Association of Primary Care Providers' Beliefs of Statins for Primary Prevention and Statin Prescription

Background The 2013 American College of Cardiology/American Heart Association Cholesterol Treatment Guideline increased the number of primary prevention patients eligible for statin therapy, yet uptake of these guidelines has been modest. Little is known of how primary care provider ( PCP ) beliefs influence statin prescription. Methods and Results We surveyed 164 PCP s from a community-based North Carolina network in 2017 about statin therapy. We evaluated statin initiation among the PCP s' statin-eligible patients between 2014 and 2015 without a previous prescription. Seventy-two PCP s (43.9%) completed the survey. The median estimate of the relative risk reduction for high-intensity statins was 45% (interquartile range, 25%-50%). A minority of providers (27.8%) believed statins caused diabetes mellitus, and only 16.7% reported always/very often discussing this with patients. Most PCPs (97.2%) believed that statins cause myopathy, and 72.3% reported always/very often discussing this with patients. Most (77.7%) reported always/very often using the 10-year atherosclerotic cardiovascular disease risk calculator, although many reported that in most cases other risk factors or patient preferences influenced prescribing (59.8% and 43.1%, respectively). Of 6172 statin-eligible patients, 22.3% received a prescription for a moderate- or high-intensity statin at follow-up. Providers reporting greater reliance on risk factors beyond atherosclerotic cardiovascular disease risk were less likely to prescribe statins. Conclusions Although beliefs and approaches to statin discussions vary among community PCP s, new prescription rates are low and minimally associated with those beliefs. These results highlight the complexity of increasing statin prescriptions for primary prevention and suggest that strategies to facilitate standardized discussions and to address external influences on patient beliefs warrant future study.

Association of Practice-Level Hospital Use With End-of-Life Outcomes, Readmission, and Weekend Hospitalization Among Medicare Beneficiaries With Cancer

PURPOSE

To determine the relationships between hospital use of treating oncology practices and patient outcomes.

PATIENTS AND METHODS

Retrospective analysis of 397,646 Medicare beneficiaries who received anticancer therapy in 2012. Each beneficiary was associated with a practice; practices were ranked on the basis of risk-adjusted hospital use, that is, inpatient intensity. Outcomes included 30-day readmission, weekend admissions, intensive care unit stays in the last month of life, and hospice stay of ≥ 7 days. Outcomes were measured for each quartile of practice-level inpatient intensity. We fit multivariable logistic regression models to calculate adjusted odds ratios (ORs) for each outcome for each quartile of inpatient intensity.

RESULTS

Total 30-day readmissions were 22.8% and 31.9% (OR, 1.45; 95% CI, 1.39 to 1.50) for patients in practices with the lowest versus highest quartiles of inpatient intensity, respectively; unplanned readmissions were 19.8% and 27.1% (OR, 1.36; 95% CI, 1.31 to 1.41), respectively. The proportion of admissions that occurred on weekends was similar across quartiles. Patients of practices in the highest quartiles of inpatient intensity had higher rates of death in an ICU stay in the last month of life (25.5% versus 18.0%; OR, 1.33; 95% CI, 1.19 to 1.49) and a lower rate of hospice stay of at least 7 days (50.9% to 42.5%; OR, 0.79; 95% CI, 0.74 to 0.86).

CONCLUSION

Medical oncology practices that seek to reduce hospitalizations should consider focusing initially on processes related to end-of-life care and care transitions.

Trends in hospital-physician integration in medical oncology

OBJECTIVES

Hospitals have rapidly acquired medical oncology practices in recent years. Experts disagree as to whether these trends are related to oncology-specific market factors or reflect a general trend of hospital-physician integration. The objective of this study was to compare the prevalence, geographic variation, and trends in physicians billing from hospital outpatient departments in medical oncology with other specialties.

STUDY DESIGN

Retrospective analysis of Medicare claims data for 2012 and 2013.

METHODS

We calculated the proportion of physicians and practitioners in the 15 highest-volume specialties who billed the majority of evaluation and management visits from hospital outpatient departments in each year, nationally and by state.

RESULTS

We included 338,998 and 352,321 providers in 2012 and 2013, respectively, of whom 9715 and 9969 were medical oncologists. Among the 15 specialties examined, medical oncology had the highest proportion of hospital outpatient department billing in 2012 and 2013 (35.0% and 38.3%, respectively). Medical oncology also experienced the greatest absolute change (3.3%) between the years, followed by thoracic surgery (2.4%) and cardiology (2.0%). There was marked state-level variation, with the proportion of medical oncologists based in hospital outpatient departments ranging from 0% in Nevada to 100% in Idaho.

