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Chaddock NJM, Harden CJ, Sorensen L, Mathieson HR, Zulcinski M, Lawson CA, O'Sullivan E, Mollan SP, Martin J, Mackie SL, Iles MM, Morgan AW. Age, anticoagulants, hypertension and cardiovascular genetic traits predict cranial ischaemic complications in patients with giant cell arteritis. Ann Rheum Dis 2024:ard-2024-225515. [PMID: 39362697 DOI: 10.1136/ard-2024-225515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 08/28/2024] [Indexed: 10/05/2024]
Abstract
OBJECTIVES This project aimed to determine whether cranial ischaemic complications at the presentation of giant cell arteritis (GCA) were associated with pre-existing cardiovascular (CV) risk factors, CV disease or genetic risk of CV-related traits. METHODS 1946 GCA patients with clinicodemographic data at GCA presentation were included. Associations between pre-existing CV-related traits (including Polygenic Risk Scores (PRS) for CV traits) and cranial ischaemic complications were tested. A model for cranial ischaemic complications was optimised using an elastic net approach. Positional gene mapping of associated PRS was performed to improve biological understanding. RESULTS In a sample of 1946 GCA patients (median age=71, 68.7% female), 17% had cranial ischaemic complications at presentation. In univariable analyses, 10 variables were associated with complications (likelihood-ratio test p≤0.05). In multivariable analysis, the two variables with the strongest effects, with or without PRS in the model, were anticoagulant therapy (adjusted OR (95% CI)=0.21 (0.05 to 0.62), p=4.95×10-3) and age (adjusted OR (95% CI)=1.60 (0.73 to 3.66), p=2.52×10-3, for ≥80 years versus <60 years). In sensitivity analyses omitting anticoagulant therapy from multivariable analysis, age and hypertension were associated with cranial ischaemic complications at presentation (hypertension: adjusted OR (95% CI)=1.35 (1.03 to 1.75), p=0.03). Positional gene mapping of an associated transient ischaemic attack PRS identified TEK, CD96 and MROH9 loci. CONCLUSION Age and hypertension were risk factors for cranial ischaemic complications at GCA presentation, but in this dataset, anticoagulation appeared protective. Positional gene mapping suggested a role for immune and coagulation-related pathways in the pathogenesis of complications. Further studies are needed before implementation in clinical practice.
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Affiliation(s)
- Natalie J M Chaddock
- School of Medicine and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Charlotte J Harden
- School of Medicine and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- NIHR Leeds Medicines and In Vitro Diagnostics Co-operative, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Louise Sorensen
- School of Medicine and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Hannah R Mathieson
- School of Medicine and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Michal Zulcinski
- School of Medicine and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | - Susan P Mollan
- Ophthalmology, University Hospitals Birmingham, Birmingham, UK
- Neurometabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Javier Martin
- Institute of Parasitology and Biomedicine, López-Neyra, IPBLN, CSIC, Granada, Spain
| | - Sarah L Mackie
- School of Medicine and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Mark M Iles
- School of Medicine and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ann W Morgan
- School of Medicine and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- NIHR Leeds Medicines and In Vitro Diagnostics Co-operative, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Delort D, Philip R, Gallou S, Dumont A, Deshayes S, Boutemy J, Maigné G, Martin Silva N, Nguyen A, Launoy G, Launay L, Aouba A, de Boysson H. Assessment of social deprivation and socioeconomic factors in patients with giant cell arteritis. Joint Bone Spine 2024; 91:105742. [PMID: 38795764 DOI: 10.1016/j.jbspin.2024.105742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 05/01/2024] [Accepted: 05/07/2024] [Indexed: 05/28/2024]
Affiliation(s)
- Diane Delort
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Rémi Philip
- Department of Internal Medicine, Caen University Hospital, Caen, France; Normandie University, UNICAEN, Caen, France
| | - Sophie Gallou
- Department of Internal Medicine, Caen University Hospital, Caen, France; Normandie University, UNICAEN, Caen, France
| | - Anael Dumont
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Samuel Deshayes
- Department of Internal Medicine, Caen University Hospital, Caen, France; Normandie University, UNICAEN, Caen, France
| | - Jonathan Boutemy
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Gwénola Maigné
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | | | - Alexandre Nguyen
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Guy Launoy
- Normandie University, UNICAEN, Caen, France
| | - Ludivine Launay
- Centre de lutte contre le cancer François-Baclesse, Inserm-UCN U1086 Anticipe, Caen, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital, Caen, France; Normandie University, UNICAEN, Caen, France
| | - Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital, Caen, France; Normandie University, UNICAEN, Caen, France.
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Dhahri AA, Hamid K, Galus TA, Swift CJ, Islam S, Dhahri MA, Jaipersad A, Rajagopalan S. Retrospective Analysis of Specimen Quality in Temporal Artery Biopsies for Giant Cell Arteritis and Disease Association in North Midlands, England. Cureus 2024; 16:e68259. [PMID: 39221306 PMCID: PMC11364959 DOI: 10.7759/cureus.68259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2024] [Indexed: 09/04/2024] Open
Abstract
Background Temporal artery biopsy (TAB) is the recommended index diagnostic method for giant cell arteritis (GCA). Per the British Society for Rheumatology (BSR) guidelines, we assessed our procedural performance. Additionally, we evaluated the occurrence of GCA diagnosis in immunosuppressed patients and other comorbidities. Methods Following the audit registration, a retrospective analysis of prospectively collected data was conducted from 2017 to 2022 at a large university hospital in North Midlands, England. Data on demographics and comorbidities were gathered. The study's primary outcome was adherence to BSR guidelines and our service provisions. Secondary outcomes included examining the relationship between biopsy-confirmed GCA and other comorbidities. Statistical analysis was carried out using SPSS version 29 (IBM Corporation, Armonk, New York, United States of America). Two-sample t-test and Chi-square/Fisher exact test were used for continuous and categorical variables, respectively. Holm-Bonferroni method was incorporated to adjust for multiple comparisons. Results A total of 156 patients who underwent temporal artery biopsy (TAB) were included in the study, with a male-to-female ratio of 0.44:1. The median age was 73. Among the patients, 19% were smokers. The procedures were performed by either a vascular surgeon (119, 76%) or by an ophthalmologist (37, 24%). Two-thirds of the patients underwent TAB within seven days of referral. In 73, 47% of cases, the post-fixation biopsy sample size exceeded 10 mm. Positive biopsy results were found in 45 patients (29%). GCA was confirmed in 39% of patients with polymyalgia rheumatica (PMR), 24% with diabetics, 20% with hypothyroidism, 29% with hypertension, 32% with hyperlipidaemia, and 26% with other inflammatory diseases. However, the p-value was below the statistically significant threshold. The biopsy outcome was also not dependent on the speciality, time from referral to biopsy, nor on the length of the post-fixation specimen. Conclusions Temporal artery biopsy remains a valuable and crucial diagnostic tool in challenging equivocal cases of giant cell arteritis (GCA), although it is limited by its sensitivity, but there is also room for improvement. There is still uncertainty regarding the relationship between biopsy positivity, post-fixation sample size, and the interval between referral and procedure. Additionally, the speciality of the clinician performing the biopsy does not appear to significantly influence the likelihood of a positive result. We still do not fully understand why this is, but the association of the GCA with other comorbidities was unpredictably insignificant.
