scholarly journals THU0443 A probability score from a fast track clinic to aid the management of suspected giant cell arteritis

2018 ◽  
Author(s):  
F. Laskou ◽  
F. Coath ◽  
S. Mackie ◽  
S. Banerjee ◽  
T. Aung ◽  
...  
Keyword(s):  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Fast Track ◽  
Probability Score

scholarly journals OP0150 WHAT IS THE ROLE OF TEMPORAL ARTERY BIOPSY IN GIANT CELL ARTERITIS FAST-TRACK PATHWAYS WHEN TEMPORAL ARTERY ULTRASOUND IS NEGATIVE?

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 95.3-95
Author(s):  
A. Sachdev ◽  
S. Dubey ◽  
C. Tiivas ◽  
M. George ◽  
P. Mehta
Keyword(s):  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Sensitivity And Specificity ◽  
Fast Track ◽  
Temporal Artery ◽  
Clinical Findings ◽  
Specimen Size ◽  
Temporal Artery Biopsy ◽  
Duration Of Treatment ◽  
Relevant Role

Background:A number of centres are now running fast track pathways for diagnosis and management of Giant cell arteritis with ultrasound as the first port of call for diagnosis1. Temporal artery biopsies (TABs) have become the second line of investigation, and it is unclear how useful TAB is in this setting.Objectives:This study looked at accuracy of Temporal artery biopsy (TAB) in patients with suspected Giant Cell arteritis (GCA) with negative/inconclusive ultrasound (U/S) and how duration of treatment on steroids prior to these investigations and arterial specimen size affected it.Methods:Prospective study of all patients with suspected GCA referred for TAB when U/S was negative or inconclusive, as part of the local fast-track pathway (Coventry). Database included clinical findings, serological work up, U/S and TAB results and treatment. Sensitivity and specificity of U/S and TAB was calculated and compared based on duration of treatment with steroids.Results:One hundred and nine patients were referred for TAB via Coventry fast-track-pathway. The sensitivity of U/S in this cohort of patients was 9.08% and specificity was 93.33%. After 3 days of steroid this was 0% and 100% respectively. For TAB when done within 10 days of starting steroids, this was 65% and 87.5% respectively. After 20 days of steroids this was 0 % and 100%. The sensitivity and specificity was 20% and 85% when arterial specimen size was 11-15mm and 47% and 100% when specimen size was 16 mm or more. Sensitivity and specificity of U/S of 644 suspected GCA patients was 48% and 98%.Conclusion:Our study demonstrates that TAB plays a relevant role in GCA fast-track-pathways, when U/S is negative/inconclusive. TAB was more sensitive than U/S in this cohort of patients, but overall sensitivity of U/S was higher when calculated for all patients suspected with GCA. Both remain useful tests if performed early. TAB specimen size should ideally be 16mm or more and done within 10 days of starting steroids.References:[1]Jonathan Pinnell, Carl Tiivas, Kaushik Chaudhuri, Purnima Mehta, Shirish Dubey, O38 The diagnostic performance of ultrasound Doppler in a fast-track pathway for giant cell arteritis,Rheumatology, Volume 58, Issue Supplement_3, April 2019, kez105.036,https://doi.org/10.1093/rheumatology/kez105.036Disclosure of Interests:None declared

scholarly journals POS0821 THE DIFFERENT SUBTYPES OF GIANT CELL ARTERITIS BY ULTRASOUND: RESULTS FROM A FAST-TRACK CLINIC

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 664.3-664
Author(s):  
I. Monjo ◽  
E. Fernández-Fernández ◽  
J. Ortega ◽  
E. De Miguel
Keyword(s):  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Fast Track ◽  
Carotid Arteries ◽  
Imaging Techniques ◽  
Vascular Involvement ◽  
Temporal Arteries ◽  
Halo Sign ◽  
Cranial Vessels ◽  
Large Vessels