CONCLUSIONS

Hospital-physician integration has been more pronounced in medical oncology than in other high-volume specialties and is increasing at a faster rate. Policy makers should take these findings into consideration, particularly with respect to recent proposals that may continue to fuel these trends.

Variation in Specialty Outpatient Care Patterns in the Medicare Population

BACKGROUND

Multiple payment reform efforts are under way to improve the value of care delivered to Medicare beneficiaries, yet few directly address the interface between primary and specialty care.

OBJECTIVE

To describe regional variation in outpatient visits for individual specialties and the association between specialty physician-specific payments and patient-reported satisfaction with care and health status.

DESIGN

Retrospective cross-sectional study.

PATIENTS

A 20 % random sample of Medicare fee-for-service beneficiaries in 2012.

MAIN MEASURES

Regions were grouped into quartiles of specialist index, defined as the observed/expected regional likelihood of having an outpatient visit to a specialist, for ten common specialties, adjusting for age, sex, and race. Outcomes were per capita specialty-specific physician payments and Medicare Current Beneficiary Survey responses.

KEY RESULTS

The proportion of beneficiaries seeing a specialist varied the most for endocrinology and gastroenterology (3.7- and 3.9-fold difference between the highest and lowest quartiles, respectively) and least for orthopedics and urology (1.5- and 1.7-fold difference, respectively). Multiple analyses suggested that this variation was not explained by prevalence of disease. Average specialty-specific payments were strongly associated with the likelihood of visiting a specialist. Differences in per capita payments from lowest (Q1) to highest quartiles (Q4) were greatest for cardiology ($89, $135, $172, $251) and dermatology ($46, $64, $82, $124). Satisfaction with overall care (median [interquartile range] across specialties: Q1, 93.3 % [92.6-93.7 %]; Q4, 93.1 % [92.9-93.2 %]) and self-reported health status (Q1, 37.1 % [36.9-37.7 %]; Q4, 38.2 % [37.2-38.4 %]) was similar across quartiles. Satisfaction with access to specialty care was consistently lower in the lowest quartile of specialty index (Q1, 89.7 % [89.2-91.1 %]; Q4, 94.5 % [94.4-94.8 %]).

CONCLUSIONS

Substantial regional variability in outpatient specialist visits is associated with greater payments with limited benefits in terms of patient-reported satisfaction with care or reported health status. Reducing outpatient physician visits may represent an important opportunity to improve the efficiency of care.

Association of high rates of practice-level inpatient-intensity with end-of-life outcomes, readmission rates, and weekend hospitalizations among Medicare patients with cancer

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Background: Substantial practice-level variation exists in use of acute hospital care for patients receiving anti-cancer therapy. The aim of this study was to determine whether patient outcomes were associated with greater inpatient-intensity at the treating practices. Methods: Retrospective analysis of 397,646 Medicare beneficiaries receiving anti-cancer therapy in 2012. Each beneficiary was associated with a practice and practices were ranked based on average payments for inpatient admissions (inpatient intensity). Outcomes included 30-day readmission, weekend admissions, intensive-care unit (ICU) stays in the last month of life, and hospice stay of at least 7 days. Outcomes were measured for each quartile of practice inpatient-intensity. We fit multivariable logistic regression models to calculate adjusted odds ratios for each outcome for each quartile of inpatient-intensity. Results: Total and unplanned 30-day readmissions increased from 22.8% to 31.9% (adjusted odds ratio and 95% confidence interval: 1.45 [1.39-1.50]) and 19.8% to 27.1% (1.36 [1.31-1.41]), respectively, for patients in practices in the lowest and highest quartiles of inpatient-intensity. The proportion of admissions occurring on the weekend was similar across quartiles. The proportion of decedents with an ICU stay in the last month of life increased from 18.0% to 25.5% (1.33, 1.19–1.49) while the proportion with a hospice stay of > = 7 days decreased from 50.9% to 42.5% (0.79, 0.74–0.86) between those in practices in the lowest and highest quartiles of inpatient intensity. Conclusions: Participants in oncology practice delivery reform may find significant opportunity to improve quality and reduce costs by initially focusing on processes related to improving end-of-life care and reducing readmissions.