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Affiliation(s)
- Adeel Abbas Dhahri
- Vascular Surgery, University Hospital North Midlands NHS Foundation Trust, Stoke-on-Trent, GBR
| | - Kamran Hamid
- Vascular Surgery, University Hospital North Midlands NHS Foundation Trust, Stoke-on-Trent, GBR
| | - Tomasz A Galus
- Hospital Medicine, University Hospital North Midlands NHS Foundation Trust, Stoke-on-Trent, GBR
| | | | - Shazab Islam
- Psychiatry, University Hospital North Midlands NHS Foundation Trust, Stoke-on-Trent, GBR
| | | | - Anthony Jaipersad
- Vascular Surgery, University Hospital North Midlands NHS Foundation Trust, Stoke-on-Trent, GBR
| | - Sriram Rajagopalan
- Vascular Surgery, University Hospital North Midlands NHS Foundation Trust, Stoke-on-Trent, GBR
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Taze D, Chakrabarty A, Mackie S, Luqmani R, Cid MC, Morgan AW, Griffin K. Re: Nair et al. Consensus statement on the processing, interpretation and reporting of temporal artery biopsy for arteritis. Cardiovasc Pathol 2024; 70:107621. [PMID: 38365062 DOI: 10.1016/j.carpath.2024.107621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/10/2024] [Indexed: 02/18/2024] Open
Affiliation(s)
- Dilek Taze
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Sarah Mackie
- Leeds Teaching Hospitals NHS Trust, Leeds, UK; University of Leeds, UK and NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Raashid Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Maria C Cid
- Department of Autoimmune Diseases (Vasculitis Research Unit), Institute of Biomedical Research, Barcelona, Spain
| | - Ann W Morgan
- Leeds Teaching Hospitals NHS Trust, Leeds, UK; University of Leeds, UK and NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Kathryn Griffin
- Leeds Teaching Hospitals NHS Trust, Leeds, UK; University of Leeds, UK and NIHR Leeds Biomedical Research Centre, Leeds, UK
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Pouncey AL, Yeldham G, Magan T, Lucenteforte E, Jaffer U, Virgili G. Halo sign on temporal artery ultrasound versus temporal artery biopsy for giant cell arteritis. Cochrane Database Syst Rev 2024; 2:CD013199. [PMID: 38323659 PMCID: PMC10848297 DOI: 10.1002/14651858.cd013199.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND Giant cell arteritis (GCA) is a systemic, inflammatory vasculitis primarily affecting people over the age of 50 years. GCA is treated as a medical emergency due to the potential for sudden, irreversible visual loss. Temporal artery biopsy (TAB) is one of the five criteria of the American College of Rheumatology (ACR) 1990 classification, which is used to aid the diagnosis of GCA. TAB is an invasive test, and it can be slow to obtain a result due to delays in performing the procedure and the time taken for histopathologic assessment. Temporal artery ultrasonography (US) has been demonstrated to show findings in people with GCA such as the halo sign (a hypoechoic circumferential wall thickening due to oedema), stenosis or occlusion that can help to confirm a diagnosis more swiftly and less invasively, but requiring more subjective interpretation. This review will help to determine the role of these investigations in clinical practice. OBJECTIVES To evaluate the sensitivity and specificity of the halo sign on temporal artery US, using the ACR 1990 classification as a reference standard, to investigate whether US could be used as triage for TAB. To compare the accuracy of US with TAB in the subset of paired studies that have obtained both tests on the same patients, to investigate whether it could replace TAB as one of the criteria in the ACR 1990 classification. SEARCH METHODS We used standard Cochrane search methods for diagnostic accuracy. The date of the search was 13 September 2022. SELECTION CRITERIA We included all participants with clinically suspected GCA who were investigated for the presence of the halo sign on temporal artery US, using the ACR 1990 criteria as a reference standard. We included studies with participants with a prior diagnosis of polymyalgia rheumatica. We excluded studies if participants had had two or more weeks of steroid treatment prior to the investigations. We also included any comparative test accuracy studies of the halo sign on temporal artery US versus TAB, with use of the 1990 ACR diagnostic criteria as a reference standard. Although we have chosen to use this classification for the purpose of the meta-analysis, we accept that it incorporates unavoidable incorporation bias, as TAB is itself one of the five criteria. This increases the specificity of TAB, making it difficult to compare with US. We excluded case-control studies, as they overestimate accuracy, as well as case series in which all participants had a prior diagnosis of GCA, as they can only address sensitivity and not specificity. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion in the review. They extracted data using a standardised data collection form and employed the QUADAS-2 tool to assess methodological quality. As not enough studies reported data at our prespecified halo threshold of 0.3 mm, we fitted hierarchical summary receiver operating characteristic (ROC) models to estimate US sensitivity and also to compare US with TAB. We graded the certainty of the evidence using the GRADE approach. MAIN RESULTS Temporal artery ultrasound was investigated in 15 studies (617 participants with GCA out of 1479, 41.7%), with sample sizes ranging from 20 to 381 participants (median 69). There was wide variation in sensitivity with a median value of 0.78 (interquartile range (IQR) 0.45 to 0.83; range 0.03 to 1.00), while specificity was fair to good in most studies with a median value of 0.91 (IQR 0.78 to 1.00; range 0.40 to 1.00) and four studies with a specificity of 1.00. The hierarchical summary receiver operating characteristic (HSROC) estimate of sensitivity (95% confidence interval (CI)) at the high specificity of 0.95 was 0.51 (0.21 to 0.81), and 0.84 (0.58 to 0.95) at 0.80 specificity. We considered the evidence on sensitivity and specificity as of very low certainty due to risk of bias (-1), imprecision (-1), and inconsistency (-1). Only four studies reported data at a halo cut-off > 0.3 mm, finding the following sensitivities and specificities (95% CI): 0.80 (0.56 to 0.94) and 0.94 (0.81 to 0.99) in 55 participants; 0.10 (0.00 to 0.45) and 1.00 (0.84 to 1.00) in 31 participants; 0.73 (0.54 to 0.88) and 1.00 (0.93 to 1.00) in 82 participants; 0.83 (0.63 to 0.95) and 0.72 (0.64 to 0.79) in 182 participants. Data on a direct comparison of temporal artery US with biopsy were obtained from 11 studies (808 participants; 460 with GCA, 56.9%). The sensitivity of US ranged between 0.03 and 1.00 with a median of 0.75, while that of TAB ranged between 0.33 and 0.92 with a median of 0.73. The specificity was 1.00 in four studies for US and in seven for TAB. At high specificity (0.95), the sensitivity of US and TAB were 0.50 (95% CI 0.24 to 0.76) versus 0.80 (95% CI 0.57 to 0.93), respectively, and at low specificity (0.80) they were 0.73 (95% CI 0.49 to 0.88) versus 0.92 (95% CI 0.69 to 0.98). We considered the comparative evidence on the sensitivity of US versus TAB to be of very low certainty because specificity was overestimated for TAB since it is one of the criteria used in the reference standard (-1), together with downgrade due to risk of bias (-1), imprecision (-1), and inconsistency (-1) for both sensitivity and specificity. AUTHORS' CONCLUSIONS There is limited published evidence on the accuracy of temporal artery US for detecting GCA. Ultrasound seems to be moderately sensitive when the specificity is good, but data were heterogeneous across studies and either did not use the same halo thickness threshold or did not report it. We can draw no conclusions from accuracy studies on whether US can replace TAB for diagnosing GCA given the very low certainty of the evidence. Future research could consider using the 2016 revision of the ACR criteria as a reference standard, which will limit incorporation bias of TAB into the reference standard.
