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Effect of Temporal Artery Biopsy Length and Laterality on Diagnostic Yield. J Neuroophthalmol 2022; 42:208-211. [PMID: 35439214 DOI: 10.1097/wno.0000000000001535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Giant cell arteritis (GCA) is the most common vasculitis in adults and is associated with significant morbidity and mortality. Temporal artery biopsy (TAB) remains the gold standard for diagnosis in the United States; however, practices vary in the length of artery obtained and whether bilateral simultaneous biopsies are obtained. METHODS Retrospective chart review of all TABs performed at the Johns Hopkins Wilmer Eye Institute between July 1, 2007, and September 30, 2017. RESULTS Five hundred eighty-six patients underwent TAB to evaluate for GCA. Of 404 unilateral biopsies, 68 (16.8%) were positive. Of 182 patients with bilateral biopsies, 25 (13.7%) had biopsies that were positive and 5 patients (2.7%) had biopsies that were discordant, meaning only 1 side was positive. There was no significant difference in the average postfixation length of positive and negative TAB specimens (positive mean length 1.38 ± 0.61 cm, negative mean length 1.39 ± 0.62 cm, P = 0.9). CONCLUSIONS There is no significant association between greater length of biopsy and a positive TAB result in our data. Although the rate of positive results was not higher in the bilateral group compared with the unilateral group, 2.7% of bilateral biopsies were discordant, similar to previously published rates. Overall, this suggests that initial bilateral biopsy may increase diagnostic yield, albeit by a small amount.
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Cucchiara BL, Kasner SE. Treatment of “Other” Stroke Etiologies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00058-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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3
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Oh LJ, Wong E, Gill AJ, McCluskey P, Smith JEH. Value of temporal artery biopsy length in diagnosing giant cell arteritis. ANZ J Surg 2016; 88:191-195. [PMID: 27800647 DOI: 10.1111/ans.13822] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 09/05/2016] [Accepted: 09/20/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Giant cell arteritis (GCA) is considered an ophthalmological emergency with severe sight and life-threatening sequelae. Temporal artery biopsy (TAB) is the current gold standard for the diagnosis of GCA; however, the required length of biopsy remains an issue of contention in the literature. METHODS Retrospective case-control study of a consecutive cohort of 545 patients who had undergone TABs across five hospitals between 1 January 1992 and 1 January 2016. In patients with either positive or negative TABs, we collected age, sex, biopsy length and erythrocyte sedimentation rate (ESR). RESULTS A total of 538 patients were included in the final analysis. Of these, 23.4% of TABs were positive, with the average length being 17.6 mm. There was a significant difference in means for positive (19.9 mm) and negative (16.8 mm) biopsies (P = 0.0009). Each millimetre increase in TAB length increased the odds of a positive TAB by 3.4% (P = 0.024). A cut-off point of ≥15 mm increased the odds of a positive TAB by 2.25 compared with a TAB <15 mm (P = 0.003). We also found that ESR ≥50 mm/h was a very strong predictor for a positive TAB result (P < 0.0001). CONCLUSION Biopsy length and ESR were significant predictors of a pathological diagnosis of GCA. We also found that the optimal length threshold predictive for GCA was 15 mm in order to avoid a false-negative GCA diagnosis. Although TAB remains the gold standard for diagnosis, clinicians should refer to both clinical and pathological data to guide their management.
