A Review of the Review Course + How to Make the Information Stick Save

I have been attending the ACR Review Course for more than a decade, and it seems every year it gets better and better. Contrary to what most people think, this is not a board review course; it is more of a review of the latest research delivered by experts condensing rheumatology in eight hours.

The most notable topics covered this year included “Sjogren’s: Sicca and Beyond” by Dr. F Vivino; “RA Therapies Update” by Dr. M Weinblatt; “MAS (macrophage activation syndrome) Update” by Dr. E Behrens; “Lupus Update” by Dr. S. Manzi;  “Behcet’s” by Dr. Y Yazici; and, “IgG4-related diseases” by Dr. John Stone.

In the past, I used to sit and listen to the lecturers and exclaimed, that was a great lecture, but as soon as I got home from the meeting, I forgot the relevant points and did not have the time to go back to review the slides provided by the ACR nor the notes I took. Since being involved with RheumNow and tweeting what I think is interesting, I find myself more engaged with the meeting and able to digest the information thoughtfully. I love sharing what I learned; if a speaker mentions something off-hand that I hadn't heard before but they did not have time to go over it in detail, I would look up that topic quickly on my phone and tweet a link of what I found to support a speaker’s point. I had gone from passive learning, to active learning, and to finally arrive at engaged learning.

The University of Michigan points out the differences between the types of learning with passive being the most ineffective; active learning requires students to do meaningful learning activities and think about what they are doing, but engaged learning is when “students have opportunities to practice in unscripted, authentic settings, where stakeholders (including the students themselves) are invested in the outcome.”  Like medical school, the scribe is usually the one who learns the material best.   

Additionally, disseminating information is an essential part of science; you just don’t do an experiment and keep it to yourself.  Knowledge traditionally has been shared by lectures, publications, collegial discussions, but in today’s current era; the most effective way to spread ideas is through social media.  It is very rewarding to see someone pick up and read your published paper; similarly, it an awesome feeling seeing someone like a tweet, but is a huge compliment when they re-tweet your tweet.  So I will share with you the main tweets that I placed from the 2019 ACR Review Course that I found fascinating, relevant to my practice, and possibly may be used as board recertification questions in the future.

1. Dr. F Vivino on Sjogren’s: Due to the new multiplex flow immunoassays used by commercial labs, isolated anti-SSB positivity is becoming more prevalent and does not necessarily correlate with Sjogren’s.  Because of this anti-SSB has been REMOVED from the new Sjogren’s classification criteria (horrified emoji). 20% of Sjogren’s patients do NOT have sicca symptoms; these are the patients who have more severe disease (lymphoma, CNS manifestations).

2. Dr. M Weinblatt on RA Therapeutics: the bottomline on biologic safety: 1. NO confirmed increase risk for melanoma 2. NO increased risk for lymphoma (it’s the disease activity) 3. NO increased risk for cancer recurrence 4. No increased risk for surgical infection (it’s the steroids) 5. NO increased risk of infection for using rituximab longterm.  The best part of this tweet was that someone replied with a comment to my tweet, “yes, in fact apple sauce has more side effects than biologics”.  

3. Dr. E Behrens on MAS: hyperferritinemia can be seen with malignancy, renal disease, infections, inflammatory conditions, but very few diseases cause ferritin > 10,000—think MAS. Diagnosis may be difficult; a bone marrow biopsy  may not show hemophagocytosis. Levels of free IL-18 may be a good biomarker to detect MAS. Therapies for MAS include high dose steroids, cyclosporine, IL-1 inhibition. Consider rituximab for EBV related hemophagocytic lymphohistiocytosis. 

4. Dr. S Manzi on Lupus: the gut microbiome has been linked to lupus disease activity (I looked up this up specifically, Runimococcus gnavus has been highly correlated to lupus disease activity).  Renal biopsy may be a thing of the past as interferon levels in tubular cells and keratinocytes can distinguish those with moderate to severe lupus nephritis from those who don’t have renal disease. Testing hydroxychloroquine levels will improve compliance in patients taking the medication.

5. Dr. Y Yazici on Behcet’s :  “Behcet’s criteria are overdiagnosing the disease.” Scrotal ulcers with scarring are very specific to Behcet’s.  Behcet’s patients with acne and arthritis have a higher incidence of enthesopathy. Patients with Behcet’s and thrombophlebitis should be screened for pulmonary artery aneurysm (high correlation of thrombotic disease and aneurysms). To prevent thrombosis, it is the immunosuppressants and not the anti-coagulation that helps. 

6. Dr. John Stone on IgG4-related disease (IgG4-RD): this is a progressive, painless, indolent but destructive immune-mediated disease that is a great mimicker. Do NOT biopsy a lymph node to make the diagnosis of IgG4-RD (all lymph nodes have IgG4 staining); target another tissue to biopsy.  The ACR/EULAR classification criteria for IgG4-RD has been validated (look this up). Pathognomonic histopathology of IgG4-RD: “lymphoplasmacytic infiltrate, storiform fibrosis, and obliterative phlebitis”.  My comment: Know these key terms as they are associated with IgG4-RD like “curvilinear bodies” are associated with hydroxychloroquine-induced myopathy. 

I hope you will participate in engaged learning and consider sharing your new found knowledge from this meeting with others. All it takes is 280 characters to make a tweet.  You can follow me on twitter @KDAO2011; add @rheumnow and #ACR19 to your tweets to spread the love.