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Affiliation(s)
| | - Geoffrey Yeldham
- Department of Ophthalmology, Cardiff & Vale University Health Board, Cardiff, UK
| | - Tejal Magan
- Kings College NHS Foundation Trust, London, UK
| | - Ersilia Lucenteforte
- Department of Statistics, Computer Science, Applications "G. Parenti", University of Florence, Florence, Italy
| | - Usman Jaffer
- Imperial College Healthcare NHS Trust, London, UK
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- IRCCS- Fondazione Bietti, Rome, Italy
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Bonnan M, Debeugny S. Giant-cell arteritis related strokes: scoping review of mechanisms and rethinking treatment strategy? Front Neurol 2023; 14:1305093. [PMID: 38130834 PMCID: PMC10733536 DOI: 10.3389/fneur.2023.1305093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 11/17/2023] [Indexed: 12/23/2023] Open
Abstract
Stroke is a rare and severe complication of giant cell arteritis (GCA). Although early diagnosis and treatment initiation are essential, the mechanism of stroke is often related to vasculitis complicated by arterial stenosis and occlusion. Its recurrence is often attributed to early steroid resistance or late GCA relapse, so immunosuppressive treatment is often reinforced. However, many questions concerning the mechanisms of stroke remain elusive, and no review to date has examined the whole data set concerning GCA-related stroke. We therefore undertook this scoping review. GCA-related stroke does not necessarily display general signs and inflammatory parameters are sometimes normal, so clinicians should observe caution. Ischemic lesions often show patterns predating watershed areas and are associated with stenosis or thrombosis of the respective arteries, which are often bilateral. Lesions predominate in the siphon in the internal carotid arteries, whereas all the vertebral arteries may be involved with a predominance in the V3-V4 segments. Ultrasonography of the cervical arteries may reveal edema of the intima (halo sign), which is highly sensitive and specific of GCA, and precedes stenosis. The brain arteries are spared although very proximal arteritis may rarely occur, if the patient has microstructural anatomical variants. Temporal artery biopsy reveals the combination of mechanisms leading to slit-like stenosis, which involves granulomatous inflammation and intimal hyperplasia. The lumen is sometimes occluded by thrombi (<15%), suggesting that embolic lesions may also occur, although imaging studies have not provided strong evidence for this. Moreover, persistence of intimal hyperplasia might explain persisting arterial stenosis, which may account for delayed stroke occurring in watershed areas. Other possible mechanisms of stroke are also discussed. Overall, GCA-related stroke mainly involves hemodynamic mechanisms. Besides early diagnosis and treatment initiation, future studies could seek to establish specific preventive or curative treatments using angioplasty or targeting intimal proliferation.
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Affiliation(s)
- Mickael Bonnan
- Service de Neurologie, Hôpital Delafontaine, Saint-Denis, France
| | - Stephane Debeugny
- Département d'Information Médicale, Centre Hospitalier de Pau, Pau, France
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Sebastian A, Coath F, Innes S, Jackson J, van der Geest KSM, Dasgupta B. Role of the halo sign in the assessment of giant cell arteritis: a systematic review and meta-analysis. Rheumatol Adv Pract 2021; 5:rkab059. [PMID: 34514295 PMCID: PMC8421813 DOI: 10.1093/rap/rkab059] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/09/2021] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES This systematic review and meta-analysis aimed to evaluate the diagnostic value of the halo sign in the assessment of GCA. METHODS A systematic literature review was performed using MEDLINE, EMBASE and Cochrane central register databases up to August 2020. Studies informing on the sensitivity and specificity of the US halo sign for GCA (index test) were selected. Studies with a minimum of five participants were included. Study articles using clinical criteria, imaging such as PET-CT and/or temporal artery biopsy (TAB) as the reference standards were selected. Meta-analysis was conducted with a bivariate model. RESULTS The initial search yielded 4023 studies. Twenty-three studies (patients n = 2711) met the inclusion criteria. Prospective (11 studies) and retrospective (12 studies) studies in academic and non-academic centres were included. Using clinical diagnosis as the standard (18 studies) yielded a pooled sensitivity of 67% (95% CI: 51, 80) and a specificity of 95% (95% CI: 89, 98%). This gave a positive and negative likelihood ratio for the diagnosis of GCA of 14.2 (95% CI: 5.7, 35.5) and 0.375 (95% CI: 0.22, 0.54), respectively. Using TAB as the standard (15 studies) yielded a pooled sensitivity of 63% (95% CI: 50, 75) and a specificity of 90% (95% CI: 81, 95). CONCLUSION The US halo sign is a sensitive and specific approach for GCA assessment and plays a pivotal role in diagnosis of GCA in routine clinical practice. REGISTRATION PROSPERO 2020 CRD42020202179.
