Temporal artery biopsy...who needs one?

OBJECTIVE: To review a 10 year period of temporal artery biopsies, using the American College of Rheumatology (ACR) 1990 criteria: a five point scoring system for the diagnosis of giant cell arteritis (GCA). DESIGN: Population based, retrospective cohort analysis. SETTING: One district general hospital in the United Kingdom, over one decade. PARTICIPANTS: All patients who underwent temporal artery biopsy from July 1994 to June 2004. MAIN OUTCOME MEASURES: ACR score and temporal artery biopsy result. RESULTS: During the 10 year period 111 patients were identified. The median (range) age at presentation was 71 (29-85) years. Seventy five patients had an initial ACR score of three or four at presentation. There were 20 positive biopsy specimens. In 19 of these cases at least three of the other criteria were positive so there was already sufficient clinical information for a confident diagnosis. In only one case did the positive result influence the diagnosis by changing the ACR score from two to three. In our series, corticosteroid treatment before biopsy did not significantly reduce the yield of the biopsy. CONCLUSIONS: The ACR score of three or more has a sensitivity of 93.5% and specificity of 91.2% for the diagnosis of GCA. Using these criteria, 68% of patients had sufficient clinical features when referred to make a confident diagnosis of GCA. Temporal artery biopsy was therefore unnecessary in this group. In the remaining group (ACR score < or =2) there was one positive biopsy. The biopsy only changed the diagnosis in this one case-less than 3% of the uncertain cases and less than 1% of the total cases. Using the ACR criteria and restricting biopsy to those cases in which it might change the diagnosis will reduce the number of biopsies by two thirds without jeopardising diagnostic accuracy.

Impact of previous surgery on time taken for incision and division of adhesions during laparotomy.

PURPOSE: Adhesions from previous surgery constitute a major problem in general surgery. Much is known of the consequences of adhesions in terms of morbidity, but there has been little documentation of the effect of previous surgery on the time taken to reoperate. METHODS: Information on incision time and division of adhesion time was recorded on 120 patients (89 elective cases and 31 emergencies) undergoing midline laparotomy under the care of a single colorectal surgeon. RESULTS: Fifty-one percent of elective and 71 percent of emergency cases had previously had abdominal surgery. Previous surgery prolonged the median incision time from 5 (range, 3-10) to 8 (range, 4-39) minutes (P < 0.001) and the median division of adhesion time from 0 (range, 0-30) to 15 (range, 0-12) minutes (P < 0.0001). CONCLUSIONS: Previous surgery significantly increases the operating time during subsequent surgery by a median of 18 minutes. This information may be of use in the planning of surgical workload and highlights the needs for cost-effective adhesion prevention strategies.

Screening for abdominal aortic aneurysm: is opportunistic detection a realistic alternative?

OBJECTIVES: To determine whether abdominal aortic aneurysms (AAA) may be detected during investigation for concurrent disease and to assess whether opportunistic detection is a feasible alternative to a formal screening programme. DESIGN: A prospective review of previous investigations in subjects attending for aortic screening. MATERIALS AND METHODS: 276 men aged 65-80 attended the Chichester AAA screening programme. They were asked whether they had consulted their General Practitioner and whether they had undergone radiological investigation within the preceding 5 years. RESULTS: Two-hundred and sixty-one subjects had consulted their General Practitioner (94.6%) within the past 5 years. Fifty-six patients had been investigated with radiological imaging: in 22 cases (8.0%) the investigation had the potential to detect an AAA. The opportunistic detection rate was 0.4% (one AAA) in comparison to 12.0% for the screening programme (33 AAA). Imaging investigations with the potential to pick up AAA failed to detect five out of six aneurysms in this group. CONCLUSIONS: Opportunistic screening for AAA is not a realistic alternative to a formal screening programme but may improve the detection rate in the community.