Matrix Matters: Assessment of Commutability among BK Virus Assays and Standards.

Quantitative testing of BK virus (BKPyV) nucleic acid has become the standard of care in transplant patients. While the relationship between interassay harmonization and commutability has been well characterized for other transplant-related viruses, it has been less well studied for BKPyV, particularly regarding differences in commutability between matrices. Here, interassay agreement was evaluated among six real-time nucleic acid amplification tests (NAATs) and one digital PCR (dPCR) BKPyV assay. Differences in the commutability of three quantitative standards was examined across all assays using a variety of statistical approaches. Panels, including 40 samples each of plasma and urine samples previously positive for BKPyV, together with one previously negative plasma sample and four previously negative urine samples, were tested using all assays, with each real-time NAAT utilizing its usual quantitative calibrators. Serial dilutions of WHO, National Institute for Standards and Technology (NIST), and commercially produced (Exact/Bio-Rad) reference materials were also run by each assay as unknowns. The agreement of the clinical sample values was assessed as a group and in a pairwise manner. The commutability was estimated using both relativistic and quantitative means. The quantitative agreement across assays in the urine samples was within a single log10 unit across all assays, while the results from the plasma samples varied by 2 to 3 log10 IU/mL. The commutability showed a similar disparity between the matrices. Recalibration using international standards diminished the resulting discrepancies in some but not all cases. Differences in the sample matrix can affect the commutability and interassay agreement of quantitative BKPyV assays. Differences in commutability between matrices may largely be due to factors other than those such as amplicon size, previously described as important in the case of cytomegalovirus. Continued efforts to standardize viral load measurements must address multiple sources of variability and account for differences in assay systems, quantitative standards, and sample matrices.

The utility of imputed matched sets. Analyzing probabilistically linked databases in a low information setting.

OBJECTIVE: To compare results from high probability matched sets versus imputed matched sets across differing levels of linkage information. METHODS: A series of linkages with varying amounts of available information were performed on two simulated datasets derived from multiyear motor vehicle crash (MVC) and hospital databases, where true matches were known. Distributions of high probability and imputed matched sets were compared against the true match population for occupant age, MVC county, and MVC hour. Regression models were fit to simulated log hospital charges and hospitalization status. RESULTS: High probability and imputed matched sets were not significantly different from occupant age, MVC county, and MVC hour in high information settings (p > 0.999). In low information settings, high probability matched sets were significantly different from occupant age and MVC county (p < 0.002), but imputed matched sets were not (p > 0.493). High information settings saw no significant differences in inference of simulated log hospital charges and hospitalization status between the two methods. High probability and imputed matched sets were significantly different from the outcomes in low information settings; however, imputed matched sets were more robust. CONCLUSIONS: The level of information available to a linkage is an important consideration. High probability matched sets are suitable for high to moderate information settings and for situations involving case-specific analysis. Conversely, imputed matched sets are preferable for low information settings when conducting population-based analyses.

Diagnosing autistic spectrum disorder in the age of austerity.

BACKGROUND: Diagnosing autistic spectrum disorder is a challenge, typically involving myriad professionals. In the current climate we explore how diagnosis is managed in the real world by professionals. METHODS: Using semi-structured interviews we thematically analyse data from psychiatrists, paediatricians and educational psychologists. RESULTS: While there is some consistency across and within these groups there are also a number of variances, and several important issues are highlighted. These include the problem of time and resources, the issue of location for diagnosis, the value of diagnostic tools and schedules, the need for supporting information, the difficulty of multi-agency working, the relevance of a physical examination and the eventual diagnostic label. CONCLUSIONS: In the current economic climate and considering changes in guidelines there is a need to evaluate current service provision and enhance services. However, attention needs to be paid to the practical and realistic application of the suggested guidance.

The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients.

