Implementation of British Thoracic Society guidelines for acute exacerbation of chronic obstructive pulmonary disease: impact on quality of life

BACKGROUND

The British Thoracic Society (BTS) guidelines have not been examined collectively for their impact on chronic obstructive pulmonary disease (COPD). Whether intensive outpatient follow up of COPD patients after acute admission, using these guidelines, improved quality of life compared to the "usual practice" of primary care follow up was investigated.

METHODS

Altogether 103 patients with a new diagnosis of COPD were admitted and screened over a four year period. Seventy patients were excluded because of another dominant medical condition or a mandatory requirement for intervention. Patients were randomised to regular primary care (control group, n = 15) or chest clinic follow up (intervention group, n = 10). Spirometry, oxygen saturation, St George's Respiratory Questionnaire (SGRQ), and Short Form 36 questionnaire were measured at baseline and six months. The intervention group was reviewed at least four times in the six month period and received spirometry, ambulatory oxygen assessment, smoking cessation advice, nebuliser assessment, a steroid trial, advice about nutrition/exercise, and introduction to a patient support group.

RESULTS

There was no significant difference between baseline measurements in the two groups. There was a significant mean (SD) improvement in the SGRQ symptom score from baseline to six months in the intervention group [20.98 (20.36)] compared with the controls [0.23 (12.55)] (p = 0.004). At six months the SGRQ symptom score, impact score, and total score was significantly better in the intervention than the control group (p = 0.01, 0.02, and 0.02).

CONCLUSION

Aggressive implementation of BTS guidelines after initial hospitalisation may improve respiratory health specific quality of life scores in patients with COPD. Larger studies are needed to confirm this finding.

A prospective study of the practical issues of local involvement in national audit of COPD

RATIONALE, AIMS AND OBJECTIVES

Variation in quality of local services is of great concern to the government and public. National audit is an important means of providing data of comparative performance but is hampered at local level by poor methodology including audit design, standard setting and data collection tools. A pilot audit of the hospital care of patients admitted with acute chronic obstructive pulmonary disease (COPD) was performed in preparation for a national audit programme and was designed and supported by experts. It was hoped to overcome these barriers. We report a prospective evaluation of the practical issues involved in local participation of hospital audit of COPD care within a national framework.

METHODS

Hospitals were recruited to the study by random selection and voluntary participation. A clinical audit study was completed over an 8-week period immediately followed by a survey of clinicians and audit staff to identify positive and negative issues of participation and the process required to achieve a successful outcome.

RESULTS

Forty-one hospitals were invited to participate, 26 (63%) accepted, and four others volunteered to meet the target of 30 enrolled centres. Reasons cited for non-participation were of inadequate resources amongst either clinicians or audit departments or prior engagement in other national or local audit schemes. Following completion of the audit most (81%) participating units reported it was a useful exercise and were willing to be involved in future audits. Negative aspects of involvement included the lack of dedicated time and manpower for audit, poor information technology and inadequate systems for identifying patient diagnoses either at admission or at discharge and incomplete case note entries. Methodological issues such as study design and data collection tools were not cited as important barriers to participation.

CONCLUSION

There is local willingness to be involved in national audit of hospital care of COPD and central provision of expert design of methods and tools may reduce some audit barriers. Nevertheless, priority must be given to improving resources identified to support audit and in improving methods and systems for data capture. These issues appear to be important in most units and represent a potentially serious barrier to achieving widespread local involvement in a national audit programme of COPD care and may also apply to other national audits designed to provide comparative assessment of National Health Service services.

Evidence for a link between mortality in acute COPD and hospital type and resources

BACKGROUND

The 1997 BTS/RCP national audit of acute care of chronic obstructive pulmonary disease (COPD) found wide variations in mortality between hospitals which were only partially explained by known audit indicators of outcome. It was hypothesised that some of the unexplained variation may result from differences in hospital type, organisation and resources. This pilot study examined the hypothesis as a factor to be included in a future national audit programme.

METHODS

Thirty hospitals in England and Wales were randomly selected by geographical region and hospital type (teaching, large district general hospital (DGH), small DGH). Data on process and outcome of care (death and length of stay) were collected retrospectively at 90 days on all prospectively identified COPD admissions over an 8 week period. Each centre completed a questionnaire relating to organisation and resources available for the care of COPD patients.

