Original Article
HIV Infection among Patients in U.S. Acute Care Hospitals — Strategies for the Counseling and Testing of Hospital Patients
N Engl J Med 1992; 327:445-452August 13, 1992
- Abstract
- Abstract
Background.
Routine, voluntary testing of hospital patients for the human immunodeficiency virus (HIV) has been proposed in order to identify those with early HIV infection in a setting where there is ready access to counseling, appropriate clinical referral, evaluation, and therapy. We studied the pattern of HIV infection among patients in 20 U.S. hospitals, in order to evaluate possible national strategies for the routine, voluntary HIV counseling and testing of hospital patients.
Methods.
Blood specimens remaining after clinical use from a systematically selected sample of patients at 20 hospitals in 15 U.S. cities were tested anonymously for antibody to HIV type 1 (HIV-1). Multivariate regression was used to determine which variables best predicted HIV seroprevalence in individual hospitals. Using these data, we estimated the number of HIV-positive patients in all U.S. hospitals and considered the efficiency of routine counseling and testing in different subgroups of patients and hospitals.
Results.
From September 1989 through October 1991, 9286 of 195,829 specimens (4.7 percent) were positive for HIV-1 in the 20 hospitals. The seroprevalence of HIV at these institutions ranged from 0.2 percent to 14.2 percent. Among HIV-positive patients, 32 percent had symptomatic HIV infection or the acquired immunodeficiency syndrome (AIDS) at the time of admission or evaluation. In the 20 hospitals, HIV seroprevalence was 10.4 times (95 percent confidence interval, 8.8 to 12.0) the AIDS-diagnosis rate (the annual number of patients with new diagnoses of AIDS per 1000 discharges in 1990). In a multivariate model that included 13 hospital-specific variables, only the AIDS-diagnosis rate was associated with the hospital-specific HIV-seroprevalence rate (P<0.001). Using these data and the AIDS-diagnosis rates for all U.S. acute care hospitals, we estimated that 225,000 HIV-positive persons were hospitalized (95 percent confidence interval, 190,000 to 260,000) in all 5558 such hospitals in 1990, including 163,000 persons presenting with conditions other than HIV or AIDS (95 percent confidence interval, 130,000 to 196,000). In 1990, in 593 U.S. hospitals with AIDS-diagnosis rates of 1.0 or more per 1000 discharges, HIV testing of patients 15 to 54 years old (3 million patients, or 12.0 percent of all patients in U.S. acute care hospitals) would have identified an estimated 68 percent of all HIV-positive patients (110,000 patients) who were admitted with conditions other than symptomatic HIV infection or AIDS.
Conclusions.
We estimate that about 225,000 HIV-positive persons were hospitalized in 1990, of whom only one third were admitted for symptomatic HIV infection or AIDS. Routine, voluntary HIV testing of patients 15 to 54 years old in hospitals with 1 or more patients with newly diagnosed AIDS per 1000 discharges per year could potentially have identified as many as 110,000 patients with HIV infection that was previously unrecognized. (N Engl J Med 1992; 327:445–52.)
Media in This Article
Figure 1
HIV Seroprevalence in Male and Female Patients, According to Age Group, in the 20 Hospitals Studied.Figure 2
HIV Seroprevalence in Patients at Least 15 Years Old in the Hospitals Studied, According to Presenting Condition.Article Activity
- Article
TESTING hospital patients for human immunodeficiency virus (HIV) infection can identify those with early infection in a setting where there is ready access to appropriate counseling, clinical referral, evaluation, and therapy.1 2 3 4 Knowledge of such infection allows infected persons to seek appropriate medical treatment with antiretroviral agents, as well as vaccines and prophylaxis against opportunistic infections. In addition, counseling and testing may help some people prevent HIV transmission by limiting their high-risk behavior.5
A national strategy for routinely offering HIV counseling and testing in hospitals depends in part on knowing the demographic and clinical distribution of HIV infection in the hospital population. With this knowledge, groups of patients likely to have the greatest need for HIV counseling and testing and clinical-referral services can be identified. A strategy focusing on hospitals where the seroprevalence of HIV is high is likely to be more cost efficient than one offering counseling and testing in all hospitals. Unfortunately, the seroprevalence of HIV in most hospitals is unknown, and little is known about the distribution of HIV infection within hospitals. Previous reports have focused on various groups of patients, including those with conditions unlikely to be associated with HIV infection,6 , 7 those at a Veterans Affairs hospital,8 those in emergency departments, and those on obstetrical services.9 10 11 12 These reports have demonstrated that hospitals care for a large number of HIV-infected persons, including both those with diseases clearly related to their HIV status and those with unrelated conditions.