Practice-Level Variation in Outpatient Cardiac Care and Association With Outcomes

BACKGROUND

Utilization of cardiac services varies across regions and hospitals, yet little is known regarding variation in the intensity of outpatient cardiac care across cardiology physician practices or the association with clinical endpoints, an area of potential importance to promote efficient care.

METHODS AND RESULTS

We included 7 160 732 Medicare beneficiaries who received services from 5635 cardiology practices in 2012. Beneficiaries were assigned to practices providing the plurality of office visits, and practices were ranked and assigned to quartiles using the ratio of observed to predicted annual payments per beneficiary for common cardiac services (outpatient intensity index). The median (interquartile range) outpatient intensity index was 1.00 (0.81-1.24). Mean payments for beneficiaries attributed to practices in the highest (Q4) and lowest (Q1) quartile of outpatient intensity were: all cardiac payments (Q4 $1272 vs Q1 $581; ratio, 2.2); cardiac catheterization (Q4 $215 vs Q1 $64; ratio, 3.4); myocardial perfusion imaging (Q4 $253 vs Q1 $83; ratio, 3.0); and electrophysiology device procedures (Q4 $353 vs Q1 $142; ratio, 2.5). The adjusted odds ratios (95% CI) for 1 incremental quartile of outpatient intensity for each outcome was: cardiac surgical/procedural hospitalization (1.09 [1.09, 1.10]); cardiac medical hospitalization (1.00 [0.99, 1.00]); noncardiac hospitalization (0.99 [0.99, 0.99]); and death at 1 year (1.00 [0.99, 1.00]).

CONCLUSION

Substantial variation in the intensity of outpatient care exists at the cardiology practice level, and higher intensity is not associated with reduced mortality or hospitalizations. Outpatient cardiac care is a potentially important target for efforts to improve efficiency in the Medicare population.

Patterns of care for clinically distinct segments of high cost Medicare beneficiaries

BACKGROUND

Efforts to improve the efficiency of care for the Medicare population commonly target high cost beneficiaries. We describe and evaluate a novel management approach, population segmentation, for identifying and managing high cost beneficiaries.

METHODS

A retrospective cross-sectional analysis of 6,919,439 Medicare fee-for-service beneficiaries in 2012. We defined and characterized eight distinct clinical population segments, and assessed heterogeneity in managing practitioners.

RESULTS

The eight segments comprised 9.8% of the population and 47.6% of annual Medicare payments. The eight segments included 61% and 69% of the population in the top decile and top 5% of annual Medicare payments. The positive-predictive values within each segment for meeting thresholds of Medicare payments ranged from 72% to 100%, 30% to 83%, and 14% to 56% for the upper quartile, upper decile, and upper 5% of Medicare payments respectively. Sensitivity and positive-predictive values were substantially improved over predictive algorithms based on historical utilization patterns and comorbidities. The mean [95% confidence interval] number of unique practitioners and practices delivering E&M services ranged from 1.82 [1.79-1.84] to 6.94 [6.91-6.98] and 1.48 [1.46-1.50] to 4.98 [4.95-5.00] respectively. The percentage of cognitive services delivered by primary care practitioners ranged from 23.8% to 67.9% across segments, with significant variability among specialty types.

CONCLUSIONS

Most high cost Medicare beneficiaries can be identified based on a single clinical reason and are managed by different practitioners.

IMPLICATIONS

Population segmentation holds potential to improve efficiency in the Medicare population by identifying opportunities to improve care for specific populations and managing clinicians, and forecasting and evaluating the impact of specific interventions.

Oncology Care Model: Short- and Long-Term Considerations in the Context of Broader Payment Reform

The authors discuss key factors to consider that may influence decisions to participate in the Oncology Care Model, by presenting comparable payment reform efforts outside of oncology.

Keeping our patients' secrets

Protecting the privacy of the patient's medical record is a central issue in current discussions about a patient bill of rights, and controversy over a proposed "unique health identifier" has raised the decibel level of these discussions. At the heart of the debate is how best to resolve the inherent conflict between the individual's right to privacy and the need for access to patients' health information for reasons of public health, research, and health care management.

Mortality of patients transferred to a tertiary care hospital

BACKGROUND

Seriously ill patients are often transferred from community hospitals to tertiary care hospitals.

OBJECTIVES

To review the numbers, sources, and outcomes of patients transferred to the Cleveland Clinic Hospital from 1989 through 1992.

METHODS

Retrospective analysis.