Background:Giant cell arteritis (GCA) is a vasculitis that affects the medium and large vessels (LV). Although cranial artery involvement is better known, awareness of the importance of LV involvement is increasing. Imaging techniques currently constitute the basis for the diagnosis of LV-GCA and have improved its diagnosis and prevalence. In recent years, differences in clinical patterns and different inflammatory and etiopathogenic mechanisms of the disease have been suggested. Therefore, improving sensitivity to diagnosis is essential to improve the knowledge and care of our population.Objectives:The aim of this study was to know the prevalence of the different ultrasound patterns of GCA in our area.Methods:Retrospective records of available data were collected from all patients referred to our ACG fast track clinic in the past three years. The clinical and laboratory characteristics were evaluated at the time of referral. All patients underwent an ultrasound scan of cranial vessels (superficial temporal arteries (TA) and their frontal and parietal branches) and large vessels (axillary, subclavian and carotid arteries). The doctor confirmed the GCA diagnosis after at least six months of follow-up. The OMERACT definitions of halo sign with a hypoechoic wall thickness ≥ 0.34 mm were used for TA pathology for the ultrasound diagnosis of GCA and for axillary, subclavian and carotid arteries and homogeneous hypoechoic thicknesses ≥ 1 mm of the arterial wall were applied. Atherosclerosis lesions were evaluated to detect this disease as a possible false positive halo sign. An Esaote Mylab Twice with a 13 MHz probe in BT and 22 MHz for cranial vessels in 2017-2019 and an Esaote Mylab X8plus with a 15 MHz probe for BT and a 24 MHz probe for cranial arteries in 2019-2020 were used by two rheumatologist with long experience in ACG ultrasound.Results:A total of 261 patients (180 women / 81 men) with suspected GCA were evaluated in our fast track clinic. The mean age (± SD) was 76 ± 9.2 years and CRP at diagnosis was 75.7 ± 68.6 mg/L. The time elapsed since the first symptoms was less than 6, 6-12, 12-24 or >24 weeks in 37.5%, 19.9%, 12.3% and 15.7% respectively. Of the 261 cases explored, 160 had GCA, of which 102 were women and 58 men, and had a mean age of 77.21 ± 7.9 years. The ultrasound patterns of GCA were: 71 patients had exclusive involvement of the TA (cranial-GCA), 54 had a mixed pattern with involvement of both TA and LV (mixed-CGA), and 35 had isolated involvement of the LV (LV-GCA). That is, 125 patients had cranial involvement with or without LV involvement and 89 had LV-GCA associated or not with cranial involvement (Figure 1).Figure 1.Ultrasound patters of GCAConclusion:Ultrasound is a useful tool for the screening of GCA and its different subtypes of vascular involvement. The isolated cranial subtype or associated with LV-GCA is the most common (78% of cases), but LV-GCA is also very common (55.6% of cases of GCA) and 21.9% presents as an isolated LV-GCA standard. The LV arteries should be included in the ultrasound examination for suspected GCA.Disclosure of Interests:Irene Monjo Speakers bureau: Roche, Novartis, UCB, Gedeon Richter, Consultant of: Roche, Elisa Fernández-Fernández: None declared, Javier Ortega: None declared, Eugenio de Miguel Speakers bureau: AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi, Paid instructor for: Janssen, Novartis, Roche, Consultant of: AbbVie, Novartis, Pfizer, Galapagos, Grant/research support from: Abbvie, Novartis, Pfizer

scholarly journals 339. COVENTRY FAST-TRACK GIANT CELL ARTERITIS PATHWAY WITH WALK-IN ULTRASOUND: 3 YEAR DATA

Rheumatology ◽  
2017 ◽  
Vol 56 (suppl_2) ◽  
Author(s):  
Shirish Dubey ◽  
Carl Tiivas ◽  
Matthew George ◽  
Purnima Mehta
Keyword(s):  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Fast Track

scholarly journals 9. Outcomes and cost effectiveness analysis of fast track pathway in giant cell arteritis

Rheumatology ◽  
2014 ◽  
Vol 53 (suppl 2) ◽  
pp. i5-i6 ◽  
Author(s):  
P. Patil ◽  
K. Achilleos ◽  
M. Williams ◽  
W. Maw ◽  
C. Dejaco ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Fast Track ◽  
Cost Effectiveness Analysis ◽  
Effectiveness Analysis

scholarly journals Corticosteroids reduce vascular ultrasound sensitivity even with short duration: results from Coventry Multi-Disciplinary Fast Track Pathway for management of Giant Cell Arteritis

2020 ◽  
Author(s):  
Jonathan Pinnell ◽  
Purnima Mehta ◽  
Carl Tiivas ◽  
Shirish Dubey
Keyword(s):  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Short Duration ◽  
Fast Track ◽  
False Negative ◽  
Real Life ◽  
Multidisciplinary Assessment ◽  
Ethical Approval ◽  
Set Up ◽  
The Impact

