Fast-track Clinic Research Articles

Diagnostic Performance of a Newly-Launched Canadian Fast-Track Ultrasound Clinic by Rheumatologists for the Diagnosis of Giant Cell Arteritis.

Giant Cell Arteritis (GCA) can present diagnostic challenges and early diagnosis is crucial due to potential ischemic complications. Recent guidelines suggest that a suspected diagnosis should be confirmed with temporal artery biopsy or imaging, including ultrasound (US). In our Canadian setting, point-of-care temporal artery US was near unavailable, and biopsy remains the standard of care. We hypothesize that launching a fast-track US clinic by rheumatologists may spare the need for a temporal artery biopsy. Therefore, this study aimed to assess the diagnostic performance of US in this newly-launched fast-track clinic. In this single-center retrospective cross-sectional analysis, 99 visits were identified from the fast-track clinic between January 2020 and July 2022. Each subject had an US according to a standard protocol for suspicion of either new-onset or relapse of GCA. Ultrasonographers were rheumatologists who acquired training on vascular US techniques before launching the clinic. For each patient presenting with suspected new-onset GCA, the pre-test probability was calculated using the Southend GCA probability score. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated using the rheumatologist clinical diagnosis as the gold standard for GCA diagnosis. A total of 22 subjects had a diagnostic of GCA and 77 had another diagnostic. Patients with and without GCA were, respectively, 81.8% vs 72.7% females, had a mean age of 76.6 ± 7.7 vs. 74.8 ± 9.8 years and a mean CRP of 73.4 ± 57.8 vs 38.3 ± 59.9 mg/L. Temporal artery US demonstrated a a sensitivity of 86.3% [95% confidence interval (CI), 65.1%-97.1%], a specificity of 90.9% (95% CI, 82.2%-96.3%), a PPV of 73.1% (95% CI, 56.8%-84.9%) and a NPV of 95.9% (95% CI, 89.0%-98.5%). 14 patients had a suspicion of relapse and were all correctly identified by the US. Among those with suspicion of new-onset 27, 34 and 24 US were performed for high, intermediate, and low pretest probability of GCA, respectively. The high-risk subgroup demonstrated higher PPV while similar sensitivity/specificity were observed between all three subgroups. Our results highlights the benefits of US as a key diagnostic tool for GCA, particularly when combined with clinical evaluations. An excellent discriminative ability for diagnosis of GCA was shown in this newly-launched clinic suggesting that the role of TAB may need to be redefined. These findings will guide on broader implementation of US programs for GCA.

Comment on: Real-world outcomes of a dedicated fast-track polymyalgia rheumatica clinic. Reply.

Comment on: Real-world outcomes of a dedicated fast-track polymyalgia rheumatica clinic. Reply.

Comment on: Real-world outcomes of a dedicated fast-track polymyalgia rheumatica clinic

Comment on: Real-world outcomes of a dedicated fast-track polymyalgia rheumatica clinic

Experience from a Fast-Track Multidisciplinary Clinic Integrating Movement Disorders Neurologists in Normal Pressure Hydrocephalus Evaluation.

In this prospective observational cohort study, we provide preliminary findings from a same-day multidisciplinary fast-tracked normal pressure hydrocephalus (NPH) clinic; incorporating the expertise of movement disorders neurologists, emphasizing the clinical characteristics, consensus classification, and management of patients referred for suspected NPH. We evaluated 111 patients (male/female: 67/44) from April 2022 to May 2023. Based on the multidisciplinary team consensus, 52 (46.8%) were classified as "probable" idiopathic NPH (iNPH), 14 (12.6%) as "possible" NPH, 42 (37.8%) as "unlikely" NPH, and three (2.7%) as secondary NPH. While parkinsonian syndromes were recognized in 19.2% of "probable" iNPH patients (vs. 7.1% in "possible" and 26.2% in "unlikely" NPH), no significant group differences were noted in the scores of the UPDRS-III scale. Degenerative spine pathologies were prevalent across all NPH categories, affecting at least 50% of patients. In the "probable" iNPH group, 78.8% received programmable ventriculoperitoneal shunts, with clinical improvement identified in 87.8% at 12-month follow-up. Our findings underscore the high prevalence of overlapping and competing movement and spinal disorders in patients with suspected NPH. Further, our novel approach, incorporating movement disorder neurologists in NPH multidisciplinary evaluation, improved diagnostic precision and streamlined personalized plans, including further neurological workups, necessary spinal interventions, and medical management or rehabilitation.

