Cardiac Findings during Uncomplicated Acute Influenza in Ambulatory Adults

Size: px
Start display at page:

Download "Cardiac Findings during Uncomplicated Acute Influenza in Ambulatory Adults"

Transcription

1 MAJOR ARTICLE Cardiac Findings during Uncomplicated Acute Influenza in Ambulatory Adults Michael G. Ison, 1 Vicky Campbell, 2 Chris Rembold, 3 John Dent, 3 and Frederick G. Hayden 1 1 Division of Infectious Diseases and International Health, 2 Breast Care Center, and 3 Division of Cardiology, University of Virginia, Charlottesville Background. Previous studies have reported abnormal cardiac findings in up to 43% of ambulatory adults with influenza. This study was conducted to determine the frequency, magnitude, and duration of myocardial dysfunction in such persons. Methods. We enrolled 30 previously healthy young adults without known cardiovascular disease who presented to the clinic 72 h after onset of influenza symptoms and had a positive influenza antigen test. Most patients received antiviral therapy, and all underwent serial electrocardiography and had blood specimens collected on days 1, 4, 11, and 28 after presentation for measurement of total creatine kinase (CK) level, CK isoenzyme MB (CK- MB) level, troponin I level, and selected cytokine levels. Echocardiography was performed on days 4, 11, and 28. Results. None of the patients had an elevated CK-MB index or troponin I level. Abnormal electrocardiogram findings were noted in 53%, 33%, 27%, and 23% of patients on days 1, 4, 11, and 28, respectively, but none of the findings were considered to be clinically significant. No patient had significant changes in the ejection fraction or abnormal wall motions. Conclusions. Most ambulatory young adults with acute influenza have clinically insignificant abnormal electrocardiogram findings early during the illness. These abnormalities resolve promptly and are not associated with changes in cardiac markers or echocardiogram findings. Influenza virus causes annual epidemics of a respiratory illness characterized by sudden onset of fever, malaise, myalgias, headache, cough, and other respiratory complaints [1]. Although most cases of influenza are uncomplicated, influenza is responsible for 294,000 excess hospitalizations and 36,000 excess deaths each year in the United States [2, 3]. In addition to exacerbation of underlying pulmonary disease and bacterial superinfections, influenza causes exacerbation of congestive heart failure and increased cardiac ischemia, which may contribute to an additional 90,000 deaths per year [4, 5]. Adverse cardiovascular events occur through a number of mechanisms, including fever, vasodilatation, hypovolemia, hypoxia, proinflammatory cytokine elaboration, and procoagulant effects [5]. In addition, influenza has also been recognized to cause direct car- Received 21 June 2004; accepted 29 September 2004; electronically published 10 January Reprints or correspondence: Dr. Frederick G. Hayden, University of Virginia Health System, PO Box , Private Clinics Bldg., Room 6577b, Charlottesville, VA (fgh@virginia.edu). Clinical Infectious Diseases 2005; 40: by the Infectious Diseases Society of America. All rights reserved /2005/ $15.00 diac changes, including myocarditis and pericarditis. Several older studies have documented cardiac changes associated with acute influenza virus infection in 15% 43% of ambulatory patients and in 14% 75% of hospitalized patients [6 8]. Influenza virus infection has been associated with 1% 18% of myocarditis cases [9 21]. During a recent study of experimentally induced influenza, one subject developed myocardial dysfunction and presumed myocarditis that temporally followed influenza (unpublished data). Consequently, the current study was undertaken to prospectively examine the frequency of cardiac abnormalities in otherwise healthy adults with acute, naturally occurring influenza. CASE REPORT In July 2000, a total of 75 healthy adult volunteers at the University of Virginia (Charlottesville) were experimentally infected with influenza B/Yamagata/88 to assess the prophylactic efficacy of the oral neuraminidase inhibitor peramivir (BCX-1812; also known as RWJ ) [22, 23]. The case patient, a 21-year-old man with no previous history of cardiac abnormalities, received the study drug and experienced an adverse Cardiac Findings in Adults with Influenza CID 2005:40 (1 February) 415