AbstractIntroductionGiant cell arteritis (GCA) is a common form of vasculitis and can result in permanent visual loss and other complications. The advent of vascular Doppler ultrasound (US) has provided a new means for early diagnosis for these patients although it is affected by introduction of corticosteroids (CS). The Coventry multidisciplinary fast track (FTGCA) pathway was set up in 2013 in collaboration with vascular physiology and ophthalmology with a view to enabling prompt multidisciplinary assessment.ObjectivesThis study aims to assess feasibility of this novel pathway and to assess the impact of CS use on the performance of US in a real life cohort.MethodsData were collected retrospectively for patients who attended the Coventry FTGCA pathway between 1st Jan 2014 to 31st December 2017. Patients were identified from US lists and clinical details were obtained from electronic medical records. Ethical approval was obtained from Research and Development department.Results620 eligible patients were included in this study. The pathway overall performed well with significant reduction in patients needing CS. US had sensitivity of 50% which improved further to ∼56% in CS naïve patients although median duration of CS use was 2 days. US specificity was >96%, and we were able to avoid using CS completely in 451 patients (73%). CS negatively impacted on utility of US with US more likely to be false negative.ConclusionsThis novel pathway demonstrates the ability to minimise use of CS through fast track multidisciplinary assessment. US was performed promptly and had reassuring real life sensitivity and specificity in this cohort. CS naïve patients showed significantly higher sensitivity for US despite the short duration of CS use.

SAT0256 THE ROLE OF FAST-TRACK ULTRASOUND IN PREVENTING EARLY COMPLICATIONS AND RELAPSES IN GIANT CELL ARTERITIS

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 1071.1-1071
Author(s):  
P. Delvino ◽  
S. Monti ◽  
A. Bartoletti ◽  
E. Bellis ◽  
F. Brandolino ◽  
...  
Keyword(s):  
Visual Impairment ◽  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Fast Track ◽  
Clinical Signs ◽  
Conventional Group ◽  
High Dose ◽  
First Relapse ◽  
The Impact

Background:Giant Cell Arteritis (GCA) is the most common form of primary systemic vasculitis, mainly affecting adults over 50 years old. Permanent visual loss (PVL) is one of the most feared complications, occurring in about 20% of cases, typically prior to initiation of high-dose glucocorticoid (GC) therapy. Color-duplex sonography (CDS) of temporal arteries (TAs) and large vessels (LVs) is recognized as a first-line diagnostic tool for patients with suspected GCA. A fast track approach (FTA), incorporating CDS has been associated to a significant reduction of PVL in two retrospective studies1,2.Objectives:To assess the impact of FTA on PVL and risk of relapses during follow-up compared to conventional care prior to the introduction of the FTA in our rheumatology clinic.Methods:Patients with new-onset GCA evaluated in our department from January 1998 to September 2019 were included in the study. The FTA approach for GCA was implemented since October 2016. The diagnosis of GCA was based on positive TAs and/or LVs CDS and/or a positive TA biopsy and clinical signs and symptoms of GCA. All patients were clinically examined by the same rheumatologist who performed the CDS. PVL was defined as total visual impairment in one or both eyes. Data on baseline clinical features and later outcomes were collected.Results:153 patients were included: 115 females (75.2%), mean age at diagnosis 71.6±8.2 years. Of these, 112 patients (73%) were evaluated conventionally and 41 (27%) with FTA. Patients in the FTA group were older (P=0.0002), presented more frequently with polymyalgia rheumatica symptoms, weight loss, jaw or tongue claudication and scalp tenderness (P<0.05 for all comparisons). The median duration of follow-up in the FTA group was shorter compared with the conventional group (1.5 vs 5.8 years). PVL occurred in 22 (19.6%) patients in the conventional group compared to 5 patient (12.2%) in the FTA, leading to a reduction of 37.9% in the relative risk of PVL with the FTA approach. Cumulative incidence of relapses and time to first relapse did not change after FTA introduction (P>0.05) (Fig. 1).Conclusion:The application of a FTA in GCA resulted in a significant reduction of PVL. However, the relapse rate did not seem to be influenced by the FTA, highlighting the need to implement further management strategies, besides earlier diagnosis and prompt initiation of GC, that would impact the course of the disease during long-term follow-upReferences:[1]Patil P, Williams M, Maw WW et al. Fast track pathway reduces sight loss in giant cell arteritis: results of a longitudinal observational cohort study. Clin Exp Rheumatol 2015;33(Suppl 89):S-103-6.[2]Diamantopoulos AP, Haugeberg G, Lindland A, Myklebust G. The fast-track ultrasound clinic for early diagnosis of giant cell arteritis significantly reduces permanent visual impairment: towards a more effective strategy to improve clinical outcome in giant cell arteritis? Rheumatology 2016;55:66_70.Fig. 1.Time to first relapse in patients with GCA and evaluated with a FTA compared to conventionally approached patients.Disclosure of Interests:None declared

scholarly journals 074 Fast track giant cell arteritis clinic and pathway for early management of suspected giant cell arteritis: an audit

