Executive summary on the optimization of the multidisciplinary and integrated approach to polymyalgia rheumatica and giant cell arteritis in Madrid region

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Specifically, PMR is considered the most common inflammatory rheumatic disease in people over 50 years of age, while GCA is the most common systemic vasculitis in adults.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>GCA, previously known as Horton's disease, temporal arteritis or cranial arteritis, is a non-necrotizing granulomatous inflammatory vasculitis that affects medium and large-caliber arteries with a preference for cranial involvement in a traditional manner.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The inflammation caused by GCA occurs most frequently in larger cranial arteries, although it can occur in large arteries anywhere in the body.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> If the inflammation occurs in other locations of the body, such as the thoracic or abdominal aorta, it is referred to as GCA with extracranial involvement of large vessels or extracranial GCA. Regarding symptoms, cranial GCA can cause headache, jaw claudication, visual disturbances, scalp hypersensitivity, facial pain, tongue necrosis, anemia and PMR. Extracranial GCA can present with intermittent limb claudication, constitutional syndrome, heart failure, chest pain, PMR, and even sudden death.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>The incidence of GCA varies depending on the geographic area, being more common in Scandinavian countries and in communities with Scandinavian ancestry. In Spain, a study carried out in Lugo between 1998 and 2001 showed an annual incidence rate of 10.13 per 100,000 inhabitants in the population over 50 years of age, increasing to a value of 23.16 per 100,000 inhabitants in the population between 70 and 79 years of age.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> At the national level, the average annual incidence rate of this disease has been estimated at up to 7%.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> In the community of Madrid, there are no specific data regarding the incidence and prevalence of these entities, although it is observed that they represent up to 20% with respect to the national total of all hospital admissions for PMR/ACG.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>In both the case of PMR and GCA, the initial symptoms are usually non-specific, which makes diagnosis difficult. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes the current classification criteria for GCA and PMR, which can help in the diagnosis of both pathologies.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> Specifically, these pathologies are considered to be underdiagnosed, understood as any erroneous, late or absent diagnosis, which can even be delayed up to a total of 9 weeks in the ACG<a class="elsevierStyleCrossRef" href="#bib0045">9</a> and up to more than 1year in the PMR.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> Underdiagnosis of these pathologies can lead to complications such as the appearance of stenosis, occlusions or aneurysms in the large vessels (aorta and its main branches)<a class="elsevierStyleCrossRef" href="#bib0055">11</a> and even irreversible sequelae, such as visual loss,<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a> although the latter has decreased in recent years thanks to the appearance of biological therapies.<a class="elsevierStyleCrossRefs" href="#bib0070">14,15</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The objective of this study is to optimize the approach to these diseases in our environment, analyzing the causes of underdiagnosis, and the generation of possible solutions that allow improving early detection and efficient referral of patients in different healthcare environments.MethodsWorkspaceThe study was developed in the Community of Madrid, based on a multidisciplinary scientific committee of ten professionals who are experts in the approach to PMR and GCA. The committee was formed with representatives of the main professional categories involved in the clinical approach to these diseases: family and community medicine, hospital emergencies, internal medicine, neurology, ophthalmology and rheumatology.The study consisted of two main phases. First, an analysis of the current situation and identification and prioritization of areas for improvement were carried out. In a second phase, a series of lines of action were generated to address the identified areas of improvement.To obtain a consensus among the members of the scientific committee, each and every one of the areas of improvement and lines of action were subject to discussion and subsequent voting. Those points in which more than 75% of the participants agreed in their votes were considered as consensual.Analysis of the current situation and identification of areas for improvementTo carry out this phase, information was collected from different sources consulted: digital questionnaires (carried out with MS Forms) on usual clinical practice completed by the health professionals of the scientific committee, group work meetings with the committee's experts and a literature review. national and international scientific.With the objective of analyzing the state of the situation and evaluating the proposed initiatives, a systematic bibliographic search has been carried out through PubMed, Embase and Google Scholar using the following search strategy: ((ACG) AND/OR (Giant cell arteritis) AND /OR (PMR) AND/OR (Polymyalgia rheumatica)) (AND/OR (Management) AND/OR (diagnostic) AND/OR (recommendations) AND/OR (guideline) AND/OR (EULAR) AND/OR (American College of Rheumatology)). Of all the results obtained, those articles and guides with relevant information regarding the care process of patients with PMR and GCA have been selected, especially at the national level. Works with a low degree of scientific evidence, clinical cases and articles outside the objective of this work have been discarded.Through a group work session with the scientific committee, all the information regarding the state of the situation regarding the approach to pathologies was analyzed and possible areas of improvement to work on were identified and prioritized.The committee evaluated the aspects most frequently involved in relation to diagnostic delay and diagnostic difficulties in addressing these pathologies. A quantitative study was not carried out due to the complexity and heterogeneity of the centers involved, as well as the limited existence of quality indicators to obtain useful figures in ACG and PMR.Generation and prioritization of lines of actionIn this phase, two group work sessions were held with the members of the scientific committee in which, based on the prioritized areas of improvement regarding the approach to pathologies, different lines of action were proposed according to criteria of impact on the approach. of the pathologies and feasibility of implementation of the proposed lines.ResultsAnalysis of the situationAccording to the patient experience map generated (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), the main entry routes for patients with PMR and/or GCA to the care circuit are Primary Care and hospital and out-of-hospital emergencies. In case of high suspicion, depending on the patient's symptoms and the capabilities of the health center, treatment with glucocorticoids (GC) is started and the patient is subsequently referred to the corresponding specialized care (either in a Hospital or a Care Center). peripheral specialties); or the patient is referred to begin treatment with GC after being evaluated by the corresponding hospital specialty. The specialties that these patients generally receive are internal medicine and rheumatology and, to a lesser extent, neurology or ophthalmology.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>After starting treatment with GC, the definitive diagnosis is confirmed. If necessary, the treatment dose is adjusted, considering the incorporation of steroid-sparing immunosuppressants, and a joint follow-up schedule is established between Primary Care and the healthcare area where the patient has been treated, whether Hospital or Peripheral Specialty Center.