2 cardiac event that was reported to the US Food and Drug Administration. He had a history of monocular blindness secondary to retinoblastoma that had been successfully treated with systemic chemotherapy, including an anthracycline agent, at 2 years of age. The patient was not taking any medications before enrollment into the study. He was a social drinker, consuming up to 12 beers per week, but he did not use tobacco and was physically active. He had no family history of cardiac disease. The prestudy evaluation revealed normal physical examination findings and laboratory studies, with the exceptions of an electrocardiogram (ECG) that revealed T wave flattening in the avf and T wave inversion in lead III and an elevated total creatinine kinase (CK) level of 505 IU/mL. The latter was attributed to his exercise regimen; a second test performed before viral inoculation revealed a CK level of 202 IU/mL. The subject became infected and shed low titers of influenza B virus on study days 3 9; he had no fever and reported only mild nasal symptoms, sore throat, and loss of appetite. On day 4 of the study, an ECG revealed new T wave inversions in leads II, avf, and v4 6 (figure 1). The patient denied having any cardiac symptoms. The CK level in a blood sample obtained 2 days later was 126 IU/mL. Findings of an ECG performed 15 days after infection had returned to those observed at baseline. At the completion of the study, the patient took a 2-week vacation to Indonesia, during which time he experienced upper respiratory infection symptoms (but no cardiac symptoms) for several days and received intranasal steroid therapy. Because of the ECG changes, the patient was asked to return and undergo echocardiography, which revealed left ventricular enlargement with severely reduced systolic function globally and minimal mitral and tricuspid regurgitation 51 days after infection. During a cardiologic evaluation, the patient was asymptomatic, and the examination revealed 6-cm jugular venous distention, normal heart sounds without gallop or rub, and a faint mitral regurgitation murmur. His lungs were clear to auscultation, and he had no hepatomegaly or peripheral edema. Serological tests were negative for Trypanosoma cruzi, cytomegalovirus, the agent of Lyme disease, HIV, coxsackieviruses (A7, A9, A10, A16, and B1 6), rheumatoid factor, and antibody to nuclear antigens. Serological findings were consistent with past Epstein- Barr virus infection. His erythrocyte sedimentation rate was 1 mm/h. Nasal wash samples collected during the study and tested by RT-PCR for enterovirus at the Centers for Disease Control and Prevention (Atlanta, GA) were negative. He was treated with lisinopril (5 mg po q.d.) and was allowed to gradually increase his exercise levels. Successive echocardiograms at 1 month and 5 months later showed progressive improvement in left ventricle function; the final study showed that the ejection fraction level had returned to low normal. The patient was clinically well at 1 year but has since been lost to follow-up. PATIENTS AND METHODS We conducted a prospective, observational cohort study at the University of Virginia during the and influenza seasons. Study population. Participants were previously healthy adults aged years who presented with a 72-h history of acute influenza symptoms and had nasal wash or nasal swab specimens that tested positive for influenza antigen by means of the QuickVue Influenza test kit (Quidel). Patients with known cardiopulmonary disorders were excluded, as were those with hypertension, chronic medical conditions requiring regular medication or indication for influenza vaccine, or hospitalization for medical illness, injury, or surgery within the past year. Patients who had received an investigational drug or vaccine within the previous 2 months were also excluded. The decision to use antiviral drugs in these patients was at the discretion of the physician caring for the patient. Written informed consent was obtained from each participant in a form approved by the University of Virginia Human Investigation Committee. Individuals were compensated for their participation in this study. Monitoring and sample collection. After confirmation of antigen positivity, medical history was obtained, symptom assessment was performed, vital signs were measured, and limited physical examination was performed to assess for enrollment suitability and to look for complications. At the time of enrollment, an ECG was performed and blood and nasal wash specimens were collected for cytokine assessment and measurement of serum markers of adverse cardiac conditions (i.e., abnormal total CK level, CK isoenzyme MB [CK-MB] level, and troponin I level); nasal wash specimens were also obtained for virus culture and titration. Volunteers were given a diary and were asked to grade 11 symptoms on a 4-point scale (0, no symptoms; 1, mild; 2, moderate; and 3, severe) and record oral temperatures twice daily for 14 days. Symptoms that were assessed included those typically associated with influenza (fever, chills, myalgia, malaise, headache, cough, sore throat, nasal congestion, rhinorrhea, and sputum production), possible cardiopulmonary disease (chest pain, dyspnea, wheezing, and palpitations), and exercise tolerance. Blood specimens were collected during follow-up visits 3 4 days (range, 2 6 days), 10 days (range, 7 14 days), and 28 days (range, days) after enrollment for determination of selected cytokine levels and markers of adverse cardiac conditions. In addition, echocardiography and ECG were performed during these 3 visits. ECGs were read initially by a single cardiologist who was masked with respect to the status of the patient s illness. A second cardiologist reviewed the serial ECGs to determine the clinical significance of the findings. Echocardiography was performed by an experienced echocardiography technologist, and 416 CID 2005:40 (1 February) Ison et al.

3 Figure 1. Serial electrocardiograms (ECGs) for the case patient. A, Baseline ECG. B, ECG obtained during influenza infection showing new T wave inversions and changes in V1. the echocardiograms were then interpreted by a single cardiologist who was masked with respect to the status of the patient s illness. Routine measurements, including assessment of global function and ejection fraction, were assessed for all echocardiograms [24]. Sample preparation. Nasopharyngeal wash specimens were collected as described elsewhere [25]. Lavage fluid was mixed thoroughly with a syringe, placed on wet ice, and freshly inoculated on Madin-Darby canine kidney cell monolayers. Samples and the resulting products that tested positive for influenza virus underwent serial 10-fold dilutions that were cultured to determine the concentration of virus, which was expressed as the log 10 median number of tissue culture infectious doses of virus (TCID 50 ) per milliliter. Blood was collected in Cardiac Findings in Adults with Influenza CID 2005:40 (1 February) 417

