An In-Training Examination for Residents in Family Practice
John P. G eym an, MD Thomas B ro w n , PhD Davis, California
An in-training examination for family practice residents has been practice residents which would provide developed and used in a regional network residency program over confidential feedback on individual the past three years. The most striking result has been the strong performance to each resident, sample cognitive skills across the breadth of preference expressed by residents for question-specific feedback in family practice, provide residents with order to facilitate learning after taking the examination. A well- an opportunity to focus learning in designed in-training examination has the potential to meet both potential deficit areas, and provide individual resident and program goals as an additional measure of program directors with feedback of resident performance and growth, as well as of the effectiveness of group data as an indirect measure of teaching effectiveness in various parts teaching in the various curricular areas. In-training examinations for of the program. residents are in use by 12 other specialties in medicine, and have Over 5,000 examination questions been well-accepted by program directors and residents. A nationally- were screened from a variety of sponsored in-training examination for family practice residents is sources, primarily published test book needed which includes maximal teaching capability through compre lets in family practice and other specialties. A number of 35 mm slides hensive and specific feedback. were gathered from audiovisual pro grams obtained for the developing Network Teaching Bank, which has been described in a previous paper.1 1 All who have been involved with this specialty. In response to this As work on test item identification family practice residency training in deficit, efforts have been directed proceeded, a criterion group including recent years have recognized the need during the last three years at the faculty and practicing family physi for improved methods of measuring University of California at Davis to cians in equal numbers was organized. growth in resident performance as well develop and test such an examination This group met to rate and determine as evaluating the quality of specific in the context of a regional network those questions which were considered areas of resident training within a residency program in central and critical to the knowledge base of every program. One approach to measure northern California. This paper will family physician. By this process an ment is an in-training examination. report our experience, both positive examination was constructed in two Such an examination has been devel and negative, with the development parts: the first part containing 105 oped for residents in 12 other and use of an in-training examination, items using multiple-choice question specialty disciplines,1"10 but an in summarize the experience of other formats, and a second part of 24 training examination for family prac specialties with in-training examina pictorial questions similar to those tice residents has not yet been tions for residents, and suggest future used by the American Board of Family developed by national organizations in directions for a more effective national Practice examination. The examina approach in family practice. tion was designed for a two-hour testing period, which could be readily From the Department of Family Practice, University of California, School of Medi scheduled in each program on an cine, Davis, California. Requests for reprints Methods should be addressed to Dr. John P. Geyman, annual basis. Patient management Department of Family Practice, School of Our goals were to develop and test problems using branching answers and Medicine, University of California, Davis, Calif 95616. an in-training examination for family erasure or invisible ink methods were
THE JOURNAL OF FAM ILY PRACTICE, VOL. 3, NO. 4, 1976 4 0 9 not used due to the cost and time of nation consisted of 100 multiple- year. A significant difference at the development and the minimal dividend choice questions and 20 slide ques .05 level or beyond using the t-test was for profiling purposes in terms of time tions. Since residents had expressed noted when all residents were com spent by the examinee on such their desire for additional feedback pared against family physicians who questions. beyond their individual profiles, attended the course and completed the The in-training examination com specific questions were discussed at examination. Interestingly, second and prised five major categories: general the end of the testing session based on third-year residents improved greatly medicine, pediatrics, obstetrics- requests covering specific items raised in the second year of testing over gynecology, surgery, and behavioral by residents. About 20 percent of the first-year residents and practicing sciences. The number of questions in questions were reviewed in this family physicians. It is possible that each area ranged from 15 to 53, with manner. residents in the second and third year the greatest emphasis placed on medi The examination has been further scored higher because of experience cine and the least in the behavioral revised for 1976, and this year in with the test in the previous year. The sciences. It was possible to further cludes a formal method of feedback few points of difference in family classify each question in a major area for each question missed. This includes physician and first-year resident scores into one or more of the following a specific statement of the content of between 1973-1974 and 1974-1975 minor categories: (1) allergy; (2) cardi the test question and a reference to a can probably be accounted for by the ology; (3) clinical pharmacology; (4) readily available text or audiovisual standard error of the examination, as dermatology; (5) emergency medicine; program defending its answer neither group had prior experience (6) geriatrics; (7) gynecology; (8) (Table 1). This approach is being taken with the examination. infectious diseases; (9) metabolism and in response to a continuing desire by In terms of both individual and endocrinology; (10) neurology; (11) residents for more specific and helpful program goals of the in-training exami obstetrics; (12) ophthalmology; (13) feedback. nation for family practice residents orthopedics; (14) otolaryngology; (15) involved in this pilot project, our preventive medicine; and (16) urology. experience has been mixed. On the The minimum number of test ques positive side, we have demonstrated tions in any minor category was set at that a reliable and valid examination five for profiling and feedback can be prepared within a single institu purposes, with some minor categories Results tion if sufficient resources are directed having up to 15 test questions. The two in-training examinations to the effort. Perhaps our most impor The examination was first adminis allowed for comparative analysis on tant outcome, however, has been the tered in the summer of 1974 to a total several parameters. First, the reliability strong desire expressed loud and clear of 37 residents from three component of the tests could be evaluated using by the residents that feedback be more programs within the residency net the Kuder-Richardson formula 21.13 specific and constructive to learning. work. During the same summer the This formula is used to determine the On the negative side, we have been examination was also given to 81 internal consistency of each question impressed with the generally low family physicians attending the depart within the examination. It is a measure priority assigned to learning by exami ment’s annual Family Practice Re of how each item is representative of nation on the part of many residents fresher Course. Confidential feedback the total examination. In the first compared with their pressing responsi was provided to each examinee for his year, a KR21 of .82 was achieved for bilities in patient care which they may or her main score on Parts One and the total test, which indicates an view as more real learning opportuni Two, a total score, and scores for each acceptable level of internal consis ties. Even though we were successful major category and all minor cate tency. In the second revised test, an in making available a fairly reliable gories. Each examinee was able to even higher KR21 of .86 was achieved, examination, valid in its content using compare his or her performance probably due to improving item per a criterion group, short in duration, against that of all other residents and formance using Chi-square as discussed and assuring total confidentiality for practicing family physicians taking the above. each examinee, the residents have examination. No individual scores A second analysis concerned resi generally internalized their feedback were made available to program direc dents as compared with practicing and it is uncertain how much subse tors, who were given grouped data family physician performance. Table 2 quent learning has taken place in areas only. shows the results of these compared of identified weakness. Follow-up by The examination was revised by performances for the first testing year. residents in areas of identified needs deleting non-discriminatory items A significant difference at the .05 level would probably be greater if program using a Chi-square method suggested or beyond using a t-test was not noted directors were to review examination by Wilson et al,12 and new questions for any of the groups. However, an results on a one-to-one basis with each were added. A new Part Two was absolute progression of higher scores resident. It is also anticipated that developed and the total examination between first, second, and third-year specific feedback by the content of was again reviewed by the criterion residents was noted. Residents as a each missed question including related group before its use in the summer of group scored higher than family physi references will generate sufficient 1975, when it was administered to 37 cians attending the 1974 Family interest by many residents to actively residents and 52 family physicians Practice Refresher Course. pursue specific learning. Our over attending the 1975 Family Practice Table 3 shows the results of these whelming experience to date indicates Refresher Course. The revised exami compared performances for the second that an in-training examination will