BACKGROUND: Among trauma patients who survive to reach hospital, exsanguination is a common cause of death. A widely practicable treatment that reduces blood loss after trauma could prevent thousands of premature deaths each year. The CRASH-2 trial aimed to determine the effect of the early administration of tranexamic acid on death and transfusion requirement in bleeding trauma patients. In addition, the effort of tranexamic acid on the risk of vascular occlusive events was assessed. OBJECTIVE: Tranexamic acid (TXA) reduces bleeding in patients undergoing elective surgery. We assessed the effects and cost-effectiveness of the early administration of a short course of TXA on death, vascular occlusive events and the receipt of blood transfusion in trauma patients. DESIGN: Randomised placebo-controlled trial and economic evaluation. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial co-ordinating centre staff) were masked to treatment allocation. All analyses were by intention to treat. A Markov model was used to assess cost-effectiveness. The health outcome was the number of life-years (LYs) gained. Cost data were obtained from hospitals, the World Health Organization database and UK reference costs. Cost-effectiveness was measured in international dollars ($) per LY. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the results to model assumptions. SETTING: Two hundred and seventy-four hospitals in 40 countries. PARTICIPANTS: Adult trauma patients (n = 20,211) with, or at risk of, significant bleeding who were within 8 hours of injury. INTERVENTIONS: Tranexamic acid (loading dose 1 g over 10 minutes then infusion of 1 g over 8 hours) or matching placebo. MAIN OUTCOME MEASURES: The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury and other. RESULTS: Patients were allocated to TXA (n = 10,096) and to placebo (n = 10,115), of whom 10,060 and 10,067 patients, respectively, were analysed. All-cause mortality at 28 days was significantly reduced by TXA [1463 patients (14.5%) in the TXA group vs 1613 patients (16.0%) in the placebo group; relative risk (RR) 0.91; 95% confidence interval (CI) 0.85 to 0.97; p = 0.0035]. The risk of death due to bleeding was significantly reduced [489 patients (4.9%) died in the TXA group vs 574 patients (5.7%) in the placebo group; RR 0.85; 95% CI 0.76 to 0.96; p = 0.0077]. We recorded strong evidence that the effect of TXA on death due to bleeding varied according to the time from injury to treatment (test for interaction p < 0.0001). Early treatment (≤ 1 hour from injury) significantly reduced the risk of death due to bleeding [198 out of 3747 patients (5.3%) died in the TXA group vs 286 out of 3704 patients (7.7%) in the placebo group; RR 0.68; 95% CI 0.57 to 0.82; p < 0.0001]. Treatment given between 1 and 3 hours also reduced the risk of death due to bleeding [147 out of 3037 patients (4.8%) died in the TXA group vs 184 out of 2996 patients (6.1%) in the placebo group; RR 0.79; 95% CI 0.64 to 0.97; p = 0.03]. Treatment given after 3 hours seemed to increase the risk of death due to bleeding [144 out of 3272 patients (4.4%) died in the TXA group vs 103 out of 3362 patients (3.1%) in the placebo group; RR 1.44; 95% CI1.12 to 1.84; p = 0.004]. We recorded no evidence that the effect of TXA on death due to bleeding varied by systolic blood pressure, Glasgow Coma Scale score or type of injury. Administering TXA to bleeding trauma patients within 3 hours of injury saved an estimated 755 LYs per 1000 trauma patients in the UK. The cost of giving TXA to 1000 patients was estimated at $30,830. The incremental cost of giving TXA compared with not giving TXA was $48,002. The incremental cost per LY gained of administering TXA was $64. CONCLUSIONS: Early administration of TXA safely reduced the risk of death in bleeding trauma patients and is highly cost-effective. Treatment beyond 3 hours of injury is unlikely to be effective. Future work [the Clinical Randomisation of an Antifibrinolytic in Significant Head injury-3 (CRASH-3) trial] will evaluate the effectiveness and safety of TXA in the treatments of isolated traumatic brain injury (http://crash3.lshtm.ac.uk/). TRIAL REGISTRATION: Current Controlled Trials ISRCTN86750102, ClinicalTrials.gov NCT00375258 and South African Clinical Trial Register DOH-27-0607-1919. FUNDING: The project was funded by the Bupa Foundation, the J P Moulton Charitable Foundation and the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 10. See HTA programme website for further project information.

