experience with the development of a UME competency committee, based on the clinical competency committee model from GME, and the first year of implementation of that committee for a single cohort of matriculating medical students in 2016-2017.The UMMS competency committee encountered a number of inter dependent but opposing tensions that did not have a correct solution; they were "both/and" problems to be managed rather than "either/or" decisions to be made. These tensions included determining the approach of the committee (problem identification versus developmental); committee membership (curricular experts versus broad-based membership); student cohort makeup (phase-based versus longitudinal); data analyzed (limited assessments versus programmatic assessment); and judgments made (grading versus developmental competency assessment).The authors applied the Polarity Management framework to navigate these tensions, leveraging the strengths of each while minimizing the weaknesses. They describe this framework as a strategy for others to use to develop locally relevant and feasible approaches to competency assessment in UME.

Background : Teaching students how to create assessments, such as those involving multiple-choice questions (MCQs), has the potential to be a useful active learning strategy. In order to optimize students' learning, it is essential to understand how they engage with such activities. Objective : To explore medical students' perceptions of how completing rigorous MCQ training and subsequently writing MCQs affects their learning. Design : In this mixed methods exploratory qualitative study, eighteen second-year medical students, trained in MCQ-writing best practices, collaboratively generated a question bank. Subsequently, the authors conducted focus groups with eight students to probe impressions of the process and the effect on learning. Responses partially informed a survey consisting of open-ended and Likert rating scale questions that the remaining ten students completed. Focus group and survey data from the eighteen participants were iteratively coded and categorized into themes related to perceptions of training and of collaborative MCQ writing. Results : Medical students felt that training in MCQ construction affected their appreciation for MCQ examinations and their test-taking strategy. They perceived that writing MCQs required more problem-solving and content-integration compared to their preferred study strategies. Specifically, generating plausible distractors required the most critical reasoning to make subtle distinctions between diagnoses and treatments. Additionally, collaborating with other students was beneficial in providing exposure to different learning and question-writing approaches. Conclusions : Completing MCQ-writing training increases appreciation for MCQ assessments. Writing MCQs requires medical students to make conceptual connections, distinguish between diagnostic and therapeutic options, and learn from colleagues, but requires extensive time and knowledge base.

The United States is facing a rheumatology provider shortage over the next decade, which will negatively affect care for patients with rheumatic disease across the nation if this deficit is not thoughtfully addressed. The increasing numbers of retiring rheumatology specialists, women entering the workforce, and rheumatology graduates seeking part-time employment were identified as the most significant factors driving the projected decline in supply of providers. The major factors driving the projected increase in demand include an aging and growing population and improved treatment options, both of which increase disease prevalence and the challenge of managing chronic rheumatologic diseases., (Published by Elsevier Inc.)

Problem: Multiple-choice question (MCQ) examinations represent a primary mode of assessment used by medical schools. It can be challenging for faculty to produce content-aligned, comprehensive, and psychometrically sound MCQs. Despite best efforts, sometimes there are unexpected issues with examinations. Assessment best practices lack a systematic way to address gaps when actual and expected outcomes do not align., Approach: The authors propose using root cause analysis (RCA) to systematically review unexpected educational outcomes. Using a real-life example of a class's unexpectedly low reproduction examination scores (University of Michigan Medical School, 2015), the authors describe their RCA process, which included a system flow diagram, a fishbone diagram, and an application of the 5 Whys to understand the contributors and reasons for the lower-than-expected performance. Using this RCA approach, the authors identified multiple contributing factors that potentially led to the low examination scores. These included lack of examination quality improvement (QI) for poorly constructed items, content-question and pedagogy-assessment misalignment, and other issues related to environment and people., Outcomes: As a result of the RCA, the authors worked with stakeholders to address these issues and develop strategies to prevent similar systematic issues from reoccurring. For example, a more robust examination QI process was developed., Next Steps: Using an RCA approach in health care is grounded in practice and can be easily adapted for assessment. Because this is a novel use of RCA, there are opportunities to expand beyond the authors' initial approach for using RCA in assessment.

