Process of care and outcomes for elderly patients hospitalized with peptic ulcer disease: results from a quality improvement project.

CONTEXT: Since publication in 1994 of guidelines for management of peptic ulcer disease (PUD), trends in physician practice and outcomes related to guideline application have not been evaluated. OBJECTIVES: To describe changes in process of care that occurred in a quality improvement program for patients hospitalized with PUD and to evaluate associations between in-hospital treatment of PUD and 1-year rehospitalization for PUD and mortality in a subset of these patients. DESIGN, SETTING, AND PATIENTS: Cohort study of 4292 sequential Medicare beneficiaries hospitalized at acute care hospitals with a principal diagnosis of PUD in 5 states (Colorado, Georgia, Connecticut, Oklahoma, and Virginia) in 1995 (baseline) and 1997 (remeasurement); outcomes were evaluated for 752 patients in Colorado. MAIN OUTCOME MEASURES: Changes in rates of screening for Helicobacter pylori infection, treatment for H pylori infection, screening for nonsteroidal anti-inflammatory drug (NSAID) use, counseling about NSAID use; outcomes included rehospitalization for PUD and all-cause mortality within 1 year of discharge in Colorado. RESULTS: Screening for H pylori infection increased significantly (12%-19% increase; P<.001) in each of the 5 states. Treatment of H pylori infection increased in each state and was significantly increased for the entire group of hospitalizations examined (8% increase overall; P =.001). Despite increased screening, detection of H pylori infection was less frequent than expected in every state, (13%-24%) and did not increase in any state. Screening for and counseling about NSAIDs did not significantly increase overall or in any state. In the Colorado cohort, the proportion of patients rehospitalized was unchanged in 1995 (8.9%) and 1997 (6.8%), and 124 patients (16%) in the combined 1995 and 1997 cohorts died within 1 year. Treatment for H pylori was not associated with a reduction in rehospitalization within 1 year (adjusted odds ratio [OR], 1.24; 95% confidence interval [CI], 0.65-2.36) or with a reduction in mortality (adjusted OR, 1.08; 95% CI, 0.68-1.71). Counseling about NSAID use was associated with a decrease in risk of 1-year rehospitalization for PUD (adjusted OR, 0.47; 95% CI, 0.22-0.99) and risk of all-cause mortality (adjusted OR, 0.44; 95% CI, 0.26-0.75). CONCLUSIONS: This quality improvement program for elderly patients with PUD resulted in increased screening for H pylori and increased treatment of H pylori infection but no change in counseling about NSAID use. However, with the low prevalence of H pylori detected, treatment of H pylori infection was not associated with a reduction in repeat hospitalization for PUD or subsequent mortality, whereas counseling about the risks of using NSAIDs was associated with a reduction in the risk of both outcomes.

The case for comprehensive quality indicator reliability assessment.

To demonstrate the importance of evaluating overall quality indicator reliability, in addition to component or variable level reliability, a comparison of interrater agreement on four chart-abstracted pneumonia-related processes of care was conducted. The hospital medical records of 356 Medicare patients' recent discharges for pneumonia were independently abstracted by different abstractors. Kappa, prevalence and bias-adjusted kappa, P(pos), P(neg), and the Bias Index were used to assess reliability of composite quality indicators and their components. The adjusted kappas for the data elements used to determine eligibility to receive as well as to derive the pneumonia-related processes of care ranged from 0.68 to 1.0. The adjusted kappa associated with overall eligibility to receive the pneumonia-related processes of care was 0.63. The kappa statistics for determining if processes of care were provided ranged from 0.56 to 0.83 and increased to 0.65 and 0.85 upon adjustment for the prevalence effect. Kappas for the composite quality indicators were lower, but improved with adjustment for the prevalence effect. The composite quality indicator with the highest adjusted kappa value was oxygenation assessment (0.93); the composite quality indicator with the lowest adjusted kappa value was antibiotic administration within 8 hours of hospital arrival (0.74). This study establishes the reliability of pneumonia indicators and underscores the need for reliability assessment at the quality indicator level, as well as at the component level.