Real-world outcomes of a dedicated fast-track polymyalgia rheumatica clinic.

To examine the clinical impact of a fast-track PMR clinic to enable early diagnosis and treatment, and to define both patient and disease characteristics in newly diagnosed PMR. Primary care physicians were invited to refer patients with new PMR to our fast-track clinic. Referral criteria included new onset shoulder or pelvic girdle pain and/or stiffness with elevated inflammatory markers in patients over 50 years. All patients were seen within 72 h of referral. Patients with a rheumatology diagnosis of PMR had an ultrasound (US) of their temporal and axillary arteries. 172 patients were referred from primary care over 12 months. 39% of patients referred with suspected PMR had an alternative diagnosis for which PMR regimen glucocorticoids was inappropriate. 55% of the non-PMR diagnoses were other inflammatory rheumatological conditions requiring follow-up. Only 20% of patients referred from primary care already on glucocorticoids were commenced on bone protection. PMR patients were co-morbid with a mean of 2.5 other conditions. 75% of PMR patients experienced a glucocorticoid-related adverse event in the first 12 months of treatment. 16% of patients with new PMR had ultrasound features of subclinical giant cell arteritis. The commencement of glucocorticoid therapy should be deferred until after specialist evaluation to enable an accurate clinical diagnosis. A delay in treatment can only realistically be avoided if GPs have access to a Fast-track PMR clinic. We believe that rheumatologists should consider establishing fast-track PMR clinics and this study provides a strong case for and a template to support this practice innovation.

Recommendations for defining giant cell arteritis fast-track clinics. English version.

A German expert committee recommends defining fast-track clinics (FTC) for the acute diagnosis of giant cell arteritis (GCA) as follows: easy and prompt reachability at least on weekdays, scheduling appointments ideally within 24 h, examination by aspecialist with GCA expertise, ≥ 2experts per FTC, ≥ 50patients with suspected GCA per year, sonologists with ≥ 300 (≥ 50) temporal and axillary artery examinations, adherence to standard operating procedures, availability of an ≥ 18 (≥ 15) MHz and alower frequency linear ultrasound probe, and collaboration with partners for neurology and ophthalmology consultations, magnetic resonance imaging (MRI), positron emission tomography-computed tomography (PET-CT, possibly CT), and for temporal artery biopsy.

The Common Carotid Artery in the Ultrasound Evaluation of Giant Cell Arteritis.

Vascular ultrasound is commonly used to diagnose giant cell arteritis (GCA). Most protocols include the temporal arteries and axillary arteries, but it is unclear which other arteries should be included. This study investigated whether inclusion of intima media thickness (IMT) of the common carotid artery (CCA) in the ultrasound evaluation of GCA improves the accuracy of the examination. We formed a fast-track clinic to use ultrasound to rapidly evaluate patients with suspected GCA. In this cohort study, patients referred for new concern for GCA received a vascular ultrasound for GCA with the temporal arteries and branches, the axillary artery, and CCA. We compared 57 patients with GCA and 86 patients without GCA. Three patients with GCA had isolated positive CCA between 1 and 1.49 mm, and 21 patients without GCA had isolated positive CCA IMT. At the 1.5-mm CCA cutoff, 4 patients without GCA had positive isolated CCA, and 1 patient with GCA had a positive isolated CCA. The sensitivity of ultrasound when adding carotid arteries to temporal and axillary arteries was 84.21% and specificity 65.12% at an intima media thickness (IMT) cutoff of ≥1 mm and 80.70% and 87.21%, respectively, at a cutoff of ≥1.5 mm. Measurement of the CCA IMT rarely contributed to the diagnosis of GCA and increased the rate of false-positive results. Our data suggest that the CCA should be excluded in the initial vascular artery ultrasound protocol for diagnosing GCA. If included, an IMT cutoff of higher than 1.0 mm should be used.