Purpose: Transforming a medical school curriculum wherein students enter clerkships earlier could result in two cohorts in clerkships simultaneously during the transition. To avoid overlapping cohorts at the University of Michigan Medical School, the length of all required clerkships was decreased by 25% during the 2016-2017 academic year, without instituting other systematic structural changes. The authors hypothe sized that the reduction in clerkship duration would result in decreases in student perfor mance and changes in student perceptions., Method: One-way analyses of variance and Tukey post hoc tests were used to compare the 2016-2017 shortened clerkship cohort with the preceding traditional clerkship cohorts (2014-2015 and 2015-2016) on the following student outcomes: National Board of Medical Examiners (NBME) subject exam scores, year-end clinical skills exam scores, evaluation of clerkships, perceived stress, resiliency, well-being, and perception of the learning environment., Results: There were no significant differences in performance on NBME subject exams between the shortened clerkship cohort and the 2015-2016 traditional cohort, but scores declined significantly over the three years for one exam. Perceptions of clerkship quality improved for three shortened clerkships; there were no significant declines. Learning environment perceptions were not worse for the shortened clerkships. There were no significant differences in performance on the clinical skills exam or in perceived stress, resiliency, and well-being., Conclusions: The optimal clerkship duration is a matter of strong opinion, supported by few empirical data. These results provide some evidence that accelerating clinical education may, for the studied outcomes, be feasible.

Rheumatoid arthritis is the most common inflammatory arthritis, and a significant cause of morbidity and mortality. Primary care providers should be able to distinguish the clinical presentation of rheumatoid arthritis from osteoarthritis, because the treatment and outcomes differ greatly between these 2 common forms of arthritis. This article provides a current overview of our understanding of rheumatoid arthritis, with an emphasis on early diagnosis and approaches to treatment., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Graduate medical education (GME), through fellowship training, plays a critical role in preparing new rheumatologists for our workforce and is an essential component when addressing the gap of excess demand for adult rheumatology care. This study was undertaken to assess the demographic characteristics and employment trends of new entrants entering the rheumatology workforce and the impact this will have on the supply of rheumatologits over the next 15 years., Methods: Primary and secondary data sources were used to develop an integrated workforce model. Factors specific to new graduates entering the workforce included available and filled fellowship positions, gender shifts, planned work schedules (part-time or full-time), practice settings (academic or non-academic, private practice), and number of international medical graduates (IMGs) anticipating US practice., Results: In 2015, there were 113 adult rheumatology programs, with 431 of 468 available positions filled. Using the 215 actual positions available annually in fellowship programs as a starting point, after all factors were applied, the projected clinical full-time equivalent number entering the workforce each year was 107; this number was affected significantly by gender and generational trends. In addition, 17% of IMGs self-identified their plan to practice outside the US. Confounding predictions included a large proportion of current rheumatologists planning retirement with substantially reduced patient loads by 2030., Conclusion: The current US adult rheumatology workforce is in jeopardy of accelerated decline at a time when demands on the workforce face tremendous growth. The current GME training structure cannot support the increased demand. Potential strategies to address this gap include innovative mechanisms for GME funding to increase fellowship training positions, incentives for pursuing rheumatology training (e.g., loan repayment programs), and novel means for recruitment of care to underserved areas of the US., (© 2018, American College of Rheumatology.)