<a class="elsevierStyleCrossRefs" href="#bib0010">2,16–18</a>Identification of areas for improvementSubsequently, and based on the current state of the situation and the patient experience map, the main areas of improvement were identified, which are grouped into 4 categories: coordination and protocols, equipment, training and awareness of the pathologies and experience. of the patient (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Prioritization of areas of improvementAfter identifying the main areas for improvement, they were prioritized based on their relevance and impact on optimizing the approach to PMR and GCA.The first four areas belong to the category of coordination and protocols, highlighting the importance of having comprehensive protocols that contemplate all levels of care and specialties involved in addressing pathologies, and that define in detail the subprocesses of the suspicion and diagnosis phases, in order to optimize early diagnosis in these pathologies. In addition, communication processes between specialties were considered of vital importance, as well as the creation of rapid referral tools that expedite the first stages of the care process.The fifth priority area for improvement was the low degree of clinical suspicion. According to the state of the situation, in the main routes of patient entry (Primary Care and hospital emergencies), obtaining a diagnosis and rapid referral is complex due to the non-specific nature of some of the early symptoms of PMR and GCA, similar to other pathologies. All this, together with the great heterogeneity of patients who are treated in the main entry routes, makes it difficult for these pathologies to be considered within the first-line differential diagnosis.Lines of actionIn order to address the prioritized areas of improvement, a series of lines of action were defined to be carried out. Each line includes a series of proposals and specific actions for their correct development. However, there is a common aspect that applies to all the proposed lines, which is the creation of multidisciplinary working groups (GTMD) with health professionals involved in addressing PMR and GCA, both in Primary and Hospital Care, capable of generating a comprehensive vision and act as an advisory body in the development of the entire care process. In a recent British study, a search for similar measures that included patient access, glucocorticoid use, access routes, ultrasound, temporal artery biopsy, access to emission tomography positrons, experience in rheumatology/ophthalmology, education and multidisciplinary work, could improve the quality of care for patients with GCA.<a class="elsevierStyleCrossRef" href="#bib0095">19</a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Absence of comprehensive action protocols for pathologies</li></ul>To demonstrate the importance of the generation and implementation of comprehensive action protocols, it is necessary to define a series of key indicators in the approach to these pathologies. With these indicators, it is possible to demonstrate, firstly, the impact of the delay in referral and diagnosis on the approach to patients and, finally, to evaluate, measure and compare the health care provided.A key tool on which to base decision-making in the generation of protocols is scientific evidence related to both pathologies. To generate scientific evidence adapted to the healthcare reality, the creation of a regional patient registry is proposed in which, in addition to clinical information, experience reported by patients (Patient Reported Experience Measurements, PREMs) and results reported by patients are included. (Patient-Reported Outcome Measurements, PROMs) collected through quality of life and experience questionnaires of patients with PMR and/or GCA.In the preparation of the protocols, the inclusion of monographic PMR and GCA consultations, dedicated exclusively to the evaluation, monitoring and treatment of patients with these pathologies, is considered appropriate. In addition to acting as a consulting body, the fact of having these monographic consultations is expected to increase the level of awareness about these pathologies in those hospitals where they are operational.<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010">2.Coordination between services involved</li></ul>When obtaining a diagnosis of patients, the performance of the necessary diagnostic tests must be ensured by defining, depending on the material and human resources of each health center, the functions and responsibilities of the services and professionals involved in the addressing pathologies. However, despite adapting the functions and responsibilities to the resources of each center, it is recommended to standardize training in Doppler ultrasound among all health professionals involved in performing the test to homogenize its performance regardless of the center where it is performed.Likewise, a series of specific criteria must be defined for carrying out diagnostic tests, in order to optimize resources and speed up the diagnostic process in patients.<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0015">3.Absence of communication channels and care continuity protocols between care levels</li></ul>Given the involvement of both levels of care in addressing pathologies, it is vitally important to establish a series of measures that ensure a correct interrelation between both.First, through comprehensive action protocols, procedures must be established for the correct referral of patients from the different levels of care. A tool to carry out this aspect is the promotion of telematic/telephone consultations, which would allow an agile referral from Primary Care to Hospital Care. Furthermore, it is considered necessary to implement a digital tool in the computer systems of health centers that allows the integration and accessibility of information between Primary and Hospital Care, facilitating continuity of care and patient monitoring.<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0020">4.Absence of a fast-track circuit for patients with high suspicion of PMR and/or GCA</li></ul>In some hospitals in the region, rapid referral or fast-track systems are already in operation for patients with suspected PMR and/or GCA focused on accelerating the referral and diagnosis of patients, avoiding the possible appearance of long-term sequelae such as appearance of stenosis, occlusions or vascular aneurysms or irreversible complications such as blindness.In this sense, the analysis of the rapid referral systems in operation is recommended for their adaptation and inclusion in the comprehensive protocols for addressing pathologies in all centers in the region.<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0025">5.Low degree of clinical suspicion</li></ul>Early clinical suspicion is vital to ensure rapid referral and diagnosis for patients. To improve the degree of clinical suspicion, it is essential to develop periodic training sessions, especially for the services involved in the entry of patients into the care circuit, Primary Care and hospital emergencies. These sessions should focus on detecting the symptoms and clinical signs of PMR and GCA in the suspicion phase and establishing referral criteria. Furthermore, the use of digital tools for continuing clinical education for all health professionals involved in the management of PMR and GCA at all levels of care can help maintain an adequate degree of clinical suspicion.Another strategy to improve the degree of clinical suspicion is the incorporation of specific data recording forms for PMR and/or GCA in the patients' clinical history. With these forms, the methodology for recording, evaluating and exploiting data is standardized among all professionals involved in addressing these pathologies and, in addition, they can generate an alarm for the healthcare professional in the event that the data collected in the clinical history is compatible with any of the pathologies.Finally, raising awareness among the general population is also essential to improve the degree of clinical suspicion and encourage early detection of PMR and GCA. Therefore, awareness campaigns must be developed (training material, infographics, digital resources, etc.) aimed at the general population to highlight the characteristics of these diseases and the importance of going to a consultation when compatible symptoms appear.ConclusionsFirst, since there is not enough top-level scientific evidence regarding the approach to PMR and GCA, especially regarding its diagnosis and referral between specialties, it is considered advisable to generate evidence capable of covering this lack of information.The greatest current challenge in the approach to PMR and GCA is the undervalued diagnosis and, under this premise, a series of lines of action were identified focused on optimizing the approach to these pathologies, especially in the phases of suspicion, including referral. between specialties, and patient diagnosis. All measures must arise and be channeled through multidisciplinary collaboration and the commitment of professionals from all healthcare specialties involved in addressing these pathologies.Given the number of health professionals who may be involved in addressing pathologies, the importance of generating and implementing comprehensive approach protocols that allow optimizing and streamlining the referral of patients and reducing the misdiagnosis of these patients was identified. The generated protocols must serve as a guide from which health centers