Recommendations for defining giant cell arteritis fast-track clinics

An expert committee recommends defining fast-track clinics (FTC) for the acute diagnostics of giant cell arteritis (GCA) as follows: low-threshold, easy and prompt reachability at least on weekdays, scheduling appointments ideally within 24 h, examination by aspecialist with GCA expertise, ≥ 2experts per FTC, ≥ 50patients with suspected GCA per year, sonologists with ≥ 300 (≥ 50) temporal and axillary artery examinations, adherence to standard operating procedures, availability of an ≥ 18 (≥ 15) MHz and alower frequency linear ultrasound probe and collaboration with partners for fast performance of neurological and ophthalmological examinations, magnetic resonance imaging (MRI), positron emission tomography-computed tomography (PET-CT, possibly CT) and for temporal artery biopsy.

The OMERACT Giant cell arteritis Ultrasonography Score: a potential predictive outcome to assess the risk of relapse during follow-up.

To determine whether the OMERACT giant cell arteritis (GCA) Ultrasonography (US) Score (OGUS) change after treatment can be used for assessing the probability of relapse. Multicenter retrospective study of GCA patients referred to two US GCA fast-track clinics over 2 years. Patients underwent US evaluation at baseline, 3 and 6 months. EULAR definitions for remission and relapse were checked at 3 and 6 months. OGUS changes at 0-3 months and 0-6 months were compared among patients with and without relapse at 6 months, as well as those with and without remission at 6 months. A total of 76 patients were included (mean age 77.2 years, 55.3% females). Nineteen (26%) patients relapsed at 6-months, of whom 14(19.1%) showed a minor relapse. EULAR remission at 6 months was achieved by 32(43.8%) patients. The standardized mean difference of OGUS between baseline and 3 and 6 months was -0.25 and -0.38, respectively. OGUS significantly improved between baseline and 6 months (1.18 vs 0.99,p=0.004) and from 3-6 months (1.08 vs 0.99,p=0.04) in non-relapsing patients, whereas no significant changes at 3 (1.17 vs 1.17;p=0.736) and 6 (1.17 vs 1.21;p=0.343) months were observed in those who experienced relapse. Mean 0-6-month OGUS improvement was lower in patients who relapsed (-0.1 vs 0.16,p=0.037). Mean 0-6-month OGUS improvement was greater in patients who achieved remission at 6 months (0.28vs -0.07,p=0.001). The absence of OGUS improvement during follow-up in GCA may be used to assess the probability of relapse and the absence of remission at 6 months.

Development of a diagnostic prediction model for giant cell arteritis by sequential application of Southend Giant Cell Arteritis Probability Score and ultrasonography: a prospective multicentre study

Giant cell arteritis is a critically ischaemic disease with protean manifestations that require urgent diagnosis and treatment. European Alliance of Associations for Rheumatology (EULAR) recommendations advocate ultrasonography as the first investigation for suspected giant cell arteritis. We developed a prediction tool that sequentially combines clinical assessment, as determined by the Southend Giant Cell Arteritis Probability Score (SGCAPS), with results of quantitative ultrasonography. This prospective, multicentre, inception cohort study included consecutive patients with suspected new onset giant cell arteritis referred to fast-track clinics (seven centres in Italy, the Netherlands, Spain, and UK). Final clinical diagnosis was established at 6 months. SGCAPS and quantitative ultrasonography of temporal and axillary arteries with three scores (ie, halo count, halo score, and OMERACT GCA Score [OGUS]) were performed at diagnosis. We developed prediction models for diagnosis of giant cell arteritis by multivariable logistic regression analysis with SGCAPS and each of the three ultrasonographic scores as predicting variables. We obtained intraclass correlation coefficient for inter-rater and intra-rater reliability in a separate patient-based reliability exercise with five patients and five observers. Between Oct 1, 2019, and June 30, 2022, we recruited and followed up 229 patients (150 [66%] women and 79 [34%] men; mean age 71 years [SD 10]), of whom 84 were diagnosed with giant cell arteritis and 145 with giant cell arteritis mimics (controls) at 6 months. SGCAPS and all three ultrasonographic scores discriminated well between patients with and without giant cell arteritis. A reliability exercise showed that the inter-rater and intra-rater reliability was high for all three ultrasonographic scores. The prediction model combining SGCAPS with the halo count, which was termed HAS-GCA score, was the most accurate model, with an optimism-adjusted C statistic of 0·969 (95% CI 0·952 to 0·990). The HAS-GCA score could classify 169 (74%) of 229 patients into either the low or high probability groups, with misclassification observed in two (2%) of 105 patients in the low probability group and two (3%) of 64 of patients in the high probability group. A nomogram for easy application of the score in daily practice was created. A prediction tool for giant cell arteritis (the HAS-GCA score), combining SGCAPS and the halo count, reliably confirms and excludes giant cell arteritis from giant cell arteritis mimics in fast-track clinics. These findings require confirmation in an independent, multicentre study. Royal College of Physicians of Ireland, FOREUM.

