Joanne Valeriano-Marcet

Myonecrosis and Myofibrosis as Complications of Sickle Cell Anemia

Painful crises in sickle cell anemia are associated with infarction and subsequent fibrosis of many different organs. Myonecrosis secondary to muscle infarction during a crisis and subsequent fibrosis are often not recognized as complications of sickle cell anemia. We describe four patients, all of whom had recurrent episodes of symmetric proximal muscle pain and swelling as prominent features of their crises. Muscle biopsies showed acute myonecrosis with a minimal inflammatory reaction as well as myofibrosis with abundant collagen deposition. Chronic sequelae consisted of muscle induration, atrophy, and contractures.

Soft tissue disease

In the assessment of patients with soft tissue complaints, it is important to consider infectious etiologies in the differential diagnosis, especially in immunocompromised hosts. The exact categorization of some bacterial infections of the soft tissues may be difficult. The structures potentially involved include the skin, subcutaneous tissue, fascia, and skeletal muscle. Classification is usually based upon the anatomic structure involved, the infecting organism, and the clinical picture. The categorization is complicated by the fact that some infections may involve several soft tissue components and multiple bacterial species. In this review, we will cover cutaneous and subcutaneous tissue infections, fasciitis, septic bursitis, tendonitis, and pyomyositis.

What Is a Rheumatologist and How Do We Make One

Graduate medical education is a critical time in the training of a rheumatologist, and purposeful evaluation of abilities during this time is essential for long‐term success as an independent practitioner. The internal medicine subspecialties collectively developed a uniform set of reporting milestones by which trainees can be assessed and receive formative feedback, providing clarity of accomplishment as well as areas for improvement in training. Furthermore, the reporting milestones provide a schema for assessment and evaluation of fellows by supervisors. The internal medicine subspecialties were also tasked with considering entrustable professional activities (EPAs), which define the abilities of a subspecialty physician who has attained sufficient mastery of the field to be accountable to stakeholders and participate in independent practice. Although EPAs have been established for a few specialties, they had not yet been described for rheumatology. EPAs have value as descriptors of the comprehensive abilities, knowledge, and skills of a practicing rheumatologist. The rheumatology EPAs have a role in defining a specialist in rheumatology upon completion of training, and also represent the ways our specialty defines our abilities that are enduring throughout practice.

Virtual rheumatology: using simulators and a formal workshop to teach medical students, internal medicine residents, and rheumatology subspecialty residents arthrocentesis.

Background:Arthrocentesis is an important skill for medical practitioners at all levels of training. Previous studies have indicated a low comfort level and performance of arthrocentesis among primary care physicians that could be improved with hands-on training. Objectives:The objective of this study was to improve comfort with knee and shoulder arthrocentesis at all levels of medical training, including medical students, internal medicine residents, and rheumatology subspecialty residents, and in arthrocentesis of the elbow, wrist, and ankle for advanced subspecialty residents in rheumatology through the use of a formal workshop using simulators. Methods:Fourth-year medical students and internal medicine residents were recruited from the University of South Florida. The rheumatology advanced subspecialty residents were participants from University of South Florida and from the American College of Rheumatology national meetings in 2008 and 2009. A 1-hour PowerPoint lecture followed by a hands-on practice session using Sawbones models (shoulder and knee for all groups, and elbow, wrist, and ankle additionally for the advanced subspecialty residents). A preworkshop self-assessment survey allowed the participant to rate his/her comfort level with arthrocentesis on a scale of 1 to 5. A survey with identical questions was completed immediately after the workshop. A follow-up survey was distributed by e-mail 3 to 6 months after the workshop. Results:One hundred forty-one medical students, 75 internal medicine residents, and 39 rheumatology subspecialty residents participated from January 2008 until January 2010. Mean comfort level in knee and shoulder arthrocentesis improved from preworkshop comfort level for all joints and among all participants. In addition, rheumatology subspecialty resident mean comfort level improved for ankle from 2.37 to 3.65, elbow from 2.56 to 3.80, and wrist from 2.31 to 3.77 (P < 0.0001). Conclusions:Our study involved a very large number of participants encompassing different levels of training and is the largest number of advanced subspecialty rheumatology residents studied with regard to joint injection training. We have confirmed that a formal joint injection workshop using simulators is an effective method of improving comfort level in arthrocentesis among participants from all levels of medical training. Future studies should evaluate the effect of such training on actual clinical use and competence.