Objective: To describe the character and composition of the 2015 US adult rheumatology workforce, evaluate workforce trends, and project supply and demand for clinical rheumatology care for 2015-2030., Methods: The 2015 Workforce Study of Rheumatology Specialists in the US used primary and secondary data sources to estimate the baseline adult rheumatology workforce and determine demographic and geographic factors relevant to workforce modeling. Supply and demand was projected through 2030, utilizing data-driven estimations regarding the proportion and clinical full-time equivalent (FTE) of academic versus nonacademic practitioners., Results: The 2015 adult workforce (physicians, nurse practitioners, and physician assistants) was estimated to be 6,013 providers (5,415 clinical FTE). At baseline, the estimated demand exceeded the supply of clinical FTE by 700 (12.9%). By 2030, the supply of rheumatology clinical providers is projected to fall to 4,882 providers, or 4,051 clinical FTE (a 25.2% decrease in supply from 2015 baseline levels). Demand in 2030 is projected to exceed supply by 4,133 clinical FTE (102%)., Conclusion: The adult rheumatology workforce projections reflect a major demographic and geographic shift that will significantly impact the supply of the future workforce by 2030. These shifts include baby-boomer retirements, a millennial predominance, and an increase of female and part-time providers, in parallel with an increased demand for adult rheumatology care due to the growing and aging US population. Regional and innovative strategies will be necessary to manage access to care and reduce barriers to care for rheumatology patients., (© 2018, American College of Rheumatology.)

Despite the prevalence of musculoskeletal disorders in the United States, physicians have received inadequate training during medical school on how to examine, diagnose, and manage these conditions. This article provides an overview of the existing literature on undergraduate medical musculoskeletal education, including learning objectives, researched methodology, and currently utilized assessment tools. A discussion of challenges to and suggested approaches for the implementation of medical school musculoskeletal curricula is presented.

We undertook this study to determine the role of Microsomal PGE Synthase-1 (mPGES-1), and mPGES-1-generated Prostaglandin (PG) E2 on Dendritic Cell (DC) phenotype and function. Using mPGES-1 KnockOut (KO) mice, we generated bone marrow derived DCs and determined their eicosanoid production profile, cell surface marker expression, and cytokine production. We also assessed DC migratory and functional capacity in vivo. Compared to wild-type, mPGES-1 deficient DCs exhibited a markedly attenuated increase in PGE2 production upon LPS stimulation, and displayed preferential shunting towards PGD2 production. mPGES-1 KO DCs did not display deficiencies in maturation, migration or ability to sensitize T cells. However, mPGES-1 deficient DCs generated reduced amounts of the Th1 cytokine IL-12, which may in part be due to increased PGD2 rather than decreased PGE2. These findings provide useful information on the effects of inducible PGE2 on the innate immune system, and have important implications regarding potential consequences of pharmacologic mPGES-1 inhibition., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Microsomal PGE synthase-1 (mPGES-1) is an inducible enzyme that acts downstream of cyclooxygenase and specifically catalyzes the conversion of PGH(2) to PGE(2). The present study demonstrates the effect of genetic deletion of mPGES-1 on the developing immunologic responses and its impact on the clinical model of bovine collagen-induced arthritis. mPGES-1 null and heterozygous mice exhibited decreased incidence and severity of arthritis compared with wild-type mice in a gene dose-dependent manner. Histopathological examination revealed significant reduction in lining hyperplasia and tissue destruction in mPGES-1 null mice compared with their wild-type littermates. mPGES-1 deficient mice also exhibited attenuation of mechanical nociception in a gene dose-dependent manner. In addition, mPGES-1 null and heterozygous mice showed a marked reduction of serum IgG against type II collagen, including subclasses IgG1, IgG2a, IgG2b, IgG2c, and IgG3, compared with wild-type mice, which correlated with the reduction in observed inflammatory features. These results demonstrate for the first time that deficiency of mPGES-1 inhibits the development of collagen-induced arthritis, at least in part, by blocking the development of a humoral immune response against type II collagen. Pharmacologic inhibition of mPGES-1 may therefore impact both the inflammation and the autoimmunity associated with human diseases such as rheumatoid arthritis.

