Razvijanje najviših standarda specijalističkog usavršavanja doktora medicine za područje Europe glavni je cilj Europske udruge liječnika specijalista (UEMS, fr. Union Européenne de Médicines Spécialistes), a što je i preduvjet usklađivanja izobrazbe specijalista i ostvarivanja podudarnih standarda zdravstvene skrbi u EU. UEMS je osnovan pred više od 60 godina udruživanjem nacionalnih liječničkih društava, a sadašnje članstvo čine 41 zemlja i 43 liječničke specijalizacije. U okviru ove institucije postoji duga tradicija provođenja specijalističkih ispita u zajedništvu s odgovarajućim stručnim društvom. Posebna radna skupina unutar UEMS-a ima savjetodavnu ulogu za organizaciju i ocjenu cjelokupnog postupka europskog specijalističkog ispita UEMS, a to je Council for Specialist Medical Assessment (CESMA). Svrha je ispita ocjena specijalističkih kompetencija, a sastoji se od pismenog ispita s pitanjima s više odgovora, ali i usmenog ispita s demonstracijom praktičnih vještina. Važan pristupni kriterij za ovaj ispit jest sadržaj specijalizantske knjižice (log-book). Certifikat (diploma) položenog UEMS ispita pokazatelj je izvrsnosti i napredak u karijeri kandidata te prestižan dokaz vrhunskih kompetencija specijalističke zdravstvene skrbi za zemlje članice EU-a, ali i ostatka svijeta. Mnoge su zemlje potpisale ugovor s UEMS-om i priznaju specijalistički ispit UEMS EU kao jednakovrijedan nacionalnom. Potrebno je istaknuti da certifikat položenog ispita UEMS EU nije licencija ili dozvola za rad. Na nacionalnoj razini certifikat UEMS EU pokazatelj je visoke kvalitete standarda specijalističke izobrazbe i tradicije specijalističkog usavršavanja u odgovarajućoj zemlji.

Background and aimStriving for harmonisation of specialty training and excellence of care in rheumatology, the European League Against Rheumatism (EULAR) established a task force to develop points to consider (PtCs) for the assessment of competences during rheumatology specialty training.MethodsA systematic literature review on the performance of methods for the assessment of competences in rheumatology specialty training was conducted. This was followed by focus groups in five selected countries to gather information on assessment practices and priorities. Combining the collected evidence with expert opinion, the PtCs were formulated by the multidisciplinary task force, including rheumatologists, medical educationalists, and people with rheumatic and musculoskeletal diseases. The level of agreement (LoA) for each PtC was anonymously voted online.ResultsFour overarching principles and 10 PtCs were formulated. The overarching principles highlighted the importance of assessments being closely linked to the rheumatology training programme and protecting sufficient time and resources to ensure effective implementation. In the PtCs, two were related to overall assessment strategy (PtCs 1 and 5); three focused on formative assessment and portfolio (PtCs 2–4); three focused on the assessment of knowledge, skills or professionalism (PtCs 6–8); one focused on trainees at risk of failure (PtC 9); and one focused on training the trainers (PtC 10). The LoA (0–10) ranged from 8.75 to 9.9.ConclusionThese EULAR PtCs provide European guidance on assessment methods throughout rheumatology training programmes. These can be used to benchmark current practices and to develop future strategies, thereby fostering continuous improvement in rheumatology learning and, ultimately, in patient care.

Patient handover is considered to be one of the most delicate medical procedures as well as the most preventable cause of medical error. It takes place at primary, secondary and tertiary healthcare, with specificities at every level of healthcare. Improvement in the quality of patient handover is therefore essential for good medical practice. Accurate and comprehensive communication between medical staff is required for patient safety and continuous adequate healthcare. In this article, we describe recommendations for successful and efficient patient handover and highlight communication errors during the process. Special attention is given to handover of rheumatological patients and transition from pediatric to adult healthcare. Also, we emphasize the necessity of education. Medical staff should be competent in sharing and exchanging relevant information when the patient transfers to another medical care provider. Teaching communication skills has been part of undergraduate and postgraduate curriculum in medical schools. At the Universitiy of Zagreb School of Medicine we have introduced a longitudinal six-year course Fundamentals of Medical Skills where special attention is given to communication skills. Nevertheless, medical specialty training still lacks educational contents specialized in patient handover and safe patient discharge.

