The effect of race/ethnicity on gestational weight gain.

Minority women are gaining more weight than recommended during pregnancy. This study aimed to determine the risk of excessive gestational weight gain (GWG) in Hispanic and Black women compared to non-Hispanic women in Colorado. A retrospective cohort study of all birth records from 2007 to 2010 in Colorado was conducted. The primary outcome was GWG, and the exposure was race/ethnicity. Covariates were marital status, education, intensity of prenatal care, age, parity, tobacco use, alcohol use and years in the US. Chi square and multiple logistic regression was performed. 230,698 records were analyzed. Half of the Hispanic and Black women began their pregnancy overweight or obese. Hispanic women had a 0.84 (95% CI 0.8-0.9) and Black women had a 0.95 (95% CI 0.9-1.0) risk of excessive GWG than NHW women. Pre-pregnancy weight is an independent risk for adverse outcomes. The study findings provide healthcare providers focal points in preconception health care and programming.

Church-based social marketing to motivate older adults to take balance classes for fall prevention: cluster randomized controlled trial.

OBJECTIVE: Determine whether a church-based social marketing program increases older adults' participation in balance classes for fall prevention. METHODS: In 2009-10, 51 churches (7101 total members aged ≥ 60) in Colorado, U.S.A. were randomized to receive no intervention or a social marketing program. The program highlighted benefits of class participation (staying independent, building relationships), reduced potential barriers (providing convenient, subsidized classes), and communicated marketing messages through church leaders, trained "messengers," printed materials and church-based communication channels. Between-group differences in balance class enrollment and marketing message recall among congregants were compared using Wilcoxon Two-Sample Test and regression models. RESULTS: Compared to 25 control churches, 26 churches receiving the social marketing program had a higher median proportion (9.8% vs. 0.3%; p<0.001) and mean number (7.0 vs. 0.5; IRR=11.2 [95%CI: 7.5, 16.8]) of older adult congregants who joined balance classes. Intervention church members were also more likely to recall information about preventing falls with balance classes (AOR=6.2; 95% CI: 2.6, 14.8) and availability of classes locally (AOR=7.7; 95% CI: 2.6, 22.9). CONCLUSIONS: Church-based social marketing effectively disseminated messages about preventing falls through balance classes and, by emphasizing benefits and reducing barriers and costs of participation, successfully motivated older adults to enroll in the classes.

Validation of a method for quantifying carotid artery calcification from panoramic radiographs.

OBJECTIVE: Carotid artery calcification can be visualized on panoramic radiographs. Incidental observation of these calcifications could identify patients in need of further screening. The purpose of this study was to validate the assessment and quantification of calcification on panoramic radiographs with the stenosis and the calculated resistive index (RI) from Doppler ultrasonography. STUDY DESIGN: Digital panoramic radiographs were used to assess the area of carotid artery calcification using tools available in NIH's ImageJ. Inpatient and outpatient discharge records were reviewed to identify subjects with a completed carotid Doppler ultrasound exam (n = 122). RESULTS: The quantification of carotid artery calcification was found to correlate well with the degree of stenosis (area under the curve [AUC] 0.81 [95% confidence interval [CI] 0.64, 0.98]) and the RI of the common carotid artery (AUC 0.79 [95% CI 0.59, 0.98]). CONCLUSION: This method for quantification of carotid artery calcification could identify patients in need of further evaluation.

Performance of 3-dimensional echocardiography in measuring left ventricular volumes and ejection fraction: a systematic review and meta-analysis.

OBJECTIVES: The primary aim of this systematic review is to objectively evaluate the test performance characteristics of three-dimensional echocardiography (3DE) in measuring left ventricular (LV) volumes and ejection fraction (EF). BACKGROUND: Despite its growing use in clinical laboratories, the accuracy of 3DE has not been studied on a large scale. It is unclear if this technology offers an advantage over traditional two-dimensional (2D) methods. METHODS: We searched for studies that compared LV volumes and EF measured by 3DE and cardiac magnetic resonance (CMR) imaging. A subset of those also compared standard 2D methods with CMR. We used meta-analyses to determine the overall bias and limits of agreement of LV end-diastolic volume (EDV), end-systolic volume (ESV), and EF measured by 3DE and 2D echocardiography (2DE). RESULTS: Twenty-three studies (1,638 echocardiograms) were included. The pooled biases ± 2 SDs for 3DE were -19.1 ± 34.2 ml, -10.1 ± 29.7 ml, and - 0.6 ± 11.8% for EDV, ESV, and EF, respectively. Nine studies also included data from 2DE, where the pooled biases were -48.2 ± 55.9 ml, -27.7 ± 45.7 ml, and 0.1 ± 13.9% for EDV, ESV, and EF, respectively. In this subset, the difference in bias between 3DE and 2D volumes was statistically significant (p = 0.01 for both EDV and ESV). The difference in variance was statistically significant (p < 0.001) for all 3 measurements. CONCLUSIONS: Three-dimensional echocardiography underestimates volumes and has wide limits of agreement, but compared with traditional 2D methods in these carefully performed studies, 3DE is more accurate for volumes and more precise in all 3 measurements.