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Affiliation(s)
- Alwin Sebastian
- Department of Rheumatology, Southend University Hospital, Mid and South Essex University Hospital Groups, Westcliff-On-Sea
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, Essex
| | - Fiona Coath
- Department of Rheumatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Sue Innes
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, Essex
| | - Jo Jackson
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, Essex
| | - Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital, Mid and South Essex University Hospital Groups, Westcliff-On-Sea
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, Essex
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de Mornac D, Agard C, Hardouin JB, Hamidou M, Connault J, Masseau A, Espitia-Thibault A, Artifoni M, Ngohou C, Perrin F, Graveleau J, Durant C, Pottier P, Néel A, Espitia O. Risk factors for symptomatic vascular events in giant cell arteritis: a study of 254 patients with large-vessel imaging at diagnosis. Ther Adv Musculoskelet Dis 2021; 13:1759720X211006967. [PMID: 34249150 PMCID: PMC8239952 DOI: 10.1177/1759720x211006967] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/10/2021] [Indexed: 12/14/2022] Open
Abstract
Aims To identify factors associated with vascular events in patients with giant cell arteritis (GCA). Methods We performed a retrospective study of GCA patients diagnosed over a 20-year-period, who all underwent vascular imaging evaluation at diagnosis. Symptomatic vascular events were defined as the occurrence of any aortic event (aortic dissection or symptomatic aortic aneurysm), stroke, myocardial infarction, limb or mesenteric ischemia and de novo lower limbs arteritis stage 3 or 4. Patients with symptomatic vascular event (VE+) and without were compared, and risk factors were identified in a multivariable analysis. Results Thirty-nine (15.4%) of the 254 included patients experienced at least one symptomatic vascular event during follow-up, with a median time of 21.5 months. Arterial hypertension, diabetes, lower limbs arteritis or vascular complication at diagnosis were more frequent in VE+ patients (p < 0.05), as an abnormal computed tomography (CT)-scan at diagnosis (p = 0.04), aortitis (p = 0.01), particularly of the descending thoracic aorta (p = 0.03) and atheroma (p = 0.03). Deaths were more frequent in the VE+ group (37.1 versus 10.3%, p = 0.0003). In multivariable analysis, aortic surgery [hazard ratio (HR): 10.46 (1.41-77.80), p = 0.02], stroke [HR: 22.32 (3.69-135.05), p < 0.001], upper limb ischemia [HR: 20.27 (2.05-200.12), p = 0.01], lower limb ischemia [HR: 76.57 (2.89-2027.69), p = 0.009], aortic atheroma [HR: 3.06 (1.06-8.82), p = 0.04] and aortitis of the descending thoracic aorta on CT-scan at diagnosis [HR: 4.64 (1.56-13.75), p = 0.006] were independent predictive factors of a vascular event. Conclusion In this study on GCA cases with large vessels imaging at diagnosis, aortic surgery, stroke, upper or lower limb ischemia, aortic atheroma and aortitis of the descending thoracic aorta on CT-scan, at GCA diagnosis, were independent predictive factors of a vascular event. Plain language summary Risk factors for symptomatic vascular events in giant cell arteritisThis study was performed to identify the risk factors for developing symptomatic vascular event during giant cell arteritis (GCA) because these are poorly known.We performed a retrospective study of GCA patients diagnosed over a 20-year-period, who all underwent vascular imaging evaluation at diagnosis.Patients with symptomatic vascular event (VE+) and without (VE-) were compared, and risk factors were identified in a multivariable analysis.Thirty-nine patients experienced at least one symptomatic vascular event during follow-up, with a median time of 21.5 months.Arterial hypertension, diabetes, lower limbs arteritis or vascular complication at diagnosis were significantly more frequent in VE+ patients, as an abnormal CT-scan at diagnosis, aortitis, particularly of the descending thoracic aorta and atheroma. Deaths were more frequent in the VE+ group.Among 254 GCA patients, 39 experienced at least one vascular event during follow-up.Aortic surgery, stroke, upper and lower limb ischemia were vascular event risk factors.Aortic atheroma and descending thoracic aorta aortitis on CT-scan were vascular event risk factors.This study on GCA cases with large vessels imaging at diagnosis, showed that aortic surgery, stroke, upper or lower limb ischemia, aortic atheroma and aortitis of the descending thoracic aorta on CT-scan, at GCA diagnosis, were independent predictive factors of a vascular event.
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Affiliation(s)
| | | | | | | | | | - Agathe Masseau
- Department of Internal Medicine, CHU Nantes, Nantes, France
| | | | | | - Chan Ngohou
- Department of Medical Information, Nantes University Hospital, Nantes, France
| | - François Perrin
- Department of Internal Medicine, Saint-Nazaire Hospital, France
| | - Julie Graveleau
- Department of Internal Medicine, Saint-Nazaire Hospital, France
| | - Cécile Durant
- Department of Internal Medicine, CHU Nantes, Nantes, France
| | - Pierre Pottier
- Department of Internal Medicine, CHU Nantes, Nantes, France
| | - Antoine Néel
- Department of Internal Medicine, CHU Nantes, Nantes, France
| | - Olivier Espitia
- Department of Internal Medicine, CHU Nantes, 1 place Alexis Ricordeau, Nantes, 44093, France
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[Glucocorticoids in the treatment of giant cell arteritis : How much, how long and how to spare?]. Z Rheumatol 2021; 80:322-331. [PMID: 33710440 DOI: 10.1007/s00393-021-00975-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 10/21/2022]
Abstract
Treatment of giant cell arteritis (GCA) with high-dose glucocorticoids (GC) regularly leads to a control of the inflammatory activity, so that high-dose GC is still the recommended standard treatment in the current guidelines; however, after discontinuation of GC treatment or reduction of the GC dosage, relapses occur in up to 70% of patients in the further course of the disease, making it necessary to resume treatment or increase the dosage. As a consequence many patients therefore have to be treated with GC often in high doses over several years, which results in a high cumulative exposure to GC. The risk for GC-associated diseases, such as diabetes, glaucoma, osteoporosis or severe infections is therefore significantly increased for patients with giant cell arteritis. For patients with GC-associated comorbidities or increased risk of developing them or patients with a relapse, the current guidelines therefore recommend GC-sparing treatment with tocilizumab or alternatively methotrexate. It is currently unclear over what period of time patients should be treated with GC and GC-sparing treatment, since high-quality study data on de-escalation strategies for GCA are currently still lacking. Decisions on treatment duration and intensity must therefore be made individually for each patient, taking into account general and patient-specific risk factors for a GC-dependent course, GCA-associated vascular damage (stenoses, aneurysms, visual loss) and treatment-associated complications.
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Lyons HS, Quick V, Sinclair AJ, Nagaraju S, Mollan SP. A new era for giant cell arteritis. Eye (Lond) 2020; 34:1013-1026. [PMID: 31582795 PMCID: PMC7253415 DOI: 10.1038/s41433-019-0608-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 04/08/2019] [Accepted: 04/10/2019] [Indexed: 12/15/2022] Open
Abstract
The landscape of the investigation and management of giant cell arteritis (GCA) is advancing. In this review we will outline the recent advances by searching the current English literature for relevant articles using key words of giant cell arteritis, temporal arteritis, Horton's disease, investigation, and treatment. Delay in diagnosis, diagnostic uncertainty and glucocorticoid (GC) morbidity are among the highest concerns of clinicians and patients in this disease area. The positive news is that fast track pathways, imaging techniques and new therapies are emerging for routine management of GCA. Future directions for intervention in the treatment paradigm will be discussed.
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Affiliation(s)
- H S Lyons
- Medical School, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - V Quick
- Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, UK
| | - A J Sinclair
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, B15 2WB, UK
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - S Nagaraju
- Department of Histopathology, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, B15 2WB, UK
| | - S P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, B15 2WB, UK.