can generate their own work procedures adapted to their own capabilities and resources.Furthermore, given the low level of awareness about these pathologies, the need to develop health professional training actions at all levels of care was highlighted to reduce the low level of clinical suspicion as for the general population.Likewise, the definition of key health care quality indicators and periodic control sessions must be included to evaluate the implemented work methodologies and their direct impact on health care.Finally, and although this study was carried out in the Community of Madrid, it is considered that the problems associated with the diagnosis of PMR and GCA also occur in other communities, which is why it is recommended to carry out similar studies in other regions, as well as at the national level with the aim of optimizing the approach to both pathologies and promoting homogeneous health care between different communities.FundingThe preparation of this project and this report has been possible thanks to the collaboration of Roche in external project consulting. Roche has not intervened at all in the selection of selected panelists/experts or in any of the subsequent steps: meetings held, data analysis, interpretation of results or writing of the manuscript.Conflicts of interestDr. A. González-García declares that he has received speaking fees from Roche.Dr. M. Frías-Vargas declares that he has received fees for scholarships, presentations or consulting work from Roche.Dr. S. Castañeda declares that he has received fees for speaking or consulting work from Amgen, BMS, Grünenthal Pharma España, Eli-Lilly, Janssen, MSD, Pfizer, Roche, SOBI and UCB.The rest of the authors declare that they have no conflict of interest related to the content of the project." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres2095292" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1785696" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2095291" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1785697" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Workspace" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Analysis of the current situation and identification of areas for improvement" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Generation and prioritization of lines of action" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Analysis of the situation" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Identification of areas for improvement" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Prioritization of areas of improvement" ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "Lines of action" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack729944" "titulo" => "Acknowledment" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-08-31" "fechaAceptado" => "2023-11-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1785696" "palabras" => array:6 [ 0 => "Polymyalgia rheumatica" 1 => "Giant Cell Arteritis" 2 => "Vasculitis" 3 => "Temporal arteritis" 4 => "Patient journey" 5 => "Horton's arteritis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1785697" "palabras" => array:6 [ 0 => "Polimialgia reumática" 1 => "Arteritis de Células Gigantes" 2 => "Vasculitis" 3 => "Arteritis temporal" 4 => "Ruta asistencial" 5 => "Arteritis de horton" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Polymyalgia rheumatica and giant cell arteritis can be a medical emergency in which a delay in correct diagnosis and therapeutic management can cause serious complications.With the aim of improving the care of patients with these pathologies in the Community of Madrid, a study was designed to identify the causes and possible solutions to address the problems related to the diagnosis of these pathologies.After the analysis, 11 areas of improvement related to four different aspects of the care process were identified: coordination and protocols, equipment, training and awareness of pathologies, and patient experience. Of all the areas identified, it was considered a priority to resolve those related to the generation of protocols for the comprehensive management of the pathologies, which include all the specialties and levels of care involved. Another crucial aspect is the increase in the degree of clinical suspicion of these pathologies." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La Polimialgia reumática y la arteritis de células gigantes pueden suponer una emergencia médica en la que el retraso en su correcto diagnóstico y manejo terapéutico pueden asociar complicaciones graves.Con el objetivo de mejorar la atención de los pacientes con estas patologías en el entorno de la Comunidad de Madrid, se diseñó un estudio para identificar las causas y posibles soluciones para hacer frente los problemas relacionados con el diagnóstico de estas patologías.Tras un análisis preliminar, se identificaron 11 áreas de mejora relacionadas con cuatro aspectos diferenciados del proceso asistencial: coordinación y protocolos, equipamientos, formación y concienciación sobre las patologías y experiencia del paciente. De todas ellas, se priorizó resolver aquellas relacionadas con la generación de protocolos de abordaje integral de las patologías, que contemplen a todas las especialidades y niveles asistenciales implicados. Otro aspecto crucial es el incremento del grado de sospecha clínica de estas patologías." ] ] "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "All authors have participated equally in the preparation of this study." "identificador" => "fn0005" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 4327 "Ancho" => 3341 "Tamanyo" => 1034221 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Multidisciplinary algorithm for the management of patients with polymyalgia rheumatica and/or giant cell arteritis." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Adapted from Dasgupta et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> and Ponte et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>." "tablatextoimagen" => array:6 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Giant cell arteritis: A score of ≥6 points is needed for the classification of giant cell arteritis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">These classification criteria should be applied to classify the patient as having giant cell arteritis when a diagnosis of medium or large vessel vasculitis has been made. Before applying the criteria, alternative diagnoses that mimic vasculitis must be excluded. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Necessary criterion: Age ≥ 50 years at diagnosis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3467378.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Additional clinical criteria \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Morning stiffness in shoulders/neck \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sudden or abrupt visual loss \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mandibular or lingual claudication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">New onset temporary headache \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scalp pain or tenderness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abnormal examination of the temporal artery: absence or decreased pulse, tenderness or hard “cord” appearance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3467381.png" ] ] 2 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Laboratory, imaging and histological criteria \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Maximum ESR≥50mm/h or maximum CRP≥10mg/l, prior to the start of treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Positive temporal artery biopsy or halo sign on temporal artery ultrasound<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bilateral axillary involvement<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aortic involvement visualized on PET/CT<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3467379.png" ] ] 3 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Polymyalgia rheumatica: Using clinical criteria alone, a score ≥4 had a sensitivity of 68% and a specificity of 78% for discriminating polymyalgia rheumatica from comparison patients. Using a combination of clinical and ultrasound criteria, a score ≥5 had a sensitivity of 66% and a specificity of 81% for discriminating patients with the disorder from comparison patients. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Necessary criteria: age ≥50 years, bilateral omalgia and alteration of acute phase reactants (c-reactive protein and erythrocyte sedimentation rate) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3467387.png" ] ] 4 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Symptom or clinical alteration \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Morning stiffness lasting more than 45min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hip pain or limited range of motion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absence of rheumatoid factor and antibodies against cyclic citrullinated peptide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absence of another joint affects \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3467386.png" ] ] 5 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ultrasound criteria \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">At least one shoulder with subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis; and at least one hip with trochanteric synovitis or bursitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Both shoulders with subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3467383.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Presence of definitive vasculitis in temporal artery biopsy (presence of giant cells, infiltration of mononuclear leukocytes and fragmentation of the internal elastic lamina) or halo sign (presence of homogeneous and hypoechoic wall thickening on ultrasound) on ultrasound of the temporal artery." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "It is defined as luminal damage (stenosis, occlusion or aneurysm) on angiography (computed tomography, magnetic resonance or catheterization) or ultrasound, halo sign on ultrasound or uptake on PET/CT." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "Abnormal PET/CT uptake in the arterial wall (eg, greater than hepatic uptake by visual inspection) of the descending thoracic and abdominal aorta." ] ] ] "descripcion" => array:1 [ "en" => "Classification criteria for giant cell arteritis and polymyalgia rheumatica." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:4 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Coordination and protocols \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 Absence of comprehensive action protocols for pathologies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Although healthcare professionals have guidelines for therapeutic management and patient monitoring, an absence of comprehensive action protocols was revealed that detail the suspicion and diagnosis phases, including referrals between specialties. It is considered that the standardization of processes in the suspicion stage can optimize and accelerate the diagnosis of pathologies and, consequently, the care process. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 Coordination between services involved \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The existence, on certain occasions, of a lack of coordination between the services involved in carrying out diagnostic tests (mainly Pathological Anatomy, Surgery, Nuclear Medicine and Radiodiagnosis) and those involved in addressing the pathologies was identified, generating delays in obtaining a definitive diagnosis for patients, with the potential risk of complications that this entails. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 Absence of communication channels and care continuity protocols between Primary Care and Hospital Care \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">It was considered that there is a certain lack of bidirectional communication channels or tools and protocols that guarantee continuity of care between Primary and Hospital Care, impacting the times until referral, obtaining diagnoses, starting treatments and, therefore, on the quality of life of patients and the appearance of complications. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 Reduced use of quality care indicators during the approach to pathologies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">According to the information obtained, the use of indicators that allow measuring the delays or waiting times that patients suffer throughout the treatment of their pathologies, that is, the times of referral, performance of diagnostic tests, obtaining the diagnosis and treatment administration, is reduced, hindering the ability to measure, compare and, finally, carry out initiatives focused on optimizing the health care of these patients. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 Absence of a fast-track circuit for patients with high suspicion of PMR and/or GCA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In most health centers in the region there are no rapid referral or fast-track circuits, which would speed up the referral and diagnosis of patients with clinical signs compatible with either of the two pathologies. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3467380.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Equipment \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 Heterogeneity in the availability of Doppler ultrasound in health centers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Some Primary Care centers in the region do not have the material or human resources necessary to perform ultrasounds. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 Heterogeneity in the availability of positron emission tomography/computed tomography (PET/CT) use \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PET/CT is a very useful tool when diagnosing extracranial forms of GCA. However, these types of devices are not available in all health centers in the Community. Furthermore, they are used in the diagnosis and monitoring of a wide variety of pathologies, which can cause delays in obtaining an adequate diagnosis in patients with these forms of GCA. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3467384.png" ] ] 2 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Training and awareness about pathologies \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 Low degree of clinical suspicion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Both PMR and GCA are diseases with non-specific early symptoms, which, together with the great variety of pathologies addressed in the main routes of entry of patients, makes it difficult for them to be considered within the differential diagnosis in the first line, impacting negative in the times of referral and diagnosis of patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 Misdiagnoses based on non-specific clinical symptoms/signs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">An excessive use of certain clinical symptoms/signs, such as headache, as unequivocal indicators of some of the pathologies was identified. However, headache may occur in up to 75%–80% of cranial GCA cases, while it may be absent in the extracranial phenotype of GCA. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 Difficulty in obtaining specialized training in PMR and ACG \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The suitability of having specialized and standardized training plans in the field of PMR and GCA, available to all professionals involved in addressing these pathologies, at all levels of care, was highlighted. Specifically, the need to ensure training for professionals in performing Doppler ultrasound of at least temporal and axillary arteries is highlighted. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">These training plans should be focused on the stages of suspicion and diagnosis of pathologies, favoring the training and awareness of the professionals involved, speeding up the time to obtain a diagnosis and generating an increase in the degree of clinical suspicion. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3467385.png" ] ] 3 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient experience \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 Delay in requesting a medical consultation due to poor awareness of pathologies on the part of patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">On certain occasions, a delay is observed in the request for clinical consultation by patients, motivated by the lack of training and knowledge about PMR and GCA and their respective symptoms. This causes a delay in visiting the health center, sometimes going when the symptoms represent a medical emergency. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3467382.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Areas for improvement have been identified. The areas prioritised by the project's Scientific Committee are underlined." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Update on the treatment of giant cell arteritis and polymyalgia rheumatica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S. El Chami" 1 => "J.M. 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"vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/22548874/0000022400000001/v3_202402230525/S2254887423001352/v3_202402230525/en/main.assets" "Apartado" => array:4 [ "identificador" => "94215" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Consensus document" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22548874/0000022400000001/v3_202402230525/S2254887423001352/v3_202402230525/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887423001352?idApp=WRCEE"]