Observational studies of patients in the emergency department: a comparison of 4 sampling methods.

STUDY OBJECTIVE: We evaluate the ability of 4 sampling methods to generate representative samples of the emergency department (ED) population. METHODS: We analyzed the electronic records of 21,662 consecutive patient visits at an urban, academic ED. From this population, we simulated different models of study recruitment in the ED by using 2 sample sizes (n=200 and n=400) and 4 sampling methods: true random, random 4-hour time blocks by exact sample size, random 4-hour time blocks by a predetermined number of blocks, and convenience or "business hours." For each method and sample size, we obtained 1,000 samples from the population. Using χ(2) tests, we measured the number of statistically significant differences between the sample and the population for 8 variables (age, sex, race/ethnicity, language, triage acuity, arrival mode, disposition, and payer source). Then, for each variable, method, and sample size, we compared the proportion of the 1,000 samples that differed from the overall ED population to the expected proportion (5%). RESULTS: Only the true random samples represented the population with respect to sex, race/ethnicity, triage acuity, mode of arrival, language, and payer source in at least 95% of the samples. Patient samples obtained using random 4-hour time blocks and business hours sampling systematically differed from the overall ED patient population for several important demographic and clinical variables. However, the magnitude of these differences was not large. CONCLUSION: Common sampling strategies selected for ED-based studies may affect parameter estimates for several representative population variables. However, the potential for bias for these variables appears small.

Loss of alveolar bone due to periodontal disease exhibits a threshold on the association with coronary heart disease.

BACKGROUND: A number of epidemiologic studies were published that looked at the association between coronary heart disease (CHD) and periodontal disease. However, debate exists about whether this association is a true relationship or simply an example of an uncontrolled confounder. This retrospective cohort study examines the relationship between periodontal disease and CHD. METHODS: Digital panoramic radiographs were used to assess alveolar bone loss (ABL) using a Schei ruler. Participants consisted of Veterans Administration (VA) patients who were eligible for dental benefits and had a digital panoramic radiograph taken at the VA Medical Center, Denver, Colorado. Information on CHD and other important clinical variables were obtained from electronic medical records. RESULTS: The examination of the relationship between ABL and CHD revealed a significant non-linear relationship with a threshold at ≈ 20% bone loss with a doubling of the probability ratios of CHD compared to those at 7.5% bone loss. CONCLUSIONS: To our knowledge, this is the first study to demonstrate a non-linear relationship between ABL and CHD. A significant positive association between ABL and CHD was found at even low levels of bone loss between 10% and 20%.

Functional and psychosocial outcomes of older adults after burn injury: results from a multicenter database of severe burn injury.

A number of factors increase the susceptibility of older adults to burn injury. The majority of studies of older adults have focused on patient and injury factors related to mortality risk. However, little is known about the long-term functional and psychological outcomes of older adults after severe burn. The purpose of this study is to examine the long-term outcomes of older adults after burn injury. The authors performed an analysis of the outcomes of older adults (age 55 years or older) enrolled in a prospective study of burn injury outcomes. Change in living situation as well as distress, functional impairment, and quality of life were examined at discharge and at 6, 12, and 24 months after hospital discharge. Mixed effects modeling was performed to compare differences across age groups and time as well as to account for missing data. A total of 737 patients aged 55 years or older were enrolled and followed in the National Institute on Disability and Rehabilitation Research burn program. Patients in all age groups had significant deficits in Short Form-36, Functional Independence Measure, and Brief Symptom Inventory scores at time of discharge. Recovery of physical and psychosocial functioning was greatest from discharge to 6 months in patients aged 55 to 74 years and greatest at 1 year for patients aged 75 years or older. This study confirms that severe burn injury significantly impacts both functional outcome and psychosocial quality of life in older adults. However, the impact seems to be age related as are recovery trajectories. Rehabilitation programs lasting up to 1 year after injury could be of tremendous benefit in helping older adults achieve maximal potential recovery.