The World Trade Center attack. The paramedic response: an insider's view.

The World Trade Center attack and collapse is the first time an aircraft has been used as a weapon of mass effect. The scale and magnitude of this manmade disaster can only be compared with a natural catastrophe such as the Armenian earthquake of December 1988. The importance of an incident command system and the Simple Triage and Rapid Treatment, and the need for fixed Casualty Collection Points, is explained.

A self-assessment program for multidisciplinary mental health teams.

OBJECTIVE: The authors describe a self-assessment training program for multidisciplinary mental health teams that was developed in a public multihospital system, the process of implementing the training at a state psychiatric hospital, and a measurement instrument, the Scale for Leadership Assessment and Team Evaluation (SLATE), which they have used for self-assessment of multidisciplinary teams and which is currently being studied. They assessed whether changes in team self-assessments could be seen after the training program. METHODS: A total of 102 mental health professionals from 12 inpatient units representing the disciplines of psychiatry, psychology, nursing, social work, and occupational and activity therapy completed the SLATE before and after participation in a training program that consisted primarily of team self-assessment in the context of treatment planning sessions. The training program included structured feedback, didactics, consultation, and videotaping of sessions. Aggregate data were used to compare mean item scores for the SLATE overall and for its four subscales (team, psychiatrist, participation, and treatment plan) at baseline and after the training. RESULTS: Scores increased significantly for the overall SLATE and for all four subscales, indicating improved team functioning in the areas addressed. The increase in mean score was greatest for the subscale that assessed the leadership of the psychiatrist. CONCLUSIONS: Treatment planning sessions can be used successfully by multidisciplinary mental health teams to examine team functioning in various areas in a self-assessment model. Participation in a training program that included videotaping of sessions, consultation, and structured attention to team functioning was associated with improved ratings of team functioning.

A population-based assessment of pediatric all-terrain vehicle injuries.

OBJECTIVE: To describe the types of injuries sustained by children who ride all-terrain vehicles (ATVs), to estimate the hospital charges associated with these injuries, and to determine adherence to existing rules and regulations governing ATV use. METHODS: Analysis of statewide hospital admissions (1992-1996) and emergency department (ED) visits (1996) in Utah. All patients who were younger than 16 years and had an external cause of injury code for ATV use were included. RESULTS: In 1996, 268 ED visits by children involved an ATV. Boys were twice as commonly injured as girls (male:female ratio: 2.1:1), and skin and orthopedic injuries were most frequent. The median ED charge was $368, and ED charges for these patients totaled $138 000. From 1992 to 1996, 130 children were hospitalized as a result of injuries sustained during ATV use, with median charges of $4240 per admission. Male to female ratio was 2.7:1, and the average age was 11.2 +/- 3.6 years. Mean injury severity score was 8.0 +/- 6.0, and median length of stay was 2 days (range: 0-43 days). Orthopedic injuries were most frequent, but 25% (n = 32) of children sustained head or spinal cord injury. Most children (94%) were discharged from the hospital, but 8 children died as a result of their injuries. Utah regulations prohibit children who are younger than 8 years from driving an ATV and advise against carrying passengers on ATVs. However, 25% (n = 15) of all injured children who were younger than 8 were driving the ATV when injured, and 15% (n = 60) of injured children were passengers on ATVs. Four of the 8 fatally injured children were younger than 8, and all were driving the ATV at the time of the crash. Finally, the estimated injury rate per 100 registered ATVs is significantly higher for children than for adults (3.41 vs 1.71). CONCLUSIONS: ATV use results in significant injuries to children. Efforts to educate parents regarding the risks of ATV use, proper supervision, and use of safety equipment are warranted. Manufacturers of ATVs should continue to improve the safety profile of these inherently unstable vehicles.