The interleukin (IL)-1 family of cytokines is strongly associated with systemic sclerosis (SSc) and pulmonary involvement, but the molecular mechanisms are poorly understood. The aim of this study was to assess the role of IL-1 alpha and IL-1 beta in pulmonary vascular and interstitial remodelling in a mouse model of SSc. IL-1 alpha and IL-1 beta were localised in lungs of SSc patients and in the fos-related antigen-2 (Fra-2) transgenic (TG) mouse model of SSc. Lung function, haemodynamic parameters and pulmonary inflammation were measured in Fra-2 TG mice with or without 8 weeks of treatment with the IL-1 receptor antagonist anakinra (25 mg.kg(-1).day(-1)). Direct effects of IL-1 on pulmonary arterial smooth muscle cells (PASMCs) and parenchymal fibroblasts were investigated in vitro. Fra-2 TG mice exhibited increased collagen deposition in the lung, restrictive lung function and enhanced muscularisation of the vasculature with concomitant pulmonary hypertension reminiscent of the changes in SSc patients. Immunoreactivity of IL-1 alpha and IL-1 beta was increased in Fra-2 TG mice and in patients with SSc. IL-1 stimulation reduced collagen expression in PASMCs and parenchymal fibroblasts via distinct signalling pathways. Blocking IL-1 signalling in Fra-2 TG worsened pulmonary fibrosis and restriction, enhanced T-helper cell type 2 (Th2) inflammation, and increased the number of pro-fibrotic, alternatively activated macrophages. Our data suggest that blocking IL-1 signalling as currently investigated in several clinical studies might aggravate pulmonary fibrosis in specific patient subsets due to Th2 skewing of immune responses and formation of alternatively activated pro-fibrogenic macrophages.

BACKGROUND/OBJECTIVES:To maintain and optimise the quality of care provided by health professionals in rheumatology (HPRs), adequate educational offerings are needed. This task force (TF) aimed to develop evidence-based recommendations for the generic core competences of HPRs, with specific reference to nurses, physical therapists (PTs) and occupational therapists (OTs) to serve as a basis for their postgraduate education. METHODS:The EULAR standardised operating procedures for the development of recommendations were followed. A TF including rheumatologists, nurses, PTs, OTs, patient-representatives, an educationalist, methodologists and researchers from 12 countries met twice. In the first TF meeting, 13 research questions were defined to support a systematic literature review (SLR). In the second meeting, the SLR evidence was discussed and recommendations formulated. Subsequently, level of evidence and strength of recommendation were assigned and level of agreement (LoA) determined (0-10 rating scale). RESULTS:Three overarching principles were identified and 10 recommendations were developed for the generic core competences of HPRs. The SLR included 79 full-text papers, 20 of which addressed the competences, knowledge, skills, attitudes and/or educational needs of HPRs from multiple professions. The average LoA for each recommendation ranged from 9.42 to 9.79. Consensus was reached both on a research and educational agenda. CONCLUSION:Evidence and expert opinion informed a set of recommendations providing guidance on the generic core competences of HPRs. Implementation of these recommendations in the postgraduate education of HPRs at the international and national level is advised, considering variation in healthcare systems and professional roles.