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Affiliation(s)
- Lawrence J Oh
- Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Opthalmology, The University of Sydney, Sydney, New South Wales, Australia
| | - Eugene Wong
- Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Opthalmology, The University of Sydney, Sydney, New South Wales, Australia
| | - Anthony J Gill
- Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Opthalmology, The University of Sydney, Sydney, New South Wales, Australia.,Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Peter McCluskey
- Department of Opthalmology, The University of Sydney, Sydney, New South Wales, Australia.,Department of Opthalmology, Sydney Eye Hospital, Sydney, New South Wales, Australia
| | - James E H Smith
- Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Opthalmology, Sydney Eye Hospital, Sydney, New South Wales, Australia
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Kasner SE, Cucchiara BL. Treatment of “Other” Stroke Etiologies. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00056-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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5
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Durling B, Toren A, Patel V, Gilberg S, Weis E, Jordan D. Incidence of discordant temporal artery biopsy in the diagnosis of giant cell arteritis. Can J Ophthalmol 2014; 49:157-61. [DOI: 10.1016/j.jcjo.2013.12.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 11/23/2013] [Accepted: 01/03/2014] [Indexed: 11/28/2022]
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González-López JJ, González-Moraleja J, Burdaspal-Moratilla A, Rebolleda G, Núñez-Gómez-Álvarez MT, Muñoz-Negrete FJ. Factors associated to temporal artery biopsy result in suspects of giant cell arteritis: a retrospective, multicenter, case-control study. Acta Ophthalmol 2013; 91:763-8. [PMID: 22938720 DOI: 10.1111/j.1755-3768.2012.02505.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the positivity rate of temporal artery biopsies (TAB) performed in suspects of giant cell arteritis (GCA) and to study the epidemiological and clinical factors associated to the biopsy result. METHODS A retrospective, multicenter, case-control study was performed, including three hundred and thirty-five patients who underwent TAB for a suspicion of GCA from 2001 to 2010. Clinical, epidemiological and pathology data were recovered from the patients' clinical records. Histologic diagnosis of GCA was made when active inflammation or giant cells were found in the arterial wall. RESULTS Eighty-one biopsies (24.2%) were considered positive for GCA. Clinical factors independently associated to TAB result in a logistic regression analysis were temporal cutaneous hyperalgesia (OR = 10.8; p < 0.001), jaw claudication (OR = 4.6; p = 0.001), recent-onset headache (OR = 4.4; p = 0.001), decreased temporal pulse (OR = 2.8; p = 0.02), pain and stiffness in neck and shoulders (OR = 2.3; p = 0.05), unintentional weight loss (OR = 1.33; p = 0.003) and age (OR = 1.085; p = 0.004). Other factors such as length of the surgical specimen (OR = 1.079; p = 0.028) and erythrocyte sedimentation rate (OR = 1.042; p < 0.001) were also statistically significant. The model was accurate (C-index = 0.921), reliable (pHosmer-Lemeshow = 0.733) and consistent in the bootstrap sensitivity analysis. No significant association was detected between TAB result and number of days of previous systemic corticosteroid treatment (p = 0.146). However, an association was observed between TAB result and the total accumulated dose of previous systemic corticotherapy (p = 0.043). CONCLUSIONS Exhaustive anamnesis and clinical examination remain of paramount importance in the diagnosis of GCA. To improve the yield of TAB, it should be performed specially in older patients with GCA-compatible clinic. TAB could be avoided in patients with an isolated elevation of acute phase reactants, without GCA-compatible clinic.
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Affiliation(s)
- Julio J González-López
- Ophthalmology Service, Hospital Universitario Ramón y Cajal, Madrid, España, SpainDepartamento de Cirugía, Facultad de Medicina, Universidad de Alcalá, Madrid, España, SpainInternal Medicine Service, Complejo Hospitalario de Toledo, Toledo, España, SpainPathology Service, Hospital Universitario Ramón y Cajal, Madrid, España, Spain
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Abstract
The initial therapeutic approach to acute ischemic stroke consists of thrombolytic therapy and early initiation of supportive care, usually commenced prior to the determination of the underlying stroke etiology. Varying stroke mechanisms may call for specific, etiology-based treatment. The majority of strokes result from cardioembolism, large-vessel atherothromboembolism, and small-vessel occlusive disease. There are scant data to support the use of acute anticoagulation therapy over anti-platelet therapy in cardioembolic stroke and large-vessel atherosclerosis, although it may be reasonable in a certain subset of patients. However, augmentation of blood flow with early surgery, stenting, or induced hypertension, may play a role in patients with large artery stenosis. The less commonly identified stroke mechanisms may warrant special consideration in treatment. Controversy remains regarding the optimal anti-thrombotic treatment of arterial dissection. Reversible cerebral vasoconstriction syndrome may benefit from therapy with calcium channel blockers, high-dose steroids, or magnesium, although spontaneous recovery may occur. Inflammatory vasculopathies, such as isolated angiitis of the central nervous system and temporal arteritis, require prompt diagnosis as the mainstay of therapy is immunosuppression. Cerebral venous thrombosis is a rare cause of stroke, but one that needs early identification and treatment with anticoagulation. Rapid determination of stroke mechanism is essential for making these critical early treatment decisions.
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Affiliation(s)
- Neelofer Shafi
- Department of Neurology, Comprehensive Stroke Center, Comprehensive Stroke Center, Philadelphia, PA 19104 USA
| | - Scott E. Kasner
- Department of Neurology, Comprehensive Stroke Center, Comprehensive Stroke Center, Philadelphia, PA 19104 USA
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Ypsilantis E, Courtney ED, Chopra N, Karthikesalingam A, Eltayab M, Katsoulas N, Tang TY, Ball RY. Importance of specimen length during temporal artery biopsy. Br J Surg 2011; 98:1556-60. [PMID: 21706476 DOI: 10.1002/bjs.7595] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2011] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Variations in surgical technique of temporal artery biopsy (TAB) performed for diagnosis of giant cell arteritis (GCA) may contribute to high false-negative rates. This was a retrospective analysis of a large database that explored potential associations between specimen length and diagnostic sensitivity of TAB.