Effect of maternal birthplace on gestational diabetes prevalence in Colorado Hispanics.

(1) Describe gestational diabetes mellitus (GDM) prevalence time trends in USborn (USWH) and Mexico-born (MWH), white Hispanic Colorado women and (2) Determine effect of maternal birthplace on GDM prevalence. Retrospective population-based study of 1995-2004 Colorado birth certificate data for live, singleton births to white, Hispanic mothers estimated prevalence, trends, and association of GDM and maternal birthplace. Univariate, bivariate and logistic regression analyses were conducted. GDM prevalence in 154,957 births increased in both USWH (1.77-2.53%, P < 0.0001) and MWH (2.38-3.08%, P < 0.0001). Over study years, MWH had higher crude odds (OR = 1.30; 95% CI = 1.22-1.38) for developing GDM than USWH. Adjustment for maternal age and maternal education reduced GDM risk by birth country (OR = 1.05; 95% CI = 0.98-1.13, P = ns). GDM prevalence increased in both US-born and Mexico-born, white, Hispanic Colorado women. Mexico-born immigrant women may have increased risk for GDM compared with their USborn counterparts. Lower education attainment may be determinant of disease risk.

Perceptions regarding workplace hazards at a veterinary teaching hospital.

OBJECTIVE: To assess perceptions of personnel working at a veterinary teaching hospital regarding risks of occupational hazards and compare those perceptions with assessments made by occupational safety experts. DESIGN: Cross-sectional study. STUDY POPULATION: A representative sample of personnel (n = 90) working at the veterinary teaching hospital at Colorado State University and a panel of 3 occupational safety experts. PROCEDURES: Hospital personnel ranked perceptions of 14 physical, chemical, and biological workplace hazards and listed the injuries, illnesses, and near misses they had experienced. The expert panel provided consensus rankings of the same 14 hazards for 9 sections of the facility. Risk perceptions provided by the 2 sources were compared. RESULTS: Risk perceptions did not differ significantly between hospital personnel and the expert panel for most of the site-specific comparisons (94/126 [75%]). Personnel perceived greater risks for some physical hazards (loud noises, sharps injuries, and ionizing radiation) and some chemical or materials exposures (insecticides or pesticides and tissue digester emissions). In contrast, the expert panel perceived greater risks for physical hazards (bite or crush and restraining and moving animals), chemical exposures (anesthetic waste gas), and biological exposures (Toxoplasma gondii, antimicrobial-resistant bacteria, and allergens). CONCLUSIONS AND CLINICAL RELEVANCE: Participants and safety experts had similar perceptions about occupational risks, but there were important differences where hospital personnel apparently overestimated or underappreciated the risks for workplace hazards. This type of study may be useful in guiding development of optimal workplace safety programs for veterinary hospitals.

Plasma 25,OH vitamin D concentrations are not associated with rheumatoid arthritis (RA)-related autoantibodies in individuals at elevated risk for RA.

OBJECTIVE: To evaluate the association between rheumatoid arthritis (RA)-related autoantibodies and plasma 25,OH vitamin D in subjects at risk for RA. METHODS: In 1210 subjects without RA, 76 were positive for anti-cyclic citrullinated peptide antibodies or for at least 2 rheumatoid factors (RF; by nephelometry: RF-IgM, RF-IgG, RF-IgA). 25,OH vitamin D was measured in these cases and 154 autoantibody-negative controls from this cohort. RESULTS: 25,OH vitamin D levels did not differ between cases and controls (adjusted OR 1.23, 95% CI 0.93-1.63). CONCLUSION: Vitamin D concentrations are not associated with RA-related autoimmunity in unaffected subjects at increased risk for RA.

Acute pain at discharge from hospitalization is a prospective predictor of long-term suicidal ideation after burn injury.