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11
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Mackie SL, Dejaco C, Appenzeller S, Camellino D, Duftner C, Gonzalez-Chiappe S, Mahr A, Mukhtyar C, Reynolds G, de Souza AWS, Brouwer E, Bukhari M, Buttgereit F, Byrne D, Cid MC, Cimmino M, Direskeneli H, Gilbert K, Kermani TA, Khan A, Lanyon P, Luqmani R, Mallen C, Mason JC, Matteson EL, Merkel PA, Mollan S, Neill L, Sullivan EO, Sandovici M, Schmidt WA, Watts R, Whitlock M, Yacyshyn E, Ytterberg S, Dasgupta B. British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis. Rheumatology (Oxford) 2020; 59:e1-e23. [DOI: 10.1093/rheumatology/kez672] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/02/2019] [Indexed: 12/20/2022] Open
Affiliation(s)
- Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Christian Dejaco
- Rheumatology, Medical University Graz, Graz, Austria
- South Tyrol Health Trust, Department of Rheumtaology, Hospital of Bruneck, Bruneck, Italy
| | - Simone Appenzeller
- Rheumatology Unit, Department of Medicine, University of Campinas, São Paulo, Brazil
| | - Dario Camellino
- Division of Rheumatology, La Colletta Hospital, Local Health Trust 3 Genoa
- Autoimmunology Laboratory, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | | | | | - Alfred Mahr
- Internal Medicine, Hôpital Saint-Louis, University Paris Diderot, Paris, France
| | - Chetan Mukhtyar
- Department of Rheumatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich
| | | | - Alexandre Wagner S de Souza
- Rheumatology Division, Universidade Federal de Sao Paulo Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, Brazil
| | - Elisabeth Brouwer
- Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marwan Bukhari
- Rheumatology, University Hospitals of Morecambe Bay NHS Foundation Trust, Kendal, Cumbria, UK
| | - Frank Buttgereit
- Department of Medicine (Rheumatology and Clinical Immunology), Charité University Medicine, Berlin, Germany
| | | | - Maria C Cid
- Hospital Clinic de Barcelona, Universitat de Barcelona, Institut d’Investigacions, Biomèdiques, August Pi I, Sunyer (IDIBAPS), Catalunya, Barcelona, Spain
| | - Marco Cimmino
- Dipartimento di Medicina Interna, Università degli Studi di Genova, Genoa, Italy
| | - Haner Direskeneli
- Rheumatology, School of Medicine, Marmara University, Istanbul, Turkey
| | | | | | - Asad Khan
- Rheumatology, Solihull Hospital, University Hospitals Birmingham, Birmingham
| | - Peter Lanyon
- Academic Rheumatology, Nottingham University Hospitals, Nottingham
| | - Raashid Luqmani
- Nuffield Orthopaedic Centre – Rheumatology, University of Oxford, Oxford
| | - Christian Mallen
- School of Primary, Community and Social Care, Keele University, Staffordshire
| | | | - Eric L Matteson
- Division of Rheumatology and Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Peter A Merkel
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Susan Mollan
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham
| | | | - Eoin O’ Sullivan
- Department of Ophthalmology, King’s College Hospital, London, UK
| | - Maria Sandovici
- Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wolfgang A Schmidt
- Medical Centre for Rheumatology Berlin-Buch, Immanuel Hospital Berlin, Berlin, Germany
| | - Richard Watts
- Rheumatology, Ipswich Hospital, Ipswich, UK
- University of East Anglia, Ipswich
| | - Madeline Whitlock
- Rheumatology, Southend University NHS Foundation Trust, Westcliff-on-Sea, Essex, UK
| | - Elaine Yacyshyn
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Steven Ytterberg
- Department of Rheumatology, Mayo Clinic of Medicine and Science, Rochester, MN, USA
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University NHS Foundation Trust, Westcliff-on-Sea, Essex, UK
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12
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Pouncey AL, Yeldham G, Magan T, Lucenteforte E, Musonda P, Jaffer U, Virgili G. Temporal artery ultrasound versus temporal artery biopsy for giant cell arteritis. Hippokratia 2018. [DOI: 10.1002/14651858.cd013199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Anna L Pouncey
- Imperial College Healthcare NHS Trust; 63 St Dunstan's Road London UK W6 8RE
| | | | - Tejal Magan
- Kings College NHS Foundation Trust; London UK
| | - Ersilia Lucenteforte
- University of Florence; Department of Neurosciences, Psychology, Drug Research and Children’s Health; viale Gaetano Pieraccini, 6 Florence Italy 50139
| | - Patrick Musonda
- Imperial College Healthcare NHS Trust; 63 St Dunstan's Road London UK W6 8RE
| | - Usman Jaffer
- Imperial College Healthcare NHS Trust; 63 St Dunstan's Road London UK W6 8RE
| | - Gianni Virgili
- University of Florence; Department of Translational Surgery and Medicine, Eye Clinic; Largo Brambilla, 3 Florence Italy 50134
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González-Gay MA, Pina T, Prieto-Peña D, Calderon-Goercke M, Blanco R, Castañeda S. Current and emerging diagnosis tools and therapeutics for giant cell arteritis. Expert Rev Clin Immunol 2018; 14:593-605. [DOI: 10.1080/1744666x.2018.1485491] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Miguel A. González-Gay
- Division of Rheumatology and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
- Department of Medicine and Psychiatry, School of Medicine, University of Cantabria, Santander, Spain
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Trinitario Pina
- Division of Rheumatology and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Diana Prieto-Peña
- Division of Rheumatology and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Mónica Calderon-Goercke
- Division of Rheumatology and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Ricardo Blanco
- Division of Rheumatology and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Santos Castañeda
- Rheumatology Division, Hospital de La Princesa, IIS-Princesa, Universidad Autónoma de Madrid (UAM), Madrid, Spain
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Kermani TA, Warrington KJ. Prognosis and monitoring of giant cell arteritis and associated complications. Expert Rev Clin Immunol 2018; 14:379-388. [DOI: 10.1080/1744666x.2018.1467758] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Tanaz A. Kermani
- Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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De Smit E, Clarke L, Sanfilippo PG, Merriman TR, Brown MA, Hill CL, Hewitt AW. Geo-epidemiology of temporal artery biopsy-positive giant cell arteritis in Australia and New Zealand: is there a seasonal influence? RMD Open 2017; 3:e000531. [PMID: 29225921 PMCID: PMC5706482 DOI: 10.1136/rmdopen-2017-000531] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/18/2017] [Accepted: 07/18/2017] [Indexed: 11/04/2022] Open
Abstract
Objective Previous studies, although inconclusive, have suggested possible associations of environmental risk factors with the development of giant cell arteritis (GCA). We aim to investigate seasonal influence on the incidence of GCA across Australia and New Zealand. Methods In establishing an international study to investigate the molecular aetiology of GCA, archived temporal artery biopsy (TAB) specimens primarily from Australia and New Zealand were obtained. Demographic details including age, sex and date of TAB were collected from collaborating pathology departments. The season in which GCA was diagnosed was determined and compared with previous reports investigating the association between environmental risk factors and GCA. Results Our study comprises data from 2224 TAB-positive patients with GCA; 2099 of which were from patients in Australia and New Zealand. The mean age at time of diagnosis was 76.4 years of age. The female-to-male ratio was 2.2:1. We noted equal distribution of the incidence rate across all four seasons (530-580 cases diagnosed every quarter). Statistical analysis of seasonal variation by Poisson regression and cosinor methods showed no incidence preponderance across seasons. Our results do not support a seasonal component contributing to the onset of disease. Our literature search identifies no consistent environmental risk factor in association with GCA. Conclusion This is the largest GCA data set reported outside of Europe. Our results demonstrate equal distribution of the incidence rate across all four seasons. In contrast to some earlier reports, we did not identify evidence of a seasonal component contributing to the onset of disease.