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Consensus Document

Executive summary on the optimization of the multidisciplinary and integrated approach to polymyalgia rheumatica and giant cell arteritis in Madrid region

Resumen ejecutivo sobre la optimización del abordaje multidisciplinar e integrado de la polimialgia reumática y la arteritis de células gigantes en la Comunidad de Madrid

A. González Garcíaa,

,1, C. del Arcob,1, D. Lucas Fernándezc,1, M. Frías-Vargasd,e,1, M. Guillánf,1, M. Méndez-Bailóng,1, M. Ruiz Grinspanh,1, A.C. Aguado-Castañoi,1, J. Fraile Mayaj,1, G. Latorre Gonzálezk,1, S. Castañedal,m,1

a Servicio de Medicina Interna, Unidad de Enfermedades Autoinmunes Sistémicas, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain

b Servicio de Urgencias, Hospital Universitario de la Princesa, Instituto de Investigación la Princesa, Madrid, Spain

c Ascendo Consulting Sanidad&Farma, Madrid, Spain

d Centro de Salud Comillas, Madrid, Spain

e Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain

f Servicio de Neurología, Unidad de Ictus, Hospital Universitario Rey Juan Carlos, Madrid, Spain

g Servicio de Medicina Interna, Hospital Clínico San Carlos, Madrid, Spain

h Servicio de Urgencias, Hospital Universitario del Henares, Coslada, Spain

i Centro de Salud Parque Lo Morant, Alicante, Spain

j Servicio de Oftalmología, Hospital Universitario La Paz, Madrid, Spain

k Servicio de Neurología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain

l Servicio de Reumatología, Hospital de La Princesa, IIS-Princesa, Madrid, Spain

m Cátedra UAM-Roche, Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain

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        "titulo" => "Resumen ejecutivo sobre la optimizaci&#243;n del abordaje multidisciplinar e integrado de la polimialgia reum&#225;tica y la arteritis de c&#233;lulas gigantes en la Comunidad de Madrid"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multidisciplinary algorithm for the management of patients with polymyalgia rheumatica and&#47;or giant cell arteritis&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Polymyalgia Rheumatica &#40;PMR&#41; and Giant Cell Arteritis &#40;GCA&#41; are two pathologies commonly associated with adulthood &#40;&#62;50 years&#41; and which have an increasing incidence with increasing age&#46; Specifically&#44; PMR is considered the most common inflammatory rheumatic disease in people over 50 years of age&#44; while GCA is the most common systemic vasculitis in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">GCA&#44; previously known as Horton&#39;s disease&#44; temporal arteritis or cranial arteritis&#44; is a non-necrotizing granulomatous inflammatory vasculitis that affects medium and large-caliber arteries with a preference for cranial involvement in a traditional manner&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The inflammation caused by GCA occurs most frequently in larger cranial arteries&#44; although it can occur in large arteries anywhere in the body&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> If the inflammation occurs in other locations of the body&#44; such as the thoracic or abdominal aorta&#44; it is referred to as GCA with extracranial involvement of large vessels or extracranial GCA&#46; Regarding symptoms&#44; cranial GCA can cause headache&#44; jaw claudication&#44; visual disturbances&#44; scalp hypersensitivity&#44; facial pain&#44; tongue necrosis&#44; anemia and PMR&#46; Extracranial GCA can present with intermittent limb claudication&#44; constitutional syndrome&#44; heart failure&#44; chest pain&#44; PMR&#44; and even sudden death&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The incidence of GCA varies depending on the geographic area&#44; being more common in Scandinavian countries and in communities with Scandinavian ancestry&#46; In Spain&#44; a study carried out in Lugo between 1998 and 2001 showed an annual incidence rate of 10&#46;13 per 100&#44;000 inhabitants in the population over 50 years of age&#44; increasing to a value of 23&#46;16 per 100&#44;000 inhabitants in the population between 70 and 79 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> At the national level&#44; the average annual incidence rate of this disease has been estimated at up to 7&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In the community of Madrid&#44; there are no specific data regarding the incidence and prevalence of these entities&#44; although it is observed that they represent up to 20&#37; with respect to the national total of all hospital admissions for PMR&#47;ACG&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In both the case of PMR and GCA&#44; the initial symptoms are usually non-specific&#44; which makes diagnosis difficult&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes the current classification criteria for GCA and PMR&#44; which can help in the diagnosis of both pathologies&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Specifically&#44; these pathologies are considered to be underdiagnosed&#44; understood as any erroneous&#44; late or absent diagnosis&#44; which can even be delayed up to a total of 9 weeks in the ACG<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and up to more than 1<span class="elsevierStyleHsp" style=""></span>year in the PMR&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Underdiagnosis of these pathologies can lead to complications such as the appearance of stenosis&#44; occlusions or aneurysms in the large vessels &#40;aorta and its main branches&#41;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and even irreversible sequelae&#44; such as visual loss&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> although the latter has decreased in recent years thanks to the appearance of biological therapies&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of this study is to optimize the approach to these diseases in our environment&#44; analyzing the causes of underdiagnosis&#44; and the generation of possible solutions that allow improving early detection and efficient referral of patients in different healthcare environments&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Workspace</span><p id="par0030" class="elsevierStylePara elsevierViewall">The study was developed in the Community of Madrid&#44; based on a multidisciplinary scientific committee of ten professionals who are experts in the approach to PMR and GCA&#46; The committee was formed with representatives of the main professional categories involved in the clinical approach to these diseases&#58; family and community medicine&#44; hospital emergencies&#44; internal medicine&#44; neurology&#44; ophthalmology and rheumatology&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study consisted of two main phases&#46; First&#44; an analysis of the current situation and identification and prioritization of areas for improvement were carried out&#46; In a second phase&#44; a series of lines of action were generated to address the identified areas of improvement&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">To obtain a consensus among the members of the scientific committee&#44; each and every one of the areas of improvement and lines of action were subject to discussion and subsequent voting&#46; Those points in which more than 75&#37; of the participants agreed in their votes were considered as consensual&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Analysis of the current situation and identification of areas for improvement</span><p id="par0045" class="elsevierStylePara elsevierViewall">To carry out this phase&#44; information was collected from different sources consulted&#58; digital questionnaires &#40;carried out with MS Forms&#41; on usual clinical practice completed by the health professionals of the scientific committee&#44; group work meetings with the committee&#39;s experts and a literature review&#46; national and international scientific&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">With the objective of analyzing the state of the situation and evaluating the proposed initiatives&#44; a systematic bibliographic search has been carried out through PubMed&#44; Embase and Google Scholar using the following search strategy&#58; &#40;&#40;ACG&#41; AND&#47;OR &#40;Giant cell arteritis&#41; AND &#47;OR &#40;PMR&#41; AND&#47;OR &#40;Polymyalgia rheumatica&#41;&#41; &#40;AND&#47;OR &#40;Management&#41; AND&#47;OR &#40;diagnostic&#41; AND&#47;OR &#40;recommendations&#41; AND&#47;OR &#40;guideline&#41; AND&#47;OR &#40;EULAR&#41; AND&#47;OR &#40;American College of Rheumatology&#41;&#41;&#46; Of all the results obtained&#44; those articles and guides with relevant information regarding the care process of patients with PMR and GCA have been selected&#44; especially at the national level&#46; Works with a low degree of scientific evidence&#44; clinical cases and articles outside the objective of this work have been discarded&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Through a group work session with the scientific committee&#44; all the information regarding the state of the situation regarding the approach to pathologies was analyzed and possible areas of improvement to work on were identified and prioritized&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The committee evaluated the aspects most frequently involved in relation to diagnostic delay and diagnostic difficulties in addressing these pathologies&#46; A quantitative study was not carried out due to the complexity and heterogeneity of the centers involved&#44; as well as the limited