Advanced Rheumatology Course

Activity 1 - Musculoskeletal Structure and Function and Inflammation and Immunity - Author: Ian M. Ward, MD
Learning Objectives - Upon completion of this activity, participants should be able to:

• Describe the structure and function of bone, skeletal muscle, articular cartilage, and connective tissue
• Classify the different types of synovial joints and periarticular tissues
• Articulate the structure and clinical relevance of functional and dysfunctional endothelium
• Identify the principle cells of the innate and adaptive immune system and concepts of immunity
• Describe the physiologic processes in inflammation, immunity, and immune deregulation
• Discuss the relationship of molecular biology to the diagnosis and current and emerging treatment of rheumatic diseases

Activity 2 - Rheumatic Disease Classification and Framework for Clinical Decision Making - Author: Christine Stamatos, DNP, ANP-C
Learning Objectives - Upon completion of this activity, participants should be able to:

• Distinguish among the three classes of rheumatic disorders, which include inflammatory arthropathies, degenerative and mechanical arthropathies, and nonarticular and central pain processing disorders, and rank their prevalence estimates
• Describe the components of a complete medical history, including assessment of a chief complaint and history of present illness, eliciting a past medical history, family history, social history, use of therapeutics, and completing a review of systems
• Describe the basic components of a musculoskeletal examination, including inspection/appearance, palpation, range of motion, and functional assessment
• Describe the components of a general physical exam, including developmental assessments across the life span
• Recognize patterns of diagnostic significance and the approach to formulating a differential diagnosis
• Detect worrisome ‘red flags'

Activity 3 - Laboratory Evaluation - Author: Mark Wener, MD
Learning Objectives - Upon completion of this activity, participants should be able to:

• Order laboratory tests which would be most useful in the evaluation, diagnosis, and prognosis of frequently occurring rheumatic diseases
• Recognize the serologic associations of rheumatic diseases
• Apply the concepts of sensitivity, specificity, likelihood ratio, and the receiver operator characteristics (ROC) curve of a diagnostic test to the clinical practice of laboratory testing. Calculate approximate post-test likelihood, given a test result and a pre-test likelihood
• Identify lab tests that are routinely used in monitoring activity of rheumatic diseases
• List laboratory tests that are part of monitoring for toxicity of anti-rheumatic therapies

Activity 4 - Imaging of Arthritis: Approach to the Diagnosis of Inflammatory Disease - Author: Patrick Astourian, MPAS, PA-C
Learning Objectives - Upon completion of this activity, participants should be able to:

• List the indications for radiographic imaging studies when evaluating persons with rheumatic disease
• Select the appropriate radiographic imaging study to evaluate various forms of rheumatic disease
• Recognize the imaging appearance of adult rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA).
• Describe the imaging appearance of the seronegative Spondylarthropathies
• Distinguish the imaging appearance of osteoarthritis and its erosive variant
• Appraise the imaging appearance of common crystalline diseases: gout and CPPD arthropathies

Activity 5 - Documentation, Coding and Practice Issues - Author: Antanya Chung, CPC, CPC-I, CRHC, CCP
Learning Objectives - Upon completion of this activity, participants should be able to:

• Discuss the scope of practice, regulatory structure, and reimbursement for nurse practitioners or physician assistants in rheumatology practices
• Identify benefits of including nurse practitioners and physician assistants in rheumatology practices and strategies to facilitate successful practice relationships between rheumatologists and nurse practitioners and physician assistants
• Apply evaluation and management services codes (E/M) for varied levels of clinical care in accordance with CMS Evaluation and Management Services Guidelines
• Assign the most accurate and detailed Current Procedural Terminology (CPT) codes for individual professional services
• Explain upcoding and downcoding, bundling and unbundling, and the use of CPT modifiers
• Explain the Resource-Based Relative Value Scale (RBRVS) System for determining provider reimbursement