4 1 0 THE JOURNAL OF FAM ILY PRACTICE, VOL. 3, NO. 4, 1976 only be successful to the extent that it grams. Feedback of examination Committee on Continuing Education teaches. results, as in orthopedic surgery, is in Otolaryngology. The examination is directed to the program director, who elective by program and is given in shares the individual results with each postgraduate years 3, 4, 5, 6, and 7. resident. Results are broken down into Feedback methods are similar to those percentiles, compared with national for Ophthalmology. In-Training Examinations in Other results by year, and include sub Pediatrics This examination is Specialties categories. Since 1974, the examina sponsored by the American Board of A recent study by the American tion has served as Part I for Board Pediatrics working in conjunction with Board of Medical Specialties explored certification. the National Board of Medical the use of in-training examinations by Dermatology - This in-training ex Examiners. It is elective by program all specialties in medicine.10 It was amination is prepared and adminis for postgraduate years 2 and 3. Feed found that 12 specialties currently use tered by the American Board of back is both to program directors and such examinations. The first resident Dermatology. The examination itself is to residents and also includes sub in-training examination was estab the previous year’s Board examination, scores and comparisons to national lished in 1961 in orthopedic surgery. and is given every other year on an results. This is presently the only Two other specialties (neurological elective basis by program. It can be specialty requiring a passing grade surgery and dermatology) established taken by residents in postgraduate before the examinee is Board-eligible. in-training examinations during the years 2 and 4, or in postgraduate year Physical Medicine and Rehabilita 1960s, and nine more have initiated 3, depending on the year the resident tion This examination is sponsored examinations since 1970. All 12 spe entered the program. Individual resi by the American Academy of Physical cialties which have started to use dents cannot take the examination Medicine and Rehabilitation. It is elec in-training examinations have con electively since it must be adminis tive by program for postgraduate years tinued to use them. Table 4 summar tered through a program. Feedback of 2, 3, and 4. Feedback is direct to izes the major features of in-training results includes subscore percentiles residents taking the examination, and examinations by specialty. with comparison with group results. may be returned to program directors We have followed up with residency Program directors share results with if the residents so choose by signing a program directors in each of these individual residents at their option. permission slip. Results for post specialties in order to obtain further Obstetrics-Gynecology This ex graduate years 2 and 3 are grouped information about their use of in amination is sponsored by the Council together, while postgraduate year 4 training examinations. A thumbnail on Residency Education of Obstetrics results are profiled separately. Results sketch by each specialty shows and Gynecology (CREOG), working in are otherwise reported in much the both commonalities and individual conjunction with the National Board same manner as in other specialties, variations. of Medical Examiners. It is elective by including subscores and national Orthopedic Surgery - This exami program, and can be taken in post comparisons. nation was initially developed by the graduate years 1, 2, 3, and 4. Feed Plastic Surgery The sponsor of American Board of Orthopedics and in back of results is both to program this in-training examination is the 1972 was turned over to the sponsor directors and to residents who took Educational Foundation of the Ameri ship of the American Academy of the examination. Results are tabulated can Society of Plastic and Reconstruc Orthopedic Surgeons. The examina in much the same way as for other tive Surgery, working in conjunction tion has been offered annually for the in-training examinations except that with the National Board of Medical past 15 years. Increasingly used by each printout also includes content Examiners. The examination is elective residents and programs over the years, areas for missed questions (eg, “low by program, and is offered every other it became required in 1975 for all forceps”). year for residents in postgraduate residents on an annual basis. Examina Ophthalmology - This examination years 4, 5, and 6. Results include tion results are returned to program is sponsored by the American Acad subscores and national comparisons directors, and are reported by per emy of Ophthalmology and Otolaryn and are returned to program directors centile and subscores, including gology through the College Assessment who usually discuss results with resi comparisons with the national group. Program. The examination is elective dents on an individual basis. A taxonomy has been developed for by program for postgraduate years 2, Anesthesiology This examination profiling of results in a number of 3, and 4, but there is increasing is jointly sponsored by the American areas, such as recall, problem-solving, interest in requiring all residents to Society of Anesthesiologists and the and overall competence. Program take it. Feedback is both to program American Board of Anesthesiology, directors discuss examination results directors and to residents, and includes working in conjunction with the on an individual basis with residents. subscore percentiles and national National Board of Medical Examiners. Neurosurgery - This in-training group results. It is anticipated that It is elective by program. The examina examination was established in 1966 senior-resident in-training examina tion is sometimes taken only once by by the American Board of Neuro tions will qualify as Part 1 of the Board the resident, usually in either post surgery, working in conjunction with examination starting in 1977. graduate year 2 or 3, although some the National Board of Medical Exami Otolaryngology - This examination programs are requiring it on an annual ners. It usually is required in post is also sponsored by the American basis. Feedback is to residents, who graduate years 2, 3, 4, 5, and 6 for Academy of Ophthalmology and may give permission for results to be those programs with five-year pro Otolaryngology and is prepared by the returned to program directors. Break-
THE JOURNAL OF FAM ILY PRACTICE, VOL. 3, NO. 4, 1976 41 1 with a comparison by year of resi Table 1. Question-Specific Feedback for In-Training Examination dency with all other residents in the country who took the examination. Feedback is to program directors, who Question No. Content Area References may discuss results with individual residents.
6 Immunization procedures in Krupp MA, Chatten MJ: ch ild re n (esp. use o f rubeola Current Medical Diagnosis vaccine) and Treatment. Los Altos, Calif, Lange Medical Discussion Publications, 1974, p 959 In connection with his work with a 19 Treatment of cavernous Sauer GC: Manual of Skin self-assessment examination for resi hemangioma in infant Diseases. Philadelphia, dents in psychiatry, Woods views the JB Lippincott, 1973, “ideal” examination for residents in pp 272-274 training in this way:8
20 Diagnosis of aspirated foreign Conn HF, Rakel RE, body in lung Johnson TW: Family Practice. Philadelphia, WB Saunders, 1973, An ideal examination for residents in pp 83 6-83 8 training would accomplish both individual and program goals. Knowledge should be 30 Side effects of reserpine Physicians Desk Reference, assessed relative to peers (those within a ed 29. Oradell, NJ, Medical resident’s program and perhaps a national Economics Co, 1975, pool) and to the educational goals and pp 1042-1043 teaching activities of the residency program. An ideal examination would not only 71 Diagnosis of perennial Ryan RE, et al: Synopsis of demonstrate general areas of strength and vasomotor rhinitis Ear, Nose and Throat weakness, but would aid in the establish Diseases. St. Louis, M o, ment of priorities. Since the best examina CV Mosby, 1970, pp 157-159 tion is one that teaches, the ideal examina tion would result in specific new learning as 99 Interpretation of T4 column Wallach J: Interpretation of well as the unlearning of erroneous data, tests of Diagnostic Tests. Boston, concepts or beliefs. . . . In the best of Mass, Little, Brown and circumstances, the examination would Company, 1974, pp 316-317 foster an attitude of self-motivated desire for periodic review and repair that would persist throughout professional life.
