Kevin Barraclough

BSR and BHPR guidelines for the management of giant cell arteritis

Scope and purpose GCA is the commonest of all the vasculitides. Visual loss occurs in up to one-fifth of patients, which may be preventable by prompt recognition and treatment [1,2]. The aim of these guidelines is to encourage the prompt diagnosis and management of GCA, with emphasis on the prevention of visual loss. Their scope is to provide evidence-based advice for the assessment and diagnosis of GCA, for initial and further management and for monitoring of disease activity, complications and relapse. This is a summary of the guidelines and the full guideline is available at Rheumatology online.

BSR and BHPR guidelines for the management of polymyalgia rheumatica

PMR is the most common inflammatory rheumaticdisease in the elderly and is one of the biggest indicationsfor long-term steroid therapy. There are difficulties indiagnosis, with heterogeneity in presentation, responseto steroids and disease course.The aim of these guidelines is a safe and specificdiagnostic process for PMR, using continued assessment,and discouragement of hasty initial treatment. Their scopeis to provide advice for the diagnosis of PMR, manage-ment and monitoring of disease activity, complicationsand relapse. The management of GCA is not coveredand is published separately.The full guideline is available at Rheumatology online.

2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative

Therapy for polymyalgia rheumatica (PMR) varies widely in clinical practice as international recommendations for PMR treatment are not currently available. In this paper, we report the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) recommendations for the management of PMR. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology as a framework for the project. Accordingly, the direction and strength of the recommendations are based on the quality of evidence, the balance between desirable and undesirable effects, patients’ and clinicians’ values and preferences, and resource use. Eight overarching principles and nine specific recommendations were developed covering several aspects of PMR, including basic and follow-up investigations of patients under treatment, risk factor assessment, medical access for patients and specialist referral, treatment strategies such as initial glucocorticoid (GC) doses and subsequent tapering regimens, use of intramuscular GCs and disease modifying anti-rheumatic drugs (DMARDs), as well as the roles of non-steroidal anti-rheumatic drugs and non-pharmacological interventions. These recommendations will inform primary, secondary and tertiary care physicians about an international consensus on the management of PMR. These recommendations should serve to inform clinicians about best practices in the care of patients with PMR.

Ménière's Disease

#### The bottom line Meniere’s disease is often considered in the differential diagnosis of episodic dizziness, although it is not a common cause of new onset vertigo. Rather it is a disorder of the inner ear, characterised by recurrent attacks of self limiting vertigo. These attacks are associated with unilateral fluctuating low frequency sensorineural hearing loss, a sense of “fullness” in the affected ear (aural fullness), and tinnitus.1 Clinical findings are initially normal between attacks but later there is unilateral hearing loss and tinnitus. Treatment of the condition has not been evidence based in the past, but new treatments look promising. In this article we discuss what is known about the pathogenic process of Meniere’s disease and consider the clinical presentation of the disease, its clinical course and prognosis, and what clinical features help to discriminate the condition from other diagnoses. We also examine the evidence for treatment. #### Sources and selection criteria We carried out a search of Medline for systematic reviews in the Cochrane Collaboration and Clinical Evidence from 1966-2013 using the key words “Meniere’s disease”, “inner ear”, “treatment”, “vertigo”, and “hearing loss”. We also base this review on the extensive experience of two of the authors (JH and AMB) in assessing and treating patients with the Meniere’s disease. Meniere’s disease was first described by Prosper Meniere, a French doctor who worked …

Polymyalgia rheumatica in primary care: a cohort study of the diagnostic criteria and outcome

BACKGROUND Polymyalgia rheumatica (PMR) is common and is usually diagnosed and managed in primary care. There are no generally accepted primary care criteria for diagnosis. OBJECTIVES To identify what features are used to diagnose PMR, to benchmark these against diagnostic criteria and to identify features at diagnosis with prognostic significance. METHODS This was a retrospective cohort study of all patients diagnosed with PMR in three UK general practices between January 1994 and December 2003. The medical records were examined for features of PMR. The duration of steroid treatment was used as a proxy for duration of disease. Analysis of prognostic predictors was by Cox proportional hazards models. RESULTS One hundred and eighty-three patients were identified, giving an overall annual incidence of 11.3 per 10 000 patients aged 50 or over. The median age at diagnosis was 75 (interquartile range 69, 79) years: 138 (75%) were female. The most common diagnostic features were proximal muscle pain in 151 (82%), raised inflammatory markers in 160 (87%), clinical response to corticosteroids in 166 (91%) and normalization of inflammatory markers in 147 (81%). Twenty (11%) had normal inflammatory indices. The median duration of treatment was 1.4 years (interquartile range 0.8, 2.4). Female sex and raised inflammatory markers were independently associated with longer treatment: female hazard ratio 1.5 (1.0, 2.2) P = 0.047 and raised inflammatory markers 2.0 (1.2, 3.2) P = 0.01. CONCLUSIONS Primary care practitioners do not use established criteria to diagnose PMR and sometimes diagnose the condition even when inflammatory markers are normal. This exposes patients to a risk of inappropriate steroid use.

2015 recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative.