RESULTS

Compared with the Cleveland Clinic's overall hospital mortality rate of 3.09% (3760 of 121,014 patients) during this period, the mortality rate among transferred patients was 8.26% (1092 of 13,226 patients). Although transferred patients accounted for only 10.9% of the total admissions, they represented 29.0% of the deaths. Transfers from other hospitals in the Cleveland Health Quality Choice (HQC) program, a community-wide quality-assessment project, increased 40.2% in 1992 (during the initial data collection period for the HQC program), while those from non-HQC hospitals increased only 0.9%.

CONCLUSIONS

Patients transferred to a tertiary care hospital from other acute care hospitals have a 2.7-fold greater chance of dying in the hospital than nontransferred patients. Public scrutiny of quality may increase the likelihood of transfer of seriously ill patients to tertiary care centers.

Quality of life in multiple sclerosis. Comparison with inflammatory bowel disease and rheumatoid arthritis

Multiple sclerosis (MS) and other chronic illnesses can drastically decrease quality of life (QOL), but there has been little systematic study of QOL in patients with chronic medical diseases. We analyzed QOL in 68 patients with MS, 164 patients with inflammatory bowel disease, and 75 patients with rheumatoid arthritis. The previously validated test instrument was a standardized interview consisting of 41 questions clustered in four subscales: functional and economic scale, social and recreational scale, affect and life in general scale, and medical problems scale. Patients were included in the study if they had a definite medical diagnosis and disease duration of 10 years or longer. In the patients with MS, Kurtzke's Expanded Disability Status Scale correlated strongly only with the medical problems score. Of Kurtzke's Functional System Scales, only the visual Functional System Scores was correlated with total QOL and subscale scores, suggesting that vision is strongly related to QOL. Duration of MS was unrelated to QOL scores. There were significant differences between patients with MS, inflammatory bowel disease, and rheumatoid arthritis on the subscale and total QOL scores. Results suggested that QOL was best in the inflammatory bowel disease group and worst in the MS group. Numerous statistically significant differences on individual questions were evident, suggesting that unique clinical profiles differentially characterize these diseases. Assessments of QOL are a meaningful addition to impairment scales, such as Kurtzke's Expanded Disability Status Scale. Furthermore, QOL scores may meaningfully measure the impact of a chronic medical disease, such as MS, compare the impacts of different diseases, and assess the effects of therapeutic intervention.

Serological detection of disease activity in SLE

Laboratory tests are commonly used to aid in monitoring disease activity in patients with systemic lupus erythematosus. Typically, tests for antinative DNA, complement, acute phase reactants, and sometimes circulating immune complexes are used for this purpose. More recently, tests for complement activation products and immunocyte activation have been suggested. We measured antinative DNA, C4, Westergren sedimentation rate, iC3b, Bb, and sIL-2R levels in a group of 100 patients with SLE evaluated clinically for activity by a modified version of the Systemic Lupus Activity Measure (SLAM); iC3b and Bb were studied in 71 of the patients and sIL-2R in 52. We found that sIL-2R and sedimentation rate correlated best with SLAM, anti-DNA was intermediate, and C4, iC3b, and Bb correlated the least. None of the tests predicted severity of disease, but sIL-2R was highest in patients with active renal disease.

A consumer guide for marketing medical services: one institution's experience

This paper describes the Cleveland Clinic Foundation's experience with the development and implementation of a 20-page quality indicator consumer guide for patients with or at risk of developing coronary artery disease. The guide, which provides six "quality indicators," was designed to enable patients to evaluate and compare quality-related information when choosing a provider. Design elements for the guide included a user-friendly format to offset the amount of information consumers are asked to absorb. Data on inquiries showed that the majority were women (53%) and adults under the age of 65 years (57%). Although the media criticized the guide as a marketing tool, it represents an effort to educate consumers about the importance of research when choosing a provider.

