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Goglin S, Kolfenbach J. The Impact of COVID-19 on Education and Training in Rheumatology: A Narrative Review. Arthritis Care Res (Hoboken) 2024; 76:32-39. [PMID: 37849427 DOI: 10.1002/acr.25258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/04/2023] [Accepted: 10/04/2023] [Indexed: 10/19/2023]
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Conran C, Kolfenbach J, Kuhn K, Striebich C, Moreland L. A Review of Difficult-to-Treat Rheumatoid Arthritis: Definition, Clinical Presentation, and Management. Curr Rheumatol Rep 2023; 25:285-294. [PMID: 37776482 DOI: 10.1007/s11926-023-01117-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
PURPOSE OF REVIEW A subset of patients with rheumatoid arthritis (RA) who fail multiple biologic therapies are deemed to have "difficult-to-treat" (D2T) RA. In 2021, a European Alliance of Associations for Rheumatology (EULAR) task force proposed a clinical definition of D2T RA. Here we review RA phenotypes and clinical assessment of RA, propose a different definition of D2T RA, discuss possible D2T RA risk factors, and summarize existing literature on the management of D2T RA. RECENT FINDINGS High disease activity at the time of diagnosis or prior to treatment with a biologic is associated with the development of D2T RA. Prolonged time from diagnosis to beginning treatment has been consistently associated with the development of D2T RA. Other clinical factors such as burden of disease, extraarticular disease, obesity, smoking, pain, fatigue, and psychological conditions have inconsistent associations with D2T RA according to current literature. D2T RA is a relatively new concept that represents an area of great need for research regarding the characterization of those with the disease as well as how best to treat the disease. With this gained knowledge, rheumatologists will be able to better identify patients at the time of diagnosis that are likely to develop D2T RA to help guide management.
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Affiliation(s)
- Carly Conran
- Department of Medicine, University of Colorado Denver - Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO, 80045, USA.
| | - Jason Kolfenbach
- Department of Medicine, Division of Rheumatology, University of Colorado Denver - Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO, 80045, USA
| | - Kristine Kuhn
- Department of Medicine, Division of Rheumatology, University of Colorado Denver - Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO, 80045, USA
| | - Christopher Striebich
- Department of Medicine, Division of Rheumatology, University of Colorado Denver - Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO, 80045, USA
| | - Larry Moreland
- Department of Medicine, Division of Rheumatology, University of Colorado Denver - Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO, 80045, USA
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Bolster MB, Kolfenbach J, Poeschla A, Criscione-Schreiber L, Hant F, Ishizawar R, Jonas B, Leverenz D, O'Rourke KS, Wolfe RM, Zickuhr L. Incorporating Telemedicine in Rheumatology Fellowship Training Programs: Needs Assessment, Curricular Intervention, and Evaluation. Arthritis Care Res (Hoboken) 2023; 75:2428-2434. [PMID: 37232060 DOI: 10.1002/acr.25165] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/07/2023] [Accepted: 05/23/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To increase the confidence of rheumatology fellows in training (FITs) in delivering virtual care (VC) and prepare them for independent practice, we developed educational materials addressing gaps in their skills. METHODS We identified gaps in telemedicine skills based on FIT performance in a virtual rheumatology objective structured clinical examination (vROSCE) station on VC delivery using video teleconference technology and survey (survey 1) responses. We created educational materials including videos of "mediocre" and "excellent" VC examples, discussion/reflection questions, and a document summarizing key practices. We measured change in the confidence levels of FITs for delivering VC with a post-intervention survey (survey 2). RESULTS Thirty-seven FITs (19 first-year, 18 second- plus third-year fellows) from 7 rheumatology fellowship training programs participated in a vROSCE and demonstrated gaps in skills mapping to several Rheumatology Telehealth Competency domains. Confidence levels of FITs improved significantly from survey 1 to survey 2 for 22 of 34 (65%) questions. All participating FITs found the educational materials helpful for learning and reflecting on their own VC practice; 18 FITs (64%) qualified usefulness as "moderately" or "a lot." Through surveying, 17 FITs (61%) reported implementing skills from the instructional videos into VC visits. CONCLUSION Continually assessing our learners' needs and creating educational materials addressing gaps in training are requisite. Using a vROSCE station, needs assessments, and targeted learning with videos and discussion-guidance materials enhanced the confidence level of FITs in VC delivery. It is imperative to incorporate VC delivery into fellowship training program curricula to ensure breadth in skills, attitudes, and knowledge of new entrants into the rheumatology workforce.