down of results is similar to most Review of the experience of the 12 other in-training examinations. Start other specialties currently using in Table 2 Comparative Scores of Residents and ing in 1977, the examination will be training examinations for residents Family Physicians — 1974 Examination Part 1 of the American Board of appears to validate the capability of Anesthesiology as the first step to these examinations to address both Board certification. individual and program goals. It is Mean Surgery - This examination is impressive that all specialties who have Group Number Score sponsored by the American College of become involved with in-training Surgeons, working in conjunction with examinations have continued to use the National Board of Medical Exam them, and that there is a trend toward Physicians iners. It is elective by program, and is increasing use in many specialties and at course 81 74 given in postgraduate years 3, 4, and 5. even required use by some specialties. Feedback is both to program directors Many program directors feel that All residents 36 78 and to residents, and is otherwise examination results provide an addi similar to most other specialties. tional useful measure of resident F irst-year Urology - This examination is pre performance as well as the capability residents 13 74 pared and administered by an indepen of their programs to teach in specific Second-year dent group on an elective basis by areas of resident training. Residents residents 14 76 program. The American Board of generally welcome the opportunity to Urology is currently evaluating this measure their progress, compare their T h ird -ye a r approach. It is normally offered in performance with national results, and residents 8 81 postgraduate years 2, 3, and 4. Results better prepare for Board certification. are reported individually by percentile Our own experience within the
4 1 2 THE JOURNAL OF FAM ILY PRACTICE, VOL. 3, NO. 4, 1976 network residency program in the national approach. It should be Table 3 University of California Davis Affili possible to meet both resident and Comparative Scores of Residents and ated Hospitals for Family Practice has program goals through such an exami Family Physicians - 1975 Examination demonstrated the strong interest by- nation, with feedback both to program residents in question-specific feedback directors and to residents. Particular in addition to categorical breakdown attention should be directed to Mean of results and comparisons with group developing an examination with maxi Group Number Score results. It is our feeling that question- mal teaching capabilities through specific feedback along the lines illus specific feedback. The greatest value trated in Table 1 can facilitate of an in-training examination may lie Physicians increased learning by residents without in its capacity to teach and motivate at course 52 75 compromising the future use of exami toward learning in specific content nation questions. areas. It is incumbent upon faculty All residents 37 83 We are aware that an in-training and program directors to set a high First-year examination for family practice is priority on the in-training examination residents 11 78 currently under development by a if it is to achieve its potential value. 11 committee of the American Academy would probably be wise to obtain Second-year of Family Physicians. Based on our further experience with a nationally residents 13 85 experience with this pilot project and sponsored in-training examination in that of other specialties using in family practice before considering Third-year training examinations during the past other uses of such an examination, residents 13 85 15 years, we strongly support the such as its possible role in eligibility desirability and necessity of such a for the Board examination itself.
Acknowledgement The work reported in this paper was made possible by grants from the WK Kellogg Foundation and the Public Health Service, Department of Health, Education and Table 4. Use of Resident In-Training Examinations by Specialty Welfare (Grant # 09D000478-02-0).
Specialty Sponsor Year Begun Frequency Com m ent
References 1. Matson DD: An in-training evalua Elective Anesthesiology Board & Society 1975 A nnual tion of residency training programs and trainees. J Med Educ 41: 47-51, 1966 2. Hubbard JP, Furlow LT, Matson B iennial E lective Dermatology Board 1968 DD: An in-training examination for resi dents as a guide to learning. N Engl J Med 276: 448-451, 1967 Neurological 3. Rubin M L: The ophthalmology resi Surgery Board 1966 A nnual R equired dent in-training examination. Am J Ophthalmol 67: 70, 1969 4. Danforth DN: In-training examina Obstetrics- tion for residents in obstetrics and gyne Gynecology C ouncil 1970 A nnual Elective cology. J Reprod Med 4: 187-188, 1970 5. Mankin HJ: The orthopedic in training examination (O ITE). Clin Orthop Ophthalmology A cadem y 1970 A nnual Elective 75: 108-116, 1971 6. Highlights of 1974, National Board Examiner 22: 2, 1975 Orthopedic 7. Role of the National Board of Medi Surgery A cadem y 1961 A nnual R equired cal Examiners in graduate and continuing medical education. National Board Exam iner 23: 1, 1975 Otolaryngology A cadem y 1971 A nnual E lective 8. Woods SM: A computerized self assessment examination for residents. Am J Psychiatry 131: 1283-1286, 1974 Pediatrics Board 1971 A nnual Required for 9. Russell KP: The 1971 in training Board-eligibility examination in obstetrics and gynecology. Obstet Gynecol 41: 148-154, 1973 10. Smith DE: Summary of Answers to Physical M edicine COSEP Inquiry of February 27, 1975: In-training Performance and Evaluation of Elective and Rehabilitation A cadem y 1972 A nnual Candidates. Chicago, American Board of Medical Specialties, 1975 11. Geyman JP, Brown TC: A teaching Plastic bank of audiovisual materials for family Surgery Society 1972 Biennial Elective practice. J Fam Pract 2: 359-363, 1975 12. Wilson JAR, Robeck MC, Michael WB: Psychological Foundations of Learning Surgery Board 1975 A nnual Elective and Teaching. New York, McGraw-Hill, 1 9 6 9 13. Guilford JP: Fundamental Statistics Urology Independent group 1975 A nnual Elective in Psychology and Education. New York, McGraw-Hill, 1972
4 1 3 THE JOURNAL OF FAM ILY PRACTICE, VOL, 3, NO. 4, 1976 Continued from page 352 least one of the white hopes to achieve Immediate Care of the Acutely Eland the objectives aimed at by the editors Injured. Edited by Hugh E. Stephen and authors of this book.” Later, he son, Jr. C. V. Mosby Company, St suggests that in future editions the Louis, 1974, 266 pp., $8.50. Marital and Sexual Counseling in Medi space now given to psychiatrist-writers This paperback publication presents cal Practice (2nd Edition). D. Wilfred should be shared equally with family an in-depth and comprehensive study Abse, Ethel M. Nash, and Lois M. R. physician specialists. of crisis medicine. Using a narrative Louden. Harper and Row, Publishers, form based on class presentations and Hagerstown, Maryland, 1974, 612 pp., Leland B. Blanchard, MD interspersed with frequent anecdotes $14.95. San Jose, California and case histories, this volume covers This book is intended to improve such crisis areas as immediate care the work of all health professionals priorities, cardiopulmonary emer engaged in marital and sexual coun gencies, mechanical trauma, poisoning, seling. Studying it and using it as a Emergency Treatment and Manage psychiatric emergencies, and selected reference guide will benefit particu ment (5th Edition). Thomas Flint, Jr. specialty problems. There are also larly those family and other primary and Harvey D. Cain. W. B. Saunders some specific comments about preven care physicians who desire to prevent Company, Philadelphia, 1975, 