Methods
Histopathological reports and medical records of patients who underwent TAB in six hospitals between 2004 and 2009 were reviewed.
Results
A total of 966 biopsies were analysed. The median postfixation specimen length was 1 (range 0·1–8·5) cm and 207 biopsies (21·4 per cent) were positive for GCA. Significant variation in prebiopsy erythrocyte sedimentation rate (ESR), arterial specimen length and positive results was noted amongst hospitals. Multivariable analysis revealed that patient age, ESR value and specimen length were independent predictors of GCA. Positive biopsies had significantly longer median specimen length compared with negative biopsies: 1·2 (range 0·3–8·5) versus 1·0 (0·2–8·0) cm respectively (P = 0·001). Receiver operating characteristic (ROC) analysis identified postfixation specimen length of at least 0·7 cm as the cut-off length with highest positive predictive value for a positive biopsy (area under ROC curve 0·574). Biopsies with specimen length of 0·7 cm or more had a significantly higher rate of positive results than smaller specimens (24·8 versus 12·9 per cent respectively; odds ratio 2·17, P = 0·001).
Conclusion
Specimen length and ESR were independent prognostic factors of a positive TAB result. A uniform referral practice and standard specimen length of approximately 1 cm could help eliminate discrepancies in the results of TAB.
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Affiliation(s)
- E Ypsilantis
- Department of Surgery, Queen Elizabeth Hospital, King's Lynn, UK.
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Treatment of “Other” Stroke Etiologies. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10054-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Gonzalez-Gay MA, Vazquez-Rodriguez TR, Lopez-Diaz MJ, Miranda-Filloy JA, Gonzalez-Juanatey C, Martin J, Llorca J. Epidemiology of giant cell arteritis and polymyalgia rheumatica. ACTA ACUST UNITED AC 2009; 61:1454-61. [PMID: 19790127 DOI: 10.1002/art.24459] [Citation(s) in RCA: 363] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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BREUER GABRIELS, NESHER GIDEON, NESHER RONIT. Rate of Discordant Findings in Bilateral Temporal Artery Biopsy to Diagnose Giant Cell Arteritis. J Rheumatol 2009; 36:794-6. [DOI: 10.3899/jrheum.080792] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective.To determine to what extent performing simultaneous bilateral temporal artery biopsies might increase the diagnostic sensitivity in giant cell arteritis (GCA).Methods.In total 173 consecutive pathology reports of temporal artery biopsies were reviewed for histological findings by a single pathologist. The rate of discordance of biopsy results was calculated in patients with GCA.Results.Biopsies were performed bilaterally and simultaneously in 132 cases; 51 had positive results. In 38 the biopsy was positive on both sides (concordant results), while in 13 patients only one side was positive (discordant results), reaching a discordance rate of 13/51 = 0.255. Therefore 12.7% of the patients (one-half of the discordance rate) could have been misdiagnosed as biopsy-negative had a biopsy been done only unilaterally in those 51 cases.Conclusion.These data suggest that performing bilateral temporal artery biopsies increases the diagnostic sensitivity of the procedure by up to 12.7%, compared to unilateral biopsies.
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Abstract
Evaluation of elderly patients who have fever of unknown origin (FUO) requires a different perspective from that needed for young patients. Differential diagnosis often varies with age, and presentation of the disease frequently is nonspecific and symptoms difficult to interpret. Noninfectious diseases are the most frequent cause of FUO in the elderly and temporal arteritis the most frequent specific cause. Tuberculosis is the most common infectious disease associated with FUO in elderly patients. FUO often is associated with treatable conditions in the elderly. Therefore, intensive, accelerated evaluation is necessary, as the lack of physiologic reserve makes this population vulnerable to irreversible changes and functional deterioration.
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Affiliation(s)
- Sari Tal
- Subacute Department, Harzfeld Geriatric Hospital, Kaplan Medical Center, Gedera, Israel.