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Affiliation(s)
| | | | | | | | - Faye Hant
- Medical University of South Carolina, Charleston
| | | | - Beth Jonas
- University of North Carolina at Chapel Hill
| | | | | | - Rachel M Wolfe
- Wake Forest School of Medicine, Winston-Salem, North Carolina
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Zickuhr L, Albert DA, Herndon C, Imundo LF, Lopker MJ, Marston B, Mian N, O'Rourke K, Torralba KD, Westrich-Robertson T, Venuturupalli RS, Kolfenbach J, Bolster MB. Addressing Competency in Rheumatology Telehealth Care Delivery. Arthritis Care Res (Hoboken) 2022; 75:1213-1219. [PMID: 36121041 DOI: 10.1002/acr.25023] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/04/2022] [Accepted: 09/13/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Telehealth is an essential facet of care delivery for patients with rheumatic diseases. The Association of American Medical College's (AAMC) telehealth competencies (TCs) define the skills required for delivering general telehealth care across the range of clinician experience. In this study, the American College of Rheumatology's (ACR) TCs working group aimed to adapt the AAMC TCs to rheumatology, outlining the skills acquisition unique to rheumatology with a focus on knowledge, skills, and behaviors expected of recent rheumatology fellowship graduates. METHODS Through a collaborative process, the working group adapted the AAMC TCs to the training structure and practice of rheumatology. The rheumatology TCs underwent peer review among recipients of the Clinician Scholar Educator Award and attendees at the ACR 2021 Convergence conference. RESULTS The rheumatology TCs define 24 essential skills required for synchronous telehealth care of patients with rheumatic diseases. The working group adapted the AAMC's 20 TCs organized within 6 domains, added 2 skills to the AAMC's domains of patient safety and appropriate use, and data collection and assessment, and created a novel domain of systems-based requirements with 2 competencies. The rheumatology TCs define expected skill levels for recent rheumatology fellowship graduates and experienced rheumatology clinicians. CONCLUSION The rheumatology TCs represent the first adaptation of the AAMC TCs to subspecialty care, expanding the scope to include rheumatology fellowship graduates and additional domains of rheumatology practice. These competencies can guide curricular innovations and measurements of proficiency in telehealth care delivery among rheumatology trainees and experienced clinicians, enhancing the care provided to patients with rheumatic diseases.
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Affiliation(s)
- Lisa Zickuhr
- Washington University in St. Louis, St. Louis, Missouri
| | - Daniel A Albert
- Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | | | - Lisa F Imundo
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | | | - Bethany Marston
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Nabeela Mian
- Wilkes-Barre Veterans Affairs Medical Center, Wilkes-Barre, Pennsylvania
| | | | | | | | | | | | - Marcy B Bolster
- Massachusetts General Hospital, Harvard Medical School, Boston
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Dua AB, Bolster MB, Gensler LS, Kolfenbach J, Mamut MH, Seo P, Jonas BL. Virtually Speaking: The Impact of a Nationwide Synchronous and Asynchronous Learning Forum. Arthritis Care Res (Hoboken) 2022. [PMID: 35724301 DOI: 10.1002/acr.24972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 05/25/2022] [Accepted: 06/14/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To address significant disruptions in didactic education precipitated by the COVID-19 pandemic, a group of rheumatology program directors collaborated with the American College of Rheumatology to create a virtual fellows-in-training (V-FIT) program. METHODS A working group was composed to develop the virtual didactic program comprising live virtual sessions of core curricular rheumatology topics that were recorded to permit asynchronous learning. Nationally recognized educators were invited to lead sessions to fill the void in didactic education occurring on a broad scale across US rheumatology fellowship training programs. Demographic information, live and asynchronous participation data, and feedback surveys were collected from participants in the program. RESULTS There were 3 components to V-FIT: the Virtual Rheumatology Learning (ViRL) series, the Virtual Rheumatology Practicum (ViP), and the Virtual Rheumatology Teaching Lessons (ViTLs). The ViRL program had global impact with more than 2,000 learners from more than 55 countries. ViP provided a standardized curriculum of rheumatology topics for incoming first-year fellows. ViTLs addressed advanced and interdisciplinary rheumatic disease topics for learners at all stages. CONCLUSION With collaboration, adaptation, and innovation, the V-FIT program not only maintained but also enhanced education for rheumatology trainees, was enriched by national and international participation, and provided standardized, broadly accessible content with interdisciplinary learning.