Serum C3 levels are diagnostically more sensitive and specific for systemic lupus erythematosus activity than are serum C4 levels. The Lupus Nephritis Collaborative Study Group

To determine whether serum C3 or C4 is more likely to be normal during systemic lupus erythematosus (SLE) remission and abnormal during SLE relapse we studied twelve SLE patients who presented with severe nephritis. The patients were followed long term (12 to 77 months) through multiple relapses (N = 41) and remissions (N = 13) defined by protocol. A total of 471 serum samples were obtained at defined intervals during these relapses and remissions and were analyzed for C3 and C4 levels by two different methods: nephelometry (N) and radial immunodiffusion (R). During SLE remission (defined by protocol and without reference to serum complement levels), C3 measured by N-assay (C3N) and by R-assay (C3R) tended to be normal (specificity of 93% and 71%, respectively). By contrast, C4 measured by N-assay (C4N) and by R-assay (C4R) showed no such tendency (specificity of 50% for both C4N and C4R). During SLE relapse (defined by protocol and without reference to serum complement levels), C3N and C3R were more likely to be abnormal (sensitivity 95% and 85%, respectively) compared with C4N and C4R (sensitivity 56% and 54%, respectively, P less than 0.001 compared with corresponding values for the C3 assay). Analysis by receiver-operator characteristic (ROC) curves demonstrated that the reduced diagnostic sensitivity of C4 versus C3 is not explained by use of an inappropriate lower limits of normal (LLN) for C4.(ABSTRACT TRUNCATED AT 250 WORDS)

Methotrexate for systemic lupus erythematosus: a retrospective analysis of 17 unselected cases

We report a retrospective study of 17 patients with systemic lupus erythematosus who were treated with oral methotrexate given as a mean weekly dose of 8.47 +/- 1.72 mg. Methotrexate treatment resulted in symptomatic improvement in 57% of patients and allowed the reduction of the mean daily dose of prednisone from 16.66 mg initially to 8.99 mg at one year follow-up. Twelve of 17 patients (70.6%) experienced at least one episode of toxicity. Factors which might be associated with toxicity are analyzed. Because of its potential as a corticosteroid-sparing agent, controlled studies of methotrexate for the treatment of systemic lupus erythematosus are indicated.

Therapy for rheumatoid arthritis: combinations of disease-modifying drugs and new paradigms of treatment

The last 10 years have witnessed a change in the way rheumatologists view rheumatoid arthritis (RA). It is no longer considered a slowly progressive disease limited to the joints, but rather an aggressive systemic disease that results in clinically significant morbidity early in its course and can contribute to excess mortality. Heightened awareness of the health impact of RA has spurred a search for effective therapy to be applied early in the course of disease for patients with moderate to severe RA. Combinations of disease-modifying antirheumatic drugs (DMARD) have become an increasingly popular alternative to sequential monotherapy. In this report, we review published series of patients with RA who have been treated with combinations of DMARDs, sometimes including chemotherapeutic agents, with some critical comment. Published paradigms of treatment are also reviewed and a new strategy is presented. The "step-down bridge" strategy allows early treatment with at least four DMARDs, but may place some patients with mild disease at an inappropriately high risk of adverse effects. The "sawtooth" strategy gives little guidance as to which DMARD(s) should be chosen for initial treatment. We describe a "graduated-step" strategy that provides numerical grading to match disease severity and disease activity with appropriate initial therapy and that facilitates therapeutic decisions throughout the course of treatment.

Folate supplementation in methotrexate-treated rheumatoid arthritis patients

Two hundred rheumatoid arthritis (RA) patients taking low dose methotrexate (MTX) were evaluated for adverse effects. During a mean follow up of 41.5 months, the mean cell volume (MCV) was elevated at some time during the course of treatment in 42 patients. The MCV was normal in the remaining 158 patients. One hundred ninety-eight patients were treated simultaneously with oral folic acid. With the exception of heartburn, which was seen more often in the high MCV group, there was no difference in the frequency of adverse effects attributable to MTX between groups. Severity of side effects and the frequency of MTX dose reduction and MTX discontinuation due to toxicity were also similar between groups. This analysis suggests that elevation of MCV in RA patients treated simultaneously with MTX and folate does not predict MTX toxicity. The authors also discuss the mechanism of action of MTX with regard to folate metabolism.

Local infectious complications following large joint replacement in rheumatoid arthritis patients treated with methotrexate versus those not treated with methotrexate

We performed a 10-year retrospective analysis of the frequency of local postoperative infectious complications in methotrexate (MTX)-treated rheumatoid arthritis patients who underwent total joint arthroplasty. Sixty patients, who had a total of 92 joint arthroplasties, were receiving MTX. A comparison group of 61 patients with a combined total of 110 total joint arthroplasties were not receiving MTX. The 2 groups were compared for the occurrence of local postoperative infectious complications and poor wound healing. Eight patients in the MTX group experienced a total of 8 complications (8.7% of procedures). In comparison, 5 patients in the non-MTX group experienced a total of 6 complications (5.5% of procedures), a difference that was not statistically significant (chi 2 = 0.816, P = 0.366). Statistical analysis of many other variables revealed none that could be identified as risk factors for postoperative complications. These results suggest that treatment in the perioperative period with weekly low-dose pulse MTX does not increase the risk of local postoperative infectious complications or poor wound healing in rheumatoid arthritis patients who undergo total joint arthroplasty.