Probabilistic linkage of computerized ambulance and inpatient hospital discharge records: a potential tool for evaluation of emergency medical services.

STUDY OBJECTIVES: Emergency medical services (EMS) is an important part of the health care system. The effect of EMS on morbidity, mortality, and costs of illness is difficult to evaluate because hospital information is not available in out-of-hospital databases. We used probabilistic linkage to create such a database from ambulance and inpatient data and demonstrate the potential for linkage to facilitate evaluation of EMS responses resulting in hospital admission. METHODS: Statewide ambulance and inpatient hospital discharge records were available for 1994 through 1996. Ambulance records indicating admission to the emergency department or hospital (165,649 records) were linked to inpatient hospital records indicating emergency admission (146,292 records) by using probabilistic linkage. Out-of-hospital data (dispatch code, treatments rendered, and ages), linkage rates, and inpatient data (discharge status, charges, length of stay, and payer category) were analyzed. RESULTS: We linked 24,299 (14.7%) ambulance events to inpatient hospital discharges. If we had used exact linkage methods, we would have only linked 14,621 record pairs, a loss of nearly 40%. Linkage rates were relatively constant between years (approximately 15%) but differed by ambulance dispatch codes. Out-of-hospital dispatch codes with high linkage rates included breathing problems (22.6%), chest pain (21.5%), diabetic problems (16.9%), drowning incidents (14.9%), falls (19.2%), strokes (32.8%), and unconsciousness or fainting episodes (16.1%). Linkage to the hospital record provided access to hospital outcome data. Inpatient mortality was 6.8%. Survivors were discharged home (60.7%), transferred to other acute-care facilities (3.6%) or intermediate-care facilities (23.3%), or discharged with home health care provision (4.9%). The median length of stay was 3 days, and median charges were $6,620; total inpatient charges were $286,737,067. CONCLUSION: Probabilistic linkage enables ambulance and hospital discharge records to be linked together and potentially increases our ability to critically evaluate EMS by providing access to hospital-based outcomes. Such evaluation will be further improved by linking to ED, other outpatient, and other public health data sources.

A population-based study of crashes involving 16- and 17-year-old drivers: the potential benefit of graduated driver licensing restrictions.

OBJECTIVE: To evaluate the potential effectiveness of graduated driver licensing programs using population-based linked data for motor vehicle crashes (MVCs) that involved teenaged drivers (TDs). METHODS: Utah crash, inpatient hospital discharge, and emergency department databases were analyzed and probabilistically linked. We computed hospital charges and compared violations, contributing factors, seatbelt use, and passengers for TDs (16-17 years old) relative to adult drivers (18-59 years old). RESULTS: TDs comprised 5.8% of the study population, but were involved in 19.0% of MVCs. TD crashes resulted in $11 million in inpatient hospital charges and 158 fatalities. TD crashes were 1.70 times (95% confidence interval [CI]: 1.34, 2.04) less likely to result in fatal injury to drivers than were crashes that involved adult drivers, but TDs were 2.20 times (95% CI: 1.96, 2.47) more likely to receive citations. The following were findings of the study: 1) 11% of all TD crashes but 19% of fatal TD crashes occurred between 2200 and 0600 hours; 2) TDs used seatbelts less often than did adult drivers (79.1% vs 84.4%) and less often with passengers present (81.9% vs 75.0%; 3) TDs were 1.72 times (95% CI: 1.38, 2.14) more likely to be involved in crashes that resulted in seriously or fatally injured occupants when driving with passengers than when driving alone. CONCLUSIONS: TDs are overrepresented in MVCs. TD crashes have a higher fatality rate at night, and TDs wear seatbelts less often than do adult drivers. Passengers affect TD crash characteristics. Graduated driver licensing programs that target state-specific characteristics of TDs may decrease morbidity and mortality.