794 tive medicine. or minimize the causes of psycho- pp., $13.75. The vast amount of material pre physiological disturbances as well as Every family physician, family sented is well organized and compre treat the symptoms. practice resident, and medical student hensive. Since much of it is taken from The book is well written by 48 involved in emergency care should class lectures, however, the presenta qualified authorities and organized for consider including this excellent refer tions are too wordy and often easy readability. Many illustrative case ence in his or her library. It is rambling, thus making it difficult fora histories are given, references are listed organized in a format which expidites reader to extract specific data or following each chapter, and 29 pages rapid reference through presentation information quickly and concisely. of double-column index are included. of problems, complaints, principles, Some unique chapters, such as Appendix A is 13 pages of a practical and procedures in emergency medi “Rescue and Extrication,” and “Eso- “Marital Information Form.” cine. In addition, an extensive index terica: Hiccups, Fish Hooks, Rings and The 40 chapters in the book could provides a ready cross-reference. These Such Things,” further illustrate the have been divided into seven sections features assist one in quickly develop total comprehensiveness of this publi under the following headings: (number ing a differential diagnosis and formu cation. of chapters in each in parentheses) lating a plan of action. As the authors The main objective is to present 1. Understanding and treating marital state in their preface to the first crisis medicine, an area often neglected and sexual disorders (12) edition, they have “endeavored to in medical education, to the medical 2. The essential functions of the outline in a rapidly available form student. This book definitely fulfills physician before marriage and during portal-to-portal care in emergency this objective and will provide excel early marriage (4) situations.” lent reading and resource material for 3. Ages, stages, and identities in mari The only suggestion this reviewer the third or fourth-year medical tal and sexual situations faced by the would have is that a larger number of student. It could also serve as a good physician (6) illustrations, particularly color photo review for the busy practicing family 4. Marital and sexual components of graphs of dermatological conditions, physician and would be an extremely specific illnesses or conditions (9) would be of value. Those that are valuable reference in hospital Emer 5. Sexual problems of the unmarried, included are of excellent quality and gency Rooms or outpatient receiving widowed, or divorced (3) complement the text. I have already centers. 6. Contributions to the physician used this book on several occasions about marriage and sex from other and have found the format excellent. William Jacott, MD disciplines (3) Each condition is briefly reviewed Duluth, Minnesota 7. The physician: his education and including signs and symptoms. Then, his personality in relation to sex and various diagnostic studies are recom marriage (3). mended when needed. Finally, treat Leg Ulcers: Medical and Surgical Man A unique feature of this compen ment plans and recommendations are agement. Henry H. Roenigk, Jr., and dium of articles is a section entitled made. Because this volume is designed Jess R. Young. Harper and Row, Pub “Afterword” written by a professor of for rapid use in emergency situations it lishers, Hagerstown, Maryland, 1975, theology and personality. This discus lacks depth, and alternate methods of 265 pp., $27.50. sion in itself constitutes a review of treatment are often not mentioned. The authors’ purpose in writing Leg the book. The writer notes that 23 of However, one must recognize that it is Ulcers was to provide an overview of the 48 contributors are psychiatrists meant to complement rather than the problem and a quick reference for and only one physician is identified replace the standard text, and in most proper diagnosis and management. with family practice. One portion of instances these omissions will cause no They accomplished this task in a very this section is entitled “Where is problems. readable, 250-page text which is well Family Medicine?” and the author organized, thorough, and succinct. goes on to state: “On the face of it, George Hess, MD family medicine would appear to be at Carson City, Nevada Continued on page 418
4 1 4 THE JOURNAL OF FAM ILY PRACTICE, VOL. 3, NO. 4, 1976 soon as the recumbent position js assumed. If the physician can visualize the precise clinical picture at the comple tion of the history taking, he win usually be capable of considerable confidence in his diagnosis of syncope or its exclusion, and often the setting will give major clues to the etiology of the spells. He can then proceed with determining the specific cause of the syncope if it is not already clear. (See Table 2.)
Neurogenic Syncope
Table 1. Questions to Ask the Patient and Observers In each of these conditions there 1. Questions for the Patient are inadequate vasoconstrictor mecha nisms. What were you doing during the hours and minutes preceding the blackout? What was your situation regarding loss of sleep, ingestion of food and alcohol, and use of drugs or medications prior to the blackout? Vasovagal (Vasodepressor, Vasomotor) What was your body position or posture? Syncope What was the first thing you noticed to be wrong? What symptoms did you experience next, in what order, and for how long? This is the common faint and it is Do you remember slumping or striking the floor? the most common type of syncope. It What was the next thing you remember and what position were you in when you regained awareness? occurs frequently in teenage girls and Did you hurt yourself in the fall, did you injure your tongue or mouth, did your young women, but it may occur in any back or muscles ache, did you have a headache, did you lose control of your bladder otherwise normal person. It is often o r bowels? How did you feel on awakening and how long did it take for you to feel entirely precipitated by emotional stress or normal again? Seconds, minutes, or longer? physical pain, or threat of pain, and it 2. Questions for the Observers tends to be recurrent. The sight of a Ask the observers to answer the above questions when appropriate. shocking accident and the sight of, or Was there any turning of the eyes or head? receipt of, a hypodermic needle or Was there any twitching or jerking of the face or extremities? blood withdrawal may also evoke an Was the skin sweaty, pale, flushed or blue? Did the patient respond to observers in any way during the apparent attack. The primary event appears to unconsciousness? be a sudden excess of vagal activity which produces a prompt bradycardia and decrease in cardiac output. At the position or posture, what was the first in cerebral blood flow. Presyncopal same time, there is a striking decrease thing that appeared to be wrong, and symptoms result and if the blood in splanchnic and extremity vascular other details summarized in Table 1. pressure continues to fall, total loss of resistance, and the combined result is a consciousness finally occurs. In older progressive fall in blood pressure patients with diminished capacity for until syncope occurs. Sometimes there cerebral vasodilation in response to Pathophysiology of Syncope is no evidence of excessive vagal relative hypotension, there may be activity and it appears that peripheral Cerebral blood flow is determined significant cerebral ischemia with vasodilation alone is causative (vaso largely by arterial blood pressure and much smaller reductions in arterial motor syncope). This