OBJECTIVE: To determine the extent to which pain contributes to risk for suicidal ideation after burn injury. DESIGN: This longitudinal cohort study evaluated participants at discharge, 6 months, and 1 year after burn injury. SETTING: Inpatient rehabilitation units of multiple regional burn centers. PARTICIPANTS: Survivors of major burns (N=128). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pain severity, assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain subscale, and passive and active suicidal ideation, assessed by self-report. RESULTS: At each time point, approximately one quarter to one third of the sample reported some form of suicidal ideation. In logistic regression analyses, pain severity at discharge was the sole consistent predictor of suicidal ideation at follow-up, with greater pain severity being associated with enhanced risk for both passive and active suicidal ideation. These associations were observed even after controlling for discharge mental health. CONCLUSIONS: These are the first findings to suggest an association between acute pain severity and the development and maintenance of suicidal ideation in burn patients. Further research in this area, including the study of improved pain management programs as a prophylaxis against suicidal ideation, may benefit those who are at elevated suicide risk as a consequence of burn injuries.

Barriers to return to work after burn injuries.

OBJECTIVE: To identify barriers to return to work after burn injury as identified by the patient. DESIGN: A cohort study with telephone interview up to 1 year. SETTING: Hospital-based burn centers at 3 national sites. PARTICIPANTS: Hospitalized patients (N=154) meeting the American Burn Association criteria for major burn injury, employed at least 20 hours a week at the time of injury, and with access to a telephone after discharge. INTERVENTION: Patients were contacted via telephone every 2 weeks up to 4 months, then monthly up to 1 year after discharge. MAIN OUTCOME MEASURES: A return to work survey was used to identify barriers that prevented patients from returning to work. A graphic rating scale determined the impact of each barrier. RESULTS: By 1 year, 79.7% of patients returned to work. Physical and wound issues were barriers early after discharge. Although physical abilities continued to be a significant barrier up to 1 year, working conditions (temperature, humidity, safety) and psychosocial factors (nightmares, flashbacks, appearance concerns) became important issues in those with long-term disability. CONCLUSIONS: The majority of patients return to work after a burn injury. Although physical and work conditions are important barriers, psychosocial issues need to be evaluated and treated to optimize return to work.

Assets and liabilities of the Burn Model System data model: a comparison with the National Burn Registry.

OBJECTIVES: To determine whether the Burn Model System (BMS) population is representative of the larger burn population and to investigate threats to internal and external validity in a multicenter longitudinal database of severe burns. DESIGN: Cohort data for the BMS project have been collected since 1994. Follow-up data have been collected at 6, 12, and 24 months postburn. The demographic and burn characteristics of the BMS population were compared with those of patients in the National Burn Registry (NBR). SETTING: The BMS, which collected data for these analyses from 5 regional burn centers in the United States, and the NBR dataset, which is a registry of information collected through the Trauma Registry of the American College of Surgeons and includes data from 70 hospitals in the United States and Canada. PARTICIPANTS: BMS study participants were severely burned patients treated at 1 of the 5 participating burn centers. We compared the BMS population with that of the NBR both in total and filtered to include only patients with comparable injuries. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Comparable demographic and burn characteristics contained in both the NBR and the 5-center BMS longitudinal database and baseline and follow-up distributions of demographic variables and burn characteristics in the BMS database. RESULTS: Although minor deviations in demographic distributions were found between the BMS and NBR and between discharge and follow-up populations, our results show that the BMS population sample is internally and externally valid and is adequate for answering research questions. CONCLUSIONS: Cohort studies examining long-term outcomes have the potential flaw of using a nonrepresentative study population. The BMS population was found to be sufficiently representative, but future analyses will require cautious and purposeful application of statistical adjustment strategies.

Mortality from pulmonary fibrosis increased in the United States from 1992 to 2003.