E023 Intimomedial mucoid degeneration. A rare vascular disease mimicking giant cell arteritis presentation

Abstract Background/Aims The accuracy of giant cell arteritis (GCA) diagnosis has greatly improved in recent years with increasing use of fast track clinics and vascular ultrasound. The “halo” sign is recognised as confirmation of a positive test and is considered virtually pathognomonic of GCA in the setting of a correlating clinical presentation. There are caveats to this and “false halos” have been reported associated with arterial thickening seen in other conditions including atherosclerosis and lymphoma. In this case a focal area of arterial wall thickening mimicking a halo on ultrasound was due to a rare vascular condition called intimomedial mucoid degeneration. Methods A 63 year old female presented via the direct assessment unit to the fast track GCA service. She reported an 8 week history of a tender right forehead lump and a 3 week history of associated new headache with marked tenderness at the site of the lump. The headache was severe and had become persistent. Mild shoulder stiffness was present. No jaw claudication. Blurring while wearing glasses noted but no definite visual change. CRP 2mg/L, ESR at usual baseline of 30mm/hr. Other indices normal. On examination: No shoulder restriction. No visual field deficit. Palpable pulsatile area of artery right side of forehead that was exquisitely tender with less marked tenderness of the artery adjacent to this. No symptoms on left side. GCA probability score (GCAPS) 10 indicating intermediate probability of GCA. Results Temporal artery ultrasound performed using GE Logiq e and 10-22mHz probe. Left side imaged entirely normally. Right side symptomatic area imaged as a focal asymmetric thickened area of frontal branch artery measuring 1.5mm maximally in compression. The frontal branch artery imaged normally proximal and distal to this as did the right common superficial and parietal branches. Features were unusual however she was commenced on prednisolone 40mg daily pending further investigations. Eye assessment detected no ischaemic concerns. She returned for reassessment after 4 days. There was some symptomatic improvement however the tender lump persisted. A second opinion on the ultrasound was sought from the interventional radiologist, who felt the focal area may be a lymph node, with thickened artery adjacent. Surgical exploration and temporal artery biopsy was subsequently performed. Conclusion Histology showed there was actually mucoid change with eccentric thickening of the artery with aneurysmal change in keeping with the rare diagnosis of intimomedial mucoid degeneration. This is a very rare condition which causes predisposition to arterial aneurysm formation, and typically presents with acute pain of the artery involved. This lady had developed an aneurysm which was excised at the time of the biopsy, relieving her symptoms. This case is a reminder to pursue additional investigations and tissue diagnosis in the setting of unusual clinical and imaging findings. Disclosure S. Black: None. M. Wray: None. H. Stewart: None. E. Durkan: None. V. Serafimov: None. P. Davey: None. L. Smith: None.

Improving Clinical Wait Times in a Veterans Affairs' Urologic Setting.