condition is cerebral vascular resistance. Cerebral blood pressure. Syncope, then, what aggravated by fasting, poor physical blood flow autoregulation is the ever its specific etiology, is due to a conditioning, a warm environment, phenomenon by which cerebral vessels relatively sudden fall in cerebral blood and excessive fatigue. A few clonic automatically constrict or dilate in flow to very low levels. This decrease jerks often occur and occasionally an response to rising or falling systemic in flow can be due, at least in part, to intense, generalized tonic spasm in blood pressure changes. This intrinsic increased cerebral vascular resistance extension results. Fecal or urinary control mechanism maintains a vir (eg, hyperventilation with its fall in incontinence is uncommon. Simple tually constant cerebral blood flow in apC02 induces [H+] changes in the syncope rarely produces a rhythmic, the face of significant physiologic or interstitial space around precapillary clonic convulsion.3 pathologic fluctuations in arterial arterioles that mediate a vasocon blood pressure. In healthy young striction of these resistance vessels). adults in the upright position, the But usually syncope is caused by a fall Orthostatic Hypotension with Syncope systolic blood pressure may fall to in systemic blood pressure either from This type of syncope occurs in 50-60 mmHg with no significant a loss of peripheral and/or splanchnic individuals who have either chronic or cerebral ischemia. Below that, cerebral vascular resistance or from a decrease transient vasomotor instability. Sud resistance vessels become maximally in cardiac output. With most causes of den rising from the recumbent or dilated and further decreases in blood syncope, blood pressure rises back to sitting position to a sitting or standing pressure result in progressive decreases the critical cerebral perfusion level as position, or standing still for several
4 2 0 THE JOURNAL OF FAM ILY PRACTICE, VOL. 3, NO. 4, 1976 pre-ganglionic autonomic neurons in rapidity and magnitude of drop in the Table 2. Types of Syncope the intermediolateral cell column of cardiac output and the posture of the I Neurogenic Syncope the spinal cord. Both Adie's syndrome patient. Frequently the patient has no A. Vasovagal B. Orthostatic Hypotension and the Riley-Day syndrome (familial cardiac symptoms associated with the 1. occasional normals dysautonomia) may be associated with syncope while at other times there 2. peripheral neuropathy may be palpitations, “skipped beats,” 3. medications orthostatic hypotension and syncope. 4. primary autonomic chest pain, or other symptoms of insufficiency cardiac awareness. In a normal indi C. R eflex 1. m ic tu ritio n vidual the mean blood pressure must 2. cough Reflex Syncope drop to a critical level or there must be 3. acute pain states a period of asystole for four or five II. Cardiogenic Syncope Micturition syncope is usually seen seconds before syncope results. A. Bradyarrhythmias in elderly males who arise from sleep B. T a c h y a rrh y th m ia s to urinate and faint while voiding. C. V alvular Disease D. Myocardial Disease Orthostatic hypotension may be a significant part of the cause, but sudden decompression of the dis Bradyarrhythmias tended bladder may induce a reflex Marked slowing of heart rate or vasodilation of the peripheral vascula asystole may result from increased minutes, results in the pooling of ture. vagal tone and/or disturbances of the blood in the lower extremities and Cough syncope usually occurs after cardiac pacemaker and conduction viscera due to the loss of their a vigorous paroxysm of coughing in system.6 In normal individuals, intense compensatory reflex peripheral vaso men with chronic obstructive lung fright or pain may induce sufficient constriction. Blood pressure falls and disease. It may be caused by the vagal stimulation to produce syncope. syncope ensues. Orthostatic hypo sudden increase in intrathoracic and Increased sensitivity of the carotid tension occurs in otherwise normal intra-abdominal pressure which in sinus may induce severe bradycardia or people after physical deconditioning, creases intracranial pressure and de cardiac standstill in patients with the especially with prolonged bed rest, creases cerebral blood flow. The carotid sinus syndrome. Disease of the fasting, and with alcohol use. Varicose Valsalva effect may also diminish sinus node, as in the sick sinus syn veins and normal pregnancy may also cardiac output. A prolonged Valsalva drome, may result in periodic sinus be implicated, and some patients maneuver in association with hyper arrest and bradycardia or asystole with following surgical sympathectomy also ventilation certainly appears to pro or without associated tachyar suffer orthostatic hypotension with duce syncope in breath-holding spells rhythmias. This condition should be faints. of infancy, weight lifter’s blackout, suspected in patients with unexplained Diabetic and other neuropathies and various blackout pranks indulged sinus bradycardia, a wandering atrial may affect the autonomic nervous in by teenagers. pacemaker, or intermittent atrial system causing impotence, impaired Acute pain states occasionally pro fibrillation. These patients do not have sweating, and paralysis of vasomotor duce syncope. These stimuli probably the normal increase in heart rate reflexes. Diminished ankle jerk re act by barraging the dorsal motor expected with exercise or with the flexes and sensation in the feet should nucleus of the vagus nerve which then administration of atropine or isopro be sought on examination as evidence induces a prominent bradycardia and terenol. Periods of complete heart of a peripheral neuropathy and should splanchnic vasodilatation. Vagal and block may occur in patients with suggest the possibility of a con glossopharyngeal neuralgia, gall blad disease of the conduction system and comitant autonomic neuropathy. der colic, perforation of a viscous and result in Stokes-Adams attacks. One Antihypertensive, antidepressant, needling of body cavities are examples should be especially suspicious of this and some other medications com of this disorder. Carotid sinus syncope condition in those patients whose monly cause orthostatic hypotension is discussed below. Intense vertigo and electrocardiogram shows bifascicular by plasma volume depletion and/or migraine headache on occasion induce block, as this conduction defect pro sympatholytic vasomotor effects. syncope presumably through this re gresses to complete heart block in a Primary autonomic insufficiency flex vagal mechanism. significant number of patients. may be caused by several primary degenerations of the autonomic nervous system, and a common feature of these diseases is orthostatic hypo Cardiogenic Syncope tension with syncope.4 The Shy- Tachyarrhythmias Drager syndrome is a disease of the Various disorders of the heart may middle-aged which usually begins with decrease cardiac output and cause Paroxysms of atrial tachycardia, sphincter disturbances and .progressive syncope.5 Transient rhythm distur flutter or fibrillation may result in orthostatic hypotension. Defective bances or valvular obstructive lesions sufficient reduction in cardiac output sweating is common, and tremor, are the most common cardiogenic to cause syncope. These tachyar rigidity and severe myoclonic jerking causes. Presyncopal symptoms may rhythmias may be followed by periods while falling asleep appear later in the occur without fainting, or the patient of marked bradycardia and may be disease. The postural hypotension is may experience immediate loss of identified only after periods of pro attributed primarily to degeneration of consciousness, depending on the longed monitoring of cardiac rhythm.