existence of quality indicators to obtain useful figures in ACG and PMR&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Generation and prioritization of lines of action</span><p id="par0065" class="elsevierStylePara elsevierViewall">In this phase&#44; two group work sessions were held with the members of the scientific committee in which&#44; based on the prioritized areas of improvement regarding the approach to pathologies&#44; different lines of action were proposed according to criteria of impact on the approach&#46; of the pathologies and feasibility of implementation of the proposed lines&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Analysis of the situation</span><p id="par0070" class="elsevierStylePara elsevierViewall">According to the patient experience map generated &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; the main entry routes for patients with PMR and&#47;or GCA to the care circuit are Primary Care and hospital and out-of-hospital emergencies&#46; In case of high suspicion&#44; depending on the patient&#39;s symptoms and the capabilities of the health center&#44; treatment with glucocorticoids &#40;GC&#41; is started and the patient is subsequently referred to the corresponding specialized care &#40;either in a Hospital or a Care Center&#41;&#46; peripheral specialties&#41;&#59; or the patient is referred to begin treatment with GC after being evaluated by the corresponding hospital specialty&#46; The specialties that these patients generally receive are internal medicine and rheumatology and&#44; to a lesser extent&#44; neurology or ophthalmology&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">After starting treatment with GC&#44; the definitive diagnosis is confirmed&#46; If necessary&#44; the treatment dose is adjusted&#44; considering the incorporation of steroid-sparing immunosuppressants&#44; and a joint follow-up schedule is established between Primary Care and the healthcare area where the patient has been treated&#44; whether Hospital or Peripheral Specialty Center&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;16&#8211;18</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Identification of areas for improvement</span><p id="par0080" class="elsevierStylePara elsevierViewall">Subsequently&#44; and based on the current state of the situation and the patient experience map&#44; the main areas of improvement were identified&#44; which are grouped into 4 categories&#58; coordination and protocols&#44; equipment&#44; training and awareness of the pathologies and experience&#46; of the patient &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Prioritization of areas of improvement</span><p id="par0085" class="elsevierStylePara elsevierViewall">After identifying the main areas for improvement&#44; they were prioritized based on their relevance and impact on optimizing the approach to PMR and GCA&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The first four areas belong to the category of coordination and protocols&#44; highlighting the importance of having comprehensive protocols that contemplate all levels of care and specialties involved in addressing pathologies&#44; and that define in detail the subprocesses of the suspicion and diagnosis phases&#44; in order to optimize early diagnosis in these pathologies&#46; In addition&#44; communication processes between specialties were considered of vital importance&#44; as well as the creation of rapid referral tools that expedite the first stages of the care process&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The fifth priority area for improvement was the low degree of clinical suspicion&#46; According to the state of the situation&#44; in the main routes of patient entry &#40;Primary Care and hospital emergencies&#41;&#44; obtaining a diagnosis and rapid referral is complex due to the non-specific nature of some of the early symptoms of PMR and GCA&#44; similar to other pathologies&#46; All this&#44; together with the great heterogeneity of patients who are treated in the main entry routes&#44; makes it difficult for these pathologies to be considered within the first-line differential diagnosis&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Lines of action</span><p id="par0100" class="elsevierStylePara elsevierViewall">In order to address the prioritized areas of improvement&#44; a series of lines of action were defined to be carried out&#46; Each line includes a series of proposals and specific actions for their correct development&#46; However&#44; there is a common aspect that applies to all the proposed lines&#44; which is the creation of multidisciplinary working groups &#40;GTMD&#41; with health professionals involved in addressing PMR and GCA&#44; both in Primary and Hospital Care&#44; capable of generating a comprehensive vision and act as an advisory body in the development of the entire care process&#46; In a recent British study&#44; a search for similar measures that included patient access&#44; glucocorticoid use&#44; access routes&#44; ultrasound&#44; temporal artery biopsy&#44; access to emission tomography positrons&#44; experience in rheumatology&#47;ophthalmology&#44; education and multidisciplinary work&#44; could improve the quality of care for patients with GCA&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Absence of comprehensive action protocols for pathologies</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">To demonstrate the importance of the generation and implementation of comprehensive action protocols&#44; it is necessary to define a series of key indicators in the approach to these pathologies&#46; With these indicators&#44; it is possible to demonstrate&#44; firstly&#44; the impact of the delay in referral and diagnosis on the approach to patients and&#44; finally&#44; to evaluate&#44; measure and compare the health care provided&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A key tool on which to base decision-making in the generation of protocols is scientific evidence related to both pathologies&#46; To generate scientific evidence adapted to the healthcare reality&#44; the creation of a regional patient registry is proposed in which&#44; in addition to clinical information&#44; experience reported by patients &#40;Patient Reported Experience Measurements&#44; PREMs&#41; and results reported by patients are included&#46; &#40;Patient-Reported Outcome Measurements&#44; PROMs&#41; collected through quality of life and experience questionnaires of patients with PMR and&#47;or GCA&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In the preparation of the protocols&#44; the inclusion of monographic PMR and GCA consultations&#44; dedicated exclusively to the evaluation&#44; monitoring and treatment of patients with these pathologies&#44; is considered appropriate&#46; In addition to acting as a consulting body&#44; the fact of having these monographic consultations is expected to increase the level of awareness about these pathologies in those hospitals where they are operational&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Coordination between services involved</p></li></ul></p><p id="par0130" class="elsevierStylePara elsevierViewall">When obtaining a diagnosis of patients&#44; the performance of the necessary diagnostic tests must be ensured by defining&#44; depending on the material and human resources of each health center&#44; the functions and responsibilities of the services and professionals involved in the addressing pathologies&#46; However&#44; despite adapting the functions and responsibilities to the resources of each center&#44; it is recommended to standardize training in Doppler ultrasound among all health professionals involved in performing the test to homogenize its performance regardless of the center where it is performed&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Likewise&#44; a series of specific criteria must be defined for carrying out diagnostic tests&#44; in order to optimize resources and speed up the diagnostic process in patients&#46;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Absence of communication channels and care continuity protocols between care levels</p></li></ul></p><p id="par0145" class="elsevierStylePara elsevierViewall">Given the involvement of both levels of care in addressing pathologies&#44; it is vitally important to establish a series of measures that ensure a correct interrelation between both&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">First&#44; through comprehensive action protocols&#44; procedures must be established for the correct referral of patients from the different levels of care&#46; A tool to carry out this aspect is the promotion of telematic&#47;telephone consultations&#44; which would allow an agile referral from Primary Care to Hospital Care&#46; Furthermore&#44; it is considered necessary to implement a digital tool in the computer systems of health centers that allows the integration and accessibility of information between Primary and Hospital Care&#44; facilitating continuity of care and patient monitoring&#46;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Absence of a fast-track circuit for patients with high suspicion of PMR and&#47;or GCA</p></li></ul></p><p id="par0160" class="elsevierStylePara elsevierViewall">In some hospitals in the region&#44; rapid referral or fast-track systems are already in operation for patients with suspected PMR and&#47;or GCA focused on accelerating the referral and diagnosis of patients&#44; avoiding the possible appearance of long-term sequelae such as appearance of stenosis&#44; occlusions