We determined the seroprevalence of HIV in 20 U.S. acute care hospitals in relation to the age, sex, race and ethnic group, and presenting medical condition of the patients, and we used information readily available in hospitals and health departments to determine which hospital-specific variables best predicted HIV seroprevalence. We estimated the number of HIV-positive patients in all U.S. acute care hospitals and the proportion who present with conditions other than symptomatic HIV infection or the acquired immunodeficiency syndrome (AIDS). Finally, we evaluated possible strategies for targeting routine, voluntary HIV counseling and testing in the hospital setting.
Methods
Selection of Hospitals
In 1989, 20 of the 39 hospitals participating in the Sentinel Hospital HIV Surveillance System6 , 13 of the Centers for Disease Control (CDC) were recruited to conduct a study in which blood specimens were collected from a systematic sample of all hospitalized patients, including those with known HIV infection, for anonymous, unlinked testing for antibody to HIV type 1 (HIV-1). The major requirement for a hospital's participation was its ability to collect 500 specimens per month without collecting a second specimen from any patient in a calendar year. The first hospitals began the study in September 1989; this analysis includes data collected through October 1991. The mean duration of collection was 20 months per hospital (range, 8 to 26).
Selection and Testing of Specimens
The institutional review committees for research on human subjects at the CDC and each participating hospital approved the study. Blood specimens obtained from inpatients and outpatients that remained after clinical testing were systematically selected to meet predetermined quotas that generated a distribution of age and sex among the patients similar to that in the U.S. population. Although the goal was to select 500 specimens each month, the mean monthly number actually selected was 480.
After the specimens were selected, information was collected on each patient's age group, sex, racial or ethnic group, status as inpatient or outpatient, and presenting condition. We categorized the presenting conditions (the primary diagnosis at the time of admission or the reason for the outpatient visit) into 23 mutually exclusive diagnostic groups (Table 1Table 1
Diagnostic Categories Used to Classify the Presenting Conditions of the Patients Studied.*). No data on secondary diagnoses or behavioral risk factors were collected.Specimens were screened for HIV-1 antibody at the hospitals with a licensed enzyme immunoassay. Repeatedly reactive specimens were tested at the CDC with a licensed Western blot kit and were considered positive if antibody bands were seen to at least two of the following three gene products: p24, gp41, and gp120/160.16
Predictors of Hospital-Specific Seroprevalence
To identify surrogate markers for the seroprevalence of HIV in a hospital, we used stepwise linear-regression analysis17 to consider 13 hospital-specific variables: the region of the country and the population of the area where the hospital was located, the number of beds, the presence of an AIDS inpatient unit, the presence of an AIDS outpatient clinic, membership in the Council of Teaching Hospitals of the Association of American Medical Colleges, hospital ownership (e.g., private, not for profit), the number of discharges in 1990, the percentage of discharged patients covered by Medicaid, the percentage of discharged patients covered by Medicare,18 the percentage of discharged patients who were members of minority groups, the number of patients with AIDS diagnosed in 1990, and the AIDS-diagnosis rate for 1990, defined as the number of patients diagnosed with AIDS annually, divided by the annual number of hospital discharges, multiplied by 1000. From the CDC AIDS Surveillance System, we determined the number of patients with AIDS who had been given diagnoses at each hospital in 1990 and whose cases had been reported through December 1991. Ninety-eight percent of the reports listed the location where the diagnosis had been made. We obtained the number of patients discharged during 1990 from each hospital.
Estimation of HIV-Positive Hospital Patients in 1990
On the basis of linear-regression analysis, the rate of AIDS diagnosis was the only hospital-specific variable associated with HIV seroprevalence. In the 20 hospitals we studied, the seroprevalence of HIV was 10.4 times the AIDS-diagnosis rate (95 percent confidence interval, 8.8 to 12.0). To calculate the expected prevalence of HIV at each hospital, we multiplied the hospital's AIDS-diagnosis rate by 10.4. We then multiplied the expected prevalence of HIV in each hospital by the estimated number of patients in the hospital to obtain an estimate of the number of HIV-positive patients in the hospital during 1990. To estimate the number of patients in each hospital, we divided the number of discharges18 by the average annual number of discharges per patient (1.3).19 We used the 95 percent confidence interval of the regression coefficient from the linear-regression model to calculate a 95 percent confidence interval for the number of HIV-infected patients hospitalized in 1990.