Background: Long clinic wait times can contribute to treatment delays and decreased patient satisfaction. Veterans are often waiting in the urology clinic for a prolonged period that delays treatments including possible surgical interventions leading to patient dissatisfaction. Purpose: The purpose of this quality improvement project was to decrease the overall procedural wait times in an outpatient urology clinic by implementing a Fast-Track procedural clinic. Methods: The Fast-Track procedural clinic was developed to expedite care for veterans actively under bladder or prostate cancer surveillance, employing lean methodology principles. We also utilized the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS) tool to assess patient satisfaction with the newly implemented Fast-Track clinic. Wait times were collected and analyzed by SPSS statistical software to determine the effectiveness of a Fast-Track clinic. Results: The Fast-Track clinic was implemented to veterans presenting to the urology clinic for procedural appointments from June 2021 to December 2021. The usage of a Fast-Track clinic decreased the overall wait times from 131 to 75 minutes within 8 weeks (43% improvement). The OAS CAHPS tool found that 55% of veterans received easy-to-understand instructions pre-Fast-Track implementation, compared with 59% post-Fast-Track implementation (a 4% improvement). Furthermore, 82% of veterans reported that they did not receive written discharge instructions post-Fast-Track implementation compared with 32% pre-Fast-Track implementation. Conclusion: Incorporating a Fast-Track procedural clinic helped minimize wait times, leading to a reduction in procedural wait times and urologic surgical delays. Implications for Nursing: The implications for practice include future studies focusing on other strategies for improving clinic wait times including block schedules and qualitative measures in the urologic and other specialty areas.

P889 Facilitating equitable IBD care trust-wide: a need for treatment targets in IBD?

Abstract Background Timely biological therapy in IBD is associated with reduced disease progression, especially in CD (Berg et al 2019). However, there are no clear UK standards detailing the timescale in which IBD care should be delivered. We evaluated the time between initial consideration of therapy and first dose in a district general hospital and tertiary referral centre in Barts Health NHS Trust. Methods Details of patients receiving biologics for IBD at Newham (NUH) and Royal London Hospital (RLH) (between 2018 – 2022) were obtained from infusion clinics; electronic records were reviewed for 50 recent referrals. The following information was collected: demographics, phenotype, drug, first documentation of consideration of biologic, completion of funding application, onset of therapy. Results Demographics: NUH: Age (median(IQR)) = 43.5(30.3 – 50.56) Gender (F:M) = 26:24, CD:UC = 34:16, Biologic: infliximab:vedolizumab:ustekinumab:adalimumab: 29:5:11:5, First biologic: n=34 RLH: Age (median(IQR)) = 31.6 (24.6 – 41.1) Gender (F:M) = 27:23 CD:UC = 23:27, Biologic: infliximab:vedolizumab:ustekinumab:adalimumab: 34:12:3:1, First biologic: n=25 There was substantially longer time between initial consideration of therapy and first dose delivered at NUH 94.5 days (44 – 174) compared with RLH 35.5 days (23.75 –69) (p<0.01). However, time from completion of funding application to first dose did not differ significantly between sites (43.5 days (30.3 – 50.6) vs 31.6 (24.6 – 41.1), p=0.42). In patients receiving first biologic, there was a trend towards a longer time since diagnosis at NUH (3.2 years (1.0 – 9.1) vs 1.7 years (0.5 – 4.3), p=0.08). Conclusion Patients treated in a tertiary referral centre started biologics sooner after consideration, and earlier in disease course. This does not appear due to availability of infusion services, but due to time to complete initial investigations and finalise escalation. This may reflect differences in service set-up; in particular, NUH manages IBD care with a single IBD nurse, and fewer options for fast-track clinic follow up. A clear UK IBD standards framework identifying recommended time frames for establishing biologics is indicated, to ensure equity in care across tertiary and DGH settings.

1874 Developing a pathway direct to elderly medicine clinic for frail patients referred via colorectal fast-track: pilot and outcomes