Screening mammography: Is it suitably targeted to older women who are most likely to benefit?

OBJECTIVES: To determine whether screening mammography is suitably targeted to older women who are most likely to benefit. DESIGN: Prospective cohort study. SETTING: New Haven County, Connecticut. PARTICIPANTS: Eight hundred forty-four community-dwelling older women were interviewed as part of the 1990 New Haven Established Populations for the Epidemiologic Study of the Elderly (EPESE) program. MEASUREMENTS: Mammography use was ascertained from Medicare Part B claims data. A four-level prognostic mortality index was developed using items previously shown to be predictive of mortality. Mammography use and all-cause mortality were evaluated by prognostic stage over a 5-year period, January 1, 1991, to December 31, 1995. RESULTS: Five-year mortality increased steadily with each prognostic stage (12% to 68%, P = .001), whereas the 5-year mammography use rate declined (48% to 7%, P = .001). Over half the women (53%) in the most favorable prognostic group did not receive a mammogram, whereas 13% in the two worst prognostic groups received at least one mammogram. CONCLUSION: Screening mammography may be underutilized among older women who are the most likely to benefit and overutilized among those who are unlikely to benefit.

Quality of care for hospitalized medicare patients at risk for pressure ulcers.

BACKGROUND: No state peer review organization has attempted to identify processes of care related to pressure ulcer prediction and prevention in US hospitals. OBJECTIVE: To profile and evaluate the processes of care for Medicare patients hospitalized at risk for pressure ulcer development by means of the Medicare Quality Indicator System pressure ulcer prediction and prevention module. METHODS: A multicenter retrospective cohort study with medical record abstraction was used to obtain a total of 2425 patients aged 65 years and older discharged from acute care hospitals after treatment for pneumonia, cerebrovascular disease, or congestive heart failure. Six processes of care for prevention of pressure ulcers were evaluated: use of daily skin assessment; use of a pressure-reducing device; documentation of being at risk; repositioning for a minimum of 2 hours; nutritional consultation initiated for patients with nutritional risk factors; and staging of pressure ulcer. The associations between processes of care and incidence of pressure ulcer were determined with Kaplan-Meier survival analyses. RESULTS: National estimates of compliance with process of care were as follows: use of daily skin assessment, 94%; use of pressure-reducing device, 7.5%; documentation of being at risk, 22.6%; repositioning for a minimum of 2 hours, 66.2%; nutritional consultation, 34.3%; stage 1 pressure ulcer staged, 20.2%; and stage 2 or greater ulcer staged, 30.9%. CONCLUSION: These results suggest that US hospitals and physicians have numerous opportunities to improve care related to pressure ulcer prediction and prevention.

Process of care performance, patient characteristics, and outcomes in elderly patients hospitalized with community-acquired or nursing home-acquired pneumonia.

STUDY OBJECTIVES: To compare process of care performance, patient characteristics, and outcomes in a contemporary cohort of elderly (> or = 65 years) patients hospitalized with community-acquired pneumonia (CAP) or with nursing home-acquired pneumonia (NHAP). DESIGN: State-wide retrospective cohort study. SETTING: Thirty-four acute-care hospitals in Connecticut. PATIENTS: Elderly Medicare patients hospitalized in 1995-1996 with CAP (1,131) or with NHAP (528). MEASUREMENTS: Antibiotic administration within 8 h of hospital arrival, blood culture collection within 24 h of hospital arrival, oxygenation assessment within 24 h of hospital arrival, demographic and clinical characteristics, in-hospital complications, mortality, and length of stay. RESULTS: Process of care performance rates for patients with CAP and NHAP were equivalent for antibiotic administration within 8 h of hospital arrival (76.8% vs 76.3%, respectively; p = 0.82), blood culture collection within 24 h of hospital arrival (78.1% vs 81.1%, respectively; p = 0.31), and oxygenation assessment within 24 h of hospital arrival (94.7% vs 95. 3%, respectively; p = 0.70). Patients with CAP were younger than those with NHAP (median age, 80 vs 84 years, respectively; p < 0. 001), had less cerebrovascular disease (16.8% vs 34.7%, respectively; p < or = 0.001), and lower mortality risk scores at hospital presentation (median, 100 vs 137, respectively; p < or = 0. 001) than patients with NHAP. The median length of stay was equivalent (7 days), but the in-hospital mortality rate was lower in patients with CAP than in patients with NHAP (8.0% vs 18.6%, respectively; p < or = 0.001). CONCLUSION: Initial hospital processes of care are performed at the same rate in patients hospitalized with CAP or NHAP. However, patients with CAP are younger, are less acutely and chronically ill, and have lower in-hospital mortality rates than patients with NHAP.