AIM:To validate Systemic Lupus International Collaborating Clinics (SLICC)-12 and American College of Rheumatology (ACR)-97 classification criteria on a patient cohort from the University Hospital Center Zagreb.METHODS:This retrospective study, conducted from 2014 to 2016, involved 308 patients with systemic lupus erythematosus (SLE) (n=146) and SLE-allied conditions (n=162). Patients' medical charts were evaluated by an expert rheumatologist to confirm the clinical diagnosis, regardless of the number of the ACR-97 criteria met. Overall sensitivity and specificity, as well as the sensitivity and specificity according to disease duration, were compared between ACR-97 and SLICC-12 classifications. Predictive value for SLE for both classifications was assessed using logistic regression and receiver operating characteristic (ROC) curves.RESULTS:The SLICC-12 criteria had significantly higher sensitivity in early disase, which increased with disease duration. The ACR-97 criteria had higher specificity. The specificity of the SLICC-12 criteria was low and decreased with disease duration. Regression analysis demonstrated the superiority of the SLICC-12 classification criteria over the ACR-97 criteria, with areas under the ROC curve of 0.801 and 0.780, respectively.CONCLUSION:Although the SLICC-12 criteria were superior to the ACR-97 and were more sensitive for diagnosing early SLE, their specificity in our population was too low. The sensitivity of the SLICC-12 classification is increased by better defined clinical features within each criterion. Our results contribute to the current initiative for developing new criteria for SLE.

Objective To summarise the available information on physician workforce modelling, to develop a rheumatology workforce prediction risk of bias tool and to apply it to existing studies in rheumatology. Methods A systematic literature review (SLR) was performed in key electronic databases (1946-2017) comprising an update of an SLR in rheumatology and a hierarchical SLR in other medical fields. Data on the type of workforce prediction models and the factors considered in the models were extracted. Key general as well as specific need/demand and supply factors for workforce calculation in rheumatology were identified. The workforce prediction risk of bias tool was developed and applied to existing workforce studies in rheumatology. Results In total, 14 studies in rheumatology and 10 studies in other medical fields were included. Studies used a variety of prediction models based on a heterogeneous set of need/demand and/or supply factors. Only two studies attempted empirical validation of the prediction quality of the model. Based on evidence and consensus, the newly developed risk of bias tool includes 21 factors (general, need/demand and supply). The majority of studies revealed high or moderate risk of bias for most of the factors. Conclusions The existing evidence on workforce prediction in rheumatology is scarce, heterogeneous and at moderate or high risk of bias. The new risk of bias tool should enable future evaluation of workforce prediction studies. This review informs the European League Against Rheumatism points to consider for the conduction of workforce requirement studies in rheumatology.

OBJECTIVE:Current methods used for forecasting workforce requirements in rheumatology are disparate, as are the parameters incorporated into workforce projection studies. The objective of these European League Against Rheumatism (EULAR points to consider (PTC) is to guide future workforce studies in adult rheumatology in order to produce valid and reliable manpower estimates.METHODS:The EULAR Standardised Operating Procedures were followed. A multidisciplinary task force with experts including patients with rheumatic diseases from 11 EULAR countries and the USA was assembled. A systematic literature review (SLR) was conducted to retrieve workforce models in rheumatology and other medical fields. PTC were based on expert opinion informed by the SLR, followed by group discussions with consensus obtained through informal voting. The level of agreement with the PTC was voted anonymously.RESULTS:A total of 10 PTC were formulated. The task force recommends models integrating supply (=workforce available in rheumatology), demand (=health services requested by the population) and need (=health services that are considered appropriate to serve the population). In general, projections of workforce requirements should consider all factors relevant for current and future workload in rheumatology inside and outside of direct patient care. Forecasts of workforce supply should consider demography and attrition of rheumatologists, as well as the effects of new developments in healthcare. Predictions of future need/demand should take demographic, sociocultural and epidemiological development of the population into account.CONCLUSION:These EULAR-endorsed PTC will provide guidance on the methodology and the parameters to be applied in future national and international workforce requirement studies in rheumatology.