the JOURNAL OF FAM ILY PRACTICE, VOL. 3, NO. 4, 1976 421 Valvular Disease and nervousness. Obtundation pro ischemia, it is associated with tinnitus gressing to coma and seizures may Conditions causing obstruction to deafness, diplopia, dysarthria, ex ensue. It is unusual for hypoglycemia the flow of blood through the heart tremity paralysis or numbness, or to produce a relatively abrupt and may result in syncope by various some other symptoms of brainstem transient loss of consciousness, and mechanisms. Aortic stenosis or hyper ischemia in the majority of cases thus this condition is not generally trophic subaortic stenosis may be Therefore, cerebral vascular disease confused with syncope. associated with syncope, especially usually produces many associated with exercise. This is due to Epileptic seizures are usually dif symptoms of focal cerebral dysfunc inadequate cardiac output either from ferent from syncope in that they have tion that readily distinguish it from direct obstruction to outflow, myo an immediate onset, they occur in the syncope. cardial ischemia, associated tachyar day or night and while active or “Drop attacks” are a puzzling rhythmias or intraventricular conduc supine, they often result in injury and phenomenon. They occur usually after tion blocks. Pulmonic stenosis may they are commonly associated with the sixth decade and are characterized by a sudden drop to the ground with also be associated with exertional incontinence. Clonic convulsive ac no apparent loss of consciousness. The syncope. Syncope associated with tivity often lasts for several minutes, patients may bruise their knees but mitral stenosis is generally the result of and after the ictus there is often they are usually otherwise unhurt and associated atrial arrhythmias. confusion, drowsiness, and headache. While no single aspect of a seizure are able to stand immediately. While Left atrial myxomas may resemble differentiates it from syncope, the the cause is not known, many believe mitral valvular disease clinically and total sequence of events usually does. there is basilar artery insufficiency may be associated with syncope as a Temporal lobe (psychomotor, limbic) producing transient ischemia to that result of intermittent obstruction of seizures may be confused with pre part of the reticular formation that atrial outflow or as a result of atrial syncope or syncope because of regulates postural tone. These patients tachyarrhythmias. autonomic symptoms and signs and often have attacks for many years because the patient loses awareness without other evidence of brainstem during the seizure (even though he ischemia, and most authors believe may not convulse). Usually there is an that a diagnosis of “vertebral-basilar aura at the onset of the ictus. While it insufficiency” cannot be made with Myocardial Disease may resemble the symptoms of confidence. Hysterical faints or swoons must be Patients with disease of the myo presyncope, it commonly produces a differentiated from syncope, particu cardium, eg, ischemia, infarction, or “dreamy” or confused state and larly emotion-induced vasovagal cardiomyopathy, may experience patients often experience hallucina syncope. Hysterical faints occur syncope as a result of drops in cardiac tions, illusions involving themselves or dramatically in the presence of others output associated with decreased their environment and/or unusual and are not associated with pallor, myocardial contractility. Increased feelings of “deja vu.” The patient frequently carries out automatic diaphoresis, or weakening or slowing systemic blood flow demands or activity during the ictus which is of the pulse. They draw attention to reduction in peripheral resistance may generally stereotyped for that patient. the hysterical personality seeking not be compensated for by increased Akinetic seizures are brief attacks of secondary gain through this and other cardiac output, arid syncope results. unconsciousness with loss of muscle physical complaints. There may be Arrhythmias may also occur in this tone, and although these seizures are prolonged periods of “unresponsive group and cause syncope. rare and occur primarily in children, ness” with resistance to passive they may be confused with syncope. opening of the eyelids, bizarre Cerebral vascular disease is rarely a posturing, or resistance to movement cause of transient loss of consciousness of the limbs. that might be confused with syncope. H yperventilation infrequently Subarchnoid hemorrhage may cause causes syncope. However, it does cause Differential Diagnosis temporary unconsciousness, but it presyncope. This faintness, along with Several disorders are commonly usually has an explosive onset with anxiety, dyspnea, palpitations. and confused with Syncope even though an severe headache, and the patient is paresthesias of the distal extremities accurate history usually avoids this typically left with obtundation and and perioral area in a setting of confusion. Particularly in the absence neck stiffness and often prominent overventilation, constitutes the hyper of an accurate history, the following neurological deficits. A major cerebral ventilation syndrome. It is usually disorders should be considered: (1) embolism or thrombosis may produce caused by acute anxiety. Sometimes hypoglycemia, (2) epilepsy, (3) cere transient unconsciousness, but residual vasodepressor mechanisms are super bral vascular disease, (4) “drop neurological deficits are present. imposed and syncope results. attacks,” (5) hysterical faints, and (6) Transient cerebral ischemic attacks hyperventilation syndrome. involving the carotid artery distribu Evaluation of Syncope (See Table 3.) Hypoglycemia typically produces tion almost never produce transient All patients middle-aged or older confusion or behavioral abnormalities unconsciousness. While dizziness is one who have a syncopal episode without and then hunger and salivation. This is of the cardinal signs of brainstem an easily identifiable benign cause followed by sympathetic hyperactivity ischemia, true syncope is uncommon. should probably be admitted to the manifested by sweating, tachycardia, When dizziness results from brainstem hospital.
4 2 2 THE JOURNAL OF FAM ILY PRACTICE, VOL. 3, NO. 4, 1976 Emphasis is placed on a detailed syncope, inquiry should be made Table 3. Evaluation of Syncope regarding the association of the history because it is the most impor History — often diagnostic tant aspect of the evaluation. In reflex syncope with exertion, dyspnea, palpi BP supine, s ittin g , standing syncope such as cough, micturition, or tations, chest pain, or other symptoms Examine for peripheral neuropathy of cardiac awareness. A history of Examine for heart disease acute pain states, the history is C onsider: virtually diagnostic. The same can be rheumatic heart disease, coronary Chest film for heart failure, artery disease, or hypertension may be chamber size and calcification said of vasovagal syncope, although a ECG and rhythm monitoring search should be made for factors important. While one rarely has the hyperventilation contributing to orthostatic hypo opportunity to examine the patient treadmill test during an episode of syncope for the echocardiogram for chamber tension. Gentle massage of one and size and valve function then the other carotid sinus with presence of an arrhythmia, one should EEG monitoring of the pulse rate and examine for abnormalities of cardiac tests for hypoglycemia rhythm or rate, hypertension, signs of drug and alcohol screen rhythm plus the blood pressures is gentle carotid massage valuable in evaluating possible carotid congestive heart failure, murmurs, or central venous pressure carotid sinus sensitivity. The chest measurement sinus syncope. Rarely consider: In orthostatic hypotension with roentgenogram should be reviewed for cardiac, aortic arch, and syncope, the mechanism is proven by evidence of congestive heart failure, cerebral angiography obtaining the blood pressure in the chamber enlargement, or calcifications supine, sitting, and