RESULTS

Eleven teaching hospitals, nine large DGHs, and 10 small DGHs provided data on 1274 cases. Mortality was high (14%) with wide variation between centres (IQR 9-19%). Small DGHs had a higher mortality (17.5%) than teaching hospitals (11.9%) and large DGHs (11.2%). When corrected for confounding factors, an excess of deaths in small DGHs was still observed (OR 1.56 (CI 1.04 to 2.35)) v teaching hospitals. Analysis of resource and organisational factors suggested higher mortality was associated with fewer doctors (OR 1.5) and with fewer patients being under the care of a specialist physician (OR 1.8). Small DGHs had fewest resources.

CONCLUSION

Significant differences in mortality may exist between hospital types. The findings justify further study in a proposed national audit.

Oxygen supplementation before or after submaximal exercise in patients with chronic obstructive pulmonary disease

BACKGROUND

Evidence for improved exercise tolerance or relief of breathlessness by short term use of oxygen before or after exercise in patients with chronic obstructive pulmonary disease (COPD) is scant, and guidelines for this treatment are lacking despite widespread provision in the UK.

METHODS

The effect of oxygenation either before or after exercise on perception of breathlessness and walk distance was studied in a group of patients with moderate to severe COPD (mean forced expiratory volume in 1 second (FEV(1)) 34% of predicted, mean 6 minute walk distance on air 283 m), all of whom desaturated by at least 4% on submaximal exercise. Oxygen (28%) or air was delivered double blind and in random order, either for 5 minutes before a standard 6 minute walk test (n=34) or for 5 minutes following the end of the test (n=18). Exercise tolerance was measured as the distance achieved and breathlessness was assessed using visual analogue scales (VAS) which were scored before and after exercise and during recovery.

RESULTS

No increase in mean walk distance after oxygen (288 v 283 m) and no improvement in mean breathlessness scores (58 v 54 mm) or recovery times occurred with oxygen taken either before (177 v 184 seconds) or after exercise (182 v 151 seconds).

CONCLUSIONS

This group of patients with COPD derived no physiological or symptomatic benefit from oxygen breathed for short periods before or after submaximal exercise. Domiciliary oxygen should only be prescribed for such patients if they have shown objective evidence of benefit on exercise testing.

Results of an extended tuberculosis screening programme among sixth formers in a London school--more questions than answers

Following the death of an unvaccinated 16-year-old school student with isoniazid resistant pulmonary tuberculosis, extended screening of sixth formers took place to identify further cases of tuberculosis and to establish the need for BCG vaccination. Eight hundred and four 16-19 year olds in the school underwent Heaf testing and completed a demographics questionnaire. Forty-nine (5.5%) of these children had a positive Heaf test and were offered a chest radiograph. Four children were diagnosed with pulmonary or mediastinal tuberculosis, none linked to the index case. Fifty-four students (6.7%) with no prior BCG had a Heaf grade 0-1 reaction and were recommended for vaccination. Ninety-one percent of students were from ethnic minority groups and 29% had been born outside the UK. British Thoracic Society recommendations on the management of tuberculin positive cases of this is open to interpretation and we suggest that a more directed and aggressive approach to TB control should be considered in inner city schools with a high proportion of at risk ethnic minority students.

Clinical audit indicators of outcome following admission to hospital with acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND

The 1997 BTS/RCP national audit of acute chronic obstructive pulmonary disease (COPD) in terms of process of care has previously been reported. This paper describes from the same cases the outcomes of death, readmission rates within 3 months of initial admission, and length of stay. Identification of the main pre-admission predictors of outcome may be used to control for confounding factors in population characteristics when comparing performance between units.

METHODS

Data on 74 variables were collected retrospectively using an audit proforma from patients admitted to UK hospitals with acute COPD. Important prognostic variables for the three outcome measures were identified by relative risk and logistic regression was used to place these in order of predictive value.

RESULTS

1400 admissions from 38 acute hospitals were collated. 14% of cases died within 3 months of admission with variation between hospitals of 0-50%. Poor performance status, acidosis, and the presence of leg oedema were the best significant independent predictors of death. Age above 65, poor performance status, and lowest forced expiratory volume in 1 second (FEV(1)) tertile were the best predictors of length of stay (median 8 days). 34% of patients were readmitted (range 5-65%); lowest FEV(1) tertile, previous admission, and readmission with five or more medications were the best predictors for readmission.