The effect of a multifaceted physician office-based intervention on older women's mammography use.

BACKGROUND: In response to identified low mammography use among older women in three geographic areas in Connecticut, a physician office-based mammography intervention was initiated under the Health Care Financing Administration's Health Care Quality Improvement Program. OBJECTIVE: To evaluate the intervention's impact on older women's mammography use. DESIGN: A quasi-experimental design comparing mammography rates for women in the intervention program with a randomly selected control sample. SETTING: Community-based physician offices. PATIENTS: Female Medicare beneficiaries aged 65 to 74 years seen by participating and control physicians for at least one primary care visit in 1995 (baseline) and 1996 (follow-up). In the baseline period, 1720 women in the intervention sample and 2761 women in the control sample were included in the study. INTERVENTION: The recruitment strategies included the use of physician opinion leaders and modified academic detailing. The multifaceted intervention incorporated patient education, physician reminders, and audit-with-feedback MEASUREMENTS: Biennial mammography rates. Patient adherence to physician mammography referral was evaluated in a restricted cohort of women selected from the intervention sample. RESULTS: The mammography rate for the intervention sample increased from 62.7% (baseline) to 73.1% (follow-up), (P<.001), whereas the control sample's rate remained essentially unchanged (68.3 to 69.5%), (P = .34). The intervention patients were 48% more likely than controls to experience an increase in biennial mammography use (OR = 1.48; 95% CI, 1.22-1.79) after adjustment for patient race and income and physician gender, specialty, and age. The proportion of women who adhered to their physicians' mammography referral was 70.6%. CONCLUSIONS: These data demonstrate the effectiveness of a multifaceted intervention program administered in the setting of community physician practices. The relatively low rate of patients' acceptance of their physicians' mammography recommendations has identified the need to address more effectively older women's concerns about mammography screening.

A prognostic rule for elderly patients admitted with community-acquired pneumonia.

PURPOSE: We sought to identify admission characteristics predicting mortality in elderly patients hospitalized with community-acquired pneumonia and to develop a prognostic staging system and discriminant rule. PATIENTS AND METHODS: We retrospectively analyzed data from 2,356 patients aged > or = 65 years admitted with community-acquired pneumonia. Multivariable analyses of a derivation cohort (n = 1,000) identified characteristics associated with hospital mortality. A staging system and discriminant rule based on these characteristics were tested in a validation cohort (n = 1,356). Our discriminant rule was compared with a rule formulated from a heterogeneous adult population with community-acquired pneumonia. RESULTS: Hospital mortality rates were 9% (derivation cohort) and 12% (validation cohort). We identified five independent predictors of mortality: age > or = 85 years [odds ratio 1.8 (95% confidence interval 1.1-3.1)], comorbid disease [odds ratio 4.1 (2.1-8.1)], impaired motor response [odds ratio 2.3 (1.4-3.7)], vital sign abnormality [odds ratio 3.4 (2.1-5.4)], and creatinine level > or = 1.5 mg/dL [odds ratio 2.5 (1.5-4.2)]. These variables stratified patients into four distinct stages with increasing mortality in the derivation cohort (Stage 1, 2%; Stage 2, 7%; Stage 3, 22%; Stage 4, 45%; P = 0.001) as well as in the validation cohort (Stage 1, 4%; Stage 2, 11%; Stage 3, 23%; Stage 4, 41%; P = 0.001). The discriminant rule developed from the derivation cohort had greater overall accuracy (77.1%) in the validation cohort than a rule formulated from a heterogeneous adult population (68.0%, P = 0.001). CONCLUSION: Elderly patients with community-acquired pneumonia have characteristics at admission that can predict mortality. Our staging system and discriminant rule improve prognostic stratification of these patients.