standing position. within the heart. The electrocardiogram In some patients vasomotor tone will may be normal, but susceptibility to not fail immediately upon standing, so tachy- or bradyarrhythmias is sug it is important to record the blood gested by unexplained sinus brady pressure immediately after standing cardia, wandering atrial pacemakers, and then at one, three, and five atrial fibrillation, or various conduc minutes or longer. A careful examina tion blocks. Findings suggesting Treatment of cardiogenic syncope tion of reflexes and sensory and motor ischemic heart disease or chamber is dependent on making the correct function should be made, looking for enlargement may give clues to the pathophysiologic diagnosis. Tachyar evidence of associated peripheral etiology of the patient’s heart disease. rhythmias may be treated in various neuropathy. If it is found, a specific Serial electrocardiograms or con ways depending on the seriousness of etiology should be sought. A drug tinuous rhythm monitoring over sev the arrhythmia. Maneuvers such as screen and alcohol level should be eral hours may document transient breath-holding, Valsalva or carotid considered. Central venous pressure rhythm disturbances. sinus massage may abort supraven can be measured when volume deple tricular tachyarrhythmias. More tion is a concern. Neurologic consulta serious arrhythmias may be controlled tion would seem prudent in a patient by the use of drugs such as quinidine, with any of the widespread neuro procainamide, digitalis, or propranolol. logical abnormalities suggesting one of Treatment Electrocardioversion or insertion of a the primary nervous system diseases The treatment of neurogenic pacemaker may be necessary in other associated with degeneration of the syncope should be directed toward patients. Syncope due to a valvular autonomic nervous system. preventing or correcting the cause of lesion may not be relieved without Two or three minutes of hyper the decreased cerebral perfusion. Vaso surgical correction. ventilation should be observed in any vagal syncope is best treated by patient suspected of the hyperventila eliminating precipitating factors such tion syndrome. Normal people may as emotional excitement, fatigue, become intensely dizzy with this hunger, inactivity, or sedative drugs. maneuver, so it is important that the These patients should be instructed to patient’s spontaneous episodes be assume a sitting or recumbent position mimicked by deep breathing before with the first presyncopal symptoms. one attributes etiologic significance to The use of measures to increase the hyperventilation. peripheral resistance such as support A glucose tolerance test, prolonged hose or ephedrine may be useful in the fasting or other provocative tests for patient with vasovagal syncope or References 1. Drachman DA, Hart CW: An ap hypoglycemia and electroencephalo orthostatic hypotension. Antihyper proach to the dizzy patient. Neurology tensive and diuretic medications 22:323-334, 1972 graphy for epilepsy should be reserved 2. Fisher CM: Vertigo in cerebrovascular for those patients in whom the should be avoided. Volume expansion disease. Arch Otolaryngol 85:529 534, 1967 through increased salt intake or 3. Gastaut H, Fischer-Williams M: Elec- diagnosis of syncope is uncertain. tro-encephalograph ic study of syncope. Rarely will aortic arch and cerebral fludrocortisone may be useful. Cardiac Lancet 2:1018-1025, 1957 slowing associated with vasovagal 4. Bannister R: Degeneration of the angiography need to be considered. autonomic nervous system. Lancet 2:175- Even if vascular abnormalities are syncope may be benefited by atropine. 1 7 9 , 1971 5. Shillingford JP: Syncope. Am J found in elderly patients, they will not Reflex syncope associated with mic Cardiol 26:609-612, 1970 necessarily be diagnostically meaning turition or coughing may be benefited 6. Dhingra RC, Denes P, Delon W, et al: Syncope in patients with chronic bifasci- ful. by having the patient avoid standing at cular block. Ann Intern Med 81:302 306, In the work-up of suspected cardiac the time of these activities. 1 9 7 4
4 2 3 THE JOURNAL OF FAM ILY PRACTICE, VO .. 3 , N O . 4 , 1 9 7 6 pediatric vaccines from Merck Sharp & Dohme
Indications: ATTENUVAX® (Measles Virus Vaccine, Live, Attenuated, MSD)— measles virus (probably the vaccine strain) from the CSF of one patient doe- Active immunization against measles (rubeola) in children one year of age suggest that some of these cases may have been caused by the vaccine' or older. The risk of such serious neurological disorders following live measles vh BIAVAX® (Rubella and Mumps Virus Vaccine, Live, MSD)—Simultaneous im vaccine administration remains far less than that for encephalitis * munization against rubella and mumps in children one year of age to puberty. measles (one per thousand reported cases). MERUVAXrtJ (Rubella Virus Vaccine, Live, MSD)—Immunization against rubella Rubella-Containing Vaccines-Adverse reactions may include fever and rash- (German measles) in children one year of age to puberty. May be useful for mild local reactions such as erythema, induration, tenderness, and region: postpubertal males to prevent or control rubella outbreaks in circumscribed lymphadenopathy; thrombocytopenia and purpura; allergic reactions sucb population groups. In postpubertal females vaccination must not be under urticaria; and arthritis, arthralgia, and polyneuritis. taken unless the woman is not pregnant, is susceptible to rubella (as shown Moderate fever (101-102.9 F) occurs occasionally, and high fever (103 p by Hemagglutination Inhibition test), understands it is imperative not to occurs less commonly. Rash occurs infrequently and is usually minimal wfe become pregnant for next three months and will follow a medically accept out generalized distribution. Encephalitis and other nervous system J able method for pregnancy prevention (also in immediate postpartum period), tions have occurred very rarely. and is informed of frequent occurrence of self-limited arthralgia and possi Transient arthritis, arthralgia, and polyneuritis vary in frequency and se«e- ble arthritis beginning two to four weeks after vaccination. ity with age and sex, being greatest in adult females and least in prepubert? M-M-R® (Measles, Mumps and Rubella Virus Vaccine, Live, MSD)—Simulta children. Symptoms relating to joints (pain, swelling, stiffness, etc.) andk neous immunization against measles, mumps, and rubella in children one peripheral nerves (pain, numbness, tingling, etc.) occurring within appro! year of age to puberty. mately two months after vaccination should be considered as possibly vac M-R-VAX® (Measles and Rubella Virus Vaccine, Live, MSD)—Simultaneous cine related. These symptoms need not be associated with other feature- immunization against measles (rubeola) and rubella (German measles) in of rubella, such as fever, rash, and lymphadenopathy. In prepubertal chi children one year of age to puberty. dren, the symptoms have generally been mild and of no more than three MUMPSVAX® (Mumps Virus Vaccine, Live, MSD)—Immunization against mumps days’ duration, with an incidence of less than 1 percent for reactions that for children over one year of age and adults. would interfere with normal activity or necessitate medical attention. Is Contraindications: Pregnancy or the possibility of pregnancy within three teen-age girls, the rates of reactions are somewhat higher but probably c- months following vaccination; infants less than one year old, except that not exceed 5 to 10 percent. In women, the rates are greater and may ex measles-containing vaccines may be administered during the first year of ceed 30 percent; the symptoms in older females tend to be more prominent life in certain populations (infants vaccinated under such conditions should and of longer duration, rarely persisting for a matter of months, but have be revaccinated after 12 months of age); sensitivity to eggs, chicken, chicken not generally interfered with normal activity. There is, at present, m feathers, or neomycin, and, for rubella-containing vaccines, duck, or duck evidence that the joint involvement or neuritis accompanying infection witi eggs or feathers; any febrile respiratory illness or other active infection; either natural rubella or the attenuated viruses predisposes to anyofth for measles-containing vaccines, active untreated tuberculosis; therapy with known chronic arthritic or neurologic diseases. Transient arthralgia at: ACTH, corticosteroids (except as replacement therapy, e.g., for Addison's arthritis in nonimmune males may occur; however, as in the natural disease disease), irradiation, alkylating agents, or antimetabolites; blood dyscrasias, the incidence is expected to be lower than in women. leukemia, lymphomas of any type, or other malignant neoplasms affecting Mumps-Containing Vaccines-?atoW\.