Abstract Introduction It is increasingly recognised within oncogeriatrics that standard fast-track pathways for suspected malignancy can be inappropriate for frail and elderly patients (Thomas et. al.; Age and Ageing; 2021; 50; ii8-ii13). Specifically for colorectal referrals, following standard pathways can mean undergoing invasive and expensive endoscopic investigations which may be unwanted and not alter overall management. Streaming frail patients to elderly medicine may increase opportunities for comprehensive geriatric assessment whilst reducing unwanted invasive tests and time spent on fast-track pathways. Methods A 3-month retrospective audit of frail patients seen in colorectal fast-track clinic was conducted to evaluate existing practice at Bradford Teaching Hospitals. This informed the design of a new pathway streaming frail patients directly to elderly clinic within 2 weeks. This was implemented in a 3-month pilot with data prospectively collected to compare outcomes. Cohorts: - 26 patients (median age 79, WHO performance status 3) seen by colorectal team March-June 2022. - 20 patients (median age 85, WHO performance status 2) streamed to elderly medicine clinic October 2022- March 2023. Results - Median time to fast-track pathway removal was 62 days for patients managed via colorectal clinic compared to 31 days via elderly medicine. - Invasive tests and imaging (CT/endoscopy) fell from 1.4 tests per patient in colorectal clinic to 0.4 patients in the pilot. - 2 diagnoses of cancer made via colorectal clinic, but no further treatment for either patient. 1 diagnosis of lung cancer in pilot group, patient undergoing radiotherapy. - Patients seen in elderly clinic had greater rates of positive diagnosis for symptoms (e.g: infective/iatrogenic). Conclusions Streaming frail elderly patients referred via colorectal fast-track to elderly medicine reduced the number of invasive investigations undertaken and time spent on fast-track pathways. Expanding this successful pilot could improve long-term clinical quality in the service and more widely if disseminated.

Recent Developments of USG Score for GCA

The 2022 European League Against Rheumatism (EULAR) guidelines have introduced a significant advancement in the diagnostic approach to Giant Cell Arteritis (GCA). According to these updated guidelines, Ultrasound (US) examinations of the cranial and axillary arteries should be considered the primary imaging method for evaluating patients who are suspected to have GCA, provided that the examinations are performed by adequately trained specialists using high-quality equipment. This recommendation marks a notable shift in the traditional management practices for GCA, as it acknowledges the effectiveness of ultrasound as a non-invasive, efficient, and reliable point-of-care test for individuals with suspected GCA. As a result, this development has paved the way for the establishment of fast-track clinics dedicated to GCA diagnosis and treatment across various parts of the globe. However, it is important to note that the use of ultrasound for diagnosing GCA comes with certain challenges. The highly technical nature of the ultrasound procedure, combined with its dependence on the expertise of the operator, often leads to criticism regarding its reliability as a clinical tool. This can create confusion among clinicians when they attempt to interpret formal ultrasound reports, especially if they are not trained in sonography themselves. In this presentation, we will thoroughly examine the evidence supporting the use of ultrasonography in the diagnosis of Giant Cell Arteritis. The discussion will encompass several key concepts, including: 1. The validity of ultrasonography as a diagnostic tool for GCA. 2. The diagnostic performance of ultrasound in identifying the condition. 3. The practical utility of ultrasound in an Australian Fast Track Clinic setting. 4. The assessment of treatment response and sensitivity to change, as measured by ultrasound findings. 5. The various scoring tools utilized in ultrasound evaluations, such as the Halo Count, the Halo Score, and the OMERACT GCA Ultrasound Score. 6. A review of the EULAR guidelines and how they have evolved over time. 7. Critical information that clinicians who are not trained in sonography need to understand regarding the use of ultrasound in GCA. Through this comprehensive review, we aim to clarify the role of ultrasonography in the diagnosis and management of Giant Cell Arteritis, empowering clinicians with the knowledge they need to effectively utilize this diagnostic tool in their practice.

Vasculitis distribution and clinical characteristics in giant cell arteritis: a retrospective study using the new 2022 ACR/EULAR classification criteria.