or vascular aneurysms or irreversible complications such as blindness&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In this sense&#44; the analysis of the rapid referral systems in operation is recommended for their adaptation and inclusion in the comprehensive protocols for addressing pathologies in all centers in the region&#46;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Low degree of clinical suspicion</p></li></ul></p><p id="par0175" class="elsevierStylePara elsevierViewall">Early clinical suspicion is vital to ensure rapid referral and diagnosis for patients&#46; To improve the degree of clinical suspicion&#44; it is essential to develop periodic training sessions&#44; especially for the services involved in the entry of patients into the care circuit&#44; Primary Care and hospital emergencies&#46; These sessions should focus on detecting the symptoms and clinical signs of PMR and GCA in the suspicion phase and establishing referral criteria&#46; Furthermore&#44; the use of digital tools for continuing clinical education for all health professionals involved in the management of PMR and GCA at all levels of care can help maintain an adequate degree of clinical suspicion&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Another strategy to improve the degree of clinical suspicion is the incorporation of specific data recording forms for PMR and&#47;or GCA in the patients&#39; clinical history&#46; With these forms&#44; the methodology for recording&#44; evaluating and exploiting data is standardized among all professionals involved in addressing these pathologies and&#44; in addition&#44; they can generate an alarm for the healthcare professional in the event that the data collected in the clinical history is compatible with any of the pathologies&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Finally&#44; raising awareness among the general population is also essential to improve the degree of clinical suspicion and encourage early detection of PMR and GCA&#46; Therefore&#44; awareness campaigns must be developed &#40;training material&#44; infographics&#44; digital resources&#44; etc&#46;&#41; aimed at the general population to highlight the characteristics of these diseases and the importance of going to a consultation when compatible symptoms appear&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conclusions</span><p id="par0190" class="elsevierStylePara elsevierViewall">First&#44; since there is not enough top-level scientific evidence regarding the approach to PMR and GCA&#44; especially regarding its diagnosis and referral between specialties&#44; it is considered advisable to generate evidence capable of covering this lack of information&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The greatest current challenge in the approach to PMR and GCA is the undervalued diagnosis and&#44; under this premise&#44; a series of lines of action were identified focused on optimizing the approach to these pathologies&#44; especially in the phases of suspicion&#44; including referral&#46; between specialties&#44; and patient diagnosis&#46; All measures must arise and be channeled through multidisciplinary collaboration and the commitment of professionals from all healthcare specialties involved in addressing these pathologies&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Given the number of health professionals who may be involved in addressing pathologies&#44; the importance of generating and implementing comprehensive approach protocols that allow optimizing and streamlining the referral of patients and reducing the misdiagnosis of these patients was identified&#46; The generated protocols must serve as a guide from which health centers can generate their own work procedures adapted to their own capabilities and resources&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Furthermore&#44; given the low level of awareness about these pathologies&#44; the need to develop health professional training actions at all levels of care was highlighted to reduce the low level of clinical suspicion as for the general population&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Likewise&#44; the definition of key health care quality indicators and periodic control sessions must be included to evaluate the implemented work methodologies and their direct impact on health care&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Finally&#44; and although this study was carried out in the Community of Madrid&#44; it is considered that the problems associated with the diagnosis of PMR and GCA also occur in other communities&#44; which is why it is recommended to carry out similar studies in other regions&#44; as well as at the national level with the aim of optimizing the approach to both pathologies and promoting homogeneous health care between different communities&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Funding</span><p id="par0220" class="elsevierStylePara elsevierViewall">The preparation of this project and this report has been possible thanks to the collaboration of Roche in external project consulting&#46; Roche has not intervened at all in the selection of selected panelists&#47;experts or in any of the subsequent steps&#58; meetings held&#44; data analysis&#44; interpretation of results or writing of the manuscript&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">Dr&#46; A&#46; Gonz&#225;lez-Garc&#237;a declares that he has received speaking fees from Roche&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Dr&#46; M&#46; Fr&#237;as-Vargas declares that he has received fees for scholarships&#44; presentations or consulting work from Roche&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Dr&#46; S&#46; Casta&#241;eda declares that he has received fees for speaking or consulting work from Amgen&#44; BMS&#44; Gr&#252;nenthal Pharma Espa&#241;a&#44; Eli-Lilly&#44; Janssen&#44; MSD&#44; Pfizer&#44; Roche&#44; SOBI and UCB&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">The rest of the authors declare that they have no conflict of interest related to the content of the project&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Polymyalgia rheumatica and giant cell arteritis can be a medical emergency in which a delay in correct diagnosis and therapeutic management can cause serious complications&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">With the aim of improving the care of patients with these pathologies in the Community of Madrid&#44; a study was designed to identify the causes and possible solutions to address the problems related to the diagnosis of these pathologies&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">After the analysis&#44; 11 areas of improvement related to four different aspects of the care process were identified&#58; coordination and protocols&#44; equipment&#44; training and awareness of pathologies&#44; and patient experience&#46; Of all the areas identified&#44; it was considered a priority to resolve those related to the generation of protocols for the comprehensive management of the pathologies&#44; which include all the specialties and levels of care involved&#46; Another crucial aspect is the increase in the degree of clinical suspicion of these pathologies&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La Polimialgia reum&#225;tica y la arteritis de c&#233;lulas gigantes pueden suponer una emergencia m&#233;dica en la que el retraso en su correcto diagn&#243;stico y manejo terap&#233;utico pueden asociar complicaciones graves&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Con el objetivo de mejorar la atenci&#243;n de los pacientes con estas patolog&#237;as en el entorno de la Comunidad de Madrid&#44; se dise&#241;&#243; un estudio para identificar las causas y posibles soluciones para hacer frente los problemas relacionados con el diagn&#243;stico de estas patolog&#237;as&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Tras un an&#225;lisis preliminar&#44; se identificaron 11 &#225;reas de mejora relacionadas con cuatro aspectos diferenciados del proceso asistencial&#58; coordinaci&#243;n y protocolos&#44; equipamientos&#44; formaci&#243;n y concienciaci&#243;n sobre las patolog&#237;as y experiencia del paciente&#46; De todas ellas&#44; se prioriz&#243; resolver aquellas relacionadas con la generaci&#243;n de protocolos de abordaje integral de las patolog&#237;as&#44; que contemplen a todas las especialidades y niveles asistenciales implicados&#46; Otro aspecto crucial es el incremento del grado de sospecha cl&#237;nica de estas patolog&#237;as&#46;</p></span>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">&#43;2</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Polymyalgia rheumatica&#58;</span> Using clinical criteria alone&#44; a score &#8805;4 had a sensitivity of 68&#37; and a specificity of 78&#37; for discriminating polymyalgia rheumatica from comparison patients&#46; Using a combination of clinical and ultrasound criteria&#44; a score &#8805;5 had a sensitivity of 66&#37; and a specificity of 81&#37; for discriminating patients with the disorder from comparison patients&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Necessary criteria&#58; age &#8805;50 years&#44; bilateral omalgia and alteration of acute phase reactants &#40;c-reactive protein and erythrocyte sedimentation rate&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3467387.png"
              ]