4 Figure 2. Trend of symptom scores over time. See Patients and Methods for definition. an EDTA tube and immediately centrifuged for 15 min at 800 g, and plasma was recovered and stored at 20 C for later analysis [25]. Determination of cytokine levels. Levels of cytokines (IL- 6, IL-8, IFN-a, and TNF-a) in nasal specimens were measured at the time of enrollment, and serum levels were measured at the time of enrollment and 3 4 and 10 days later. Cytokine levels were determined in the laboratory of Dr. Stephen Straus at the National Institutes of Health (Bethesda, MD) with commercially available ELISA kits, according to manufacturer protocols. The limits of sensitivity were!1 pg/ml for the IL-6 assay (Endogen), 18.1 pg/ml for the IL-8 assay (R&D Systems),!3 pg/ml for the IFN-a assay (Endogen), and!0.18 pg/ml for the TNF-a assay (R&D Systems). Review of ECGs from previous influenza studies. For all experimental human influenza studies done at the University of Virginia in which paired ECGs were obtained, the pre- and postinoculation ECGs were copied from the source documents and provided to a masked cardiologist, who determined abnormal findings and their possible clinical significance. Statistical analysis. Comparisons between cytokine levels measured after inoculation with those determined at baseline were performed using the Wilcoxon rank-sum test. Correlation between symptoms, fever, and cytokine levels was analyzed using Spearman s nonparametric correlation test. Statistical analysis was performed using S-Plus 2000, release 3 (Insightful). RESULTS Patients. A total of 30 young adult patients were enrolled in the study over 2 seasons, of whom 17 participated during the first season, and 13 participated during the second season. The mean age was 21.4 years, and 21 patients (70%) were women. Most patients were given antiviral therapy (20 received oseltamivir, 6 received amantadine, and 1 received rimantadine; 3 did not receive antivirals), and most used antipyretics. During the first year, 8 of 17 patients were infected with influenza B virus, whereas all 13 patients enrolled during the second year were infected with influenza A virus. Among influenza A viruses, subtypes H3N2 and H1N1 were predominant in the first season and second seasons, respectively. One patient who had negative culture results despite a compatible clinical syndrome and a positive influenza antigen test result was kept in the analysis. Serologic studies for detection of influenza virus were not performed. The mean nasal wash viral titer at enrollment was 4.42 log 10 TCID 50 per ml. Illness. Most patients presented within 48 h after symptom onset and reported relatively mild symptoms. The peak mean symptom score (15) was on the initial day of enrollment (figure 2), and most symptoms had improved by day 5 of the study, although 50% of patients had at least 1 symptom still present on day 14 of the study. All had their highest temperature during the first 2 days of the study; fever resolved by study day 3 in all subjects. Cardiac markers. Elevations in the total CK level were found in 2 patients at enrollment (1001 and 5430 IU/mL in patients 1 and 19, respectively), 2 on day 2 (274 and 4929 IU/ ml in patients 14 and 19, respectively), 2 on day 7 (485 and 310 IU/mL in patients 7 and 12, respectively), and 4 on day 28 (264, 2257, 288, and 260 IU/mL in patients 2, 9, 13, and 18, respectively). No patients had an elevated CK-MB index or troponin I level to suggest cardiac cellular damage at enrollment or on any of the subsequent study days (table 1). ECG findings. The majority of patients (53%) had abnormal ECG findings at enrollment, although most findings were classified as not clinically significant by the interpreting physician (tables 1 and 2). At the time of enrollment, 47% of patients had unremarkable ECG findings, whereas 23% had ECG findings that remained unchanged in all 4 time points (5 patients had large QRS complexes, and 1 patient had slight intraventricular conduction delay). Of those with transient abnormal ECG findings at enrollment, 3 patients had peaked T waves, 2 patients had tachycardia, 1 patient had a transient QT shortening, 1 had inferior changes in the ST segment, 1 had transient early repolarization, and 1 had diffuse T wave inversions. The 2 patients with tachycardia, one of the patients with peaked T waves, and the patient with the shortened QT interval had resolution of their ECG abnormalities by study day 2. One patient had enlarged QRS complexes on ECGs performed on the second and seventh study day. One patient had diffuse elevation in the ST segment throughout the study that was interpreted as being consistent with 418 CID 2005:40 (1 February) Ison et al.

5 Table 1. Results of laboratory tests and electrocardiography (ECG) for markers of adverse cardiac events in 30 patients with influenza, according to study day. Characteristic Study day CK level, IU/mL Mean a 102 b 192 c Range Abnormal CK-MB Mean % of total CK level Abnormal index Detectable level Abnormal troponin I level ECG findings Normal Normal or unchanged Mean ejection fraction SD Not done d e NOTE. Data are % of patients, unless otherwise indicated. Upper limit of normal for creatine kinase (CK) level, 237 IU/mL; for CK isoenzyme MB (CK-MB) index, 5% of total CK level; and for troponin I,!0.05. a P p.85, compared with study day 1. b P p.25, compared with study day 1. c P p.51, compared with study day 1. d P p.53, compared with study day 1. e P p.11, compared with study day 1. pericarditis (figure 3). This patient was asymptomatic, had no abnormal findings on any of her echocardiograms, and had similar findings on an ECG obtained 2 months after enrollment. All other ECGs were normal or unchanged by study day 7. Echocardiography. All patients had normal echocardiograms throughout the study without a significant change in ejection fractions (mean ejection fraction [ SD], 65% 4% ) (table 1). Cytokine responses. Plasma TNF-a, IL-6, and IL-8 levels were detectable at enrollment and decreased over time, whereas there was a steady increase in INF-a levels during the study period. No correspondence between elevated CK levels or transient ECG changes and plasma cytokine levels were noted (data not shown). ECG data from previous University of Virginia studies. Subjects in 4 studies conducted from June 1998 through July 2000 had ECGs performed before and after infection (table 3). Two studies were early treatment trials, and 2 were prophylaxis trials with peramivir. All studies were placebo controlled; 2 used influenza A, and 2 used influenza B. The patient described in the case report participated in the final study. Overall, 16.6% of patients were noted to have new abnormal ECG findings after inoculation. The most frequent findings were sinus arrhythmia, high QRS voltage, and sinus bradycardia. All changes were considered to be not clinically significant by the reviewing cardiologist, and none of the changes were similar to those observed in the case patient (e.g., new T wave inversions). If the case patient is assumed to have developed myocarditis after infection, the estimated risk of such an event after experimental influenza would be 0.4% (1 of 236 patients; 95% CI, 0% 2.0%). DISCUSSION This is the first contemporary study to look for cardiac dysfunction during acute influenza using the multiple modalities of electrocardiography, echocardiography, and serial measurements of markers of adverse cardiac events. We found that previously healthy ambulatory young adults with acute uncomplicated influenza have frequent but clinically insignificant ab- Table 2. Frequency of abnormal electrocardiogram (ECG) findings for 30 patients with influenza. Study day Patients with abnormal ECG findings, % Type of abnormal ECG finding 1 53 T wave changes, tachycardia, early repolarization, short QT, and STsegment elevation 4 33 T wave changes, early repolarization, large QRS complexes, and ST-segment elevation Large QRS complexes and ST-segment elevation ST-segment elevation NOTE. All ECG findings were considered as not being clinically significant. All changes present at day 28 were present at all time points, suggesting these were normal variants for these patients. Cardiac Findings in Adults with Influenza CID 2005:40 (1 February) 419

