scholarly journals AB1174 TRACKING THE EFFECTS ON A CLINICAL SERVICE OF INTRODUCING ULTRASOUND FOR DIAGNOSIS OF GIANT CELL ARTERITIS: DESIGN OF A SERVICE EVALUATION USING LEAN METHODOLOGY

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 1877.2-1878
Author(s):  
S. Mackie ◽  
A. Barr ◽  
A. Cracknell ◽  
S. Farrell ◽  
J. Parvin ◽  
...  
Keyword(s):  
Lead Time ◽  
Axillary Artery ◽  
Care Pathway ◽  
Temporal Artery ◽  
Service Evaluation ◽  
Significant Shift ◽  
Temporal Artery Biopsy ◽  
Prednisolone Dose ◽  
Patient Feedback ◽  
The Impact

Background:In our large, multi-site hospital, patients with suspected GCA are started promptly on high-dose prednisolone but until 2019, patients waited for temporal artery biopsy (TAB) until the GCA diagnosis could be confirmed (“GCA”) or refuted (“not-GCA”). Reports of the impact of introducing temporal and axillary artery ultrasound (TAUS) have mainly come from smaller hospitals. Agreement between TAUS and TAB has been reported by others with a Cohen’s kappa of 0.35 [1] and 0.40 [2]. We used Lean methodology to identify metrics across 5 key domains: delivery, quality, service, morale and cost.Objectives:To design metrics for a service evaluation to measure impact of introducing TAUS, and to test their feasibility of measurement within routine care.Methods:Our primary driver was time from presenting to our service to diagnostic confirmation (lead time). Pathway mapping, value stream mapping and a driver diagram identified key ideas for improvement.We chose to measure: Delivery (mean lead time for each month), Quality (proportion of patients with GCA and positive TAB/TAUS; total (cumulative) prednisolone dose in patients with not-GCA, Service (patient feedback), Morale (staff feedback) and Cost (number of patients; cost of tests per patient; overall costs). We plotted these by month on run charts and defined a significant shift as 6 consecutive monthly values below baseline median. Cohen’s kappa was calculated using GraphPad QuickCalcs.Results:Routine TAUS for suspected GCA was introduced from January 2019, alongside a multidisciplinary team monthly meeting. TAUS was done a median of 2.5 days from referral. Agreement between TAB and TAUS results was good (Table 1). The run chart showed a significant shift in our Delivery (median lead time fell from 28.7 days to 21 days after introduction of ultrasound) and both Quality metrics (proportion of GCA with positive TAB/TAUS increased from 29% to 69%; total prednisolone dose for not-GCA fell from 1.335g to 0.846g).Table 1.Concordance between temporal and axillary artery ultrasound (TAUS) and temporal artery biopsy (TAB) in scans performed through 2019. Cohen’s weighted kappa 0.59 (including equivocal results as separate category).TAUS positiveTAUS negativeTAUS equivocalTAB positive1411TAB negative5275TAB equivocal030Within Costs, average per-patient costs of TAB/TAUS declined from £1004/patient to £792/patient, but total referrals for TAB/TAUS increased from 6/month to 10/month, increasing overall costs. Staff and patient feedback (Service, Morale) revealed that further improvements to the care pathway were needed to manage the additional complexity.Conclusion:Lean methodology identified multiple metrics for evaluating the impact of TAUS on our service. Introducing TAUS improved Delivery and Quality, but measuring Costs, Morale and Service helped identify unintended consequences. Concordance between TAUS and TAB was good. We plan to continue to improve and monitor the care pathway based on our multi-stakeholder feedback.References:[1]Luqmani et al., HTA 2016[2]Mukhtyar et al., Clin Rheum 2019Disclosure of Interests:Sarah Mackie Grant/research support from: Roche (attendance of EULAR 2019; co-applicant on research grant), Consultant of: Sanofi, Roche/Chugai (monies paid to my institution not to me), Andrew Barr: None declared, Alison Cracknell: None declared, Shannon Farrell: None declared, Jimmy Parvin: None declared, Ajay Patil: None declared, Ian Simmons: None declared, Kate Smith Grant/research support from: Medical education grants from Sanofi and Biogen, Speakers bureau: Novartis, Andrea Sweeting: None declared, Max Troxler: None declared, Tara Webster: None declared, Richard Wakefield Speakers bureau: Novartis, Janssen, GE

scholarly journals The impact of Temporal Artery Biopsy for the diagnosis of Giant Cell Arteritis in clinical practice in a tertiary University Hospital