Warfarin use following ischemic stroke among Medicare patients with atrial fibrillation.

BACKGROUND: Elderly patients with ischemic stroke and atrial fibrillation are at especially increased risk for recurrent stroke. Warfarin sodium is highly effective in reducing this risk. OBJECTIVE: To determine the use of warfarin among a population sample of elderly patients with atrial fibrillation hospitalized for ischemic stroke. METHODS: The Connecticut Peer Review Organization conducted a chart review of Medicare patients, aged 65 years or older, hospitalized in 1994 with a diagnosis of atrial fibrillation. Patients with a principal diagnosis of acute myocardial infarction or another indication for anticoagulation were excluded. RESULTS: Among 635 patients (402 women; 585 white; 218 > or =85 years old; 147 with a new diagnosis of atrial fibrillation), 334 had stroke as a principal diagnosis. Among those discharged alive after a stroke, only 147 (53%) of 278 were prescribed warfarin at discharge. Furthermore, among 130 (47%) of 278 patients not prescribed warfarin at discharge, 81 (62%) of 130 were also not prescribed aspirin. Increased potential benefit (additional vascular risk factors) was not associated with a higher rate of warfarin use. Low risk for anticoagulation (lack of risk factors for bleeding) was associated with a slightly higher rate of warfarin use. Among those with an increased risk of stroke and a low risk for bleeding (ideal candidates), 124 (62%) of 278 were discharged on a regimen of warfarin. CONCLUSION: Anticoagulation of elderly stroke patients with atrial fibrillation, even among ideal candidates, is underused. The increased use of warfarin among these patients represents an excellent opportunity for reducing the risk of recurrent stroke in this high-risk population.

The impact of a physician intervention program on older women's mammography use.

The Mammography Optimum Referral Effort (MORE) is a physician office-based intervention program initiated by the Connecticut Peer Review Organization (CPRO) to increase mammography use among older women in Connecticut. Three locales in the state were targeted for the MORE intervention based on identified low mammography rates in women aged 65 years and older. Thirty-seven physicians participated from March 1, 1996, to August 31, 1996. Annual mammography rates were derived by merging Medicare Part B mammography claims with a database from the Connecticut Tumor Registry. This strategy allowed us to exclude women with a prior history of breast cancer from the analysis, in order to estimate screening rates. The MORE intervention was associated with an absolute increase of 5.9%, which represents a relative increase of 15.4%, in annual mammography use. Our findings suggest that a multifaceted physician intervention is capable of increasing mammography use among older women.

Quality of care, process, and outcomes in elderly patients with pneumonia.