6 Figure 3. Example electrocardiogram for the patient who had persistent ST-segment elevations normal ECG findings during the early stage of illness. These resolve promptly and are not associated with changes in markers of cardiac injury or echocardiogram findings. Older studies [6, 7] were limited by the use of nonspecific CK measurements, which may be reflective of skeletal involvement, and by the nonspecific nature of many of the ECG changes that could be the direct result of respiratory alkalosis or fever and not of influenza itself. A recent study found that most increases in CK levels seen during influenza in ambulatory adults are likely of skeletal muscle origin [8]. Our study confirms this finding, and together, these observations suggest that myocarditis is a very uncommon complication of natural influenza in previously healthy persons. Because of the small sample size of the current study of naturally occurring influenza, there is 95% confidence that the incidence of clinically significant cardiac involvement during influenza in ambulatory adults is!9.5%, using exact methods. If our cohort of experimentally infected subjects is considered, there is 95% confidence that the incidence of clinically significant cardiac involvement during influenza in ambulatory adults is!2.0% This value is consistent with the study by Greaves et al. [8], in which 0 of 152 adult patients in the study had evidence of myocarditis. This results in an estimated incidence (upper 95% confidence limit) of myocarditis complicating influenza of!1.9%. Similarly, a community-based casecontrol study of complications in 342 persons with naturally occurring influenza found no cases of clinically diagnosed myocarditis and an estimated risk (upper 95% confidence limit) of!1.1% [10]. The current study suggests that, although frequently present, ECG changes early during the early stages of influenza are both transient and clinically insignificant. The same cardiologist read all of the ECGs performed in the study of patients who had experimentally induced influenza at the University of Virginia. During these 6 years, only the case patient had changes significant enough to warrant additional work-up. Older studies found more frequent changes. A Finnish study of previously healthy military recruits found that 6 (15%) of 40 patients with influenza had abnormal ECG findings, and all had regional myocardial dysfunction confirmed by echocardiography. The CK-MB level, as measured by electrophoresis, was elevated in 3 of the patients [6]. Such findings are consistent with myocarditis and suggest a much higher risk than observed in this trial. In contrast, other recent studies [8, 9] have documented Table 3. Electrocardiogram changes (ECG) noted in 4 other studies conducted at the University of Virginia (Charlottesville) during Study Influenza virus type Study type No. (%) of patients with abnormal ECG findings a 1 A Treatment 59 (19) 2 A Prophylaxis 71 (16) 3 B Treatment 30 (7) 4 B Prophylaxis 75 (20) NOTE. A total of 6 influenza studies were performed in which ECG data were collected; only 4 collected both pre- and postinfection ECGs. a The most common ECG findings were sinus arrhythmia and large QRS complex. ECGs were review by a cardiologist (blinded to the condition of the patients) who considered all findings as not being clinically significant. 420 CID 2005:40 (1 February) Ison et al.