2019 ◽  
Author(s):  
E Kaltsonoudis ◽  
E Pelechas ◽  
A Papoudou-Bai ◽  
E.T. Markatseli ◽  
M Elisaf ◽  
...  
Keyword(s):  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Laboratory Data ◽  
Unknown Origin ◽  
Temporal Artery ◽  
University Hospital ◽  
Temporal Artery Biopsy ◽  
Acute Phase Reactants ◽  
Anemia Of Chronic Disease ◽  
The Impact

ABSTRACTBackgroundTemporal artery biopsy (TAB) is useful in assisting with giant cell arteritis (GCA) diagnosis but lacks sensitivity. The aim of our study was to assess the diagnostic impact of TAB histology in patients with suspected GCA on hospital admission.MethodsA prospectively maintained database was queried for all TABs performed between 1-1-2000 until 31-12-2017 at the University Hospital of Ioannina. Thus, inclusion criteria were made on the grounds of every patient that underwent a TAB during the above-mentioned period, regardless of demographic, clinical and laboratory data.ResultsTwo hundred forty-five TABs were included (149 females and 96 males), with a mean age of 64.5 (±3.5) years. The mean symptoms duration until admission to the hospital was 8.6 (±1.3) weeks and all had elevated acute phase reactants on admission. The reasons of admission were fever of unknown origin (FUO) in 114 (46.5%) patients, symptoms of polymyalgia rheumatica (PMR) in 84 (34.3%), new headache in 33 (13.5%), anemia of chronic disease (ACD) in 8 (3.32%) and eye disturbances in 6 (2.5%) patients. Positive results were found in 49 (20%) TABs. More specifically, in 14% of patients with FUO, 21% in those with PMR, while in patients with a new headache the percentage was 27%. Finally, 5 out of 6 (83.3%) of patients with ocular symptoms and only one (12.5%) of those suffering from ACD. Visual manifestations and FUO are correlated with a positive TAB.ConclusionIt seems that TAB is useful in assisting with GCA diagnosis, but lacks sensitivity.

scholarly journals The impact of temporal artery biopsy for the diagnosis of giant cell arteritis in clinical practice in a tertiary university hospital

PLoS ONE ◽  
2019 ◽  
Vol 14 (3) ◽  
pp. e0210845 ◽  
Author(s):  
Evripidis Kaltsonoudis ◽  
Eleftherios Pelechas ◽  
Alexandra Papoudou-Bai ◽  
Theodora E. Markatseli ◽  
Moses Elisaf ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Temporal Artery ◽  
University Hospital ◽  
Temporal Artery Biopsy ◽  
The Impact

scholarly journals The impact of temporal artery biopsy on surgical practice

2016 ◽  
Vol 11 ◽  
pp. 47-51 ◽  
Author(s):  
Adam Thomas Cristaudo ◽  
Ryo Mizumoto ◽  
Rasika Hendahewa
Keyword(s):  
Temporal Artery ◽  
Temporal Artery Biopsy ◽  
Surgical Practice ◽  
The Impact

scholarly journals P37: THE IMPACT OF TEMPORAL ARTERY BIOPSY AT A UK TERTIARY PLASTIC SURGERY UNIT

2021 ◽  
Vol 108 (Supplement_1) ◽  
Author(s):  
BJW Chew ◽  
A Khajuria ◽  
J Ibanez
Keyword(s):  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Steroid Therapy ◽  
Temporal Artery ◽  
Clinical Suspicion ◽  
Temporal Artery Biopsy ◽  
Diagnostic Uncertainty ◽  
Number Of Patients ◽  
Significant Difference ◽  
The Impact

Abstract Introduction Guidelines recommend temporal artery biopsy (TAB) for patients suspected of having giant cell arteritis (GCA). We evaluated the impact of TAB on the diagnosis and management of patients with suspected GCA at a tertiary plastic surgery unit. Method A retrospective review of all TAB procedures performed at our centre over 7 years was performed. One hundred and one patients were included in the study. Patients were classified into 3 diagnostic groups: confirmed (positive TAB), presumed (negative TAB with high clinical suspicion) and unlikely (negative TAB with low clinical suspicion). The clinical presentation and management for each group were compared. Result The average American College of Rheumatology (ACR) score was 3.07. The number of patients with an ACR score of ≥3 before TAB was 72 (71.3%) and remained the same after TAB. The number of patients who remained on steroid therapy was lower in the group with an unlikely diagnosis of GCA compared to the group with a confirmed diagnosis (p<0.05). Conversely, there was no significant difference in steroid therapy between those with a presumed and confirmed diagnosis (p>0.05). Conclusion This study found a significant difference in steroid treatment between those with confirmed GCA and those where the diagnosis was unlikely showing that TAB may support decisions regarding steroid therapy. However, TAB was inappropriately requested for patients whose pre-TAB ACR score was ≥3 as this score is sufficient for the diagnosis of GCA. Therefore, the use of TAB should be limited to cases of diagnostic uncertainty. Take-home message while temporal artery biopsy has a role to play in the diagnosis of GCA, its use should be limited to cases of diagnostic uncertainty and not requested for every patient with a suspicion of Giant Cell Arteritis.