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            4 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Symptom or clinical alteration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Morning stiffness lasting more than 45<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#43;2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hip pain or limited range of motion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#43;1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Absence of rheumatoid factor and antibodies against cyclic citrullinated peptide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#43;2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Absence of another joint affects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#43;1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3467386.png"
              ]
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            5 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ultrasound criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">At least one shoulder with subdeltoid bursitis&#44; biceps tenosynovitis&#44; or glenohumeral synovitis&#59; and at least one hip with trochanteric synovitis or bursitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#43;1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Both shoulders with subdeltoid bursitis&#44; biceps tenosynovitis&#44; or glenohumeral synovitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#43;1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3467383.png"
              ]
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          ]
          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Presence of definitive vasculitis in temporal artery biopsy &#40;presence of giant cells&#44; infiltration of mononuclear leukocytes and fragmentation of the internal elastic lamina&#41; or halo sign &#40;presence of homogeneous and hypoechoic wall thickening on ultrasound&#41; on ultrasound of the temporal artery&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">It is defined as luminal damage &#40;stenosis&#44; occlusion or aneurysm&#41; on angiography &#40;computed tomography&#44; magnetic resonance or catheterization&#41; or ultrasound&#44; halo sign on ultrasound or uptake on PET&#47;CT&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Abnormal PET&#47;CT uptake in the arterial wall &#40;eg&#44; greater than hepatic uptake by visual inspection&#41; of the descending thoracic and abdominal aorta&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Classification criteria for giant cell arteritis and polymyalgia rheumatica&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0015"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:4 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Coordination and protocols&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 Absence of comprehensive action protocols for pathologies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Although healthcare professionals have guidelines for therapeutic management and patient monitoring&#44; an absence of comprehensive action protocols was revealed that detail the suspicion and diagnosis phases&#44; including referrals between specialties&#46; It is considered that the standardization of processes in the suspicion stage can optimize and accelerate the diagnosis of pathologies and&#44; consequently&#44; the care process&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 Coordination between services involved&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The existence&#44; on certain occasions&#44; of a lack of coordination between the services involved in carrying out diagnostic tests &#40;mainly Pathological Anatomy&#44; Surgery&#44; Nuclear Medicine and Radiodiagnosis&#41; and those involved in addressing the pathologies was identified&#44; generating delays in obtaining a definitive diagnosis for patients&#44; with the potential risk of complications that this entails&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 Absence of communication channels and care continuity protocols between Primary Care and Hospital Care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">It was considered that there is a certain lack of bidirectional communication channels or tools and protocols that guarantee continuity of care between Primary and Hospital Care&#44; impacting the times until referral&#44; obtaining diagnoses&#44; starting treatments and&#44; therefore&#44; on the quality of life of patients and the appearance of complications&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 Reduced use of quality care indicators during the approach to pathologies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">According to the information obtained&#44; the use of indicators that allow measuring the delays or waiting times that patients suffer throughout the treatment of their pathologies&#44; that is&#44; the times of referral&#44; performance of diagnostic tests&#44; obtaining the diagnosis and treatment administration&#44; is reduced&#44; hindering the ability to measure&#44; compare and&#44; finally&#44; carry out initiatives focused on optimizing the health care of these patients&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 Absence of a fast-track circuit for patients with high suspicion of PMR and&#47;or GCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In most health centers in the region there are no rapid referral or fast-track circuits&#44; which would speed up the referral and diagnosis of patients with clinical signs compatible with either of the two pathologies&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3467380.png"
              ]
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            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Equipment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 Heterogeneity in the availability of Doppler ultrasound in health centers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Some Primary Care centers in the region do not have the material or human resources necessary to perform ultrasounds&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 Heterogeneity in the availability of positron emission tomography&#47;computed tomography &#40;PET&#47;CT&#41; use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PET&#47;CT is a very useful tool when diagnosing extracranial forms of GCA&#46; However&#44; these types of devices are not available in all health centers in the Community&#46; Furthermore&#44; they are used in the diagnosis and monitoring of a wide variety of pathologies&#44; which can cause delays in obtaining an adequate diagnosis in patients with these forms of GCA&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3467384.png"
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            ]
            2 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Training and awareness about pathologies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 Low degree of clinical suspicion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Both PMR and GCA are diseases with non-specific early symptoms&#44; which&#44; together with the great variety of pathologies addressed in the main routes of entry of patients&#44; makes it difficult for them to be considered within the differential diagnosis in the first line&#44; impacting negative in the times of referral and diagnosis of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 Misdiagnoses based on non-specific clinical symptoms&#47;signs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">An excessive use of certain clinical symptoms&#47;signs&#44; such as headache&#44; as unequivocal indicators of some of the pathologies was identified&#46; However&#44; headache may occur in up to 75&#37;&#8211;80&#37; of cranial GCA cases&#44; while it may be absent in the extracranial phenotype of GCA&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 Difficulty in obtaining specialized training in PMR and ACG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The suitability of having specialized and standardized training plans in the field of PMR and GCA&#44; available to all professionals involved in addressing these pathologies&#44; at all levels of care&#44; was highlighted&#46; Specifically&#44; the need to ensure training for professionals in performing Doppler ultrasound of at least temporal and axillary arteries is highlighted&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">These training plans should be focused on the stages of suspicion and diagnosis of pathologies&#44; favoring the training and awareness of the professionals involved&#44; speeding up the time to obtain a diagnosis and generating an increase in the degree of clinical suspicion&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3467385.png"
              ]
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            3 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient experience&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 Delay in requesting a medical consultation due to poor awareness of pathologies on the part of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">On certain occasions&#44; a delay is observed in the request for clinical consultation by patients&#44; motivated by the lack of training and knowledge about PMR and GCA and their respective symptoms&#46; This causes a delay in visiting the health center&#44; sometimes going when the symptoms represent a medical emergency&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Areas for improvement have been identified&#46; The areas prioritised by the project&#39;s Scientific Committee are underlined&#46;</p>"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2023.12.009

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