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      Probability-based algorithm using ultrasound and additional tests for suspected GCA in a fast-track clinic

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          Abstract

          Objectives

          Clinical presentations of giant cell arteritis (GCA) are protean, and it is vital to make a secure diagnosis and exclude mimics for urgent referrals with suspected GCA. The main objective was to develop a joined-up, end-to-end, fast-track confirmatory/exclusionary, algorithmic process based on a probability score triage to drive subsequent investigations with ultrasound (US) and any appropriate additional tests as required.

          Methods

          The algorithm was initiated by stratifying patients to low-risk category (LRC), intermediate-risk category (IRC) and high-risk category (HRC). Retrospective data was extracted from case records. The Southend pretest probability score (PTPS) overall showed a median score of 9 and a 75th percentile score of 12. We, therefore, classified LRC as PTPS <9, IRC 9–12 and HRC >12. GCA diagnosis was made by a combination of clinical, US, and laboratory findings. The algorithm was assessed in all referrals seen in 2018–2019 to test the diagnostic performance of US overall and in individual categories.

          Results

          Of 354 referrals, 89 had GCA with cases categorised as LRC (151), IRC (137) and HRC (66). 250 had US, whereas 104 did not (score <7, and/or high probability of alternative diagnoses). In HRC, US showed sensitivity 94%, specificity 85%, accuracy 92% and GCA prevalence 80%. In LRC, US showed sensitivity undefined (0/0), specificity 98%, accuracy 98% and GCA prevalence 0%. In IRC, US showed sensitivity 100%, specificity 97%, accuracy 98% and GCA prevalence 26%. In the total population, US showed sensitivity 97%, specificity 97% and accuracy 97%. Prevalence of GCA overall was 25%.

          Conclusions

          The Southend PTPS successfully stratifies fast-track clinic referrals and excludes mimics. The algorithm interprets US in context, clarifies a diagnostic approach and identifies uncertainty, need for re-evaluation and alternative tests. Test performance of US is significantly enhanced with PTPS.

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          Most cited references 30

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          Glucocorticoid therapy in giant cell arteritis: duration and adverse outcomes.

          To evaluate the course of glucocorticoid (GC) therapy and associated adverse events in a population-based cohort of patients with giant cell arteritis (GCA). We identified 125 Olmsted County residents with GCA diagnosed between 1950 and 1991 and obtained followup information on the 120 patients who were diagnosed antemortem and agreed to participate in this study. Clinical variables, GC doses, and GC adverse events on each patient were recorded. The relationship between GC therapy and the development of adverse events was studied by the Cox and Anderson-Gill proportional hazards models. All patients were treated with GCs and responded rapidly (median initial dosage 60 mg prednisone/day). The dosage was later reduced according to the treating physicians' judgment. The median duration required to reach 7.5 mg/day was 6.5 months and the median duration required to reach 5 mg/day was 7.5 months. Relapses or recurrences occurred in 57 patients. For the 87 patients followed to discontinuation of GC therapy and permanent remission of GCA (median of 22 months), the total median dose of prednisone was 6.47 gm. Adverse events associated with GCs were recorded in 103 (86%) patients and 2 or more events occurred in 70 patients (58%). Age and higher cumulative dose of GCs were associated with the development of adverse GC side effects. GCs are therapeutically effective in GCA and the prednisone dosage was reduced to physiologic levels in three-fourths of the patients within 1 year. However, most patients developed serious adverse side effects related to GCs, indicating that less toxic therapeutic measures are needed.
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            Does this patient have temporal arteritis?