Giant cell arteritis (GCA) is the most common vasculitis of the elderly. In recent years, advanced imaging has to a certain extent replaced temporal artery biopsy (TAB) to aid diagnosis in many institutions and helped to identify three major phenotypes of GCA, namely, cranial GCA (c-GCA), large-vessel non-cranial GCA (LV-GCA), and a combination of these two patterns called mixed-GCA, which all show different clinical patterns. Recent 2022 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria respect the changing conception and clinical practice during the last two decades. In this cohort study, we present vasculitis distribution and baseline characteristics using the 2022 ACR/EULAR classification criteria as well as the EULAR core data set. In this retrospective study from Southern Norway, we identified all patients diagnosed with GCA between 2006 and 2019 in our single-center fast-track clinic (FTC). We included all patients who were examined using ultrasound (US) of cranial as well as non-cranial large vessels at diagnosis to depict vascular distribution. EULAR core data set, ACR 1990, and 2022 ACR/EULAR classification criteria were used to characterize the cohort. Seventy-seven patients were diagnosed with GCA at our institution in the aforementioned period. Seventy-one patients (92.2%) were diagnosed with the help of US and included in the further analysis. The 2022 ACR/EULAR classification criteria allocated 69 patients (97.2%), while the ACR 1990 classification criteria allocated 49 patients (69.0%) in our cohort as having GCA. Mixed-GCA was the most common type in 33 patients (46.5%). Weight loss was significantly more common in patients with large-vessel non-cranial vasculitis in LV-GCA and mixed-GCA. Headache, on the other hand, was significantly more common in patients with involvement of cranial vessels. Mixed GCA was the most common form of GCA in our cohort. In our study, the 2022 ACR/EULAR classification criteria seem to be a more useful tool compared with the old ACR 1990 classification criteria to allocate GCA patients diagnosed and treated at our US-based FTC as having GCA.

External validation of the 2022 ACR/EULAR classification criteria in patients with suspected giant cell arteritis in a Dutch fast-track clinic

ObjectiveRecently the Diagnostic and Classification Criteria in Vasculitis Study group developed and published new American College of Rheumatology/EULAR classification criteria for giant cell arteritis (GCA). To test robustness in a...

P207 External validation of the Southend giant cell arteritis pre-test probability score in a Dorset fast-track clinic

Abstract Background/Aims Giant cell arteritis (GCA) is a common referral to rheumatology departments and timely and accurate diagnosis is important to prevent ischaemic complications. The current BSR and EULAR guidelines support the use of temporal and axillary artery ultrasound for ruling out GCA in low-probability cases or for confirming GCA in high-probability cases. The Southend GCA pre-test probability score (PTPS) is a tool that can be used to risk-stratify patients and guide the need for additional investigations. Previous publications have categorised patients as low-risk (PTPS <9), intermediate-risk (PTPS 9-12) and high-risk (PTPS >12). We aimed to provide external validation of the Southend PTPS by assessing its performance in patients attending the fast-track GCA clinic at Poole Hospital. Methods Between 5th January 2018 and 17th June 2022, 576 patients were seen in the GCA fast-track clinic at Poole Hospital and 506 (87.8%) had a calculated PTPS. Patients were diagnosed with ‘confirmed GCA’, ‘possible GCA’, ‘probable GCA’, ‘presumed GCA’, ‘not GCA’, or ‘large vessel vasculitis’ based on clinical, laboratory, ultrasound, biopsy or additional imaging. For the purpose of this analysis, we included only those patients who were diagnosed with ‘confirmed GCA’ (86 patients) or ‘not GCA’ (319 patients). A PTPS ≥9 was used to calculate the sensitivity, specificity, positive and negative predictive values for a diagnosis of GCA. Results The mean age of patients with ‘confirmed GCA’ in our cohort was 78.8 years and the percentage who were female was 72.1%. A PTPS ≥9 had a sensitivity of 97.7% and specificity of 63% for a diagnosis of GCA. The positive predictive value was 41.6% and negative predictive value was 99%. Conclusion Our results show that the Southend PTPS can be used to risk stratify patients into high- and low-risk groups and validates the PTPS outside the centre in which it was developed. Our results are comparable to those published by other external centres. The high negative predictive value of the test suggests it is particularly helpful in ruling out GCA and could conceivably have a role in screening referrals to the fast-track clinic; however, further work would be needed to determine the optimal cut-off score. Disclosure J. Carroll: None. F. Griffith: None. C. Fox: None. M. Khurshid: None.