Statistical Analysis
To obtain the best approximation of the actual seroprevalence of HIV in our 20 hospitals, all the crude seroprevalence results for each hospital were adjusted for the age and sex distribution of the patients in that hospital. In the analyses of HIV-positive patients, such as that of the proportion who presented with symptomatic HIV infection or AIDS, the results were weighted according to the adjusted age and sex distribution of the HIV-positive patients in these hospitals. To assess the representativeness of our selection of hospitals, we compared our hospitals with all other U.S. hospitals using a logistic-regression analysis17 that incorporated the 13 hospital-specific variables mentioned above.
Strategies for HIV Counseling and Testing
We considered the efficiency of potential strategies of HIV counseling and testing in all 5558 U.S. acute care hospitals in 1990. The theoretical efficiency was evaluated on the basis of the proportion of all HIV-positive hospital patients presenting with conditions other than symptomatic HIV infection or AIDS who would have been identified, and the proportion of all patients who would have been tested had HIV counseling and testing been routinely offered and accepted in hospitals with an AIDS-diagnosis rate greater than or equal to a given value.
On the basis of linear-regression analysis, the seroprevalence of HIV among the 98.4 percent of patients in the 20 hospitals who presented with conditions other than symptomatic HIV infection or AIDS was 7.7 times (95 percent confidence interval, 6.1 to 9.2) the AIDS-diagnosis rate of the hospital in question. We calculated the number of patients expected to present with conditions other than symptomatic HIV infection or AIDS for each hospital by multiplying the AIDS-diagnosis rate for that hospital by 7.7 times 98.4 percent of the estimated number of patients in the hospital in 1990.
To estimate the theoretical efficiency of a program of counseling and testing for patients 15 to 54 years old, we calculated age-specific AIDS-diagnosis rates and hospital discharges for all hospitals in the United States.18 , 19 On the basis of linear-regression analysis, the seroprevalence of HIV among patients 15 to 54 years old with presenting conditions other than symptomatic HIV infection or AIDS in the 20 hospitals was 6.7 times (95 percent confidence interval, 5.4 to 7.9) the hospital-specific AIDS-diagnosis rate for persons 15 to 54 years old. To calculate the number of HIV-positive patients with conditions other than symptomatic HIV infection or AIDS in this age group, we multiplied the age-specific rate of AIDS diagnosis by 6.7 times the estimated number of patients 15 to 54 years old in each hospital.
Results
Of the 20 centers participating in this study, 15 were teaching hospitals, 15 had AIDS outpatient clinics, 4 had AIDS inpatient units, 13 were private, not-for-profit hospitals, and 10 had more than 500 beds each. In these 20 hospitals, 44 percent of the patients either were uninsured or were insured by Medicaid.
HIV Seroprevalence in the 20 Hospitals
From September 1989 through October 1991, 4.7 percent of the 195,829 specimens sampled (9286) were confirmed as reactive to HIV-1. The adjusted hospital-specific seroprevalence rates ranged from 0.2 percent in hospitals in Omaha, Nebraska, and Salt Lake City to 14.2 percent in a hospital in the Bronx, New York (Table 2Table 2
Seroprevalence of HIV According to Sex and Racial or Ethnic Group, among All Patients in the 20 Hospitals Studied.*).The adjusted hospital-specific seroprevalence according to sex and racial or ethnic group is shown in Table 2. Seroprevalence was consistently highest among men 25 to 44 years old (Fig. 1Figure 1
HIV Seroprevalence in Male and Female Patients, According to Age Group, in the 20 Hospitals Studied.); in individual hospitals, rates ranged from a low of 1.3 percent to a high of 39.8 percent.HIV seroprevalence varied according to the presenting condition, as shown in Figure 2Figure 2
HIV Seroprevalence in Patients at Least 15 Years Old in the Hospitals Studied, According to Presenting Condition.. When hospital-specific seroprevalence rates and patients presenting with symptomatic HIV infection or AIDS were disregarded, patients with infectious conditions and drug-related conditions consistently had the highest seroprevalence rates, whereas patients with no medical problems or with gynecologic or obstetrical conditions had the lowest. Patients presenting with conditions other than symptomatic HIV infection or AIDS made up 98.4 percent of the patients tested (192,598). Among patients 15 to 54 years old who had presenting conditions other than symptomatic HIV infection or AIDS, the seroprevalence rate ranged from 0.7 percent to 23.6 percent in men, and from 0.1 percent to 12.4 percent in women.The proportion of HIV-positive patients who presented with symptomatic HIV infection or AIDS differed widely among the hospitals (range, 0 to 64.2 percent). Overall, 32.4 percent of the HIV-positive patients presented with a diagnosis related to HIV infection, and 67.6 percent presented with other conditions. The age distribution of the HIV-positive patients with presenting conditions other than symptomatic HIV infection or AIDS was as follows: newborns, 3.9 percent; 0 to 14 years old, 9.3 percent; 15 to 54 years old, 81.9 percent; and ≥55 years old, 4.9 percent. No other subgroup of patients presenting with conditions other than symptomatic HIV infection or AIDS constituted as large a proportion of the HIV-positive patients as the group 15 to 54 years old. Fifty-six percent of the HIV-positive patients with presenting conditions other than symptomatic HIV infection or AIDS were male, 65 percent were black, 17 percent were white, 16 percent were Hispanic, and 36 percent presented with pneumonia, acute gastroenteritis, upper respiratory infection, or another infectious condition.