CONCLUSIONS

Important predictors of outcome have been identified and formal recording of these may assist in accounting for confounding patient characteristics when making comparisons between hospitals. There is still wide variation in outcome between hospitals that remains unexplained by these factors. While some of this variance may be explained by incomplete recording of data or patient factors as yet unidentified, it seems likely that deficiencies in the process of care previously identified are responsible for poor outcomes in some units.

Effects of marine reserves on adjacent fisheries

Marine reserves have been widely promoted as conservation and fishery management tools. There are robust demonstrations of conservation benefits, but fishery benefits remain controversial. We show that marine reserves in Florida (United States) and St. Lucia have enhanced adjacent fisheries. Within 5 years of creation, a network of five small reserves in St. Lucia increased adjacent catches of artisanal fishers by between 46 and 90%, depending on the type of gear the fishers used. In Florida, reserve zones in the Merritt Island National Wildlife Refuge have supplied increasing numbers of world record-sized fish to adjacent recreational fisheries since the 1970s. Our study confirms theoretical predictions that marine reserves can play a key role in supporting fisheries.

Meeting the needs of patients with limited English proficiency

Recent guidelines have been promulgated to protect the rights of patients with limited English proficiency when they receive care from health Providers. It behooves Providers to supply access to proper interpreter services to assure appropriate and efficient care. Furthermore, legal strictures that apply include issues of malpractice on the basis of lack of informed consent and the government's ability to exclude non-compliant Providers from federally funded programs including Medicare and Medicaid.

Audit of acute admissions of COPD: standards of care and management in the hospital setting

Despite publication of several management guidelines for COPD, relatively little is known about standards of care in clinical practice. Data were collected on the management of 1400 cases of acute admission with Chronic Obstructive Pulmonary Disease in 38 UK hospitals to compare clinical practice against the recommended British Thoracic Society standards. Variation in the process of care between the different centres was analysed and a comparison of the management by respiratory specialists and nonrespiratory specialists made. There were large variations between centres for many of the variables studied. A forced expiratory volume in one second measurement was found in only 53% of cases. Of the investigations recommended in the acute management arterial blood gases were performed in 79% (interhospital range 40-100%) of admissions and oxygen was formally prescribed in only 64% (range 9-94%). Of those cases with acidosis and hypercapnia 35% had no further blood gas analysis and only 13% received ventilatory support. Long-term management was also deficient with 246 cases known to be severely hypoxic on admission yet two-thirds had no confirmation that oxygen levels had returned to levels above the requirements for long-term oxygen therapy. Only 30% of current smokers had cessation advice documented. To conclude, the median standards of care observed fell below those recommended by the guidelines. The lowest levels of performance were for patients not under the respiratory specialists, but specialists also have room for improvement. The substantial variation in the process of care between hospitals is strong evidence that it is possible for other centres with poorer performance to improve their levels of care.

Provision of an electronic library at the clinical frontline: evaluation of impact on hospital medical staff

Doctors need convenient access to the latest information if they are to meet the demands of clinical governance and evidence-based medicine. Forest Healthcare NHS Trust used its intranet to provide clinical areas with direct 24-hour access to library materials.

The Holyoake Codependency Index: investigation of the factor structure and psychometric properties

The Holyoake Codependency Index is being developed to measure the extent to which a person endorses codependent beliefs and attributions. A 28-item pilot version was administered to 39 male and 268 female clients of a family counseling agency. Factor analysis, used to identify the shortest version with acceptable reliability, yielded a 13-item final version comprising three subscales (external focus, self-sacrifice, and reactivity). The subscales correspond to key themes within the literature on codependency. Scores on each subscale correlated significantly in the predicted direction with relevant measures of psychological functioning; providing initial evidence of construct validity. The 13-item scale was administered to a general community sample of 303 women and the factor structure was fully replicated. Internal consistency of the subscales ranged from .74 to .84 with the family counseling sample and from .73 to .83 with the general community sample.

A pilot Internet teaching project to support specialist medical training

Regional training programmes involving specialist medical trainees at geographically separate sites lend themselves to distance learning methods. This paper describes the setting up and early evaluation of an internet-based project designed to support regional study days across North East Thames for respiratory medicine.