7 infrequent myocarditis secondary to influenza, which is consistent with the findings in the present study. In addition to its small sample size, this study has several other limitations. Most patients had a mild disease course, and so complications would be expected to be less frequent. Additionally, most patients received antiviral therapy for their infection, which potentially explains the mild course. This antiviral therapy may have reduced the likelihood of cardiac complications. A recent analysis of individuals with a policy from a large insurance company during a single influenza season in the United States suggested a protective effect of oseltamivir treatment for influenza against adverse cardiac outcomes, such as unstable angina, myocardial infarction, arrhythmia, or congestive heart failure [26]. In this retrospective study, the outcomes for patients with influenza who were treated with oseltamivir at the first visit were compared with those for patients with influenza who had not received oseltamivir. The adjusted incidence rate ratio for major cardiac outcomes was 0.56 (95% CI, ) for those without a history of major cardiac disease and 0.81 (95% CI, ) for those with cardiac disease. An additional limitation is that we enrolled healthy patients who had not had cardiac disease before enrollment. It is likely that the incidence of cardiac abnormalities would be higher if patients with a history of cardiac disease were included. Of note, in a murine model of arteriosclerotic disease, influenza caused severe inflammatory changes in aortic lesions but not in arteriosclerosis-free aortas [27]. Future studies should be conducted that involve patients with underlying cardiopulmonary disorders, those with severe influenza virus infections, and those who have not received antiviral therapy. Additionally, because influenza viruses change from year to year in antigenicity and may vary in virulence characteristics, additional studies should be done with disparate viruses to confirm the findings of this study. In summary, this study found that clinically significant cardiac involvement occurs uncommonly in cases of acute influenza in ambulatory, previously healthy young adults. The most frequent abnormal findings are clinically insignificant ECG changes that resolve rapidly. Acknowledgments Financial support. R. W. Johnson (unrestricted grant). Potential conflicts of interest. F.G.H. has received grant support or lecture honoraria from and/or served as a consultant for Johnson & Johnson, Biocryst, Roche, Abbott, Biota, and GlaxoSmithKline, each of which has been involved in the development of neuraminidase inhibitors. All other authors: no conflicts. References 1. Nicholson KG, Wood JM, Zambon M. Influenza. Lancet 2003; 362: Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA 2004; 292: Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus. JAMA 2003; 289: Nichol KL, Nordin J, Mullooly J, Lask R, Fillbrandt K, Iwane M. Influenza vaccination and reduction in hospitalizations for cardiac disease and stroke among the elderly. N Engl J Med 2003; 348: Madjid M, Naghavi M, Litovsky S, Casscells SW. Influenza and cardiovascular disease: a new opportunity for prevention and the need for further studies. Circulation 2003; 108: Karjalainen J, Nieminen MS, Heikkila J. Influenza A1 myocarditis in conscripts. Acta Medica Scandinavica 1980; 207: Verel D, Warrack AJ, Potter CW, Ward C, Rickards DF. Observations on the A2 England influenza epidemic: a clinicopathological study. Am Heart J 1976; 92: Greaves K, Oxford JS, Price CP, Clarke GH, Crake T. The prevalence of myocarditis and skeletal muscle injury during acute viral infection in adults: measurement of cardiac troponins I and T in 152 patients with acute influenza infection. Arch Intern Med 2003; 163: Bowles NE, Ni J, Kearney DL, et al. Detection of viruses in myocardial tissues by polymerase chain reaction. evidence of adenovirus as a common cause of myocarditis in children and adults. J Am Coll Cardiol 2003; 42: Connolly AM, Salmon RL, Lervy B, Williams DH. What are the complications of influenza and can they be prevented? Experience from the 1989 epidemic of H3N2 influenza A in general practice. BMJ 1993; 306: Fairley CK, Ryan M, Wall PG, Weinberg J. The organisms reported to cause infective myocarditis and pericarditis in England and Wales. J Infect 1996; 32: Oseasohn R, Andelson L, Kaji M. Clinicopathologic study of thirtythree fatal cases of Asian influenza. N Engl J Med 1959; 260: Kaji M, Oseasohn R, Jordan WS Jr, Dingle JH. Isolation of Asian virus from extrapulmonary tissues in fatal human influenza. Proc Soc Exp Biol Med 1959; 100: Guarner J, Shieh WJ, Dawson J, et al. Immunohistochemical and in situ hybridization studies of influenza A virus infection in human lungs. Am J Clin Pathol 2000; 114: Woodruff JF. Viral myocarditis. Am J Pathol 1980; 101: Onitsuka H, Imamura T, Miyamoto N, et al. Clinical manifestations of influenza A myocarditis during the influenza epidemic of winter J Cardiol 2001; 37: Proby CM, Hackett D, Gupta S, Cox TM. Acute myopericarditis in influenza A infection. Q J Med 1986; 60: Craver RD, Sorrells K, Gohd R. Myocarditis with influenza B infection. Pediatr Infect Dis J 1997; 16: Engblom E, Ekfors TO, Meurman OH, Toivanen A, Nikoskelainen J. Fatal influenza A myocarditis with isolation of virus from the myocardium. Acta Med Scand 1983; 213: Witzleb W, Witzleb H, Mehlhorn J, Sprossig M, Wutzler P. Demonstration of influenza virus A in human heart by semiquantitative virus assay and immunofluorescence. Acta Virol 1976;20: Ray CG, Icenogle TB, Minnich LL, Copeland JG, Grogan TM. The use of intravenous ribavirin to treat influenza virus associated acute myocarditis. J Infect Dis 1989; 159: Sidwell RW, Smee DF. Peramivir (BCX-1812, RWJ ): potential new therapy for influenza. Expert Opin Investig Drugs 2002; 11: Young D, Fowler C, Bush K. RWJ (BCX-1812): a novel neuraminidase inhibitor for influenza [review]. Philos Trans R Soc London B Biol Sci 2001; 356: Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography. Summary article: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (ACC/ Cardiac Findings in Adults with Influenza CID 2005:40 (1 February) 421

8 AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 2003; 108: Kaiser L, Fritz RS, Straus SE, Gubareva L, Hayden FG. Symptom pathogenesis during acute influenza: Interleukin-6 and other cytokine responses. J Med Virol 2001; 64: Enger C, Nordstrom BL, Thakrar B, Sacks S, Rothman KJ. Health outcomes among patients receiving oseltamivir. Pharmacoepidemiol Drug Saf 2003; 12: Naghavi M, Wyde P, Litovsky S, et al. Influenza infection exerts prominent inflammatory and thrombotic effects on the atherosclerotic plaques of apolipoprotein E deficient mice. Circulation 2003; 107: CID 2005:40 (1 February) Ison et al.