Therapy for polymyalgia rheumatica (PMR) varies widely in clinical practice as international recommendations for PMR treatment are not currently available. In this paper, we report the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) recommendations for the management of PMR. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology as a framework for the project. Accordingly, the direction and strength of the recommendations are based on the quality of evidence, the balance between desirable and undesirable effects, patients’ and clinicians’ values and preferences, and resource use. Eight overarching principles and nine specific recommendations were developed covering several aspects of PMR, including basic and follow‐up investigations of patients under treatment, risk factor assessment, medical access for patients and specialist referral, treatment strategies such as initial glucocorticoid (GC) doses and subsequent tapering regimens, use of intramuscular GCs and disease modifying anti‐rheumatic drugs (DMARDs), as well as the roles of non‐steroidal anti‐rheumatic drugs and non‐pharmacological interventions. These recommendations will inform primary, secondary and tertiary care physicians about an international consensus on the management of PMR. These recommendations should serve to inform clinicians about best practices in the care of patients with PMR.

Chronic cough in adults

This case is an example of how “test of treatment” (doi:10.1136/bmj.b1312) can be used when the diagnosis is uncertain

Giant cell arteritis

#### Case scenario A previously fit and well 72 year old man presented to his general practitioner after several months of malaise and weight loss. When asked about any pain, he pointed to his left scalp as being painful. Examination was normal except that his left temporal artery was not palpable. Suspecting giant cell arteritis, the GP started 40 mg prednisolone and requested an erythrocyte sedimentation rate, which was 86 mm/h. The symptoms largely disappeared in 48 hours. She also referred the patient for a temporal artery biopsy, which showed giant cell arteritis. Giant cell arteritis affects large and medium sized arteries, often branches of the external carotid artery but also the ciliary and retinal arteries. The symptoms are caused by local ischaemia due to endovascular damage and cytokine mediated systemic illness. There is considerable overlap with polymyalgia rheumatica: 16-21% of patients with polymyalgia rheumatica have giant cell arteritis on temporal artery biopsy, and symptoms of polymyalgia rheumatica are present in 40-60% of patients with giant cell arteritis.1 #### How common is it? A systematic review analysed the presenting clinical features in a mixture of studies with a total of 1435 cases of giant cell arteritis.3 The sensitivity of individual clinical features was relatively …

Is omission of free text records a possible source of data loss and bias in Clinical Practice Research Datalink studies? A case–control study

Objectives To estimate data loss and bias in studies of Clinical Practice Research Datalink (CPRD) data that restrict analyses to Read codes, omitting anything recorded as text. Design Matched case–control study. Setting Patients contributing data to the CPRD. Participants 4915 bladder and 3635 pancreatic, cancer cases diagnosed between 1 January 2000 and 31 December 2009, matched on age, sex and general practitioner practice to up to 5 controls (bladder: n=21 718; pancreas: n=16 459). The analysis period was the year before cancer diagnosis. Primary and secondary outcome measures Frequency of haematuria, jaundice and abdominal pain, grouped by recording style: Read code or text-only (ie, hidden text). The association between recording style and case–control status (χ2 test). For each feature, the odds ratio (OR; conditional logistic regression) and positive predictive value (PPV; Bayes’ theorem) for cancer, before and after addition of hidden text records. Results Of the 20 958 total records of the features, 7951 (38%) were recorded in hidden text. Hidden text recording was more strongly associated with controls than with cases for haematuria (140/336=42% vs 556/3147=18%) in bladder cancer (χ2 test, p<0.001), and for jaundice (21/31=67% vs 463/1565=30%, p<0.0001) and abdominal pain (323/1126=29% vs 397/1789=22%, p<0.001) in pancreatic cancer. Adding hidden text records corrected PPVs of haematuria for bladder cancer from 4.0% (95% CI 3.5% to 4.6%) to 2.9% (2.6% to 3.2%), and of jaundice for pancreatic cancer from 12.8% (7.3% to 21.6%) to 6.3% (4.5% to 8.7%). Adding hidden text records did not alter the PPV of abdominal pain for bladder (codes: 0.14%, 0.13% to 0.16% vs codes plus hidden text: 0.14%, 0.13% to 0.15%) or pancreatic (0.23%, 0.21% to 0.25% vs 0.21%, 0.20% to 0.22%) cancer. Conclusions Omission of text records from CPRD studies introduces bias that inflates outcome measures for recognised alarm symptoms. This potentially reinforces clinicians’ views of the known importance of these symptoms, marginalising the significance of ‘low-risk but not no-risk’ symptoms.

Diagnosis and management of giant cell arteritis

Giant cell arteritis (GCA) is the commonest form of large-vessel vasculitis and affects branches of the external carotid artery but also the ciliary and retinal arteries. The symptoms are caused by local ischaemia due to endovascular damage and cytokine-mediated systemic illness. There is considerable overlap with polymyalgia rheumatica (PMR): 16–21% of patients with PMR have GCA on temporal artery biopsy, and symptoms of PMR are present in 40–60% of patients with GCA.1 GCA occurs in 2.2 per 10 000 patient-years in the UK.2 A full-time GP may expect to see one new case every 1–2 years. It is virtually unknown in people aged under 50 years. Early recognition is critical to prevent visual loss, that otherwise occurs in up to 20% of cases.3 Once high-dose corticosteroids are started, visual loss is extremely rare. Guidelines for the diagnosis and management of GCA, have recently been published by the British Society of Rheumatologists and British Health Professionals in Rheumatology.4 A 2002 systematic review analysed the presenting clinical features in a mixture of studies, with a total of 1435 cases of giant cell arteritis.5 The mean duration of symptoms at diagnosis was 3.5 months.5 The …