Predictors of HIV Seroprevalence
In a stepwise linear-regression model, the AIDS-diagnosis rate was the only variable associated with HIV seroprevalence in a given hospital (P<0.001) at a level of significance below 0.15. The seroprevalence rate was 10.4 times the AIDS-diagnosis rate (Fig. 3Figure 3
Relation between the Seroprevalence of HIV and the AIDS-Diagnosis Rate at Each of the 20 Hospitals Studied.). In addition, the two rates were highly correlated (Spearman correlation coefficient,17 0.84).After we controlled for the AIDS-diagnosis rate, logistic-regression analysis showed that the hospitals we studied were more likely (P<0.05) than other U.S. hospitals to have a higher percentage of patients whose hospital expenses were paid by Medicaid, to be located in urban areas, to have more discharges, and to have teaching programs. In a linear-regression model of HIV seroprevalence that included the AIDS-diagnosis rate and these four variables, the AIDS-diagnosis rate was the only variable associated with HIV seroprevalence; the seroprevalence was 10.1 times the AIDS-diagnosis rate.
In 1990, the median AIDS-diagnosis rate in the hospitals we studied was 2.4 per 1000 discharges, and the median seroprevalence of HIV was 2.3 percent. In 1990, the mean AIDS-diagnosis rate for all 5558 acute care hospitals in the United States was 0.4 per 1000 discharges (median, 0; range, 0 to 77.9). Of the 5558 hospitals, 41.7 percent reported at least one patient with a new diagnosis of AIDS. The 593 hospitals (10.7 percent) with an AIDS-diagnosis rate of 1.0 or more per 1000 discharges accounted for 22.1 percent of hospital discharges in the United States and reported 76.9 percent of the patients with AIDS.
Strategies for HIV Counseling and Testing in U.S. Hospitals
We estimate that 225,000 HIV-positive patients (95 percent confidence interval, 190,000 to 260,000) were cared for in U.S. hospitals in 1990. In that year, if all 25 million patients in the 5558 such hospitals had been offered HIV counseling and testing services and had accepted them, an estimated 163,000 HIV-positive patients presenting with conditions other than symptomatic HIV infection or AIDS (95 percent confidence interval, 130,000 to 196,000) would have been identified (Table 3Table 3
Theoretical Efficiency of HIV Testing in U.S. Acute Care Hospitals in 1990, According to Whether All Patients or Only Those 15 to 54 Years Old Are Targeted.). A more efficient scheme would have involved testing the 3 million patients 15 to 54 years of age (12.0 percent of all U.S. hospital patients) in the 593 hospitals with AIDS-diagnosis rates of 1.0 or more per 1000 discharges, which we estimate would have resulted in the identification of approximately 110,000 HIV-positive patients (Table 3).Discussion
HIV seroprevalence rates varied widely in the 20 acute care hospitals we studied, with the incidence of HIV infection ranging from 1 in 7 patients in a hospital in New York City to 1 in 500 patients in hospitals in Nebraska and Utah. Although the demographic distribution of these infections was similar to that of AIDS cases, with the highest rates found among male patients, persons 25 to 44 years old, and patients in the Northeast,20 HIV infection was detected in both sexes, in every age group, and in all racial or ethnic groups in most of the hospitals. In the hospitals with the lowest seroprevalence rates, this infection was detected primarily in patients with conditions (e.g., infectious diseases) that might have raised the suspicion of HIV infection, but in the hospitals with the highest seroprevalence, rates of HIV infection were high in nearly all diagnostic categories.