THIS ACTIVITY HAS EXPIRED. CME CREDIT IS NO LONGER AVAILABLE

THIS ACTIVITY HAS EXPIRED. CME CREDIT IS NO LONGER AVAILABLE THIS ACTIVITY HAS EXPIRED. CME CREDIT IS NO LONGER AVAILABLE The following content is provided for informational purposes only. PREVENTION AND CONTROL OF INFLUENZA Lisa McHugh, MPH Influenza can be a serious

More information

Q: If antibody to the NA and HA are protective, why do we continually get epidemics & pandemics of flu?

Q: If antibody to the NA and HA are protective, why do we continually get epidemics & pandemics of flu? Influenza virus Influenza virus Orthomyxoviridae family of viruses RNA enveloped viruses that make up three genera Influenzavirus A Influenzavirus B Influenzavirus C The type A viruses are the most virulent

More information

INFLUENZA (Outbreaks; hospitalized or fatal pediatric cases)

INFLUENZA (Outbreaks; hospitalized or fatal pediatric cases) INFLUENZA (Outbreaks; hospitalized or fatal pediatric cases) 1. Agent: Influenza viruses A, B, and C. Only influenza A and B are of public health concern since they are responsible for epidemics. 2. Identification:

More information

PEDIATRIC INFLUENZA CLINICAL PRACTICE GUIDELINES

PEDIATRIC INFLUENZA CLINICAL PRACTICE GUIDELINES PEDIATRIC INFLUENZA CLINICAL PRACTICE GUIDELINES DEFINITIONS AND BACKGROUND Uncomplicated influenza illness is characterized by the abrupt onset of constitutional and respiratory signs and symptoms. Signs

More information

Respiratory Syncytial Virus (RSV) in Older Adults: A Hidden Annual Epidemic. Webinar Agenda

Respiratory Syncytial Virus (RSV) in Older Adults: A Hidden Annual Epidemic. Webinar Agenda Respiratory Syncytial Virus (RSV) in Older Adults: A Hidden Annual Epidemic Wednesday, November 2, 2016 12:00 PM ET Webinar Agenda Agenda Welcome and Introductions William Schaffner, MD, NFID Medical Director

More information

INFLUENZA VACCINATION AND MANAGEMENT SUMMARY

INFLUENZA VACCINATION AND MANAGEMENT SUMMARY INFLUENZA VACCINATION AND MANAGEMENT SUMMARY Morbidity and mortality related to influenza occur at a higher rate in people over 65 and those with underlying chronic medical conditions. Annual influenza

More information

4/11/2017. Cardiomyopathy. John Steuter, MD Bryan Heart. Disclosures. No Conflicts. Cardiomyopathy. WHO Classification

4/11/2017. Cardiomyopathy. John Steuter, MD Bryan Heart. Disclosures. No Conflicts. Cardiomyopathy. WHO Classification Cardiomyopathy John Steuter, MD Bryan Heart Disclosures No Conflicts Cardiomyopathy WHO Classification Anatomy & physiology of the LV 1. Dilated Enlarged Systolic dysfunction 2. Hypertrophic Thickened

More information

Influenza A positive but H1N1 negative myocarditis in a patient coming from a high outbreak region of new influenza

Influenza A positive but H1N1 negative myocarditis in a patient coming from a high outbreak region of new influenza CASE REPORT Cardiology Journal 2011, Vol. 18, No. 4, pp. 441 445 Copyright 2011 Via Medica ISSN 1897 5593 Influenza A positive but H1N1 negative myocarditis in a patient coming from a high outbreak region

More information

Myocarditis in Infants and Children

Myocarditis in Infants and Children in Infants and Children Guideline of the German Society of Pediatric Cardiology Thomas Paul, Carsten Tschöpe, Reinhard Kandolf Children s Heart Center, Georg-August-University, Göttingen Department of

More information

ECG Workshop. Nezar Amir

ECG Workshop. Nezar Amir ECG Workshop Nezar Amir Myocardial Ischemia ECG Infarct ECG in STEMI is dynamic & evolving Common causes of ST shift Infarct Localisation Left main artery occlusion: o diffuse ST-depression with ST elevation

More information

Orthomyxoviridae and Paramyxoviridae. Lecture in Microbiology for medical and dental medical students

Orthomyxoviridae and Paramyxoviridae. Lecture in Microbiology for medical and dental medical students Orthomyxoviridae and Paramyxoviridae Lecture in Microbiology for medical and dental medical students Orthomyxoviridae and Paramyxoviridae are ss RNA containng viruses Insert Table 25.1 RNA viruses 2 SIZE

More information

Influenza. Tim Uyeki MD, MPH, MPP, FAAP

Influenza. Tim Uyeki MD, MPH, MPP, FAAP Influenza Tim Uyeki MD, MPH, MPP, FAAP Influenza Division National Center for Immunization and Respiratory Diseases Coordinating Center for Infectious Diseases Centers for Disease Control and Prevention