Outcome of first-trimester exposure to low-dose methotrexate in eight patients with rheumatic disease

PURPOSE

Methotrexate (MTX), when used to treat malignancy or psoriasis, has been implicated in anecdotal reports as a teratogen or abortifacient in the first trimester of pregnancy. We are unaware of any previous reports that describe the course of gestation and the effect on subsequent offspring in patients treated with low-dose oral MTX for rheumatoid arthritis, and therefore present our experience.

PATIENTS AND METHODS

We report on eight women experiencing 10 pregnancies. Mean number of weeks of gestation while taking MTX was 7.5 (range 2 to 20 weeks). Outcome of pregnancies included five full-term babies (FTB), three spontaneous abortions (SAB), and two elective abortions.

RESULTS

There were no significant differences in either the FTB or SAB group when considering risk factors including smoking, alcohol, concomitant medications, and age. One of three in the SAB group had recurrent abortions prior to MTX therapy. All five of the FTB group had uncomplicated pregnancies and deliveries. All offspring were of normal height and weight at birth with no physical abnormalities. All children reached growth, development, and intellectual stages normally, and their present mean age is 11.5 years. No observed learning disabilities or medical abnormalities have occurred in any of these children.

CONCLUSION

In this uncontrolled study we failed to demonstrate tertogenicity of MTX. However, the possibility of abortion due to MTX use remains.

Response of immunoregulatory lymphocyte subsets to methotrexate in rheumatoid arthritis

In an attempt to define the immunoregulatory mechanisms operating in rheumatoid arthritis, the authors examined peripheral blood functional lymphocyte subsets in 15 patients with active rheumatoid arthritis who were not receiving remittive therapy, as well as 33 healthy controls. The percentage and absolute numbers of total T cells (CD3), T-helper/inducer cells (CD4), and T-suppressor/cytotoxic cells (CD8) did not differ among the groups, nor did the CD4:CD8 ratio or the numbers of T cells coexpressing CD4 and the activation markers Ia or IL-2R. However, rheumatoid arthritis patients did have reduced percentages and numbers of CD4+ cells coexpressing the 2H4 antigen (CD45R-naive T cells) (P less than .0003) and CD8+ cells coexpressing the Leu-15 (CD11b) marker (suppressor/effectors) (P less than .0005). Twelve patients then received oral methotrexate, 7.5 mg weekly. Most showed clinical improvement by 4 weeks and all did by 8 weeks. Although changes in the T-cell subsets were not statistically significant, several tended toward normalization. These findings may help explain the immunoregulatory defect in rheumatoid arthritis and the effectiveness of methotrexate in modifying disease activity.

Effectiveness of testing for anti-DNA and the complement components iC3b, Bb, and C4 in the assessment of activity of systemic lupus erythematosus

Seventy-one patients with systemic lupus erythematosus (SLE), seen in an outpatient setting for follow-up evaluation during a 3-mo period, were tested (in addition to routine lupus monitoring studies) with enzyme immunoassays (EIAs) for anti-DNA, iC3b, and factor Bb to determine the relationship of these test results to disease activity. SLE activity was scored by four previously reported scoring systems, and six patients were identified as active by all four systems. We found that the EIA for anti-DNA was the best indicator of disease activity and that iC3b and Bb were not informative for this purpose in this group of patients. Mean iC3b levels were higher in a subset of seven patients with past biopsy evidence of severe (WHO class IV) glomerulonephritis than in the rest of the study population, even though none of these patients had active disease at the time of this study.

Anticardiolipin antibodies in systemic lupus erythematosus

Forty-seven patients with systemic lupus erythematosus were studied to determine the presence of IgM and IgG anticardiolipin antibodies and their association with clinical syndromes. Eleven (23.4%) of the patients had IgG anticardiolipin antibodies; four of these also had IgM anticardiolipin antibodies. The cardiolipin-positive group had significantly lower platelet counts, but no increased history of thrombosis was observed. The anticardiolipin activity of seven of the 11 sera could be decreased by preincubation with DNA, providing confirmatory evidence that anticardiolipin activity actually resides in some populations of anti-DNA.