Activity 6 - Therapeutic Interventions and Resources - Authors: Donna K. Everix, MPA, PT and Jennifer L. Trizuto, MPT
Learning Objectives - Upon completion of this activity, participants should be able to:

• Describe the components of the arthritis self-management program in the management of rheumatic diseases and the benefits of participation
• Distinguish between cognitive behavioral models and biomedical models of care in patients with rheumatic diseases
• Analyze the benefits of participation in a rehabilitation program
• Detect the benefits of physical modalities in managing symptoms associated with rheumatic diseases
• Integrate referrals to physical and occupational therapists for commonly occurring problems for people with rheumatic diseases into ones clinical practice
• State the role of the following health care team members in the care of persons with rheumatic diseases: rheumatologists, orthopedic surgeons, physiatrists, physical therapists, occupational therapists, psychologists and counselors, dieticians, podiatrists/pedorthists, and social workers
• Identify community resources for rheumatology health professionals and children, adults, and families dealing with rheumatic diseases

Activity 7 - Osteoarthritis - Author: Anne-Marie Malfait, MD, PhD
Learning Objectives - Upon completion of this activity, participants should be able to:

• Define Osteoarthritis
• Identify epidemiology, pathogenesis and risk factors for osteoarthritis
• Describe the clinical course and prognosis for osteoarthritis
• Determine the differential diagnoses to be considered when assessing patients with joint pain
• Identify the clinical features of osteoarthritis through integration of data obtained in the history, physical examination and diagnostic studies
• Apply general principles of management to caring with persons with osteoarthritis
• Explain future directions in understanding osteoarthritis

Activity 8 - Rheumatoid Arthritis and Seronegative Inflammatory Arthropathies - Author: Gregory C. Gardner, MD, FACP
Learning Objectives - Upon completion of this activity, participants should be able to:

• Differentiate the three basic causes of joint pain, characterizing joint presentations and developing a limited differential diagnosis of joint pain
• State the epidemiology, risk factors and genetics associated with rheumatoid arthritis
• Chart the progressive nature of the disease process including the basic immunology of RA and the rationale for early aggressive therapy in rheumatoid arthritis
• Categorize the distribution of joint involvement and extra-articular manifestations for early, advancing and end-stage rheumatoid arthritis disease
• Summarize laboratory abnormalities, utility of rheumatoid factor and cyclic citrullinated antibodies and radiologic changes in rheumatoid arthritis
• Discuss specific language of clinical trials, the utility of outcome measures and the Disease Activity Score for rheumatoid arthritis
• Integrate the historical and current context of treating rheumatoid arthritis, including the side effects of medications and the schedule for monitoring for adverse events, when caring for persons with rheumatoid arthritis

Activity 9 - Systemic Lupus Erythematosus - Author: Sima Terebelo, MD, MPH
Learning Objectives - Upon completion of this activity, participants should be able to:

• Define lupus and its various presentations
• Cite the epidemiology and pathogenesis of SLE
• Recognize the clinical course of SLE
• Determine the differential diagnoses associated with SLE
• Select autoantibodies and other common laboratory tests in SLE
• Comprehend the principles of disease management
• Discuss future directions including opportunities for research

Activity 10 - Scleroderma, Myositis and Sjögren’s Syndrome - Author: Vivek Nagaraja, MBBS and Emily Myers, MD

Scleroderma

• Define scleroderma
• Describe the epidemiology and pathogenesis of scleroderma
• Describe the clinical features, differential diagnosis, clinical course, and prognosis of scleroderma
• Discuss the treatment of scleroderma
• Discuss future directions in assessing and managing immune-mediated disorders (scleroderma and idiopathic inflammatory myositis)

Idiopathic Inflammatory Myositis (IIM)

• Define idiopathic inflammatory myositis, or IIM
• Describe the epidemiology and pathogenesis of IIM
• Describe the clinical features, differential diagnosis, clinical course, and prognosis of IIM
• Discuss the treatment of IIM
• Discuss future directions in assessing and managing immune-mediated disorders (scleroderma and idiopathic inflammatory myositis)