More information

ORIGINAL INVESTIGATION. Impact of Oseltamivir Treatment on Influenza-Related Lower Respiratory Tract Complications and Hospitalizations

ORIGINAL INVESTIGATION. Impact of Oseltamivir Treatment on Influenza-Related Lower Respiratory Tract Complications and Hospitalizations Grippe 8701 ORIGINAL INVESTIGATION Impact of Treatment on Influenza-Related Lower Respiratory Tract Complications and Hospitalizations Laurent Kaiser, MD; Cynthia Wat, MBBS, MRCP; Tracy Mills, MSc; Paul

More information

Ischemic Heart Disease

Ischemic Heart Disease Ischemic Heart Disease Dr Rodney Itaki Lecturer Division of Pathology University of Papua New Guinea School of Medicine & Health Sciences Division of Pathology General Consideration Results from partial

More information

The Prevalence and Findings of Subclinical Influenza-associated Cardiac Abnormalities among Japanese Patients

The Prevalence and Findings of Subclinical Influenza-associated Cardiac Abnormalities among Japanese Patients doi: 10.2169/internalmedicine.0316-17 http://internmed.jp ORIGINAL ARTICLE The Prevalence and Findings of Subclinical Influenza-associated Cardiac Abnormalities among Japanese Patients Takahide Ito, Kanako

More information

1918 Influenza; Influenza A, H1N1. Basic agent information. Section I- Infectious Agent. Section II- Dissemination

1918 Influenza; Influenza A, H1N1. Basic agent information. Section I- Infectious Agent. Section II- Dissemination 1918 Influenza; Influenza A, H1N1 Basic agent information Section I- Infectious Agent Risk Group: - RG3 Synonym or Cross reference: - Spanish Flu - 1918 Flu - El Grippe Characteristics: - SELECT AGENT

More information

It is occasionally problematic to differentiate ST-segment

It is occasionally problematic to differentiate ST-segment CLINICAL INVESTIGATION Differential Diagnosis of Acute Pericarditis From Normal Variant Early Repolarization and Left Ventricular Hypertrophy With Early Repolarization: An Electrocardiographic Study Ravindra

More information

10/6/2014. INFLUENZA: Why Should We Take The Vaccine? OUTLINE INFLUNZA VIRUS INFLUENZA VIRUS INFLUENZA VIRUS

10/6/2014. INFLUENZA: Why Should We Take The Vaccine? OUTLINE INFLUNZA VIRUS INFLUENZA VIRUS INFLUENZA VIRUS INFLUENZA: Why Should We Take The Vaccine? Baptist Hospital Baptist Children s Hospital Doctors Hospital J. Milton Gaviria, MD, FACP October 17, 2014 Homestead Hospital Mariners Hospital Baptist Cardiac

More information

Guidance for Influenza in Long-Term Care Facilities

Guidance for Influenza in Long-Term Care Facilities Guidance for Influenza in Long-Term Care Facilities DSHS Region 2/3 Epidemiology Team January 2018 1. Introduction Every year, the flu affects people around the world, regardless of age. However, residents

More information

Study No.: Title: Rationale: Phase: Study Period: Study Design: Centers: Indication: Treatment: Objectives: Primary Outcome/Efficacy Variable:

Study No.: Title: Rationale: Phase: Study Period: Study Design: Centers: Indication: Treatment: Objectives: Primary Outcome/Efficacy Variable: The study listed may include approved and non-approved uses, formulations or treatment regimens. The results reported in any single study may not reflect the overall results obtained on studies of a product.

More information

Update I had a little bird, It s name was Enza, I opened up the window, And In Flu Enza.

Update I had a little bird, It s name was Enza, I opened up the window, And In Flu Enza. I had a little bird, It s name was Enza, I opened up the window, And In Flu Enza. Update 2014 2015 Timothy R. Cassity, Ph.D. Microbiologist Southern Ohio Medical Center January 16, 2015 The opinions expressed

More information

WHO Technical Consultation on the severity of disease caused by the new influenza A (H1N1) virus infections

WHO Technical Consultation on the severity of disease caused by the new influenza A (H1N1) virus infections WHO Technical Consultation on the severity of disease caused by the new influenza A (H1N1) virus infections Original short summary posted 6 May 2009. Revised full report posted May 9 2009. On 5 May 2009

More information

3. Rapidly recognize influenza seasons in which the impact of influenza appears to be unusually severe among children.

3. Rapidly recognize influenza seasons in which the impact of influenza appears to be unusually severe among children. 07-ID-14 Committee: Title: Infectious Disease Influenza-Associated Pediatric Mortality Statement of the Problem: In 2004, CSTE adopted influenza-associated pediatric mortality reporting with a provision

More information

Texas Influenza Summary Report, Season (September 28, 2008 April 11, 2009)

Texas Influenza Summary Report, Season (September 28, 2008 April 11, 2009) Texas Influenza Summary Report, 2008 2009 Season (September 28, 2008 April 11, 2009) Background Influenza and influenza-like illnesses (ILI) were last reportable by law in any county in Texas in 1993 (1).