Background: Workforce requirement studies should be conducted in order to ensure the right number of people with the right skills, in the right place at the right time to deliver organizational objectives. Objectives: As part of the EULAR project to develop points to consider for the conduction of workforce studies in rheumatology, we reviewed the literature on workforce prediction with the aim to develop a workforce prediction quality appraisal tool and apply it to existing studies in rheumatology. Methods: Two literature searches were performed in Ovid MEDLINE, EMBASE, CINAHL, Cochrane Library and the grey literature comprising: (1) an update of a previous systematic literature review (SLR) of workforce prediction studies in rheumatology[1] and (2) a hierarchical SLR of workforce prediction studies in other medical fields. We extracted data on type of model used, details on need, demand and supply factors considered in the model, and other relevant aspects such as regional heterogeneity or uncertainty analyses. Based on the results, key general as well as specific need/demand, and supply factors for workforce calculation in rheumatology were identified and each factor was assigned a quality level (low, moderate, high). The quality appraisal tool was applied to the existing workforce modeling studies in rheumatology. Results: Data was extracted from 14 original workforce prediction studies in rheumatology and 10 SLRs in other fields. Studies used a variety of prediction models based on a heterogeneous set of need and/or demand and/or supply factors. While only a few studies attempted to empirically validate the prediction quality of the model (n=3), the consensus was that an integrated model including all these factors is expected to have the highest validity. Based on the different factors considered in existing studies, our quality appraisal tool included the three groups of factors: general factors (e.g. type of the model, stakeholder involvement), need/demand factors (e.g. scope of diseases covered by rheumatologists, morbidity, demography) and supply factors (e.g. time dedicated to clinical work, entry to profession, demographic composition of workforce) (table 1). The majority of studies scored low or moderate on most of the factors. Conclusions: The existing evidence on workforce prediction in rheumatology and other fields is scarce, heterogeneous and of low or moderate quality. The workforce prediction quality appraisal tool will enable future evaluation of workforce prediction studies. This review informs the EULAR points to consider for the conduction of workforce requirement studies in rheumatology. Reference 1. Dejaco C, et al. Arthritis Care Res (Hoboken)2016. Disclosure of Interest: None declared

Background The Union of European Medical Specialists (UEMS) seeks through its speciality Sections and Boards (S&B) to enhance the training of its doctors and to encourage and support the movement of doctors between countries. The Rheumatology S&B has delegates from all EU countries and has developed a document (European Training Requirements (ETR) – at uemsrheumatology.eu) that provides guidance about the rheumatology curriculum. Objectives To determine: 1. The extent of use of the Rheumatology ETR by EU countries 2. The extent of use of logbooks in recording the progress of a trainee 3. If training centres are accredited 4. If national assessment programmes exist for trainees 5. If a country has quality assurance and enhancement processes in rheumatology training Methods A questionnaire was sent to all S&B members asking questions in relation to all of the objectives with one follow-up questionnaire to non-responders. Verification of responses as well as obtaining responses from continuing non-responders occurred in December 2016. Results Nineteen countries responded. Most (18/19) have developed and implemented their own curriculum, often with the influence of the ETR, and also are using a logbook to record the progress of trainees. Training Centres are required to undergo accreditation in 15/19 countries. Another three countries are planning to introduce this. One country does not have an accreditation programme. After accreditation only 8 countries have quality assurance (QA) and enhancement (QE) programmes. In one of these countries the QA and QE processes are variable. Two other countries are either discussing or developing such processes. In 14 countries trainees are assessed to determine their suitability to become specialists. In one of these countries the approach is variable. Two other countries are planning to introduce assessments. Three countries do not assess their trainees. Conclusions Most EU countries have implemented their own, and varied, curricula for rheumatology training. All countries either use or are planning to use a portfolio, again variable in nature, to record trainees9 progress. Thus, it appears that at present any pan-European standardised curriculum or logbook will be of limited utility. Most countries require training centres to undergo accreditation. However, less than half of the countries have a continuation of quality assurance or quality enhancement processes after accreditation with some countries it seems having no plans to do so. At present, a specialist in one European country is required by European law to be recognised as such in another. This study did not determine the nature of the assessments undertaken in different countries but this is not of current relevance within Europe as regards the possible movement of a doctor from one country to another for professional reasons. Disclosure of Interest None declared

The aim of this project was to analyze and compare the educational experience in rheumatology specialty training programs across European countries, with a focus on self-reported ability.