Sjögren’s syndrome (SS)

• Define Sjögren’s syndrome (SS)
• Describe the epidemiology and pathogenesis of SS
• Describe the clinical features, differential diagnosis, clinical course, and prognosis of SS
• Discuss the treatment of SS
• Discuss future directions in assessing and managing SS

Activity 11 - Vasculitis, Arteritis and PMR - Author: Jason M. Springer, MD, MS
Learning Objectives - Upon completion of this activity, participants should be able to:

• Define vasculitis, and describe the clinical features and the spectrum of disease entities in which vasculitis is seen
• Describe the epidemiology, clinical features, differential diagnosis, treatment, and outcome for polymyalgia Rheumatica (PMR)
• Describe the epidemiology, clinical features, differential diagnosis, treatment, and outcome of giant cell arteritis (GCA)
• Describe the epidemiology, clinical features, differential diagnosis, treatment, and outcome of Granulomatosis with polyangiitis (GPA)
• Describe the epidemiology, clinical features, differential diagnosis, treatment, and outcome of polyarteritis nodosa
• Describe cutaneous vasculitis and its potential causes, diagnostic evaluation, and therapeutic principles

Activity 12 - Crystal-induced Arthropathies - Author: Puja Khanna, MD, MPH
Learning Objectives - Upon completion of this activity, participants should be able to:

• Cite the common crystal deposition disorders
• Recognize the clinical presentation, causes, relevant diagnostic tests, and management of gout
• Identify the clinical presentation; causes, relevant diagnostic tests, and management of calcium pyrophosphate dehydrate (CPPD) deposition disease
• Discuss the clinical presentation, causes, relevant diagnostic tests, and management of basic calcium phosphate (BCP) deposition disease
• State the clinical presentation, causes, relevant diagnostic tests, and management of oddball crystals
• Summarize future directions for crystal-induced arthropathies

Activity 13 - Pain Syndromes - Author: Afton L. Hassett, PsyD and Daniel J. Clauw, MD
Learning Objectives - Upon completion of this activity, participants should be able to:

• Differentiate the underlying mechanisms of pain by utilizing the history and physical exam to gather appropriate data, regardless of the specific condition causing pain
• Develop a plan for pharmacologic treatment of the individual’s pain, utilizing information about the underlying mechanisms of pain
• Identify the nonpharmacologic therapies for chronic pain that are supported by the strongest evidence
• Organize a multifaceted the approach for the treatment of chronic pain that addresses six key factors

Activity 14 - Spondylarthropathies - Author: Atul Deodhar, MD, MRCP
Learning Objectives - Upon completion of this activity, participants should be able to:

• Define Spondyloarthritis, the spectrum of conditions, and their common clinical features
• Differentiate between mechanical back pain and inflammatory back pain
• Enumerate the classification criteria for axial Spondyloarthritis, peripheral Spondyloarthritis, ankylosing spondylitis, and psoriatic arthritis
• Develop a plan for how to investigate a patient with inflammatory back pain
• Discuss the epidemiology and pathogenesis of Spondyloarthritis
• Describe the clinical course and prognosis of ankylosing spondylitis, reactive arthritis, psoriatic arthritis (PA), and inflammatory bowel disease (IBD)-associated arthritis
• Integrate in practice non-pharmacologic and pharmacologic disease management choices

Activity 15 - Infection Related Arthritis - Author: Stanley J. Naides, MD
Learning Objectives - Upon completion of this activity, participants should be able to:

• Differentiate between the different types of septic arthritis, the pathogenesis, incidence, risk factors, diagnostic features and the treatment for each type
• Cite the epidemiology and identify the clinical features and treatment of each stage of Lyme disease
• Distinguish between the post-viral arthritides and the pathogenesis, clinical features, diagnostic studies and treatment for each disease
• State the articular and non-articular manifestations of HIV that mimic rheumatic diseases
• Evaluate the articular manifestations and clinical course of Hepatitis B and C
• Apply the general principles of disease recognition and management in patients with suspected infectious arthritis