Performance on the adult rheumatology in-training examination and relationship to outcomes on the rheumatology certification examination.

The American College of Rheumatology (ACR) Adult Rheumatology In‐Training Examination (ITE) is a feedback tool designed to identify strengths and weaknesses in the content knowledge of individual fellows‐in‐training and the training program curricula. We determined whether scores on the ACR ITE, as well as scores on other major standardized medical examinations and competency‐based ratings, could be used to predict performance on the American Board of Internal Medicine (ABIM) Rheumatology Certification Examination.

Myelodysplasia and Malignancy-Associated Vasculitis

While the link between malignancy and vasculitis has been known for some time, the association of vasculitis and myelodysplastic syndrome (MDS) has only recently been reported. This article reviews the most current and landmark publications regarding MDS, as well as malignancy-associated vasculitis. We include theories of paraneoplastic associations, immune pathogenesis including an associated cytokine transcriptional factor (interferon regulatory factor-1 [IFN-1]), and the relationship to treatment. Key clinical features that suggest underlying malignancy in patients with vasculitis are highlighted. Although the association between vasculitis and malignancy is rare, leukocytoclastic vasculitis is the most common vasculitis associated with MDS, hematologic malignancies as well as solid tumors. We review several articles that demonstrate a paraneoplastic association between vasculitis and various malignancies, but overall, the connection is still unclear and not well defined. Certain features that suggest a true paraneoplastic association are outlined. Further studies are needed to advance our understanding of this complex topic.

Relationship between performance on the Rheumatology in‐training and certification examinations

The American College of Rheumatology (ACR) Adult Rheumatology In‐Training Examination (ITE) is a feedback tool designed to identify strengths and weaknesses in the content knowledge of individual fellows‐in‐training and the training program curricula. We determined whether scores on the ACR ITE, as well as scores on other major standardized medical examinations and competency‐based ratings, could be used to predict performance on the American Board of Internal Medicine (ABIM) Rheumatology Certification Examination.

New Roadmap for the Journey From Internist to Rheumatologist

Measurement is necessary to gauge improvement. US training programs have not previously used shared standards to assess trainees’ mastery of the knowledge, skills, and attitudes necessary to practice rheumatology competently. In 2014, the Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System began requiring semiannual evaluation of all medicine subspecialty fellows on 23 internal medicine subspecialty reporting milestones. Since these reporting milestones are not subspecialty specific, rheumatology curricular milestones were needed to guide rheumatology fellowship training programs and fellows on the training journey from internist to rheumatologist.

Innovative virtual interactive teaching tool "Arthur" for clinical diagnosis of musculoskeletal diseases.

