OBJECTIVES: Giant Cell Arteritis (GCA) remains a challenge both in terms of diagnosis and management as patients may present to several different specialists. The objectives were to determine incidence of biopsy-proven GCA in Malta and to compare the management between rheumatologists and nonrheumatologists. METHODS: This was a retrospective observational population study of patients with suspected GCA who underwent a temporal artery biopsy (TAB) between 2012 and 2015. Data collected consisted of demographics, presenting symptoms, TAB histology reports, treatment and outcome. The British Society for Rheumatology (BSR) 2010 guidelines were used as standard of care. RESULTS: 136 patients underwent a TAB for suspected GCA of which 26 were positive. The incidence of biopsy-proven GCA in Malta was 3.82 per 100,000 patient years in the over 50 population. There were 63 patients who were treated as GCA. Only 43.3% of confirmed cases had rheumatology input. TABs requested by rheumatologists were twice more likely to be positive compared to requests by non-rheumatologists (30.5% vs. 14.1%).The majority of patients were started on a Prednisolone dose between 40-60mg. Rheumatologists maintained patients on high doses for at least 1 month in 54% of cases as opposed to 20% under non-rheumatologists. Monitoring was more regular for cases followed up by rheumatologists (40% vs. 21%). CONCLUSIONS: Malta has a low incidence of biopsy proven GCA. Although rheumatologists are more likely to adhere to the recommended guidelines, improvement is needed. Rheumatologists should take the lead to minimise variation and optimise management of GCA.

BackgroundGiant cell arteritis (GCA) is the commonest vasculitis affecting large and medium vessels. GCA presents with varying symptomatology which makes timely diagnosis and management challenging. A number of guidelines for the management of GCA have been published.1,2 In clinical practice, patients present to various specialists including general practitioners, general physicians, neurologists, rheumatologists and ophthalmologists which may result in wide variations in clinical care.ObjectivesTo establish the incidence of GCA in the Maltese population and whether rheumatologists are able to diagnose and manage giant cells arteritis better than non rheumatologists.MethodsThis was a population observational study of Maltese patients between 2012 and mid 2015. All patients who underwent a temporal artery biopsy (TAB) were recruited and their case notes reviewed.ResultsThere were 122 patients (80 females) who underwent a TAB over 3.5 years for suspected GCA and out of these, 29 were positive. The incidence of biopsy proven temporal arteritis in Malta was 6.4 per 100,000 inhabitants aged over 50 years. Mean age was 72.6 (SD 10.5) years. An additional 27 patients were treated for GCA on clinical grounds. Median CRP was 31 mg/L (IQR 6–87) and ESR 81 mm/hr (53.5–102.5).A total of 53 patients presented to the rheumatologists and 69 patients to non rheumatologists, and a positive TAB was obtained in 32% and 11.6% of patients respectively. Glucocorticoids were initiated before taking a TAB in 39.6% by rheumatologists and 34.7% and non rheumatologists. Overall (including TAB negative patients) 60.4% of patients presenting to the rheumatologists and 33% of patients presenting to non rheumatologists were treated as GCA.The starting dose of Prednisolone was between 40–60mg in 82% of rheumatologist treated patients compared to 65% by non rheumatologists. The tailoring regimes varied widely and documentation was poor for many patients treated by non rheumatologists. Rheumatologists treated 50% of patients with a Prednisolone dose of 40 mg or greater for at least a month, 37.5% were given lower doses while the treatment regimen was unclear in 12.5%. Non rheumatologists treated 20.8% with a Prednisolone dose of 40 mg or greater for at least a month, 33.3% were given lower doses and in 45.8% regimen was unclear. The main differential diagnoses were sepsis/infection (7 cases), PMR (4 cases), pyrexia of unknown origin (4 cases) and cluster headache (2 cases).ConclusionsMalta seems to have a low incidence of GCA comparable to other Mediterranean countries but lower than northern European countries.3GCA presents to a wide variety of specialists leading to a broad variation in treatment regimens. Non rheumatologists seem to have a lower threshold for TABs and possibly perform a number of unnecessary TABs.In order to ensure timely and appropriate management rheumatologists should take the lead and set up interspecialist pathways based on international guidelines that work in the local context. These pathways should include guidance abou...

normal platelet count (314k/ul), elevated INR (2.8), PTT (45.4), lactate (3.5mmol/L), and low fibrinogen (215mg/dL) levels. Thrombo-elastography was also normal. The surgery was postponed and a diagnosis of acute fatty liver of pregnancy (AFLP) with superimposed pre-eclampsia was confirmed by clinical, laboratory, and imaging features. Methods Hematological abnormalities such as thrombocytopenia and decrease in clotting factors may develop in preeclamptic women. The risk of abnormal hemostasis increases with the severity of pre-eclampsia. Results Platelet count is routinely used as a primary test to evaluate the coagulation status in parturients with SP 1. It has been shown that when the platelet count < 100,000/mm3, other hemostatic abnormalities, such as prolonged prothrombin time (PT) and partial thromboplastin time (PTT), and reduced fibrinogen concentration, may also be presented 2. About 50% of patients with AFLP have preeclampsia, and there is some overlap with the HELLP syndrome 3. Conclusions This case highlights that in parturients with SP, the platelet count should not be used as the sole mean to evaluate the coagulation status, as there are conditions such as acute fatty liver of pregnancy and viral-hepatitis that can mimic or overlap pre-eclampsia in the absence of thrombocytopenia.