Activity 16 - Metabolic Bone Disorders - Author: Michael Maricic, MD

• Learning Objectives - Upon completion of this activity, participants should be able to:

• Recognize the risk factors for fracture in women with postmenopausal osteoporosis
• Interpret bone density reports and demonstrate how to use bone density studies for clinical decision making
• Describe the important nutritional components of bone health including calcium and Vitamin D and the consequences of deficiencies
• Formulate basic treatment plans for patients with postmenopausal osteoporosis
• Design a clinical profile for men at risk for osteoporosis and discuss a metabolic workup for men with osteoporosis
• Contrast the pathophysiology of glucocorticoid induced osteoporosis (GIOP) with postmenopausal osteoporosis and formulates treatment plans for patients on glucocorticoids therapy
• Evaluate the epidemiology, pathophysiology, clinical and radiological aspects, and a treatment plan for Paget's disease

Activity 17- Chronic Arthropathies of Childhood - Author: Elizabeth Roth Wojcicki, RN, MS, CPNP
Learning Objectives - Upon completion of this activity, participants should be able to:

• Identify and differentiate between the three classifications systems of juvenile idiopathic arthritis (JIA)
• Recite the epidemiology and pathogenesis of each subtype of JIA
• Define the subtypes of JIA: oligoarticular, extended oligoarthritis, polyarticular, systemic, enthuses-related arthritis, psoriatic arthritis, and other category
• Differentiate the clinical course of the subtypes of JIA
• Explain how JIA affects growth and development in children
• Describe the prognosis of the subtypes of JIA
• Recognize disorders that can mimic JIA
• Distinguish the clinical features of JIA through integration of data obtained in the history, physical, and diagnostic studies
• Identify major sequelae or life-threatening complications of JIA: chronic uveitis, Serositis, and macrophage activation syndrome (MAS)
• Discuss general principles of disease management specific to children
  • Pharmacologic therapies approved by the FDA for use in childhood rheumatic diseases
  • Drug metabolism and dosing different from adults

Activity 18 - Pediatric Connective Tissue Diseases (CTD): Systemic Lupus, Juvenile Dermatomyositis, and Scleroderma - Author: Murray H. Passo, MD, Med
Learning Objectives - Upon completion of this activity, participants should be able to:

• Define the three common connective tissue diseases in children: juvenile dermatomyositis (JDM), systemic lupus erythematosus (SLE), and scleroderma
• Recognize the epidemiology and pathogenesis, clinical features, differential diagnosis, clinical course, and prognosis of juvenile dermatomyositis (JDM)
• Restate the epidemiology and pathogenesis, clinical features, differential diagnosis, clinical course, and prognosis of childhood-onset systemic lupus erythematosus
• State the epidemiology and pathogenesis, clinical features, differential diagnosis, clinical course, and prognosis of scleroderma in children and adolescents

Activity 19 - Pediatric Non-inflammatory Musculoskeletal Pain - Author: Susan Shenoi, MBBS, MS
Learning Objectives - Upon completion of this activity, participants should be able to:

• Describe the epidemiology, pathogenesis, clinical features, differential diagnosis, clinical course and prognosis of Growing Pains
• Cite the epidemiology, pathogenesis, clinical features, differential diagnosis, clinical course and prognosis of Patello-Femoral Syndrome
• Summarize the epidemiology, pathogenesis, clinical features, differential diagnosis, clinical course and prognosis of Benign Joint Hypermobility Syndrome
• Explain the epidemiology, pathogenesis, clinical features, differential diagnosis, clinical course and prognosis of Complex Regional Pain Syndrome (CRPS)
• Discuss the epidemiology, pathogenesis, clinical features, differential diagnosis, clinical course and prognosis of Juvenile Primary Fibromyalgia Syndrome (JPFS)