MDC-L, a novel metalloprotease disintegrin cysteine-rich protein family member expressed by human lymphocytes

The metalloprotease disintegrin cysteine-rich (MDC) proteins are a recently identified family of transmembrane proteins that function in proteolytic processing of cell surface molecules and in cell adhesion. Since lymphocytes must interact with a constantly changing environment, we hypothesized that lymphocytes would express unique MDC proteins. To identify MDC proteins expressed in human lymph node, a polymerase chain reaction-based strategy combined with degenerate oligonucleotide primers was employed. We report here the identification of MDC-L (ADAM 23), a novel member of the MDC protein family. The results obtained from cDNA cloning and Northern blot analysis of mRNA isolated from various lymphoid tissues indicate that a 2.8-kilobase mRNA encoding a transmembrane form, MDC-Lm, and a 2.2-kilobase mRNA encoding a secreted form, MDC-Ls, are expressed in a tissue-specific manner. MDC-L mRNA was shown to be predominantly expressed in secondary lymphoid tissues, such as lymph node, spleen, small intestine, stomach, colon, appendix, and trachea. Furthermore, immunohistochemical staining with an anti-MDC-L antibody demonstrated that cells with typical lymphocyte morphology are responsible for expression of the MDC-L antigen in these lymphoid tissues. MDC-Lm was found to be expressed on the surface of human peripheral blood lymphocytes and transformed B- and T-lymphocyte cell lines as an 87-kDa protein. Thus, we have identified a novel lymphocyte-expressed MDC protein family member.

Clinical value and cost of a respiratory sleep-related breathing disorders screening service for snorers referred to a District General Hospital ENT department

Sleep-related breathing disorders and snoring often co-exist in the community. We hypothesized that a significant proportion of patients referred from primary care to ENT surgeons for management of snoring might have significant sleep-related breathing disorders requiring medical management. The Respiratory Medicine Department at Whipps Cross Hospital, London, U.K. screened all such referrals using sleep questionnaires, overnight oximetry and diagnostic sleep studies where necessary as recommended by the Royal College of Physicians of London. Over 38 months, 115 patients were screened, of whom 43 (38%) had clinically significant sleep-disordered breathing. One-third were established on nasal continuous positive airway pressure ventilation and the remainder were mainly offered conservative treatment. The cost of the screening service is estimated at 14,000 Pounds for the initial year. The savings to the ENT service and the possible long-term benefits to the patients identified as having sleep-disordered breathing balance this. We conclude that screening all referred snorers for sleep-disordered breathing using a simple protocol identifies a significant number requiring medical management at a relatively low cost to the service provider.

Screening child playgroup contacts of an adult with smear negative tuberculosis

A childcare assistant with smear negative, culture positive tuberculosis worked for four months with 85 children who attended playgroups for 2.5 to 5 hours each week. Eighty-two of the children completed contact tracing procedures. No evidence was found of transmission of disease to any child.

Screening patients in general practice with COPD for long-term domiciliary oxygen requirement using pulse oximetry

Epidemiological data suggest long-term oxygen therapy (LTOT) delivered by oxygen concentrators in patients with severe hypoxic chronic obstructive pulmonary disease (COPD) is under-prescribed by General Practitioners (GPs) in England and Wales. One reason for this may be the unavailability to GPs of a measure of arterial oxygenation needed to fulfil the defined prescription criteria. Provision of a non-invasive measure of oxygenation may improve detection of hypoxic subjects and increase appropriate prescribing. This study aimed to evaluate pulse oximetry in a general practice setting and to screen for severe undetected hypoxaemia fulfilling the LTOT prescription criteria in patients with COPD. All COPD patients attending surgery in two practices were screened with oximeters for hypoxaemia. Those with an oxygen saturation of < or = 92% were referred to hospital for formal arterial blood gas analysis and an oxygen concentrator assessment. GPs were asked to evaluate their experience in the ease of use and application of oximetry. The number of patients receiving oxygen by concentrator before the study was compared with the national rate and the number after the study with the estimated need suggested by epidemiological studies. Over a 12-month period a total of 114 patients were screened in the two practices with a combined list size of 15,742. Thirteen patients had saturations of < or = 92%. Two refused and 11 underwent formal arterial gas analysis. Three had PaO2 < 7.3 kPa and new prescriptions for oxygen concentrators were made in these previously unsuspected severely hypoxaemic subjects as a result. One other hypoxaemic subject was referred and found to have another treatable medical condition. The initial prevalence of concentrator prescription (0.013% CI 0.003, 0.047) was similar to the national rate (0.024%) and the prevalence observed after screening (0.031%, CI 0.013, 0.073) fell within the lower suggested prescription need of previous epidemiological data (0.02-0.10%). All practitioners found the oximeters simple to use and helpful in assisting with assessment of the severity of their patient's condition. Oximetry provides a readily usable non-invasive method of screening and when applied to all COPD patients seen in general practice can reveal those fulfilling the criteria for long term oxygen who would otherwise not be identified as needing this treatment.