Tumor necrosis factor-alpha inhibitors have become an established therapeutic regimen for patients with rheumatoid arthritis. Regarding their harmful potential they are classified as category B medications. Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women. Disease-modifying antirheumatic drugs (DMARDs) are often used in combination with biological therapy and treatment with methotrexate has shown good results. This antimetabolite is classified as a category X drug and its teratogenic effect is well known. The incidence of inflammatory rheumatic diseases is significantly higher in women. There are many reports on pregnant patients treated with biological therapy, oft en in combination with DMARDs. The effects of such a therapy on reproductive health is a theme of debate, with controversial views on the matter. We present a patient with rheumatoid arthritis whose pregnancy was discovered at 31 weeks of gestation. During that period she had been treated with methotrexate and infliximab, with no adverse effects.

Rheumatoid arthritis (RA) may have an onset at older age. Th e onset of the disease at the age of 60 and over is called late-onset rheumatoid arthritis (LORA). Th e aim of this study was to analyze the clinical, laboratory, radiological, and treatment characteristics of patients with LORA compared to those with early-onset RA (EaORA), provided that all the patients had an approximately equal duration of the disease. Th is is an observational single-center study, which involved 120 patients with an established diagnosis of RA, of which 60 patients had LORA, and 60 patients EaORA. Th e disease activity, measured by the Disease Activity Score 28 (DAS28-ESR), was signifi cantly higher in the LORA group compared to the EaORA group (p<0.05). Signifi cantly more patients with LORA had involvement of the shoulders (LORA vs. EaORA, 30% vs. 15%; p <0.05) and knees (LORA vs. EaORA, 46.7% vs. 16.7%; p <0.05). Radiological erosive changes were signifi cantly more frequent in the LORA group in comparison with EaORA (p <0.05). Th ere was no diff erence between the groups regarding rheumatoid factor (RF) positivity (p>0.05), while the number of patients positive for anti-citrullinated protein antibody (ACPA) was signifi cantly greater in the EaORA group (p<0.05). Th e values of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were signifi cantly higher in the LORA than in the EaORA group. Hemoglobin levels were lower in the LORA group (11.96±1.64 g/dL) than in the EaORA group (12.18±1.56 g/dL). Th e most used disease-modifying antirheumatic drugs (DMARDs) were methotrexate and sulfasalazine, while biological drugs were not used. In conclusion, based on the results of our study, LORA has some features that distinguish it from EaORA, such as higher disease activity, more frequent involvement of large joints, and more pronounced structural damage. Th is should be taken in account in clinical practice, especially regarding treatment choices. Ključne riječi: Reumatoidni artritis – epidemiologija, patofi ziologija, radiografi ja, farmakoterapija; Reumatoid ni faktor – u krvi; Autoantitijela – u krvi; Ciklički peptidi – imunologija; C-reaktivni protein – analiza; Zglobovi – patologija; Antireumatici – terapijska primjena; Dobna granica pojavnosti; Indeks težine bolesti Sažetak. Reumatoidni artritis (RA) može imati početak u starijoj životnoj dobi. Nastup bolesti sa 60 i više godina naziva se RA kasnog početka (engl. Late-Onset Rheumatoid Arthritis – LORA). Cilj ove studije bio je analiziraProfessional paper