Rheumatology ◽  
2018 ◽  
Vol 57 (suppl_3) ◽  
Author(s):  
Faidra Laskou ◽  
Coath Fiona ◽  
Tin Aung ◽  
Siwalik Benerjee ◽  
Bhaskar Dasgupta
Keyword(s):  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Fast Track ◽  
Early Management

scholarly journals P204 An evaluation of a daily fast-track diagnostic ultrasound service for patients with suspected new onset giant cell arteritis during the COVID-19 pandemic

Rheumatology ◽  
2021 ◽  
Vol 60 (Supplement_1) ◽  
Author(s):  
Jonathan P White ◽  
Germana Sallemi ◽  
Binaya Dhungana ◽  
Shirish Dubey ◽  
Raashid A Luqmani
Keyword(s):  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Clinical Evaluation ◽  
Fast Track ◽  
Median Number ◽  
Wall Thickening ◽  
Temporal Artery Biopsy ◽  
Diagnostic Certainty ◽  
Significant Difference ◽  
The Impact

Abstract Background/Aims  COVID-19 has reinforced the necessity for a faster and more accurate diagnostic pathway for suspected giant cell arteritis (GCA) patients so that unnecessary use of glucocorticoids can be avoided/minimised. During the COVID-19 pandemic, we replaced a twice weekly service with a 5 day per week ultrasound-based fast-track pathway within a secondary/tertiary hospital. The aim was to determine the impact of a more frequent diagnostic service for GCA, based on rapid access to ultrasound and clinical evaluation on the diagnostic certainty in evaluating patients with newly suspected GCA. Methods  We reviewed records from patients referred between November 2019 to July 2020, comparing those seen during 17 weeks ‘pre-COVID’, using the twice weekly service, with patients seen during 17 weeks of a 5 day per week service, termed ‘intra-COVID’. All patients underwent clinical evaluation and an eight-site ultrasound of temporal and axillary arteries. Those with hypoechoic, non-compressible peri-luminal arterial wall-thickening (or halo sign) were considered ultrasound ‘positive’. Results  We audited 139 patients with suspected GCA (63 pre-COVID period vs 76 intra-COVID). A clinical diagnosis of GCA was made in 33.3% pre-COVID and 42% intra-COVID (p = 0.289). Ultrasound sensitivity improved from 38.1% to 68.6% (p &lt; 0.0001), whilst specificity remained unchanged (100%, p &lt; 0.0001) for both periods. The proportion of patients seen within seven days of referral improved by 61.6% (p &lt; 0.0001), from 31.7% (pre-COVID) to 93.3% (intra-COVID). The median number of days from referral to assessment fell over four-fold, from 12.5 (interquartile range [IQR]=8.25) to 3 (IQR=3.5) respectively. Median number of days of steroid exposure fell over seven-fold from 15 days (IQR=11.25) pre-COVID to 2 days (IQR=5) intra-COVID. Similar proportions in both periods were empirically commenced on steroids prior to assessment (71% vs 68% respectively, p = 0.700). Mean number of ‘halos’ increased from 0.25 (standard deviation [SD]1.19) pre-COVID to 3.05 (SD = 1.82) intra-COVID. The was no significant difference in the number of GCA visual complications (p = 0.894). Ultrasound positivity was associated with fewer days of steroid exposure: the median number of days on steroids in negative versus positive scans was 16 and 5.5 (pre-COVID); compared to 2.5 and 1 days (intra-COVID). The proportion of patients without GCA who were empirically commenced on steroids reduced from 71.4% to 56.8% (pre-COVID vs intra-COVID, p = 0.158) and median days steroid exposure reduced from 9.5 (IQR=17.5) to 1 (IQR=5), respectively. Conclusion  A regular, daily ultrasound service for diagnosing suspected GCA significantly improved diagnostic accuracy and reduced unnecessary steroid exposure in patients who did not have GCA. The sensitivity of ultrasound improved by 30.5% and the delay from steroid exposure to diagnosis was reduced by 76%. An ultrasound-based daily fast-track service significantly improved the diagnostic certainty of suspected GCA, especially during the COVID-19 pandemic when availability of temporal artery biopsy was very limited. Disclosure  J.P. White: None. G. Sallemi: None. B. Dhungana: None. S. Dubey: None. R.A. Luqmani: None.