Distinctive emergency department usage for injury for workers' compensation cases in Utah in 1996.

To compare emergency department services paid by worker's compensation (WC) with services paid by other payers, a state database of 72,747 emergency department visits for injured adults (ages 21 to 54) in 1996 in Utah was analyzed. WC visits accounted for 21.6% (15,704) of all adult injury visits. The mean emergency department charge for WC visits was $282, and the admission rate was 17 per 1000 visits. The mean charge for other payers was $334, and the admission rate was 43 per 1000 visits. Differences were also found between these groups for Injury Severity Scores and diagnoses. In summary, WC emergency department usage was associated with less severe injuries than was emergency department usage for other payers in Utah in 1996.

New areas for psychological assessment in general health care settings: what to do today to prepare for tomorrow.

Unique roles of the professional psychologist are outlined with respect to increasingly restrictive utilization practices of managed care. Suggestions of how to develop less traditional venues of practice, the types of instruments to use, and report formats, along with ways to persuade primary care physicians (PCPs), managed care organizations, and facilities to utilize psychological assessment services are provided. Medical cost offsets, cost-efficient quality of care, and models of practice are also discussed.

Evaluation of post extracorporeal membrane oxygenation follow-up testing.

The purpose of this study was to evaluate all post extracorporeal membrane oxygenation (ECMO) tests for their ability to detect any change in the incidence of unanticipated medical problems, and their charge to the patient. The current post ECMO protocol consists of the following tests: brain stem auditory evoked response, head computed tomography, cerebral blood flow, head ultrasonography, electroencephalography, eye examination for retinopathy of prematurity, and pneumocardiography. A retrospective review was conducted for all surviving neonatal ECMO patients treated from January, 1985, to December, 1994. The results of each test were classified as either normal, having a minor abnormality, or having a major abnormality. Statistical analyses were performed on each test comparing the incidence of minor and major abnormalities to all neonates in the neonatal intensive care nursery. Two hundred ninety-six infants survived their course on ECMO, and composed the study population. There were no significant differences between the incidence of abnormal results compared with the expected values for the following tests: cerebral blood flow (p=0.13), the eye examination (p=0.54), and pneumocardiography (p=0.22). The analyses for the brain stem auditory response, head computed tomography, head ultrasonography, and electroencephalography showed higher than expected incidences of abnormal results (p < 0.01). The data also were evaluated for major abnormalities on computed tomography and head ultrasonography. Of 161 infants who had both tests performed, 11 (6.8%) had normal head ultrasonography results, yet had a major abnormality noted on computed tomography (p < 0.01). This study is the first to review the current post ECMO protocol comprehensively, and the results suggest excluding the cerebral blood flow, eye, and pneumocardiography tests. This would result in a significant savings of $1,400 without compromising patient care. In addition, comparisons of neuroradiographic studies indicate that computed tomography of the head is sensitive enough to detect all central nervous system abnormalities that were found by ultrasonography. Excluding the post ECMO head ultrasonography, an additional savings of $300 would occur. These recommended changes reflect the current post ECMO protocol at Kosair Children's Hospital.

TAT results in a longitudinal study of bereaved college students.

The authors analyzed projective data obtained from 141 college students who wrote stories on three separate occasions to selected cards from the Thematic Apperception Test (TAT). The students included 46 members of support groups for bereaved college students, 34 members of a bereavement control group, and 61 nonbereaved students. The study used a repeated-measures pretest-posttest control group design to gather longitudinal data about the trajectory of bereavement with and without support group intervention. Coders, who reached consistently high interrater reliability, looked for themes of death, grief, coping, and affiliation in the stories. Multivariate analysis of variance (MANOVA) and repeated-measures MANOVA tests were applied to analyze coding results. Overall MANOVA results indicated significant group differences in the responses to the TAT cards. Repeated-measures MANOVA found group differences in use of themes of death and grief and found Group x Time differences in maintaining a sense of self-efficacy while in a crisis. A majority of the stories contained affiliation imagery but without any group differences in the use of such imagery.