‘‘A rthur’’ is a unique, innovative interactiveWeb-based teaching tool that has been developed and used for the education of medical trainees at the University of South Florida College of Medicine and James A. Haley Veterans Administration. It was developed in response to literature that has shown a deficit in the education of musculoskeletal (MSK) medicine across trainees at various levels. Both allopathic and osteopathic medical graduates have reached only a minimum passing level on basic MSK competency examination. Medical schools’ curricula have been reviewed, and reform of MSK education suggested. We chose to focus specifically on the complex clinical skill of joint pattern recognition, which we proposed as fundamental to the understanding of rheumatology. Emphasis is given to both the combination of peripheral and axial joint involvement in inflammatory arthritis, in contrast to the different patterns of joint involvement in noninflammatory osteoarthritis. Nonarticular findings, such as the tender point locations characteristic of fibromyalgia, are also illustrated. We believe that these important differences are central to the understanding of MSK disorders. This educational tool was initially developed as a PowerPoint presentation but then adapted to be an interactive program, to enable independent learning. The clinical scenario is illustrated, and multiple potential diagnoses are selected from a drop-down menu. Our initial study included internal medicine residents who chose to rotate through an elective month of rheumatology. They were all given access to the initial version (V.1) of the interactive ‘‘Arthur V.1’’ educational tool. Twenty-four of 29 residents voluntarily completed a prerotation and postrotation multiple-choice quiz, which included feedback of which answers were correct or incorrect as well as a suggested reading list. All 24 residents had improvement in prerotation and postrotation scores, but those who used this interactive, Web-based tool improved their scores significantly over those who did not, 21% versus 13% (P G 0.03). Nine Arthur users improved from 45% to 65% correct. Fifteen nonusers improved from 39% to 48% correct. Most residents used the program once. On postrotation surveys, the participants who used Arthur reported that they did find it helpful and applicable to real patients. We then performed a qualitative evaluation of fourth-year medical students undergoing their ‘‘skin and bones’’ MSK rotation of 4 weeks in the specialties of rheumatology, orthopedics, and dermatology. Sixty-four (60%) of 107 fourth-year medical students completed Arthur V.1 and the follow-up survey. Thirty-five percent of the respondents reported it useful for learning joint pattern recognition. In response to the question regarding specific areas for improvement, 48% identified the need for addition of explanations for each differential diagnosis. Based on these data, the current version of ‘‘Arthur V.2’’ includes detailed explanations of the differential diagnoses for each case, with short explanations for the incorrect answer and longer explanations for the correct answer. Whether users will use these to improve scores further over the borderline success of 65% of the residents will need study. The following academic year, during their ‘‘skin and bones’’ rotation, fourth-year medical students completed the survey of open-ended questions for feedback on the use of this updated version of Arthur V.2 with the addition of these explanations. Of 63 students, 27 completed all the Arthur cases between 1 and 3 times. Again, the majority of respondents, 58%, thought that it helped most with joint pattern recognition and differential diagnosis when responding to the open-ended question: ‘‘What aspects of Arthur have helped in your understanding of rheumatology?’’ Explanations and pictures were the focus of what was liked most about the program in 33% respondents. Criticisms were few, but specific points mentioned were as follows: (1) some explanations were too lengthy and needed clarification (8%) and (2) more detailed history and physicals were needed (13%). Although these data are very limited by survey bias, small numbers, and low response rate, it suggests that Arthur facilitates learning and acquisition of clinical skills to help with evaluation of MSK problems, as presented from resident and student feedback. The improvement of the program by the use of explanations for correct and incorrect answers and the visualization and interactive nature have helped the majority of trainees who used this virtual educational teaching tool over the last 5 years. It has been useful in both teaching and learning the ‘‘nuances’’ of rheumatology and the differential diagnoses of MSK conditions. Additional limitations of our studies were that it was difficult to obtain data on pretesting and posttesting as most students preferred to use Arthur as a learning tool rather than a testing tool, and thus, few tests were completed. It is important to note that although the month rotation was required, use of the Arthur educational tool was not mandatory. The differing numbers of students is due to a version change of the computer model from V.1 to V.2, which did not align exactly with academic years. Initially, Arthur was presented in a PowerPoint format by teaching faculty, but as expected, the interactive tool has been more popular, which is consistent with prior literature that suggests that medical trainees prefer Web-based interactive teaching tools as supplements to traditional textbooks. Specific studies have demonstrated the superiority of multimedia education over traditional printed materials for trainees learning physical examination skills as well as anatomy. Fleming10,11 described the VARK acronym, which incorporates visual, aural, CONCISE REPORT