            Clinicians must be able to confidently diagnose temporal arteritis (TA), since failure to make a correct diagnosis may lead to irreversible visual loss as well as inappropriate evaluation and treatment of headache, fatigue, and other potential presenting symptoms. The diagnostic value of particular signs and symptoms among patients with suspected TA is unknown. To determine the accuracy of historical features, physical examination, and erythrocyte sedimentation rate (ESR) in diagnosis of TA. We performed a MEDLINE search of English-language articles published between January 1966 and July 2000 and a hand search of bibliographies of retrieved articles, previous reviews, monographs, and textbooks. Studies that provided detailed clinical information on patients who had been referred for temporal artery biopsy. Of 114 studies retrieved, 41 met our inclusion criteria; 21 included both biopsy-positive and biopsy-negative patients and formed the core of our review. Both authors independently reviewed each study to determine eligibility, abstracted data using a standardized instrument, and classified study quality using predetermined criteria. The prevalence of TA in the general population is less than 1%. However, in our 21 core studies, 39% of patients referred for temporal artery biopsy had positive results. The only 2 historical features that substantially increased the likelihood of TA among patients referred for biopsy were jaw claudication (positive likelihood ratio [LR], 4.2; 95% confidence interval [CI], 2.8-6.2) and diplopia (positive LR, 3.4; 95% CI, 1.3-8.6). The absence of any temporal artery abnormality was the only clinical factor that modestly reduced the likelihood of disease (negative LR, 0.53; 95% CI, 0.38-0.75). Predictive physical findings included temporal artery beading (positive LR, 4.6; 95% CI, 1.1-18.4), prominence (positive LR, 4.3; 95% CI, 2.1-8.9), and tenderness (positive LR, 2.6; 95% CI, 1.9-3.7). Normal ESR values indicated much less likelihood of disease (negative LR for abnormal ESR, 0.2; 95% CI, 0.08-0.51). A small number of clinical features are helpful in predicting the likelihood of a positive temporal artery biopsy among patients with a clinical suspicion of disease; the most useful finding is a normal ESR, which makes TA unlikely.
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              Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce-Part 2: reliability and application to multiple joints of a standardised consensus-based scoring system

              Objectives To test the reliability of new ultrasound (US) definitions and quantification of synovial hypertrophy (SH) and power Doppler (PD) signal, separately and in combination, in a range of joints in patients with rheumatoid arthritis (RA) using the European League Against Rheumatisms–Outcomes Measures in Rheumatology (EULAR-OMERACT) combined score for PD and SH. Methods A stepwise approach was used: (1) scoring static images of metacarpophalangeal (MCP) joints in a web-based exercise and subsequently when scanning patients; (2) scoring static images of wrist, proximal interphalangeal joints, knee and metatarsophalangeal joints in a web-based exercise and subsequently when scanning patients using different acquisitions (standardised vs usual practice). For reliability, kappa coefficients (κ) were used. Results Scoring MCP joints in static images showed substantial intraobserver variability but good to excellent interobserver reliability. In patients, intraobserver reliability was the same for the two acquisition methods. Interobserver reliability for SH (κ=0.87) and PD (κ=0.79) and the EULAR-OMERACT combined score (κ=0.86) were better when using a ‘standardised’ scan. For the other joints, the intraobserver reliability was excellent in static images for all scores (κ=0.8–0.97) and the interobserver reliability marginally lower. When using standardised scanning in patients, the intraobserver was good (κ=0.64 for SH and the EULAR-OMERACT combined score, 0.66 for PD) and the interobserver reliability was also good especially for PD (κ range=0.41–0.92). Conclusion The EULAR-OMERACT score demonstrated moderate-good reliability in MCP joints using a standardised scan and is equally applicable in non-MCP joints. This scoring system should underpin improved reliability and consequently the responsiveness of US in RA clinical trials.
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                Author and article information

                Journal
                RMD Open
                RMD Open
                rmdopen
                rmdopen
                RMD Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2056-5933
                2020
                29 September 2020
                : 6
                : 3
                Affiliations
                [1 ] departmentRheumatology , Southend University Hospital NHS Foundation Trust , Westcliff-on-Sea, UK
                [2 ] departmentUnit of Immunology, Rheumatology, Allergy and Rare Diseases , San Raffaele Scientific Institute , Milan, Italy
                [3 ] departmentRheumatology , Marques de Valdecilla University Hospital , Santander, Spain
                Author notes
                Correspondence to Bhaskar Dasgupta; bhaskar.dasgupta@ 123456southend.nhs.uk
                Article
                rmdopen-2020-001297
                10.1136/rmdopen-2020-001297
                7547539
                32994361
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

                Funding
                Funded by: Royal College of Physicians of Ireland;
                Award ID: Bresnihan-Molloy international educational fellows
                Categories
                Vasculitis
                Original research

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