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Padró-Miquel A, Fuentes-Arderiu X. Quality control strategy to verify day-to-day imprecision of length of blood sedimentation reaction measurements with the TEST-1 analyzer. Clin Chem Lab Med 2007; 45:930-1. [PMID: 17617042 DOI: 10.1515/cclm.2007.150] [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: 11/15/2022]
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Mahr A, Saba M, Kambouchner M, Polivka M, Baudrimont M, Brochériou I, Coste J, Guillevin L. Temporal artery biopsy for diagnosing giant cell arteritis: the longer, the better? Ann Rheum Dis 2006; 65:826-8. [PMID: 16699053 PMCID: PMC1798165 DOI: 10.1136/ard.2005.042770] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To investigate the relation between temporal artery biopsy (TAB) length and diagnostic sensitivity for giant cell arteritis. METHODS Histological TAB reports generated from four hospital pathology departments were reviewed for demographics, histological findings, and formalin fixed TAB lengths. A biopsy was considered positive for giant cell arteritis if there was a mononuclear cell infiltrate predominating at the media-intima junction or in the media. RESULTS Among 1821 TAB reports reviewed, 287 (15.8%) were excluded because of missing data, sampling errors, or age < 50 years. Mean TAB length of the 1520 datasets finally analysed (67.2% women; mean (SD) age, 73.1 (10.0) years) was 1.33 (0.73) cm. Histological evidence of giant cell arteritis was found in 223 specimens (14.7%), among which 164 (73.5%) contained giant cells. Statistical analyses, including piecewise logistic regression, identified 0.5 cm as the TAB length change point for diagnostic sensitivity. Compared with TAB length of < 0.5 cm, the respective odds ratios for positive TAB without and with multinucleated giant cells in samples > or = 0.5 cm long were 5.7 (95% confidence interval, 1.4 to 23.6) and 4.0 (0.97 to 16.5). CONCLUSIONS A fixed TAB length of at least 0.5 cm could be sufficient to make a histological diagnosis of giant cell arteritis.
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Affiliation(s)
- A Mahr
- Department of Internal Medicine, Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, 75679 Paris Cedex 14, France.
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Abstract
In summary, neurologists should be aware of emergent neuro-ophthalmic conditions: (1) temporal arteritis (GCA), (2) IIH, (3) intracranial shunt malfunction, (4) pituitary apoplexy, and (5) pupil-involved TNP. Earlier recognition and treatment of these disorders makes a difference in final out-come. Appropriate evaluation and management may be vision or life saving.
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Affiliation(s)
- Andrew G Lee
- Departments of Ophthalmology, Neurology, and Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
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Cortelli P, Cevoli S, Nonino F, Baronciani D, Magrini N, Re G, De Berti G, Manzoni GC, Querzani P, Vandelli A. Evidence‐Based Diagnosis of Nontraumatic Headache in the Emergency Department: A Consensus Statement on Four Clinical Scenarios. Headache 2004; 44:587-95. [PMID: 15186303 DOI: 10.1111/j.1526-4610.2004.446007.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To provide to emergency department (ED) physicians with guidelines for diagnosis of patients with nontraumatic headaches. BACKGROUND Many patients present to an ED with the chief complaint of headache. Causes of nontraumatic headache include life-threatening illnesses, and distinguishing patients with such ominous headaches from those with a primary headache disorder can be challenging for the ED physician. CONCLUSION We present a consensus statement aimed to be a useful tool for ED doctors in making evidence-based diagnostic decisions in the management of adult patients with nontraumatic headache. METHODS A multidisciplinary work performed an extensive review of the medical literature and applied the information obtained to commonly encountered scenarios in the ED.
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Affiliation(s)
- Pietro Cortelli
- Department of Neurologoical Sciences, University of Modena-Reggio Emilia, Modena, Italy
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Kasner SE. Treatment of "Other" Causes of Stroke. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50062-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
In a given year, over 5% of persons in the United States seek medical care for headaches, most often seeing their primary care physician. The five cases here review diagnosis and treatment of migraine and other primary headaches, medication rebound headaches, and headaches in the elderly including temporal arteritis. Although headaches (along with dizziness and back pain) may be one of the least preferred diseases internists see, the increasing number of effective treatments may favorably change this opinion and result in better care for their patients.
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Abstract
Fever of unknown origin (FUO) means fever that does not resolve itself in the period expected for self-limited infection and whose cause cannot be ascertained despite considerable diagnostic efforts. The differential diagnosis is often different in older patients, and presentation of disease is frequently nonspecific and symptoms are difficult to interpret. Multisystem disease has emerged as the most frequent cause of FUO in the elderly, and temporal arteritis is the most frequent specific diagnosis. Infections, particular tuberculosis, remain an important group. FUO is often associated with treatable conditions in this age group. Early recognition and prompt initiation of appropriate empirical therapy are cornerstones of the strategy.
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Affiliation(s)
- S Tal
- Subacute Department, Harzfeld Geriatric Hospital, Kaplan Medical Center, Gedera 70750, Israel.
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Lee AG. Efficacy of unilateral versus bilateral temporal artery biopsies for the diagnosis of giant cell arteritis. Am J Ophthalmol 2000; 129:118-9. [PMID: 10653435 DOI: 10.1016/s0002-9394(99)00375-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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