Characteristics of women with and without breast augmentation.

OBJECTIVE: To compare selected characteristics of women with and without augmentation mammaplasty to identify differences between these 2 groups of women. DESIGN AND STUDY PARTICIPANTS: White women identified as controls in previously conducted population-based, case-control studies formed the study population for the present cross-sectional analysis (N=3570). MAIN OUTCOME MEASURE: Interview information on selected characteristics was compared between women who had received augmentation mammaplasty (n=80) and other women (n=3490) using the prevalence odds ratio (pOR) as the measure of association. RESULTS: Women with breast implants were more likely to drink a greater average number of alcoholic drinks per week (for > or =7 drinks vs 0 drinks: pOR=2.9, 95% confidence interval [CI]=1.5-5.5), be younger at first pregnancy (for age <20 years vs age 20-29 years: pOR=1.6, 95% CI=1.0-2.7), be younger at first birth (for age <20 years vs age 20-29 years: pOR=1.9, 95% C1=1.1-3.3), have a history of terminated pregnancies (for > or =1 termination vs 0 terminations: pOR=2.0, 95% CI=1.2-3.4), have ever used oral contraceptives (pOR=2.2, 95% CI=1.0-4.7), have ever used hair dyes (pOR=4.5, 95% CI=1.3-15.4), and have had a greater lifetime number of sexual partners (for > or =14 partners vs < or =4 partners: pOR=8.9, 95% CI=3.1-25.5) than other women. A history of smoking, lactation, high blood pressure, or thyroid disorders, as well as the number of pregnancies, full-term births, or miscarriages, differed little between women with and without implants. Women with breast augmentation were much less likely to be heavy than other women (for > or =74 kg vs <56 kg: pOR=0.1, 95% CI=0.03-0.3). CONCLUSION: The differences we found between women with and without breast implants suggest that consideration and evaluation of confounding factors in future studies will help to clarify some of the long-term health consequences of having breast implants.

Vitamin A and vitamin E statuses of preschool children of socioeconomically disadvantaged families living in the midwestern United States.

OBJECTIVE: To determine the vitamin A and vitamin E statuses of socioeconomically disadvantaged preschool American children. DESIGN: Cross-sectional study of preschool children from socioeconomically disadvantaged families. SETTING: Central Iowa, USA. SUBJECTS: A group of 77 apparently healthy children was studied with the following characteristics: 5 mo-6 y; 37 males, 40 females, 56 non-Hispanic Caucasians, 3 Hispanics, 18 Afro-Americans. METHODS: Modified relative dose response (MRDR) test for vitamin A status assessment; serum retinol, alpha-tocopherol, cholesterol, and carotenoids; weight for age. RESULTS: Although the mean weight for age was the 53rd percentile of the NCHS standard, a significant number of children (P = 0.006, chi(2)) were either markedly underweight or overweight. Ratios of 3,4-didehydroretinol to retinol (DR/R) were > 0.030, in 32% of the children. Mean serum retinol, alpha-tocopherol and cholesterol (+/- s.d.) were 1.09 +/- 0.23 microM/L, 16.8 +/- 6.3 microM/L and 4.01 +/- 0.8 microM/L. Three children (3.9%) showed a serum retinol value < 0.7 microM/L. One child with a serum retinol value < 0.7 microM/L and one additional child showed a ratio of alpha-tocopherol to cholesterol < 1.44 mumol/mmol. The mean alpha-tocopherol to cholesterol ratio for the group (4.31 +/- 1.71 mumol/mmol), however, was satisfactory. The only significant (P < or = 0.05) age-related changes were an increase in the serum cholesterol (P = 0.005) and decrease in the alpha-tocopherol to cholesterol ratio (P < 0.005) between the 0-2 y and the 2-4 y groups. Serum cholesterol (P = 0.0165, two-tailed) and lycopene (P = 0.004) concentrations of Afro-Americans were significantly higher than those of Caucasians. Median serum concentrations of alpha-carotene and beta-carotene were lower and, of lycopene higher than those found in children studied in a national survey. Serum carotenoid concentrations generally increased with age. CONCLUSIONS: Larger percentages of underweight and overweight children and a significant degree (32%) of inadequate vitamin A status were found in this group of socioeconomically disadvantaged children. Afro-Americans showed higher serum cholesterol and lycopene concentrations than did Caucasians, but otherwise were nutritionally similar. Age-related changes were small. Of nutritional parameters considered, the vitamin A status of socioeconomically disadvantaged segments of our population clearly needs attention.