RATIONALE: From the late 1970s to the early 1990s, studies found that mortality rates for pulmonary fibrosis were increasing. Recent data for mortality from pulmonary fibrosis are unavailable. OBJECTIVES: We sought to determine mortality rates for pulmonary fibrosis in the United States from 1992 through 2003. METHODS: Using data from the National Center for Health Statistics, we calculated age-adjusted mortality rates from the deaths of persons with pulmonary fibrosis and stratified the data to determine differences in mortality rates by age, sex, race/ethnicity, and geography of the decedent. We developed a multivariable model to predict future mortality rates, and we determined the underlying cause of death in patients with pulmonary fibrosis. MEASUREMENTS AND MAIN RESULTS: From 1992 to 2003, there were 28,176,224 deaths in the United States and 175,088 decedents with pulmonary fibrosis. The average age- and sex-adjusted mortality rate was 50.8 per 1,000,000 people. The age-adjusted mortality rate increased 28.4% in men (from 40.2 deaths per 1,000,000 in 1992 to 61.9 deaths per 1,000,000 in 2003) and 41.3% in women (from 39.0 deaths per 1,000,000 in 1992 to 55.1 deaths per 1,000,000 in 2003). While increases were significant in both men and women (p < 0.0001), the rate of increase was higher in women (p < 0.0001). The most common cause of death in patients with pulmonary fibrosis was the disease itself. CONCLUSIONS: From 1992 to 2003, mortality rates for pulmonary fibrosis significantly increased. Further investigation is needed to determine the etiology of these trends, which are predicted to continue to increase.

Risk factors for asthma among cosmetology professionals in Colorado.

PROBLEM: After receiving several reports of occupational asthma among cosmetology professionals, we studied the prevalence, work-attributable risk, and tasks associated with asthma in this industry. METHODS: We selected a stratified random sample of cosmeticians, manicurists, barbers, and cosmetologists holding licenses in Colorado for a mail survey instrument. RESULTS: The prevalence of physician-diagnosed asthma among the 1883 respondents (68% response rate) was 9.3%; of these, 67 (38%) developed asthma after entering the cosmetology profession. Multivariate analyses showed that hairstyling, application of artificial nails, and shaving and honing were significantly associated with asthma arising in the course of employment (P < 0.005) with relative risks of 2.6-2.9. CONCLUSIONS: The increased risk of asthma with onset during employment among cosmetologists is probably attributable to their exposure to sensitizers and irritants in tasks demonstrated to be associated with asthma.

Profile of patients lost to follow-up in the Burn Injury Rehabilitation Model Systems' longitudinal database.

We sought to identify whether patterns exist in the Burn Injury Rehabilitation Model Systems' database among participants lost to follow-up at 6, 12, or 24 months after injury and to define characteristics that reliably discriminate between persons who are lost to follow-up and those who are not. All participants met the American Burn Association criteria for major burn injury, were 18 years of age or older, received care from one of four burn model systems, and consented to participate in a 2-year prospective data-collection process. Step-wise logistic regression was used to develop three prediction models for the probability of loss to follow-up. The percent of individuals successfully contacted for follow-up were 64% at 6 months, 54% at 12 months, and 42% at 24 months after injury. Individuals who were younger, not employed at time of burn, with less than a high school level education, a history of drug abuse, circumstances of injury involving suspected assault, and having no insurance for care were lost to follow-up. Longer stay in the hospital, on the other hand, increased the likelihood of follow-up. The same risk factors remained significant with or without adjusting for site indicating that these factors are independent and significant in spite of any potential site differences. Successful follow-up at 6- and 12-month intervals increased the likelihood of achieving a follow-up at 24 months after injury. The sociodemographic risk factors for attrition identified in this study represent significant enduring vulnerabilities. The findings necessitate a close examination of several factors and the use of strategies to reduce the risk of attrition.

Uncomplicated acute renal failure and hospital resource utilization: a retrospective multicenter analysis.

BACKGROUND: Although acute renal failure (ARF) complicating nonrenal organ dysfunction in the intensive care unit is associated with significant mortality and hospital costs, hospital resource utilization attributed to uncomplicated ARF is not well known. The goal of this study is to characterize the costs and lengths of stay (LOSs) incurred by hospitalized patients with uncomplicated ARF and their important determining factors. METHODS: We obtained hospital case-mix data sets from 23 Massachusetts hospitals for a 2-year period (1999 to 2000) from the Massachusetts Division of Health Care Finance and Policy. A total of 2,252 records of patients hospitalized with uncomplicated ARF were identified. Patient records of other common medical diagnoses were studied for comparison. RESULTS: Patients hospitalized with uncomplicated ARF incurred median direct hospital costs of 2,600 dollars, median hospital LOS of 5 days, and mortality of 8%. Dialysis was independently associated with significantly greater hospital costs and LOSs for patients with uncomplicated ARF (P < 0.05). Male sex and nonwhite race were associated with significantly lower hospital costs and LOSs, whereas type of hospital had opposing effects on these 2 resource utilization outcomes (P < 0.05). Unadjusted aggregate resource utilization associated with uncomplicated ARF exceeded that of many other common illnesses. CONCLUSION: Demographic and hospital factors, as well as dialysis therapy, are significant determinants of hospital resource utilization for patients with uncomplicated ARF. Uncomplicated ARF appears to incur greater hospital costs and longer LOSs compared with other common medical conditions. Greater focus should be directed toward further understanding of the factors influencing resource utilization for ARF.