Determinations of the need for routine, voluntary programs of HIV counseling and testing in hospitals should be based on the identification of patients with unsuspected HIV infection who would benefit from such a program.1 However, in this anonymous study we collected information only on presenting conditions, and therefore we could not determine whether infections in HIV-positive patients were suspected by the patients' physicians. HIV infection could have been suspected in at least some HIV-positive patients who presented with conditions other than symptomatic HIV infection or AIDS because of the patients' presenting condition (e.g., pneumonia) or history of risky behavior. For this reason, on the basis of our results, our predictions of the number of HIV-positive patients with unsuspected infection who would be identified by HIV testing may be too high. In a special study in a hospital with a low HIV seroprevalence, 16 percent of HIV-positive patients had unsuspected infections.21 Nevertheless, our overall estimate that two thirds of the HIV-positive patients in the 20 hospitals studied presented with conditions other than symptomatic HIV infection or AIDS is consistent with the suggestion of most other investigators that a high proportion of HIV infections are clinically unrecognized — 65 percent at one hospital.8 In one study of patients in the emergency room of a hospital with a high HIV seroprevalence, 85 percent of the HIV-positive patients had undocumented infections (unpublished data), whereas other studies in emergency departments have shown that 55 percent to 77 percent of infections were unrecognized.10 , 11 , 22
Although some have called for routine HIV testing of all hospital patients,23 , 24 our data indicate that targeted counseling and testing based on age would be more efficient. Patients 15 to 54 years of age make up 52 percent of hospitalized patients,19 and in this study they accounted for 82 percent of the HIV-positive patients with presenting conditions other than symptomatic HIV infection or AIDS. Of the 18 percent of HIV-positive patients outside this age range, nearly one quarter were newborns who could have been identified if childbearing women were counseled and tested.
In this study, we also considered strategies for targeting HIV counseling and testing on the basis of sex, race, and presenting medical condition, but no single subgroup made up as large a proportion of the HIV-infected patients with conditions other than symptomatic HIV infection or AIDS as the group of patients 15 to 54 years old. Offering counseling and testing to patients on the basis of risk factors for HIV infection is another logical strategy, one that has been recommended as a part of medical evaluations.25 Accurate information on risks may be difficult to obtain in health care settings,26 however, and not all HIV-infected patients have discernible risk factors.9
Decisions about which hospitals should offer routine, voluntary counseling and testing may be based in part on HIV-seroprevalence rates in the hospitals. Although these rates are unknown at most hospitals, we found that the AIDS-diagnosis rate was an excellent surrogate for seroprevalence in the 20 hospitals we studied. Our data suggest that the relation between the AIDS-diagnosis rate and HIV seroprevalence may be valid at most U.S. hospitals. Although the hospitals we studied were likely to be larger, more likely to be urban teaching hospitals, and likely to have a higher percentage of Medicaid discharges than other U.S. hospitals, none of these characteristics were associated with HIV seroprevalence when we controlled for the AIDS-diagnosis rate.
Caution is necessary when our estimate of the number of HIV-infected patients in U.S. hospitals in 1990 is interpreted, because we measured seroprevalence in only 20 hospitals. Nonetheless, because in our analyses the characteristics associated with our hospitals had little effect on the magnitude of the relation between the AIDS-diagnosis rate and HIV seroprevalence, our extrapolations seem plausible. We estimate that 62,000 HIV-positive persons were hospitalized for symptomatic HIV infection or AIDS in 1990, or approximately 53 percent of the estimated number of persons with AIDS27 alive during that year. Although no strictly comparable data are available, this proportion is similar in magnitude to the estimate of the proportion of patients with AIDS hospitalized for any reason in another study.28 In that study of more than 50 clinics, hospitals, and medical practices in nine U.S. cities, 52 percent of HIV-positive patients with AIDS were hospitalized in a one-year period.