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Affiliation(s)
| | | | | | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
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Liebowitz JE, Torralba KD, Kolfenbach J, Marston B, Dua AB, O'Rourke KS, McKown K, Battistone MJ, Valeriano-Marcet J, Edgar L, McLean S, Gouze KR, Bolster MB. Rheumatology Milestones 2.0: A Roadmap for Competency-Based Medical Training of Rheumatology Fellows in the 21st Century. Arthritis Care Res (Hoboken) 2022; 74:675-685. [PMID: 33181000 DOI: 10.1002/acr.24507] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 10/08/2020] [Accepted: 11/05/2020] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Anisha B Dua
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Kevin McKown
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Michael J Battistone
- University of Utah Health Sciences Center and George E. Whalen Veterans Affairs Health Sciences Center, Salt Lake City
| | | | - Laura Edgar
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - Sydney McLean
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - Karen R Gouze
- Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Marcy B Bolster
- Harvard Medical School and Massachusetts General Hospital, Boston
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Zickuhr L, Kolfenbach J, Bolster MB. Applying Educational Theory to Optimize Trainee Education in the Ambulatory Virtual Care Environment. Med Sci Educ 2021; 31:1715-1722. [PMID: 34422453 PMCID: PMC8370462 DOI: 10.1007/s40670-021-01365-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 05/10/2023]
Abstract
Virtual care (VC) encounters have become an essential part of outpatient clinical care. The theory of situated learning and legitimate peripheral participation posits that medical trainees learn best when they participate in authentic patient care experiences and engage effectively with their preceptors, members of the health care team, and the clinical learning environment. This theory can provide a framework from which to approach teaching in the VC setting, whereby preceptors may capitalize on the unique learning and assessment opportunities provided during VC encounters and optimize educational experiences for trainees as well as clinical outcomes for patients. In this monograph, we propose an approach grounded in situated learning and legitimate peripheral participation for teaching in the VC environment, particularly during real-time video visits.
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Affiliation(s)
- Lisa Zickuhr
- Department of Medicine, Washington University School of Medicine, St. Louis, MO USA
| | - Jason Kolfenbach
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO USA
| | - Marcy B. Bolster
- Department of Medicine, Massachusetts General Hospital, Boston, MA USA
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Abstract
BACKGROUND/OBJECTIVE Rheumatoid arthritis (RA) is a complex disease that may require treatment with one or several disease-modifying antirheumatic drugs (DMARDs). Many DMARDs have potential teratogenic effects or are newer agents with limited safety data in pregnancy. This study evaluated 20 common RA medications and the rate of contraceptive prescribing and counseling patterns in women with RA of childbearing ability. METHODS This was an observational study of women with RA and childbearing ability aged 18 to 44 years who were seen at an academic rheumatology clinic from April 1, 2014, to March 31, 2016. Descriptive statistics and univariate logistic regression were used for analysis. RESULTS One hundred fifty women were included in the analysis. The majority of patients were taking methotrexate (55.3%), followed by chronic prednisone (31.3%) and hydroxychloroquine (28.7%). A documented method of contraception was noted in 64/150 (42.7%). For women on contraception, most used combined oral contraceptives (31/64, 48.4%) or levonorgestrel intrauterine device (10/64, 15.6%). Of the 86 patients not on contraception, 19 (22.1%) received counseling regarding a pregnancy plan. CONCLUSIONS Most women with RA of childbearing age and ability were not using contraception. Among these patients, only a minority prescribed DMARD therapy had documented pregnancy or contraceptive counseling. Women with RA who were prescribed with a DMARD should discuss the use of effective contraception with their provider if sexually active and not desiring pregnancy or wanting to avoid potential teratogenic effects. Potential strategies are discussed to improve healthcare delivery to this population in hopes of avoiding unintended pregnancy and potential teratogenic effects of RA medications.