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Affiliation(s)
- Elisabeth De Smit
- Department of Ophthalmology, Centre for Eye Research Australia, The University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
| | - Linda Clarke
- Department of Ophthalmology, Centre for Eye Research Australia, The University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
| | - Paul G Sanfilippo
- Department of Ophthalmology, Centre for Eye Research Australia, The University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
| | - Tony R Merriman
- Department of Biochemistry, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Matthew A Brown
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Translational Research Institute, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Catherine L Hill
- Department of Rheumatology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Alex W Hewitt
- Department of Ophthalmology, Centre for Eye Research Australia, The University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia.,School of Medicine, Menzies Research Institute Tasmania, University of Tasmania, Hobart, Tasmania, Australia.,Lions Eye Institute, University of Western Australia, Perth, Western Australia, Australia
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16
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Prior JA, Ranjbar H, Belcher J, Mackie SL, Helliwell T, Liddle J, Mallen CD. Diagnostic delay for giant cell arteritis - a systematic review and meta-analysis. BMC Med 2017; 15:120. [PMID: 28655311 PMCID: PMC5488376 DOI: 10.1186/s12916-017-0871-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/09/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Giant cell arteritis (GCA), if untreated, can lead to blindness and stroke. The study's objectives were to (1) determine a new evidence-based benchmark of the extent of diagnostic delay for GCA and (2) examine the role of GCA-specific characteristics on diagnostic delay. METHODS Medical literature databases were searched from inception to November 2015. Articles were included if reporting a time-period of diagnostic delay between onset of GCA symptoms and diagnosis. Two reviewers assessed the quality of the final articles and extracted data from these. Random-effects meta-analysis was used to pool the mean time-period (95% confidence interval (CI)) between GCA symptom onset and diagnosis, and the delay observed for GCA-specific characteristics. Heterogeneity was assessed by I 2 and by 95% prediction interval (PI). RESULTS Of 4128 articles initially identified, 16 provided data for meta-analysis. Mean diagnostic delay was 9.0 weeks (95% CI, 6.5 to 11.4) between symptom onset and GCA diagnosis (I 2 = 96.0%; P < 0.001; 95% PI, 0 to 19.2 weeks). Patients with a cranial presentation of GCA received a diagnosis after 7.7 (95% CI, 2.7 to 12.8) weeks (I 2 = 98.4%; P < 0.001; 95% PI, 0 to 27.6 weeks) and those with non-cranial GCA after 17.6 (95% CI, 9.7 to 25.5) weeks (I 2 = 96.6%; P < 0.001; 95% PI, 0 to 46.1 weeks). CONCLUSIONS The mean delay from symptom onset to GCA diagnosis was 9 weeks, or longer when cranial symptoms were absent. Our research provides an evidence-based benchmark for diagnostic delay of GCA and supports the need for improved public awareness and fast-track diagnostic pathways.
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Affiliation(s)
- James A Prior
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK.
| | - Hoda Ranjbar
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK
| | - John Belcher
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK
| | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Toby Helliwell
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK
| | - Jennifer Liddle
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK.,Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Christian D Mallen
- Research Institute for Primary Care and Health Sciences, Keele University, ST5 5BG, Newcastle, UK
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18
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Saleh M, Turesson C, Englund M, Merkel PA, Mohammad AJ. Visual Complications in Patients with Biopsy-proven Giant Cell Arteritis: A Population-based Study. J Rheumatol 2016; 43:1559-65. [PMID: 27252424 DOI: 10.3899/jrheum.151033] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To study the clinical and laboratory characteristics of patients with biopsy-proven giant cell arteritis (GCA) with visual complications, and to evaluate the incidence rate of visual complications in GCA compared to the background population. METHODS Data from 840 patients with GCA in the county of Skåne, Sweden, diagnosed between 1997 and 2010, were used for this analysis. Cases with visual complications were identified from a diagnosis registry and confirmed by a review of medical records. The rate of visual complications in patients with GCA was compared with an age- and sex-matched reference population. RESULTS There were 85 patients (10%) who developed ≥ 1 visual complication after the onset of GCA. Of the patients, 18 (21%) developed unilateral or bilateral complete visual loss. The mean age at diagnosis was 78 years (± 7.3); 69% were women. Compared with patients without visual complications, those with visual complication had lower C-reactive protein levels at diagnosis and were less likely to have headache, fever, and palpable abnormal temporal artery. The use of β-adrenergic inhibitors was associated with visual complications. The incidence of visual complications among patients with GCA was 20.9/1000 person-years of followup compared to 6.9/1000 person-years in the reference population, resulting in a rate ratio of 3.0 (95% CI 2.3-3.8). CONCLUSION Ten percent of patients with GCA developed visual complications, a rate substantially higher than that of the general population. Patients with GCA who had visual complications had lower inflammatory responses and were more likely to have been treated with β-adrenergic inhibitors compared with patients without visual complications.
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Affiliation(s)
- Muna Saleh
- From the Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital, Helsingborg; Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; Department of Clinical Sciences, Orthopaedics and Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden; Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts; Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.M. Saleh, MD, Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital; C. Turesson, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; M. Englund, MD, PhD, Department of Clinical Sciences, Orthopaedics, Lund University, and the Clinical Epidemiology Research and Training Unit, Boston University School of Medicine; P.A. Merkel, MD, MPH, Division of Rheumatology, University of Pennsylvania; A.J. Mohammad, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, and the Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Carl Turesson
- From the Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital, Helsingborg; Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; Department of Clinical Sciences, Orthopaedics and Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden; Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts; Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.M. Saleh, MD, Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital; C. Turesson, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; M. Englund, MD, PhD, Department of Clinical Sciences, Orthopaedics, Lund University, and the Clinical Epidemiology Research and Training Unit, Boston University School of Medicine; P.A. Merkel, MD, MPH, Division of Rheumatology, University of Pennsylvania; A.J. Mohammad, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, and the Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Martin Englund
- From the Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital, Helsingborg; Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; Department of Clinical Sciences, Orthopaedics and Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden; Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts; Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.M. Saleh, MD, Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital; C. Turesson, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; M. Englund, MD, PhD, Department of Clinical Sciences, Orthopaedics, Lund University, and the Clinical Epidemiology Research and Training Unit, Boston University School of Medicine; P.A. Merkel, MD, MPH, Division of Rheumatology, University of Pennsylvania; A.J. Mohammad, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, and the Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Peter A Merkel
- From the Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital, Helsingborg; Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; Department of Clinical Sciences, Orthopaedics and Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden; Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts; Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.M. Saleh, MD, Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital; C. Turesson, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; M. Englund, MD, PhD, Department of Clinical Sciences, Orthopaedics, Lund University, and the Clinical Epidemiology Research and Training Unit, Boston University School of Medicine; P.A. Merkel, MD, MPH, Division of Rheumatology, University of Pennsylvania; A.J. Mohammad, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, and the Vasculitis and Lupus Clinic, Addenbrooke's Hospital
| | - Aladdin J Mohammad
- From the Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital, Helsingborg; Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; Department of Clinical Sciences, Orthopaedics and Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden; Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts; Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK.M. Saleh, MD, Department of Internal Medicine, Section of Rheumatology, Helsingborg Hospital; C. Turesson, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Malmö, Rheumatology, Malmö; M. Englund, MD, PhD, Department of Clinical Sciences, Orthopaedics, Lund University, and the Clinical Epidemiology Research and Training Unit, Boston University School of Medicine; P.A. Merkel, MD, MPH, Division of Rheumatology, University of Pennsylvania; A.J. Mohammad, MD, PhD, Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Rheumatology, Lund, and the Vasculitis and Lupus Clinic, Addenbrooke's Hospital.