A summary of fraud and abuse issues affecting clinical research programs

In an environment where the health care industry is under unprecedented scrutiny, it is important for all of those involved in the delivery of patient care and clinical research to be aware of and adhere to government grant requirements and billing practices. Fraud and abuse violations, no matter how minor they may seem, can result in substantial consequences for the grantee institutions and the investigators themselves.

The value of forced expiratory volume in 1 s in screening subjects with stable COPD for PaO2 < 7.3 kPa qualifying for long-term oxygen therapy

Guidelines on the management of chronic obstructive pulmonary disease (COPD) issued by the European Respiratory Society (ERS), British Thoracic Society (BTS), American Thoracic Society (ATS), and Department of Health for England and Wales (DoH) suggest differing values of forced expiratory volume in 1 s (FEV1) below which arterial blood gas analysis should be performed to determine the presence of severe hypoxaemia and possible long-term oxygen therapy (LTOT) requirement. This study aimed to determine the value of FEV1 at these different levels in screening for LTOT requirement defined as PaO2 < 7.3 kPa in subjects with stable COPD. Comparative measures were taken against other lung function tests of volume and diffusing capacity. A retrospective analysis of paired lung function and arterial oxygen measurements in 491 subjects was made. The positive and negative predictive values, sensitivity and specificity of FEV1 < 70% predicted (ERS), FEV1 < 50% predicted (ATS), FEV1 < 40% predicted (BTS) and FEV1 < 1.51 (DoH) were determined for fulfilling LTOT criteria (PaO2 < 7.3 kPa). The correlation between lung function variables and PaO2 was established. Logistic regression analysis was used to classify subjects with PaO2 < 7.3 kPa and PaO2 > or = 7.3 kPa. Using FEV1 to screen for LTOT requirement produced a high negative predictive value at all four suggested limits (FEV1 < 70% 100%, FEV1 < 50% 96%, FEV1 < 40% 95%, FEV1 < 1.51 97%). However, the positive predictive values were low (FEV1 < 70% 13%, FEV1 < 50% 16%, FEV1 < 40% 19%, FEV1 < 1.51 15%) as were sensitivities. No single lung function variable was a strong determinant of PaO2. FEV1 % pred (r = 0.40), FVC % pred (r = 0.34) and TLCO % pred (r = 0.27) had the strongest relationships. Logistic regression also placed FEV1 % pred and TLCO % pred as the best predictors of PaO2 < 7.3 kPa. We conclude no lung function variable correlates well with PaO2 in subjects with stable COPD. The best predictor of PaO2 < 7.3 kPa was FEV1 % pred. Whilst a low FEV1 is a poor predictor of LTOT requirement in an individual, PaO2 < 7.3 kPa is only found in subjects with a low FEV1. A high FEV1 may be used to exclude subjects from further investigation for LTOT and prevent unnecessary arterial sampling.

Connectivity and management of caribbean coral reefs

Surface current patterns were used to map dispersal routes of pelagic larvae from 18 coral reef sites in the Caribbean. The sites varied, both as sources and recipients of larvae, by an order of magnitude. It is likely that sites supplied copiously from "upstream" reef areas will be more resilient to recruitment overfishing, less susceptible to species loss, and less reliant on local management than places with little upstream reef. The mapping of connectivity patterns will enable the identification of beneficial management partnerships among nations and the design of networks of interdependent reserves.

Comparison of the efficacy of a demand oxygen delivery system with continuous low flow oxygen in subjects with stable COPD and severe oxygen desaturation on walking

BACKGROUND

Provision of ambulatory oxygen using an intermittent pulsed flow regulated by a demand oxygen delivery system (DODS) greatly increases the limited supply time of standard portable gaseous cylinders. The efficacy of such a system has not previously been studied during submaximal exercise in subjects with severe chronic obstructive pulmonary disease (COPD) in whom desaturation is likely to be great and where usage is often most appropriate.

METHODS

Fifteen subjects with severe COPD and oxygen desaturation underwent six minute walk tests performed in random order to compare the efficacy of a demand oxygen delivery system (DODS) with continuous flow oxygen. Walk distance, breathlessness, oxygen saturation, resting time, and recovery time (objective and subjective) were recorded and compared for each walk.