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Affiliation(s)
- Emily Ingram
- From the Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
| | - Liza Claus
- From the Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
| | - Jason Kolfenbach
- Division of Rheumatology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Garth Wright
- From the Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
| | - Laura M Borgelt
- From the Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
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Dimou A, Barron G, Merrick DT, Kolfenbach J, Doebele RC. Granulomatosis with polyangiitis in a patient treated with dabrafenib and trametinib for BRAF V600E positive lung adenocarcinoma. BMC Cancer 2020; 20:177. [PMID: 32131760 PMCID: PMC7057580 DOI: 10.1186/s12885-020-6661-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 02/20/2020] [Indexed: 12/27/2022] Open
Abstract
Background Dabrafenib and trametinib combination therapy is approved for the treatment of patients with BRAF V600E positive tumors including melanoma and lung cancer. The effect of BRAF and MEK inhibitors on the immune system is not fully understood although a number of case reports indicate autoimmune side effects related to the use of these drugs. Here, we discuss a case of a patient diagnosed with granulomatosis with polyangiitis (GPA) shortly after starting treatment with dabrafenib and trametinib for BRAF V600E positive metastatic lung adenocarcinoma. Case presentation A 57 years old female patient was diagnosed with recurrent lung adenocarcinoma following initial lobectomy for early stage disease. A BRAF V600E mutation was identified at the time of recurrence and she received combination dabrafenib and trametinib therapy. Shortly after commencement of treatment, she developed persistent fevers necessitating withholding both drugs. Pyrexia continued and was followed by left vision loss and acute kidney injury. Further rheumatological workup led to the unifying diagnosis of GPA. The patient was then treated with rituximab for GPA to the present date while all antineoplastic drugs were held. Lung cancer oligoprogression was addressed with radiation therapy and has not required further systemic treatment whereas GPA has been controlled to-date with rituximab. Conclusions This case report raises awareness among clinicians treating patients with lung cancer for the possibility of triggering a flare of autoimmune diseases like GPA in patients with BRAF V600E positive lung cancer receiving treatment with BRAF directed therapy.
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Affiliation(s)
- Anastasios Dimou
- Division of Medical Oncology, University of Colorado, Anschutz Medical Campus, 13001 E 17th Pl, Aurora, CO, 80045, USA.
| | - Gregory Barron
- Division of Rheumatology, University of Colorado, Anschutz Medical Campus, 13001 E 17th Pl, Aurora, CO, 80045, USA
| | - Daniel T Merrick
- Department of Pathology, University of Colorado, School of Medicine, 13001 E 17th Pl, Aurora, CO, 80045, USA
| | - Jason Kolfenbach
- Division of Rheumatology, University of Colorado, Anschutz Medical Campus, 13001 E 17th Pl, Aurora, CO, 80045, USA
| | - Robert C Doebele
- Thoracic Oncology Research Initiative, Division of Medical Oncology, University of Colorado, School of Medicine, 12801 E. 17th Ave., MS 8117, Aurora, CO, 80045, USA
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Li MY, Kolfenbach J, Schocket A. Not All Rashes Are Allergic: Keratoderma Blennorrhagicum-Like Rash Masquerading as Contact Dermatitis. Allergy�Rhinol (Providence) 2018; 9:2152656718811566. [PMID: 30546925 PMCID: PMC6287317 DOI: 10.1177/2152656718811566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Maxwell Y. Li
- Division of Allergy and Clinical Immunology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Division of Allergy and Clinical Immunology, National Jewish Health, Denver, Colorado
| | - Jason Kolfenbach
- Division of Rheumatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Alan Schocket
- Division of Allergy and Clinical Immunology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Demoruelle K, Weisman M, Harrington A, Derber L, Kolfenbach J, Striebich C, Pedraza I, Lynch D, Sachs P, Petersen B, Strickland C, Norris J, Holers VM, Deane K. Lung abnormalities in subjects with elevations of rheumatoid arthritis-related autoantibodies without arthritis by examination and imaging suggest the lung is an early and perhaps initiating site of inflammation in rheumatoid arthritis. Ann Rheum Dis 2012. [DOI: 10.1136/annrheumdis-2011-201231.16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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