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Robson JC, Kiran A, Maskell J, Hutchings A, Arden N, Dasgupta B, Hamilton W, Emin A, Culliford D, Luqmani R. Which Patients with Giant Cell Arteritis Will Develop Cardiovascular or Cerebrovascular Disease? A Clinical Practice Research Datalink Study. J Rheumatol 2016; 43:1085-92. [DOI: 10.3899/jrheum.151024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2016] [Indexed: 02/07/2023]
Abstract
Objective.To evaluate the risk of cerebrovascular disease and cardiovascular disease (CVD) in patients with giant cell arteritis (GCA), and to identify predictors.Methods.The UK Clinical Practice Research Datalink 1991–2010 was used for a parallel cohort study of 5827 patients with GCA and 37,090 age-, sex-, and location-matched controls. A multivariable competing risk model (non-cerebrovascular/CV-related death as the competing risk) determined the relative risk [subhazard ratio (SHR)] between patients with GCA compared with background controls for cerebrovascular disease, CVD, or either. Each cohort (GCA and controls) was then analyzed individually using the same multivariable model, with age and sex now present, to identify predictors of CVD or cerebrovascular disease.Results.Patients with GCA, compared with controls, had an increased risk SHR (95% CI) of cerebrovascular disease (1.45, 1.31–1.60), CVD (1.49, 1.37–1.62), or either (1.47, 1.37–1.57). In the GCA cohort, predictors of “cerebrovascular disease or CVD” included increasing age, > 80 years versus < 65 years (1.98, 1.62–2.42), male sex (1.20, 1.05–1.38), and socioeconomic status, most deprived quintile versus least deprived (1.34, 1.01–1.78). These predictors were also present within the non-GCA cohort.Conclusion.Patients with GCA are more likely to develop cerebrovascular disease or CVD than age-, sex-, and location-matched controls. In common with the non-GCA cohort, patients who are older, male, and from the most deprived compared with least deprived areas have a higher risk of cerebrovascular disease or CVD. Further work is needed to understand how this risk may be mediated by specific behavioral, social, and economic factors.
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20
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Koster MJ, Warrington KJ, Kermani TA. Update on the Epidemiology and Treatment of Giant Cell Arteritis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2016. [DOI: 10.1007/s40674-016-0046-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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21
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Mackie SL, Taylor JC, Haroon-Rashid L, Martin S, Dasgupta B, Gough A, Green M, Hordon L, Jarrett S, Pease CT, Barrett JH, Watts R, Morgan AW. Association of HLA-DRB1 amino acid residues with giant cell arteritis: genetic association study, meta-analysis and geo-epidemiological investigation. Arthritis Res Ther 2015; 17:195. [PMID: 26223536 PMCID: PMC4520081 DOI: 10.1186/s13075-015-0692-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 06/18/2015] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Giant cell arteritis (GCA) is an autoimmune disease commonest in Northern Europe and Scandinavia. Previous studies report various associations with HLA-DRB1*04 and HLA-DRB1*01; HLA-DRB1 alleles show a gradient in population prevalence within Europe. Our aims were (1) to determine which amino acid residues within HLA-DRB1 best explained HLA-DRB1 allele susceptibility and protective effects in GCA, seen in UK data combined in meta-analysis with previously published data, and (2) to determine whether the incidence of GCA in different countries is associated with the population prevalence of the HLA-DRB1 alleles that we identified in our meta-analysis. METHODS GCA patients from the UK GCA Consortium were genotyped by using single-strand oligonucleotide polymerization, allele-specific polymerase chain reaction, and direct sequencing. Meta-analysis was used to compare and combine our results with published data, and public databases were used to identify amino acid residues that may explain observed susceptibility/protective effects. Finally, we determined the relationship of HLA-DRB1*04 population carrier frequency and latitude to GCA incidence reported in different countries. RESULTS In our UK data (225 cases and 1378 controls), HLA-DRB1*04 carriage was associated with GCA susceptibility (odds ratio (OR) = 2.69, P = 1.5×10(-11)), but HLA-DRB1*01 was protective (adjusted OR = 0.55, P = 0.0046). In meta-analysis combined with 14 published studies (an additional 691 cases and 4038 controls), protective effects were seen from HLA-DR2, which comprises HLA-DRB1*15 and HLA-DRB1*16 (OR = 0.65, P = 8.2×10(-6)) and possibly from HLA-DRB1*01 (OR = 0.73, P = 0.037). GCA incidence (n = 17 countries) was associated with population HLA-DRB1*04 allele frequency (P = 0.008; adjusted R(2) = 0.51 on univariable analysis, adjusted R(2) = 0.62 after also including latitude); latitude also made an independent contribution. CONCLUSIONS We confirm that HLA-DRB1*04 is a GCA susceptibility allele. The susceptibility data are best explained by amino acid risk residues V, H, and H at positions 11, 13, and 33, contrary to previous suggestions of amino acids in the second hypervariable region. Worldwide, GCA incidence was independently associated both with population frequency of HLA-DRB1*04 and with latitude itself. We conclude that variation in population HLA-DRB1*04 frequency may partly explain variations in GCA incidence and that HLA-DRB1*04 may warrant investigation as a potential prognostic or predictive biomarker.
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Affiliation(s)
- Sarah Louise Mackie
- School of Medicine and NIHR-Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, LS7 4SA, West Yorkshire, UK.
| | - John C Taylor
- School of Medicine and NIHR-Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, LS7 4SA, West Yorkshire, UK.
| | - Lubna Haroon-Rashid
- School of Medicine and NIHR-Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, LS7 4SA, West Yorkshire, UK.
| | - Stephen Martin
- School of Medicine and NIHR-Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, LS7 4SA, West Yorkshire, UK.
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital, Prittlewell Chase, Southend, SS0 0RY, Essex, UK.
| | - Andrew Gough
- Department of Rheumatology, Harrogate and District Foundation NHS Trust, Lancaster Park Road, Harrogate, HG2 7SX, North Yorkshire, UK.
| | - Michael Green
- Department of Rheumatology, York Teaching Hospital NHS Foundation Trust, Wigginton Road, York, YO31 8HE, North Yorkshire, UK.
| | - Lesley Hordon
- Department of Rheumatology, Dewsbury and District Hospital, Halifax Road, Dewsbury, WF13 4HS, West Yorkshire, UK.
| | - Stephen Jarrett
- Department of Rheumatology, Pinderfields General Hospital, Aberford Road, Wakefield, WF1 4DG, West Yorkshire, UK.
| | - Colin T Pease
- Department of Rheumatology, Chapel Allerton Hospital, Leeds, Leeds, LS7 4SA, West Yorkshire, UK.
| | - Jennifer H Barrett
- School of Medicine and NIHR-Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, LS7 4SA, West Yorkshire, UK.
| | - Richard Watts
- Department of Rheumatology, Ipswich Hospital NHS Trust, Heath Road, Ipswich, IP4 5PD, Suffolk, UK.
| | - Ann W Morgan
- School of Medicine and NIHR-Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, LS7 4SA, West Yorkshire, UK.