Factors contributing to construction injury at Denver International Airport.

BACKGROUND: Detailed information about factors contributing to construction injury is important to support design of safety programs directed at particular risks. METHODS: We linked over 4,000 injury reports, including text describing injury events, with an administrative workers' compensation (WC) database, and, using Haddon's matrix as a framework, classified factors contributing to injury during construction of Denver International Airport (DIA). RESULTS: Patterns of contributing factors varied according to injury mechanism and type of work: environmental factors contributed more than any other factor to slip/trip injuries, and building materials contributed to more than 40% of injuries to workers in carpentry, concrete construction, glass installation, and roofing. Rates at which factors contributed to injury also varied among types of work: environmental factors contributed at relatively high rates to injuries in glass installation, metal/steel installation and iron/steel erection >or= 2 stories, and victim factors contributed at high rates to conduit construction and metal/steel installation injuries. WC payment rates for different factors varied widely, ranging from $0.53/$100 payroll to $3.08/$100. DISCUSSION: This approach allows systematic analysis of classes of injuries, contributing factors, types of work, and other variables to assist in setting prevention priorities.

"Opioid creep" is real and may be the cause of "fluid creep".

Recent studies have shown that burn patients receive larger volumes of fluids than predicted by the Baxter formula and the reason for this is unclear. One potential reason is that increased analgesics are used which could blunt the response to fluid resuscitation. The purpose of this study was to compare the administration of opioid agonists in patients treated at a single burn center in the 1970s and in the year 2000. We performed a retrospective chart review comparing two matched cohorts. Group I consisted of 11 patients admitted between 1975 and 1978. Group II consisted of 11 patients admitted in 2000 matched for age, sex and %TBSA. Patients in Group II received a significantly higher mean opioid equivalent than those in Group I (26.5 +/- 12.3 versus 3.9 +/- 2.2 in the first 24h, P < 0.001). In addition, in Group II, a larger variety and combination of opioid agonists were used. This review demonstrates a significant increase from the 1970s to 2000 in the type, dose prescribed and dose delivered of opioid agonists. Along with "fluid creep", we have also increased our use of opioid agonists or "opioid creep". Higher doses of opioid agonists may have hemodynamic consequences, which may contribute to the increased fluid volumes.

An 8-center study to evaluate the utility of mid-term genetic sonograms among high-risk pregnancies.

OBJECTIVE: A multicenter study was undertaken to evaluate the diagnostic efficacy of a genetic sonogram. METHODS: Eight centers provided data on 176 pregnancies complicated by fetal Down syndrome. One hundred thirty-four pregnancies were considered high risk because of advanced maternal age (> 35 years), and 42 were considered high risk for having "abnormal" triple-screen results (risk > 1:250). Each center provided fetal biometric data, information regarding the presence or absence of major structural abnormalities, and between 3 and 6 additional ultrasonographic markers for trisomy 21. The heterogeneity of our 8 independent "sensitivity estimates" was evaluated by Poisson regression, and a single combined estimate of the sensitivity was calculated. RESULTS: Of the total 176 cases of trisomy 21, 125 fetuses (71.0%) had either an abnormal long bone length (femur length, humerus length, or both), a major structural abnormality, or a Down syndrome marker. The combined diagnostic sensitivity was 71.6%, with a range of 63.6% (7 of 11) to 80% (8 of 10). Five centers had sensitivity estimates falling between 64% and 76%. The sensitivity of individual markers varied between 3% (sandal gap) and 46.5% (nuchal skin fold thickness). A condensed regimen of nuchal skin fold thickness, femur length, and a standard anatomic survey would screen in 56.8% of fetuses with Down syndrome. CONCLUSIONS: This 8-center study that included many fetuses with Down syndrome validates the concept that the genetic sonogram can be used to better adjust the Down syndrome risk for high-risk patients.