CONTEXT: Pneumonia is a frequent cause of hospitalization and death among elderly patients, but the relationships between processes of care for pneumonia and outcomes are uncertain, making quality improvement a challenge. OBJECTIVES: To assess quality of care for Medicare patients hospitalized with pneumonia and to determine whether process of care performance is associated with lower 30-day mortality. DESIGN: Multicenter retrospective cohort study with medical record review. SETTING: A total of 3555 acute care hospitals throughout the United States. PATIENTS: A total of 14069 patients at least 65 years old hospitalized with pneumonia. MAIN OUTCOME MEASURES: Four processes of care: time from hospital arrival to initial antibiotic administration; blood culture collection before initial hospital antibiotics; blood culture collection within 24 hours of hospital arrival; and oxygenation assessment within 24 hours of hospital arrival. Associations between processes of care and 30-day mortality were determined with logistic regression analysis. RESULTS: National estimates of process-of-care performance were antibiotic administration within 8 hours of hospital arrival, 75.5% (95% confidence interval [CI], 73.1-77.9); blood cultures before antibiotics, 57.3% (95% CI, 54.5-60.1); initial blood culture collection, 68.7% (95% CI, 66.2-71.2); and initial oxygenation assessment, 89.3% (95% CI, 87.5-90.9). Lower 30-day mortality was associated with antibiotic administration within 8 hours of hospital arrival (odds ratio [OR], 0.85; 95% CI, 0.75-0.96) and blood culture collection within 24 hours of arrival (OR, 0.90; 95% CI, 0.81-1.00). State and territory performance estimates varied from 49.0% to 89.7% for antibiotics given within 8 hours and from 45.6% to 82.6% for blood cultures drawn within 24 hours. CONCLUSIONS: Administering antibiotics within 8 hours of hospital arrival and collecting blood cultures within 24 hours were associated with improved survival. The fact that states varied widely in the performance of these measures suggests that opportunities exist to improve hospital care of elderly patients with pneumonia.

Warfarin use among patients with atrial fibrillation.

BACKGROUND AND PURPOSE: Warfarin reduces the rate of stroke among patients with atrial fibrillation. We sought to determine warfarin use within a population sample of elderly patients with atrial fibrillation. METHODS: The Connecticut Peer Review Organization conducted a chart review of Medicare patients aged > or = 65 years with a history of atrial fibrillation before a hospitalization during the first 6 months of 1994. RESULTS: Among 488 patients (308 women; 457 white; 173 aged > or = 85 years), 38% (184/488) had a relative contraindication to anticoagulation (history of bleeding, dementia, alcohol use, falls, cancer, or the need for nonsteroidal anti-inflammatory drugs). Among the remaining patients (with known atrial fibrillation, but without a contraindication), only 38% (117/304) had been prescribed warfarin. Of those not prescribed warfarin, 63% (117/187) were also not taking aspirin. There were 272 patients with at least one additional vascular risk factor and no contraindication to anticoagulation. Among these patients at moderate to high risk for stroke, anticoagulation had been prescribed in 40% (109/272). Overal, among those not prescribed warfarin, 58% (95/163) were not taking aspirin. Patients admitted with a stroke were more likely to be significantly underanticoagulated (with international normalized ratio < 1.5) (43.5% versus 20.9% for those without stroke; P < .005). Anticoagulation was most effective for those with an international normalized ratio > or = 2.0. CONCLUSIONS: Warfarin anticoagulation with atrial fibrillation, even among "ideal" candidates, appears dramatically underutilized. In addition, among those prescribed warfarin, patients are often undertreated. Increased warfarin use among patients with atrial fibrillation represents an excellent opportunity for stroke prevention in the elderly.

Mammography underutilization among older women in Connecticut.