- Wellcome Trust Brenner Building, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, West Yorkshire, UK.
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Abstract
BACKGROUND Giant cell arteritis (GCA) is a common inflammatory condition that affects medium and large-sized arteries and can cause sudden, permanent blindness. At present there is no alternative to early treatment with high-dose corticosteroids as the recommended standard management. Corticosteroid-induced side effects can develop and further disease-related ischaemic complications can still occur. Alternative and adjunctive therapies are sought. Aspirin has been shown to have effects on the immune-mediated inflammation in GCA, hence it may reduce damage caused in the arterial wall. OBJECTIVES To assess the safety and effectiveness of low-dose aspirin, as an adjunctive, in the treatment of giant cell arteritis (GCA). SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2013, Issue 12), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to January 2014), EMBASE (January 1980 to January 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to January 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en) and the US Food and Drugs Administration (FDA) web site (www.fda.gov). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 24 January 2014. SELECTION CRITERIA We planned to include only randomised controlled trials (RCTs) comparing outcomes of GCA with and without concurrent adjunctive use of low-dose aspirin. DATA COLLECTION AND ANALYSIS Two authors independently assessed the search results for trials identified by the electronic searches. No trials met our inclusion criteria, therefore we undertook no assessment of risk of bias or meta-analysis. MAIN RESULTS We found no RCTs that met the inclusion criteria. AUTHORS' CONCLUSIONS There is currently no evidence from RCTs to determine the safety and efficacy of low-dose aspirin as an adjunctive treatment in GCA. Clinicians who are considering the use of low-dose aspirin as an adjunctive treatment in GCA must also recognise the established haemorraghic risks associated with aspirin, especially in the context of concurrent treatment with corticosteroids. There is a clear need for effectiveness trials to guide the management of this life-threatening condition.
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Affiliation(s)
- Susan P Mollan
- Queen Elizabeth HospitalOphthalmology Department, University Hospitals Birmingham NHS TrustBirminghamUK
| | - Noor Sharrack
- Medical School, University of BirminghamEdgbastonUKB15 2TT
| | - Mike A Burdon
- Queen Elizabeth HospitalOphthalmology Department, University Hospitals Birmingham NHS TrustBirminghamUK
| | - Alastair K Denniston
- Queen Elizabeth HospitalOphthalmology Department, University Hospitals Birmingham NHS TrustBirminghamUK
- University of Birmingham, Birmingham and Midland Eye CentreAcademic Unit of OphthalmologyDudley RoadBirminghamUKB18 7QU
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Hayward RA, Rathod T, Muller S, Hider SL, Roddy E, Mallen CD. Association of polymyalgia rheumatica with socioeconomic status in primary care: a cross-sectional observational study. Arthritis Care Res (Hoboken) 2014; 66:956-60. [PMID: 24403212 PMCID: PMC4171747 DOI: 10.1002/acr.22276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 11/27/2013] [Accepted: 12/27/2013] [Indexed: 11/17/2022]
Abstract
Objective Polymyalgia rheumatica (PMR) is an inflammatory musculoskeletal condition predominantly diagnosed and managed in the community. Socioeconomic status (SES) is known to be associated with many inflammatory rheumatologic conditions, but has not been investigated in relation to PMR. This study aimed to investigate the association between PMR and SES at both the area and individual levels. Methods Patients ages >50 years registered with 8 general practices in North Staffordshire were sent a questionnaire requesting details of their general health, SES, and lifestyle. Individual SES was measured using occupation, educational level, and perceived adequacy of income. Area-level SES was measured using the Index of Multiple Deprivation, derived from respondents' postcodes. Electronic primary care medical records were searched for Read code diagnoses of PMR 2 years before and after the survey. Results Of the 13,831 respondents, 141 had a recorded PMR diagnosis in their electronic medical records, a prevalence of 10 per 1,000 patients. No association between PMR and SES was seen at either the individual or area level. Conclusion No association was found between PMR and SES at either the area or individual level. Unlike several of the inflammatory arthritides that are more common in the more deprived areas, PMR shows no such association. In part this may be due to PMR affecting an older population. Although socioeconomic factors are important for clinicians and researchers to consider, in patients with PMR, further epidemiologic work is needed to fully characterize this disabling disorder.
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O’Neill J, Rader T, Guillemin F, Boonen A, Christensen R, Lyddiatt A, Pardo JP, Welch V, Singh JA, Tugwell P. Including Health Equity Considerations in Development of Instruments for Rheumatology Research: An Introduction to a Novel OMERACT Paradigm. J Rheumatol 2013; 41:150-2. [DOI: 10.3899/jrheum.130812] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The Outcome Measures in Rheumatology (OMERACT) Equity Special Interest Group (SIG) was established in 2008 to create a preliminary core set of outcome measures for clinical trials that can assess equity gaps in healthcare and the effectiveness of interventions to close or narrow gaps between advantaged and disadvantaged populations with musculoskeletal (MSK) conditions. At the OMERACT 11 meeting in 2012, the Equity SIG workshop focused on health assessment scales and their applicability for disadvantaged patients with MSK conditions. The intent was to determine whether the items and domains in 2 common questionnaires, the Health Assessment Questionnaire and the Medical Outcome Study Short Form-36 Survey, are appropriate for the activities and life experiences of certain disadvantaged populations, and whether completion of any of the scales would present a challenge to disadvantaged persons. To generate discussion, we considered the reading level of items in these questionnaires and whether they would be accessible to people with different levels of literacy. The group concluded that the choice of measurement instrument may contribute to “outcome measure–generated inequalities” because disadvantaged groups might have difficulty understanding some of the questions. The future work of the Equity SIG will explore the appropriateness of different measurement scales as they relate to inequities in arthritis as well as the risk of exacerbating disadvantages for patients with low literacy.
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Zöller B, Li X, Sundquist J, Sundquist K. Occupational and socio-economic risk factors for giant cell arteritis: a nationwide study based on hospitalizations in Sweden. Scand J Rheumatol 2013; 42:487-97. [DOI: 10.3109/03009742.2013.793777] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Liozon E, Ly KH, Robert PY. Manifestations ophtalmologiques de la maladie de Horton. Rev Med Interne 2013; 34:421-30. [DOI: 10.1016/j.revmed.2013.02.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 02/15/2013] [Indexed: 10/27/2022]
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Abstract
Giant cell arteritis is the most common vasculitis in Caucasians. Acute visual loss in one or both eyes is by far the most feared and irreversible complication of giant cell arteritis. This article reviews recent guidelines on early recognition of systemic, cranial, and ophthalmic manifestations, and current management and diagnostic strategies and advances in imaging. We share our experience of the fast track pathway and imaging in associated disorders, such as large-vessel vasculitis.
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Affiliation(s)
| | | | - Shaifali Jain
- Department of Radiology, Southend University Hospital, Westcliff, Essex, United Kingdom
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Isik M, Karadag O. Comment on: Ischaemic manifestations in giant cell arteritis are associated with area level socio-economic deprivation, but not cardiovascular risk factors. Rheumatology (Oxford) 2012; 51:955; author reply 955-6. [PMID: 22361225 DOI: 10.1093/rheumatology/kes009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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