E042 The Newcastle Giant Cell Arteritis (GCA) Fast Track Clinic: a clinical service evaluation

Abstract Background/Aims Patients with suspected new-onset giant cell arteritis (GCA) require urgent specialist assessment to establish a diagnosis. Early review reduces unnecessary treatment with high dose glucocorticoids in those without GCA and enhances sensitivity of temporal artery ultrasound. Ensuring patients are rapidly triaged and diagnosed poses a logistical challenge for rheumatology departments working alongside colleagues in both primary care and ophthalmology. To address this, we established a rheumatology-led Newcastle Hospital GCA fast track clinic, a service led by four consultant rheumatologists who perform clinical assessments and temporal artery ultrasound scans. Methods Data were collected prospectively from 2017. We performed a clinical service evaluation based on a retrospective review of clinical records of patients assessed in this service between 2017 to 2020. Results A total of 626 consecutive patients were assessed, with 145 (23%) diagnosed with GCA over the four-year period. Average age was 72 (range 41-96 years) and 452 (72%) were female. The cardinal symptoms of headache, jaw claudication and visual disturbance were present in 518, 103 and 283 patients respectively. The majority of referrals came from ophthalmology (42%) and primary care (34%). 614 patients had an ultrasound scan performed, returning a positive result in 121 (19.7%), negative in 415 (67.6%) and inconclusive in 78 (12.7%). A biopsy was requested for 147 patients over the four-year period; 33 were positive, 95 negative and six were inconclusive. Within this cohort, 47 patients had a biopsy performed despite a negative ultrasound scan, of which five were found to be positive for GCA. Conclusion Our data illustrate the key clinical, imaging and histological findings within one of the largest inception cohorts of GCA in the UK and demonstrate the feasibility of a one-stop rapid access clinical service for patient benefit. Disclosure C.M. Lin: None. J. Berry: None. B. Thompson: None. J. Heaney: None. K. Houghton: None. K. Baker: None. G. Reynolds: None. A. Lorenzi: None.

Intima-media thickness cut-off values depicting "halo sign" and potential confounder analysis for the best diagnosis of large vessel giant cell arteritis by ultrasonography.

Vascular ultrasound enables fast-track diagnosis of giant cell arteritis (GCA), but this method remains subjective. We aimed to determine intima-media thickness (IMT) cut-off values for large vessel GCA (LV-GCA) and identify the clinically relevant factors influencing it. We included 214 patients referred for ultrasound evaluation within a fast-track clinic due to suspected GCA. IMT was measured in axillary, brachial, subclavian, superficial femoral, and common carotid arteries (CCA), in a place without identifiable atherosclerotic plaques. IMT cut-off values for vasculitis were determined by comparing measurements in arteries classified as vasculitis vs. controls without GCA/polymyalgia rheumatica (PMR). Giant cell arteritis was diagnosed in 81 individuals, including extracranial LV-GCA in 43 individuals. Isolated PMR was diagnosed in 50 subjects. In 83 remaining patients, another diagnosis was confirmed, and they served as controls. The rounded optimal IMT cut-off values for the diagnosis of axillary vasculitis were 0.8 mm, subclavian-0.7 mm, superficial femoral-0.9 mm, CCA-0.7 mm, and brachial-0.5 mm. The IMT cut-off values providing 100% specificity for vasculitis (although with reduced sensitivity) were obtained with axillary IMT 1.06 mm, subclavian-1.35 mm, superficial femoral-1.55 mm, CCA-1.27 mm, and brachial-0.96 mm. Axillary and subclavian arteritis provided the best AUC for the diagnosis of GCA, while carotid and axillary were most commonly involved (24 and 23 patients, respectively). The presence of calcified atherosclerotic plaques was related to an increase of IMT in both patients and controls, while male sex, age ≥ 68, hypertension, and smoking increased IMT in controls but not in patients with GCA. Cut-off values for LV-GCA performed best in axillary and subclavian arteritis but expanding examination to the other arteries may add to the sensitivity of GCA diagnosis (another location, e.g., brachial arteritis) and its specificity (identification of calcified atherosclerotic plaques in other arteries such as CCA, which may suggest applying higher IMT cut-off values). We proposed a more linear approach to cut-off values with two values: one for the most accurate and the other for a highly specific diagnosis and also considering some cardiovascular risk factors.