Background: The purpose of this study was to examine the effect of aldosterone receptor blockade on the immunopathogenesis and progression of nephritis in the (NZB x NZW) F1 murine lupus model., Methods: Female NZB/W F1 mice (11 weeks old) were treated daily with 25 or 50 mg/kg oral spironolactone or vehicle. Proteinuria, renal function, and serum autoantibody levels were monitored. Renal histopathology, immune complex deposition, and immunohistochemistry were analyzed at various time points. Targeted microarray analysis was performed on renal tissue, with subsequent real-time PCR analysis of several differentially expressed genes., Results: Treatment with spironolactone was well tolerated by the mice throughout the course of their disease progression, with no significant differences in azotemia or serum potassium levels between vehicle-treated and spironolactone-treated animals. By 36 weeks of age, fewer spironolactone-treated mice developed nephrotic range proteinuria as compared with the control mice (control 70.8%, 25 mg/kg spironolactone 51.3%, and 50 mg/kg spironolactone 48.6%). Compared with control mice, mice treated with 25 mg/kg spironolactone had significantly lower serum anti-single-stranded DNA levels (2,042 microg/ml versus 1,036 microg/ml; P = 0.03) and anti-double-stranded DNA levels (3,433 microg/ml versus 614 microg/ml; P = 0.05). Spironolactone-treated mice exhibited decreased histopathologic evidence of inflammation and tissue damage, as compared with control mice. Additionally, spironolactone treatment resulted in decreased expression in the kidney of several inflammatory and proapoptotic genes, including those encoding interferon-gamma, B lymphocyte stimulator (BlyS), tumor necrosis factor related apoptosis inducing ligand (TRAIL), tumor necrosis factor related weak inducer of apoptosis (TWEAK), and Fas ligand., Conclusion: Aldosterone receptor blockade is safe and well tolerated in progressive murine lupus nephritis, and it results in decreased levels of clinical proteinuria, lower serum levels of autoantibodies, and decreased kidney damage. It appears to modulate inflammatory changes during the progression of glomerulonephritis and may also have a previously undescribed role in attenuating apoptosis.

Introduction: There is a growing body of evidence implicating aberrant dendritic cell function as a crucial component in the immunopathogenesis of systemic lupus erythematosus. The purpose of the present study was to characterize the phagocytic capacity and expression of receptors involved in pathogen recognition and self-nonself discrimination on myeloid dendritic cells from patients with lupus., Methods: Unstimulated or stimulated monocyte-derived dendritic cells were obtained from lupus patients and healthy control individuals, and expression of C-type lectin receptors (mannose receptor and dendritic cell-specific intercellular adhesion molecule-grabbing nonintegrin), complement-receptor 3 and Fc gamma receptors was determined by flow cytometry. Dextran uptake by lupus and control dendritic cells was also assessed by flow cytometry. Serum IFN gamma was quantified by ELISA, and uptake of microbial products was measured using fluorescently labeled zymosan., Results: When compared with dendritic cells from healthy control individuals, unstimulated and stimulated lupus dendritic cells displayed significantly decreased dextran uptake and mannose receptor and dendritic cell-specific intercellular adhesion molecule-grabbing nonintegrin expression. Decreased expression of the mannose receptor was associated with high serum IFN gamma levels, but not with maturation status or medications. Diminished dextran uptake and mannose receptor expression correlated with lupus disease activity. There were no differences between control and lupus dendritic cells in the expression of other pattern recognition receptors or in the capacity to uptake zymosan particles, Conclusions: Lupus dendritic cells have diminished endocytic capacity, which correlates with decreased mannose receptor expression. While this phenomenon appears primarily intrinsic to dendritic cells, modulation by serum factors such as IFN gamma could play a role. These abnormalities may be relevant to the aberrant immune homeostasis and the increased susceptibility to infections described in lupus.

Trigeminal trophic syndrome (TTS) is an unusual complication after peripheral or central damage to the trigeminal nerve, characterized by anesthesia, paresthesias, and ala nasi ulceration. We describe a patient with classic TTS after trigeminal rhizotomy who underwent several extensive evaluations for nasal ulceration and received prolonged immunosuppressive therapy for a presumed autoimmune disorder before the correct diagnosis was made. An understanding of the predisposing factors and clinical presentation of TTS is important to ensure a timely diagnosis of this difficult-to-treat illness. Differentiation of TTS from malignancy, infection, or vasculitis is possible on the basis of clinical history, tissue biopsy, and serologic evaluation.