RESULTS

Breathing continuous oxygen compared with baseline air breathing improved mean walk distance (295 m versus 271 m) and recovery time (47 seconds versus 112 seconds), whilst the lowest recorded saturation (81% versus 74%) and time desaturated below 90% (201 seconds versus 299 seconds) were reduced. When the DODS was compared with air breathing only the walk distance changed (283 m versus 271 m). A comparison of the DODS with continuous oxygen breathing showed the DODS to be less effective at oxygenating subjects with inferior lowest saturation (78% versus 81%), time spent below 90% (284 seconds versus 201 seconds), time to objective recovery (83 seconds versus 47 seconds), and walk distance (283 m versus 295 m).

CONCLUSIONS

Neither of the delivery systems was able to prevent desaturation in these subjects. The use of continuous flow oxygen, however, was accompanied by improvements in oxygenation, walk distance, and recovery time compared with air breathing. The DODS produced only a small increase in walk distance without elevation of oxygen saturation, but was inferior to continuous flow oxygen in most of the measured variables when compared directly.

Concept mapping: an effective instructional strategy for diet therapy

Concept mapping is an instructional strategy that requires learners to identify, graphically display, and link key concepts in instructional reading material. Although proven effective in numerous disciplines as a means to promote critical thinking and self-directed learning, concept mapping has not been tested in diet therapy. The objective of this study was to implement concept mapping as a small-group, cooperative learning strategy in an upper-division diet therapy course and to evaluate student attitudes about the effect of concept mapping on knowledge, self-directed learning, problem-solving, and collaborative skills. Students in the first semester (n = 27) initially learned course material by lecture (4 weeks) followed by an integrated mapping/lecture format (12 weeks); the second semester (n = 25) used an integrated mapping lecture format for the full 16 weeks. At the end of both semesters, students completed a 10-item original survey questionnaire. Responses for first (n = 25) and second (n = 21) semesters were analyzed independently. Results indicated that a majority of students thought participation in concept mapping enhanced knowledge of diet therapy principles (n = 19 of 25; 18 of 21), self-directed learning (n = 14 of 25; 18 of 21), critical thinking (n = 21 of 25; 14 of 21), problem-solving (n = 22 of 25; 16 of 21), and collaboration (n = 24 of 25; 20 of 21) skills. When noncooperation of teammates was a factor, concept mapping was viewed as more frustrating and time consuming than lecture. This study demonstrated concept mapping as an effective learning strategy for diet therapy; it improves students' ability to engage in self-directed learning, critical thinking, collaboration, and creative problem solving. Results suggest that concept mapping is most effective when accompanied with comprehensive training, coordinated lectures, instructor guidance, and long-term practice.

The autoantibody response to Ro/SSA in cutaneous lupus erythematosus

BACKGROUND AND DESIGN

Seventeen patients with subacute cutaneous lupus erythematosus (SCLE) were compared with 15 patients with discoid lupus erythematosus (DLE) to evaluate the relationship of 60- and 52-kd Ro/SSA autoantibodies to the clinical diagnosis and to evaluate assays for anti-Ro/SSA.

RESULTS

All serum samples from patients with SCLE had precipitating anti-Ro/SSA antibodies in immunodiffusion, and all had high titer anti-60-kd Ro/SSA in enzyme-linked immunosorbent assay. Immunoblotting was inadequately sensitive for detecting anti-60-kd Ro/SSA. Fifteen patients with SCLE had anti-52-kd Ro/SSA (11 high titer, four low titer). Only one of the 15 patients with DLE had precipitating, high-titer anti-Ro/SSA. Nine other patients with DLE had low-titer anti-60-kd Ro/SSA, and four had low-titer anti-52-kd Ro-SSA. Low-titer anti-Ro/SSA did not confer an increased risk for photosensitivity in the DLE group.

CONCLUSIONS

High-titer, precipitating antibodies to Ro/SSA are typical of SCLE and unusual in DLE. Low-titer, nonprecipitating antibodies to Ro/SSA are common in DLE and could be an indication of pathogenic factors shared with SCLE. However, low titers of anti-Ro/SSA do not confer a significant risk for SCLE skin lesions. For the purpose of clinical evaluation of skin disease, immunodiffusion assays for anti-Ro/SSA are cost-effective and informative.