scholarly journals AB0384 IMPACT OF TEMPORAL ARTERY ULTRASOUND ON SURVIVAL OF PATIENTS WITH GIANT CELL ARTERITIS

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 1219.2-1220
Author(s):  
P. Estrada ◽  
D. Reina ◽  
V. Navarro ◽  
O. Camacho ◽  
D. Cerda ◽  
...  
Keyword(s):  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Fast Track ◽  
Temporal Artery ◽  
Rapid Diagnosis ◽  
Diagnostic Approach ◽  
Term Survival ◽  
Significant Difference ◽  
Group A ◽  
The Impact

Background:Giant cell arteritis (GCA) is the most common primary systemic vasculitis in adults over 50 years of age. Its incidence increases with age, with a peak between 70-80 years and predominates in women, 3:1. It is a medical emergency that, if not diagnosed, can lead to irreversible complications. The delay in time from diagnosis to start of treatment is crucial to avoid possible serious outcomes on short, medium and long term. Survival in GCA is estimated between 60-90% at 5 years and 48-81% at 10 years. Efforts have been made to implement rapid diagnostic circuits to assess patients and initiate treatment without delay with good results both in reducing permanent vision loss and in reducing the costs of these patients due to emergency visits and admissions. The morbidity and mortality of this disease is high, but the use of efficient diagnostic strategies, such as ultrasound of superficial temporal arteries, has proven to be a useful, practical, cost-effective and, above all, quick tool to make the diagnostic approach.Objectives:Analyze the impact of early temporal artery ultrasound on survival for patients with GCA.Methods:Survival study of 48 patients with GCA, in two different “stages” in terms of diagnostic approach: Group A (n = 27), patients diagnosed between 2002 - 2011 using only ACR 1990 criteria and Group E (n = 21) diagnosed between 2010-2015 using ACR criteria and TAUS. TAUS was performed by Rheumatologists with extensive experience in ultrasound and within a period of no more than 7 days for these patients. The definitive diagnosis of GCA was based on the clinical criteria of the Rheumatologist within the clinical and analytical context and with the specific complementary examinations for each case (Ultrasound, PET-CT, biopsy). Demographic data, comorbidities, signs and symptoms at debut, analytical data, complementary examinations, treatment and evolution were obtained retrospectively through the electronic medical record of the patient, based on the database of our GCA cohort. A survival analysis was performed considering death as the main outcome. The statistic used was the Kaplan-Meier test. In addition, other complications related to treatment or pathology are collected.Results:The mean age at diagnosis of our patients was 79 + - 6 years, with a female: male ratio of 3: 1. The follow-up was between 2 and 16 years with a mean of 5.8 + - 3 years, until the last visit collected or until the outcome of death. Group A had a survival at 5 and 10 years of 53.4% and 36.7% respectively, while group E of 79.5% at both cut-off points. (Figure 1).There is a significant difference between the survival of both groups, p <0.01, this being better in the group in which TAUS was implemented for rapid diagnosis (group E). The main causes of death were cardiovascular events, 30%, predominantly in group E (75%), and infection, 30%, predominantly in group A. The median from diagnosis to death was 3 years (range 1 - 13).Figure 1.Group A (red line) according to ACG 1990 criteria and Group B (green line) according to ACG criteria and implementing TAUS for rapid diagnosisConclusion:The implementation of temporal artery ultrasound (TAUS) is associated with a significant improvement in the survival rate of patients with GCA and a reduction in treatment-related complications in patients who were diagnosed with ultrasound in less than 7 days compared to those diagnosed by the conventional healthcare attention routes.References:[1]Gonzalez-Gay MA, et al. Giant cell arteritis: epidemiology, diagnosis, and management. DOI: 10.1007/s11926-010-0135-9[2]Patil P, et al. Fast track pathway reduces sight loss in giant cell arteritis: results of a longitudinal observational cohort study. PMID: 26016758[3]Breuer GS, et al. Survival of patients with giant cell arteritis: a controversial issue. PMID: 31969222[4]Diamantopoulos AP, et al. The fast-track ultrasound clinic for early diagnosis of giant cell arteritis significantly reduces permanent visual impairment: towards a more effective strategy to improve clinical outcome in giant cell arteritis? 10.1093/rheumatology/kev289Disclosure of Interests:None declared

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