\s. Rarely, purpura and allergic reactions the bone marrow or lymphatic systems; gamma globulin deficiency, i.e., such as urticaria. Very rarely, encephalitis and other nervous system reac agammaglobulinemia, hypogammaglobulinemia, and dysgammaglobulinemia. tions. With the monovalent mumps vaccine, mild fever occurs occasionally, Precautions: Administer subcutaneously; do not give intravenously. Epineph and fever above 103 F is uncommon. rine should be available for immediate use should an anaphylactoid re Shipment, Storage, and Reconstitution: During shipment, to insure that there action occur. Should not be given less than one month before or after is no loss of potency, the vaccine must be maintained at a temperature o: immunization with other live virus vaccines, with the exception of mono 10 C (50 F) or less. Before reconstitution, store vaccines at 2-8 C valent or trivalent poliovirus vaccine, live, oral, which may be admin (35.6-46.4 F) and protect from light. Use only diluent supplied to reconstitute istered simultaneously. Vaccinations should be deferred for at least three vaccines. If not used immediately, store reconstituted vaccines in a dart months following blood or plasma transfusions or administration of more place at 2-8 C (35.6-46.4 F), and discard if not used within eight hours. than 0.02 ml human immune serum globulin per pound of body weight. Color change: The usual color of the vaccine when reconstituted is pinkish Attenuated measles, mumps, and rubella virus vaccines, live, given sep to red due to the presence of phenol red, a pH indicator. Some vacciii; arately, may result in a temporary depression of tuberculin skin sensitivity; which has been shipped in dry ice may exhibit a variation in color whei therefore, if a tuberculin test is to be done, it should be administered be reconstituted because carbon dioxide has been absorbed from the dry ice. fore or simultaneously with any virus vaccine. This vaccine, if crystal clear on reconstitution, is acceptable for use whethe: Measles-Containing Vaccines—Due caution should be employed in children it is red, pink, or yellow. with a history of febrile convulsions, cerebral injury, or any other condition in How Supplied: ATTENUVAX® (Measles Virus Vaccine, Live, Attenuated, MSDj- which stress due to fever should be avoided. The physician should be alert Single-dose vials of lyophilized vaccine, containing when reconstituted net to the temperature elevation which may occur 5 to 12 days after vac less than 1,000 TCIDso (tissue culture infectious doses) of measles v im s cination. The occurrence of thrombocytopenia and purpura has been ex vaccine expressed in terms of the assigned titer of the FDA Reference tremely rare. Measles Virus, and approximately 25 meg neomycin. Rubella-Containing Vaccines—Excretion of live attenuated rubella virus from BIAVAX® (Rubella and Mumps Virus Vaccine, Live, MSD)—Single-dose vialsol the throat has occurred in the majority of susceptible individuals admin lyophilized vaccine, containing when reconstituted not less than 1,000 TCID-,; istered rubella vaccine. There is no definitive evidence to indicate that such of rubella virus vaccine, live, and 5,000 TCID50 of mumps virus vaccine, lit virus is contagious to susceptible persons who are in contact with vac expressed in terms of the assigned titer of the FDA Reference Rubella am cinated individuals. Consequently, transmission, while accepted as a the Mumps Viruses, and approximately 25 meg neomycin. oretical possibility, has not been regarded as a significant risk. MERUVAX® (Rubella Virus Vaccine, Live, MSD)—Single-dose vials of lyophilized Adverse Reactions: To date, clinical evaluation of the combination vaccines vaccine, containing when reconstituted not less than 1,000 TCID50 oi has revealed those adverse reactions expected to follow administration of rubella virus vaccine expressed in terms of the assigned titer of the FBI the monovalent vaccines given separately. Reference Rubella Virus, and approximately 25 meg neomycin. Measles-Containing Vaccines-Occasionally, moderate fever (101-102.9 F); M-M-R® (Measles, Mumps and Rubella Virus Vaccine, Live, MSD)—Single-dosi less commonly, high fever (above 103 F); rarely, febrile convulsions. Infre vials of lyophilized vaccine, containing when reconstituted not less than quently, rash, usually minimal without generalized distribution. Reactions 1,000 TCID50 of measles virus vaccine, live, attenuated, 5,000 TCID50of at injection site. Local reactions characterized by marked swelling, redness, mumps virus vaccine, live, and 1,000 TCID50 of rubella virus vaccine, lit and vesiculation at the injection site of attenuated live measles virus vac expressed in terms of the assigned titer of the FDA Reference Measles cines have occurred in children who received killed measles vaccine pre Mumps, and Rubella Viruses, and approximately 25 meg neomycin. viously; the combination vaccines were not given under this condition in M-R-VAX® (Measles and Rubella Virus Vaccine, Live, MSD)—Single-dose v ia ls clinical trials. of lyophilized vaccine, containing when reconstituted not less than l.O O v Experience from more than 44 million doses of all live measles vaccines TCIDso of measles virus vaccine, live, attenuated, and 1,000 TCID50«! given in the U.S. by mid-1971 indicates that significant central nervous rubella virus vaccine, live, expressed in terms of the assigned titer of ths system reactions such as encephalitis, occurring within 30 days after vac FDA Reference Measles and Rubella Viruses, and approximately 25 mt; cination, have been temporally associated with measles vaccine approxi neomycin. mately once for every million doses. In no case has it been shown that MUMPSVAX® (Mumps Virus Vaccine, Live, MSD)—Single-dose vials of lyophil reactions were actually caused by vaccine. The Center for Disease Control ized vaccine, containing when reconstituted not less than 5,000 TCID50® has pointed out that “ a certain number of cases of encephalitis may be mumps virus vaccine expressed in terms of the assigned titer of the FM expected to occur in a large childhood population in a defined period of Reference Mumps Virus, and approximately 25 meg neomycin. time even when no vaccines are administered. A survey conducted in Each of these vaccines is supplied as a single-dose vial packed with < New Jersey in 1965 showed that 2.8 cases of encephalitis (of unknown cause) disposable syringe containing diluent and fitted with a 25-gauge, % " needle occurred per million children, ages 1-9 years per 30-day period.” ! However, and as a box of 10 single-dose vials with an accompanying box of 10 diluent the Center for Disease Control has analyzed the reported reactions following containing disposable syringes with affixed needles. iW IC fi measles vaccines and pointed out that "the clustering of cases in the For more detailed information, consult your MSD i r t S D period 6 through 13 days after inoculation as well as the recovery of representative or see fu ll prescribing information. M ERCK fNational Communicable Disease Center, Encephalitis Merck Sharp & Dohme, Division o f Merck & Co., INC., SHARR Surveillance Report, 1965 Annual Supplement, July 1,1966. West Point, Pa. 19486. DOHMt