Giant cell arteritis: early diagnosis is key

Iyza F Baig,1 Alexis R Pascoe,1 Ashwini Kini,2 Andrew G Lee2–9 1McGovern Medical School, The University of Texas Health Science Center in Houston, Houston, TX, USA; 2Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA; 3Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA; 4Department of Ophthalmology, 5Department of Neurology, 6Department of Neurosurgery, Weill Cornell Medical College, Houston, TX, USA; 7The University of Texas Medical Branch, Galveston, TX, USA; 8The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 9Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA Abstract: Giant cell arteritis (GCA) is an inflammatory vasculitis typically affecting elderly that can potentially cause vision loss. Studies have demonstrated that early recognition and initiation of treatment can improve visual prognosis in patients with GCA. This review addresses the benefits of early diagnosis and treatment, and discusses the available treatment options to manage the disease.Keywords: giant cell arteritis, imaging in GCA, laboratory values in GCA, steroids in GCA, steroid-sparing agents in GC

Training in and comfort with diagnosis and management of ophthalmic emergencies among emergency medicine physicians in the United States

Background/objectives Patients with ophthalmic emergencies often present to emergency rooms. Emergency medicine (EM) physicians should feel comfortable encountering these conditions. We assessed EM physicians' comfort working up, diagnosing, and managing ophthalmic emergencies. Subjects/methods 329 EM physicians participated in this cross-sectional multicentre survey. Questions inquired about the amount, type, and self-perceived adequacy of ophthalmic training. Likert scales were used to assess confidence and comfort working up, diagnosing, and managing ophthalmic emergencies. Results Participants recall receiving a median of 5 and 10 h of ophthalmic training in medical school and residency, respectively. Few feel this prepared them for residency (16.5%) or practice (52.0%). Only 50.6% feel confident with their ophthalmic exam. Most (75.0%) feel confident in their ability to identify an ophthalmic emergency, but 58.8% feel well prepared to work them up. Responders feel more comfortable diagnosing acute retrobulbar hematoma (72.5%), retinal detachment (69.8%), and acute angle closure glaucoma (78.0%) than central retinal artery occlusion (28.9%) or giant cell arteritis (53.2%). Only 60.2% feel comfortable determining if canthotomy and cantholysis is necessary in the setting of acute retrobulbar hematoma, and 40.3% feel comfortable performing the procedure. There was a trend towards attending physicians and providers in urban and academic settings feeling more comfortable diagnosing and managing ophthalmic emergencies compared to trainees, non-urban, and non-academic physicians. Conclusions Many participants do not feel comfortable using ophthalmic equipment, performing an eye exam, making vision or potentially life-saving diagnoses, or performing vision-saving procedures, suggesting the need to increase ophthalmic training in EM curricula

External validation of LACE+ scores

BACKGROUND: Unplanned hospital readmissions are common adverse events. The LACE+ score has been used to identify patients at the highest risk of unplanned readmission or death, yet the external validity of this score remains uncertain. METHODS: We constructed a cohort of patients admitted to hospital between October 1, 2014 and January 31, 2017 using population-based data from British Columbia (Canada). The primary outcome was a composite of urgent hospital readmission or death within 30 days of index discharge. The primary analysis sought to optimize clinical utility and international generalizability by focusing on the modified LACE+ (mLACE+) score, a variation of the LACE+ score which excludes the Case Mix Group score. Predictive performance was assessed using model calibration and discrimination. RESULTS: Among 368,154 hospitalized individuals, 31,961 (8.7%) were urgently readmitted and 5,428 (1.5%) died within 30 days of index discharge (crude composite risk of readmission or death, 9.95%). The mLACE+ score exhibited excellent calibration (calibration-in-the-large and calibration slope no different than ideal) and adequate discrimination (c-statistic, 0.681; 95%CI, 0.678 to 0.684). Higher risk dichotomized mLACE+ scores were only modestly associated with the primary outcome (positive likelihood ratio 1.95, 95%CI 1.93 to 1.97). Predictive performance of the mLACE+ score was similar to that of the LACE+ and LACE scores. CONCLUSION: The mLACE+, LACE+ and LACE scores predict hospital readmission with excellent calibration and adequate discrimination. These scores can be used to target interventions designed to prevent unplanned hospital readmission.Medicine, Faculty ofNon UBCMedicine, Department ofPopulation and Public Health (SPPH), School ofReviewedFacultyResearcherGraduat