OBJECTIVES: The primary goals were to examine mammography use rates among older women in Connecticut and to determine if there was significant variation among different areas and racial groups in the state. The secondary goal was to examine what impact the initiation of Medicare reimbursement for mammography screening has had on mammography use. DESIGN: Statewide use rates were determined by retrospective Medicare Part B mammography claims analysis. Small area analysis methodology (SAA) was used to identify mammography rates for 23 hospital service areas (HSAs), representing all of the catchment areas for Connecticut's acute care hospitals. PARTICIPANTS: Female Medicare beneficiaries 65 years and older with Part B coverage residing in Connecticut during the study period. MEASUREMENTS: The main outcome (the use of at least one mammogram) was calculated for the calendar years 1991, 1992, and 1993. Mean annual use rates in 1993 were generated for the 23 HSAs and the different racial groups in Connecticut. To examine the effect that Medicare reimbursement for screening mammograms has had on mammography use, rates were calculated for women who met Medicare reimbursement criteria in 1991 through 1993. The rates in 1992 and 1993 were then compared with those in 1991, when the reimbursement program was first initiated. MAIN RESULTS: The mean statewide annual rates among women aged 65 years and older were 23.4% (1991), 24.5% (1992), and 24.9% (1993). The mammography use rates among black women 65 years and older were significantly lower than their white peers in 1991 (18.8% black vs 23.8% white, P < .001), 1992 (20.6% vs 24.7%, P < .001), and 1993 (22.0% vs 25.1%, P < .001). Significant variation was identified among hospital service areas (HSAs) within the state for each time interval studied. The use rates among women aged 65 years and older who were eligible for Medicare screening mammography reimbursement increased significantly from 14.6% in 1991, when Medicare reimbursement for screening mammograms was first initiated, to 18.9% in 1992 (P < .001). The rates in 1993 (17.4%) also increased from the baseline year 1991 (P < .001). However, the observed increases since 1991 have been limited in magnitude. CONCLUSIONS: Low mammography use persists among older women in Connecticut and, in particular, among older black women. The initiation of Medicare reimbursement for screening mammograms in 1991 has had some impact on mammography use although its effects are still limited. Through the use of small area analysis methodology, significant underutilization of mammography in localized areas of the state was identified. These findings have facilitated local outreach interventions. Additional research is needed to understand if health service barriers are contributing to the local variation in rates observed in this study.

Hypersensitivity reactions and specific antibodies in workers exposed to industrial enzymes at a biotechnology plant.

Thirty-six employees who produced industrial enzymes from selected strains of bacteria and fungi were evaluated by epicutaneous threshold testing and enzyme-linked immunosorbent assays (ELISA) for specific IgE and IgG antibodies. The workers complained of 'asthma- and flu-like' symptoms, which generally lessened away from work. The enzymes evaluated were: alpha-amylase (1,4-alpha-d-glucan glucanohydrolase) from Bacillus licheniformis (alpha ABl), B. subtilis formation 1 (alpha A1Bs) and B. subtilis formation 2 (alpha A2Bs); purified alpha-amylase from B. licheniformis (C alpha ABl) and A. oryzae (C alpha AAo); alkaline protease from B. licheniformis (APBl) and purified alkaline protease (CAPBl); amyloglucosidase (1,4-alpha-d-glucan glucohydrolase) from A. niger (AGAn) and purified amyloglucosidase (CAGAn). Statistically significant increases (P > 0.05) in the proportion of workers having positive skin tests to CAPBl, AGAn and CAGAn were found. Significantly elevated (P > 0.05) mean specific IgE results were observed for C alpha AAo CAGAn and AGAn, and elevated (P > 0.05) mean specific IgGs were observed for C alpha AAo, CAGAn, AGAn, alpha A1Bs, alpha AB1 and alpha A2Bs. These results indicate that occupational exposure to some industrial enzymes can cause immediate-onset cutaneous hypersensitivity reactions, pulmonary function deficits and significantly elevated specific antibody levels. Our results are equivocal as to whether work-related respiratory and cutaneous hypersensitivity reactions are antibody mediated, as there was no statistically significant association between these reactions and specific IgE or IgG levels.

Correlation between lipid-associated sialic acid and tumor burden in melanoma.

Recent studies have suggested that lipid-associated sialic acid (LSA) may be a useful tumor marker for monitoring patients with melanoma, but the relationship between LSA and tumor burden has not been previously studied. We therefore examined LSA levels in 240 patients of whom 169 had no clinical evidence of disease (NED) and 71 had metastatic disease. There was a statistically significant difference in LSA levels in patients with NED compared with metastatic disease as well as those with high tumor burden compared with low or intermediate tumor burden. There was no difference between the groups with low and intermediate tumor burden. An LSA level of 25 mg/dl provided a positive predictive value of 70% and a negative value of approximately 80%. Our data show that LSA levels correlate with tumor burden in patients with melanoma.