Objectives To describe the confidence and training experience acquired during rheumatology training in 21 core competences across the different European countries. Methods As part of a European project to evaluate the differences and similarities in training in rheumatology across Europe, we developed an online survey to assess the training experience. The target population was trainees in rheumatology and rheumatologists certified in the past 5 years. We selected 21 competences, core to rheumatology clinical practice, from the UEMS European curriculum framework (1). For each competence, respondents were asked to assess the confidence in their abilities (0-10 numerical rating scale), the existence of formal education (yes/no), the exposure to patients (0; 1-10; 11-50; 51-100; 101-150; >150) and the existence of an assessment (yes/no) where appropriate. All questions referred to the training period. The survey (June-December 2014) was disseminated in each country by a national PI. Results We gathered 1433 answers to the survey of which 1243 could be included in the analysis (28% of overall target population). Respondents came from the 41 EULAR countries with rheumatology training (30% male, 58% trainees). A summary of the results is presented in Table 1. For any given competence, mean confidence was higher in respondents who had received formal education than in those who had not. Similarly, for all clinical competences and rheumatologic techniques, mean confidence was also higher amongst those who had a higher patient exposure during their training that in those who managed ≤10 patients with that given disease. Mean acquired confidence was also higher in respondents who had a longer training period (internal medicine plus rheumatology) than in those with a shorter training period for all competences except osteoporosis and hand Xray interpretation. The level of confidence was also higher for specialists (vs trainees). Conclusions The acquired confidence in competences during the rheumatology training program considered core for rheumatology practice is variable, but overall reasonably high. Most of the trainees seem to receive formal education and have some patient exposure in all competences, though only around half are assessed in each competence. References European Board of Rheumatology (a section of UEMS). The European Rheumatology Curriculum Framework. www://dgrh.de/fileadmin/media/Praxis_Klinik/european_curriculum_uems_april_2008.pdf Disclosure of Interest None declared

Rheumatoid arthritis and primary biliary cirrhosis coexist in up to 6% of cases. Tumor necrosis factor alpha seems to have an important role in the pathogenesis of both diseases. Tumor necrosis factor alpha inhibitors have become an established therapeutic regimen for patients with rheumatoid arthritis. The only approved drug for primary biliary cirrhosis is ursodeoxycholic acid. We describe the case of a female patient with both rheumatoid arthritis and primary biliary cirrhosis in a long term remission of both diseases induced with adalimumab. This case report is an important addendum to a few published similar reports.

OBJECTIVES:To analyse the similarities and discrepancies between the official rheumatology specialty training programmes across Europe. METHODS:A steering committee defined the main aspects of training to be assessed. In 2013, the rheumatology official training programmes were reviewed for each of the European League Against Rheumatism (EULAR) countries and two local physicians independently extracted data on the structure of training, included competencies and assessments performed. Analyses were descriptive. RESULTS:41 of the 45 EULAR countries currently provide specialist training in rheumatology; in the remaining four rheumatologists are trained abroad. 36 (88%) had a single national curriculum, one country had two national curricula and four had only local or university-specific curricula. The mean length of training programmes in rheumatology was 45 (SD 19) months, ranging between 3 and 72 months. General internal medicine training was mandatory in 40 (98%) countries, and was performed prior to and/or during the rheumatology training programme (mean length: 33 (19) months). 33 (80%) countries had a formal final examination. CONCLUSIONS:Most European countries provide training in rheumatology, but the length, structure, contents and assessments of these training programmes are quite heterogeneous. In order to promote excellence in standards of care and to support physicians' mobility, a certain degree of harmonisation should be encouraged.

Training Requirements for the Specialty Rheumatology - European Standards of Postgraduate Specialty Training was endorsed by UEMS in 2014. The document describes the training requirements for trainee (content of training with learning outcomes and organisation of training), training requirements for trainer (process of recognition of trainer and quality management for trainers), training requirements for institutions (process of recognition of training centre and quality management within training institution); the proposed record of clinical work and list of conditions are included. Based on the training requirements, assessments of knowledge, skills and professional behaviour is needed. Progressively, the common approach to determining whether an individual is suitable to be recognised as a European Rheumatologist is expected. In order to develop the assessment strategy it was agreed that a discussion of how best to ensure that a trainee meets the outcomes of the Training Requirements will be organised. The questionnaire is being developed seeking for the information on the record of clinical work and clinical skills, that exists in many European countries. Within the set of questions it is asked how is the trainee9s knowledge examined, how a trainee9s involvement with the care of patients is determined, how is the competency in a range of clinical procedures assessed, which topics related to professional behaviours are in use and how they are assessed, which evidence of a doctor9s good standing are provided. The answers from the countries9 representatives and a follow-up questionnaire would allow the Section and Board to develop an agreed way in which European trainees might be assessed. Disclosure of Interest None declared