scholarly journals 051 Overlapping syndrome of giant cell arteritis and ANCA-associated vasculitis complicated by severe axonal neuropathy: a case report

2019 ◽  
Vol 90 (e7) ◽  
pp. A17.1-A17
Author(s):  
Laura Perju-Dumbrava ◽  
Fariha Islam ◽  
Rohitha Makonahalli ◽  
Catriona McLean ◽  
Hedley Griffiths ◽  
...  
Keyword(s):  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Axonal Neuropathy ◽  
Temporal Artery ◽  
Giant Cells ◽  
Temporal Artery Biopsy ◽  
Vasculitic Neuropathy ◽  
Prednisolone Dose ◽  
Anca Associated Vasculitis ◽  
Peripheral Nerve Involvement

CaseA 61-year- old woman presented with what was thought to be a refractory, temporal artery biopsy-proven giant cell arteritis (GCA). After 4 months of therapy she was unable to get the prednisolone dose below 40 mg/day, so weekly subcutaneous Tocilizumab was introduced but with minimal response after 8 weeks. She was then admitted to hospital with a severe rapidly progressive length dependent sensorimotor peripheral neuropathy. Nerve conduction studies showed predominantly an axonal neuropathy with multiple pseudo-conduction blocks.Sural nerve and gastrocnemius biopsies revealed a necrotising vasculitis with numerous giant cells and active axonal degeneration. She proved to be ANCA-PR3 positive, without other systemic manifestations. ANCA-associated vasculitic neuropathy was diagnosed and she was treated with two 1g Rituximab infusions, 2 weeks apart.On follow-up after a month, she had regained some strength but still required a wheelchair for mobility. Further Rituximab infusion after 6 months is planned; prednisolone had been successfully weaned to 10 mg/day.ConclusionPeripheral nerve involvement, which is relatively common in ANCA-associated vasculitis, has also been reported in 14% of GCA cases. But ANCA-PR3 positivity is rare in biopsy-proven GGA, with only a handful of well-documented cases.Heightened suspicion of an alternative diagnosis in the face of an unusual clinical course (lack of steroid response and appearance of small vessel vasculitic symptoms for what is accepted to be a large vessel vasculitis) is critical and our experience highlights the important fact that a diagnosis of one of these disorders does not preclude the subsequent diagnosis of the other.

The ROLE OF CHINA-PAK ECONOMIC CORRIDOR (CPEC) IN LOGISTIC SYSTEM OF PAKISTAN’S AND CHINA’S

2019 ◽  
Vol 6 (1) ◽  
pp. 48-50
Author(s):  
Ikram Uddin
Keyword(s):  
Persian Gulf ◽  
Lead Time ◽  
Fiber Optic ◽  
Delivery Time ◽  
Fiber Optic Cable ◽  
Total Cost ◽  
Economic Complexity ◽  
Shipping Cost ◽  
The Impact

This study will explain the impact of China-Pak Economic Corridor (CPEC) on logistic system of China and Pakistan. This project is estimated investment of US $90 billion, CPEC project is consists of various sub-projects including energy, road, railway and fiber optic cable but major portion will be spent on energy. This project will start from Kashgar port of china to Gwadar port of Pakistan. Transportation is sub-function of logistic that consists of 44% total cost of logistic system and 20% total cost of production of manufacturing and mainly shipping cost and transit/delivery time are critical for logistic system. According to OEC (The Observing Economic Complexity) currently, china is importing crude oil which 13.4% from Persian Gulf. CPEC will china for lead time that will be reduced from 45 days to 10 days and distance from 2500km to 1300km. This new route will help to china for less transit/deliver time and shipping cost in terms of logistic of china. Pakistan’s transportation will also improve through road, railway and fiber optic cabal projects from Karachi-Peshawar it will have speed 160km per hour and with help of pipeline between Gwadar to Nawabshah gas will be transported from Iran. According to (www.cpec.inf.com) Pakistan logistic industry will grow by US $30.77 billion in the end of 2020.

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