Our data suggest that from an epidemiologic viewpoint, a patient's age and a hospital's AIDS-diagnosis rate are useful in developing strategies for counseling and testing that are more cost efficient than those targeting all hospital patients. If one assumes that a large proportion of HIV-positive patients in U.S. acute care hospitals had unsuspected HIV infection and that each such patient would have accepted HIV counseling and testing, to test each patient 15 to 54 years old in hospitals with AIDS-diagnosis rates of 1.0 or more per 1000 discharges in 1990 would have required testing only 12 percent of all patients, yet it might have identified two thirds of HIV-infected patients. In hospitals with low AIDS-diagnosis rates, an efficient strategy could be to provide counseling and testing to patients with clinical conditions suggestive of HIV infection and to those with behavioral histories29 that raise suspicion of an exposure to HIV. When a national strategy for the HIV counseling and testing of hospital patients is developed, however, factors other than the efficiency of testing should be considered, including the availability of resources for counseling, testing, and medical services.
Our estimates of the potential efficiency of strategies for identifying HIV-positive patients are most applicable to the first year of a program of counseling and testing. In subsequent years, counseling and testing would probably identify fewer HIV-positive patients.21 In addition, because some persons with behavior placing them at risk for HIV infection may be less likely to consent to be tested,30 , 31 the actual efficiency of counseling and testing may be lower than our estimates.
Of the approximately 1 million persons infected with HIV in the United States,27 one fifth were hospitalized in 1990. A program offering HIV counseling and testing to such patients, with the requisite referrals for appropriate medical evaluation, treatment, and preventive services, can potentially reach a large number of HIV-infected persons. For example, a national strategy in which voluntary counseling and testing were routinely offered to patients 15 to 54 years old in hospitals with AIDS-diagnosis rates of 1.0 or more per 1000 discharges could potentially identify as many as 110,000 patients with unsuspected HIV infections in one year, or 11 percent of all HIV-infected persons in the United States.
*For a list of participants in the Hospital HIV Surveillance Group, see the Appendix.
We are indebted to Van Munn, Rita Davis, Calvin Hightower, and Brent McRae for assistance in data management; to Jean Smith and Janet Brzuskiewicz for assistance with graphics; to Dr. Richard Selik, Dr. Celine Hanson, and Ken Bell for reviewing the data; and to Drs. John Karon, Harold Jaffe, Ruth Berkelman, and James Curran for comments on the manuscript.
Source Information
From the HIV Seroepidemiology Branch (R.S.J., M.E.S., S.E.C., L.R.P., R.S.S., N.O., T.J.D.), the Statistics and Data Management Branch (G.A.S., D.L.H.), the AIDS Surveillance Branch (J.W. W.), and the Laboratory Investigations Branch (C.A.S.), Division of HIV/AIDS, National Center for Infectious Diseases, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Atlanta. Address reprint requests to Dr. Janssen at Technical Information Activity, Division of HIV/AIDS, Mailstop E-46, Centers for Disease Control, Atlanta, GA 30333.
Appendix
The following persons participated in the Hospital HIV Surveillance Group: P. Brown, King—Drew Medical Center, Los Angeles; D. Brennessel, Queens Hospital Center, Queens, N.Y.; T.J. Cleary, University of Miami—Jackson Memorial Medical Center, Miami; R.S. Cox, Creighton University School of Medicine, Omaha, Nebr.; L.R. Crane, Wayne State University, Detroit; M. Easley, University Medical Center, Jacksonville, Fla.; JA. Ernst, Bronx Lebanon Hospital Center, Bronx, N.Y.; S.L. Groseclose, Baltimore City Health Department, Baltimore; K. Henry, University of Minnesota, St. Paul; J.A. Jacobson, University of Utah, Salt Lake City; A.S. Klainer, Columbia University College of Physicians and Surgeons, New York; J.M. Lombardo, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark; E. Mailhot, Santa Clara Valley Medical Center, San Jose, Calif; A. Mayrer, Sinai Hospital of Baltimore and Johns Hopkins University School of Medicine, Baltimore; P. Murphy, Johns Hopkins University School of Medicine, Baltimore; R. Murphy, Northwestern University, Chicago; P. Rice, Boston City Hospital, Boston; H. Simpkins, Staten Island University Hospital, Staten Island, N.Y.; G.A. Storch, Washington University School of Medicine, Children's Hospital, St. Louis; R.A. Weinstein, Michael Reese Hospital and Medical Center, Chicago; I. Weisfuse, New York City Health Department, New York; and W. Welch, Kaiser Permanente Medical Care Program, Los Angeles.
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