Neuron-specific enolase as a tumor marker in metastatic melanoma.

Neuron-specific enolase (NSE) has been shown by some investigators to be a useful tumor marker for melanoma, but the relationship between NSE and tumor burden has not been extensively studied. We therefore examined NSE levels in 240 patients of whom 169 had no clinical evidence of disease (NED) and 71 had metastatic disease. There was no statistically significant difference in NSE levels in patients with NED compared with metastatic disease as well as those with high tumor burden compared with low or intermediate tumor burden. In addition, the mean absolute values of NSE, despite a slight elevation with tumor burden, were within the normal range (< 20 ng/ml). Our data suggest that NSE levels measured by the method used in our study are of no benefit in melanoma.

The low prevalence of occupational asthma and antibody-dependent sensitization to diphenylmethane diisocyanate in a plant engineered for minimal exposure to diisocyanates.

BACKGROUND: Diisocyanate chemicals are leading causes of occupational asthma (OA). METHODS: We conducted a cross-sectional study of 243 workers exposed to diphenylmethane diisocyanate (MDI) in a urethane mold plant that had been designed to minimize MDI exposure (levels were maintained below 0.005 ppm and were continuously monitored). All participants were screened by questionnaire and tests for serum antibodies to MDI-human serum albumin (HSA). On the basis of questionnaire responses, diagnoses were derived that included OA; non-OA; work-related and non-work-related rhinitis; and lower respiratory irritant responses. Serial peak expiratory flow rate studies were performed for 2 weeks in 43 workers with and in 23 workers without lower respiratory symptoms. RESULTS: Results of serial peak expiratory flow rate studies were abnormal in 3 (33%) of 9 workers with OA, in 2 (50%) of 4 with non-OA, and in 2 (9%) of 23 case control subjects. A significant association was found between peak flow rate variability and a questionnaire asthma diagnosis (chi 2 p < 0.002). Physicians confirmed three cases of OA, one of which occurred in a control worker who was free of symptoms. In all three cases asthma symptoms remitted after the worker left the workplace. Serum specific IgE and IgG levels were elevated in 2 of 243 workers, one of whom was prick test positive to MDI-HSA and had had cutaneous anaphylaxis after MDI exposure. CONCLUSIONS: On the basis of these cases, specific work activities associated with exposure to MDI were identified and corrective measures were instituted. Strict control and monitoring of ambient MDI exposure was associated with a low prevalence of specific sensitization to MDI and a lower than expected prevalence of OA.

Angioneurotic edema with acquired C1- inhibitor deficiency and autoantibody to C1- inhibitor: response to plasmapheresis and cytotoxic therapy.

A patient with severe acquired angioneurotic edema had essentially no C1- inhibitor activity in his serum and nearly died of cardiopulmonary arrest during an acute episode of facial, oral, and pharyngeal edema. This patient had an antibody directed against C1- inhibitor and C1- inhibitor-anti-C1- inhibitor complexes in his serum. The antibody required a normal residue (Arg) in the reactive center of the inhibitor for its optimal interaction with the inhibitor. Plasmapheresis with 5% human serum albumin replacement relieved him of his antibody load and the edema; additional treatment with pulsed cyclophosphamide has provided a sustained remission. The 5% albumin solution that was used contained functional C1- inhibitor; other lots that were tested contained only traces or none. No underlying disease has yet been identified. During this acute episode of edema, the C1- inhibitor in the patient's plasma was a 92 kd component, and on recovery, a 105 kd component reappeared. C1- inhibitor isolated from the patient's plasma, which was obtained before pheresis, was mainly in lower molecular weight forms (56 kd and 45 kd). The antibody in the patient's serum appeared to render C1- inhibitor susceptible to proteolysis, for when purified antibody was added to normal serum, a cleaved form of C1- inhibitor was generated.