Gaining access to Native American cultures by non-Native American nursing researchers.

The authors sought to identify the problems non-Native American nurse researchers might have in gaining access to Native American cultures. The authors' method was nursing ethnography; several different tribes were observed. Findings revealed five significant categories of barriers to health care: understanding of cultural differences, language barriers, differences in interpersonal communication, historical antipathy/fear of exploitation by Native Americans, and distrust of researcher motivation. The authors make several recommendations for researchers to prepare extensively if they plan to work with Native Americans.

An assessment of teratology training provided by masters level genetic counseling programs.

The increasing demand in the clinical genetics setting for information about teratogen exposures has created a need for genetic counselors to have the capabilities to appropriately address patient concerns. In order to assess how training in teratogen counseling is currently being conducted, the GLaRGG Teratogen Subcommittee surveyed all 17 genetic counseling training programs in North America in September 1993. Information was obtained from training programs about coursework, resources, and clinical training. In addition, each training program was asked to provide information about how their teratogen training needs could better be met. While all programs responded that some information in their coursework applicable to teratogen counseling was provided, there was wide variation in the amount of time devoted to this topic. The programs also greatly differed in the provision of clinical training in teratogen counseling. For both coursework and clinical work, genetic counselors were the main trainers in teratogen counseling. In spite of this, fewer than 25% of training programs have a defined teratogen clinical rotation. Data from the survey are discussed and recommendations presented.

The impact of college prematriculation immunization requirements on risk for measles outbreaks.

OBJECTIVE: To assess whether prematriculation immunization requirements (PIRs) affect the number of measles cases on college campuses. DESIGN: We surveyed a stratified random sample of 880 colleges and universities to determine their immunization policies and practices and occurrence of measles outbreaks from 1988 through 1991. We merged national measles surveillance data with survey data by county to determine the risk for measles introduction on college campuses. We used logistic regression methods to estimate the effect of PIRs and assess risk factors for college measles outbreaks. SETTING: A total of 3205 US colleges and universities listed in standard guides. RESULTS: Of selected schools, 91 (11%) of the 796 responding schools reported one or more measles cases occurring from 1988 through 1991. Schools with a state-mandated PIR were significantly less likely to report measles outbreaks of two or more cases than other institutions (adjusted relative risk [RR] = 0.30; 95% confidence interval [Cl], 0.11 to 0.84). None of the 14 schools that reported outbreaks of 10 or more cases was subject to state regulation or had a PIR specifying two doses of measles vaccine in place. Of schools with introduction of measles, residential colleges were more likely to report extensive spread of measles (five or more cases) than nonresidential colleges (RR = 35.8; 95% Cl, 2.08 to 617.0). Of public schools, 4-year programs had a higher risk of a large outbreak (five or more cases) than 2-year programs. CONCLUSIONS: These results strongly support current recommendations for requiring proof of vaccination of college students to decrease the risk for measles outbreaks on college campuses. State regulations mandating PIRs ensure the best protection against widespread measles transmission.