More information

Human Infection with Novel Influenza A Virus Case Report Form

Human Infection with Novel Influenza A Virus Case Report Form Human Infection with Novel Influenza A Virus Case Report Form Form Approved OMB No. 0920-0004 Exp. Date 6/30/2013 Reporter Information State: Date reported to state/local health department: / / (MM/DD/YYYY)

More information

THE FRAMINGHAM STUDY Protocol for data set vr_soe_2009_m_0522 CRITERIA FOR EVENTS. 1. Cardiovascular Disease

THE FRAMINGHAM STUDY Protocol for data set vr_soe_2009_m_0522 CRITERIA FOR EVENTS. 1. Cardiovascular Disease THE FRAMINGHAM STUDY Protocol for data set vr_soe_2009_m_0522 CRITERIA FOR EVENTS 1. Cardiovascular Disease Cardiovascular disease is considered to have developed if there was a definite manifestation

More information

Respiratory Outbreaks Including Influenza. Module 6

Respiratory Outbreaks Including Influenza. Module 6 Respiratory Outbreaks Including Influenza Module 6 Learner Outcomes By the end of this module you will be able to: Outline the case definition for a respiratory outbreak. Outline the case definition for

More information

Food finds its way to a woman s heart: Campylobacter jejuni-associated myopericarditis

Food finds its way to a woman s heart: Campylobacter jejuni-associated myopericarditis OPEN ACCESS 1 Spectrum Health Medical Group 2 Spectrum Health Frederik Meijer Heart & Vascular Institute *Email: manivannan.veerasamy @spectrumhealth.org Images in cardiology Food finds its way to a woman

More information

NOVEL INFLUENZA A (H1N1) Swine Flu

NOVEL INFLUENZA A (H1N1) Swine Flu Introduction Definitions Influenza-like Illness Emergency Department Assessment Anitiviral Medication Oseltamivir (Tamiflu) Dosing Infection Control Issues Staff Exposure References Introduction This guideline

More information

Swine Influenza Update #3. Triage, Assessment, and Care of Patients Presenting with Respiratory Symptoms

Swine Influenza Update #3. Triage, Assessment, and Care of Patients Presenting with Respiratory Symptoms Updated 12:00 p.m. April 30, 2009 Swine Influenza Update #3 Introduction: This document revises our last update which was sent April 28 th, 2009. The most important revisions include the following: 1.

More information

Supplementary Appendix

Supplementary Appendix Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Jain S, Kamimoto L, Bramley AM, et al. Hospitalized patients

More information

Pandemic Preparedness: Pigs, Poultry, and People versus Plans, Products, and Practice

Pandemic Preparedness: Pigs, Poultry, and People versus Plans, Products, and Practice SUPPLEMENT ARTICLE Pandemic Preparedness: Pigs, Poultry, and People versus Plans, Products, and Practice Julie L. Gerberding Centers for Disease Control and Prevention, Atlanta, Georgia Influenza pandemic

More information

Influenza-Associated Pediatric Mortality rev Jan 2018

Influenza-Associated Pediatric Mortality rev Jan 2018 rev Jan 2018 Infectious Agent Influenza A, B or C virus BASIC EPIDEMIOLOGY Transmission Transmission occurs via droplet spread. After a person infected with influenza coughs, sneezes, or talks, influenza

More information

Influenza. Dr Bhakti Vasant Public Health Physician Metro South Public Health Unit. Metro South Public Health Unit

Influenza. Dr Bhakti Vasant Public Health Physician Metro South Public Health Unit. Metro South Public Health Unit Metro South Public Health Unit Influenza Dr Bhakti Vasant Public Health Physician Metro South Public Health Unit Source of image: CDC. Influenza images. Available from URL: https://www.cdc.gov/flu/images/h1

More information

Echocardiography as a diagnostic and management tool in medical emergencies

Echocardiography as a diagnostic and management tool in medical emergencies Echocardiography as a diagnostic and management tool in medical emergencies Frank van der Heusen MD Department of Anesthesia and perioperative Care UCSF Medical Center Objective of this presentation Indications

More information

Novel H1N1 Influenza. It s the flu after all! William Muth M.D. Samaritan Health Services 9 November 2009

Novel H1N1 Influenza. It s the flu after all! William Muth M.D. Samaritan Health Services 9 November 2009 Novel H1N1 Influenza It s the flu after all! William Muth M.D. Samaritan Health Services 9 November 2009 Influenza A Primer.. What is the flu? How do you get it? What s a virus anyhow? Can the flu be prevented,

More information

Study methodology for screening candidates to athletes risk

Study methodology for screening candidates to athletes risk 1. Periodical Evaluations: each 2 years. Study methodology for screening candidates to athletes risk 2. Personal history: Personal history of murmur in childhood; dizziness, syncope, palpitations, intolerance

More information

Nothing to disclose. Influenza Update. Influenza Biology. Influenza Biology. Influenza A 12/15/2014

Nothing to disclose. Influenza Update. Influenza Biology. Influenza Biology. Influenza A 12/15/2014 Influenza Update Nothing to disclose. Lisa Winston, MD UCSF / San Francisco General Hospital Divisions of Infectious Diseases and Hospital Medicine Influenza Biology Influenza Biology Influenza viruses

More information

Diagnosing and managing

Diagnosing and managing www.bpac.org.nz keyword: influenza influenza Diagnosing and managing Key reviewers: Associate Professor Mark Thomas, Infectious Disease Specialist, School of Medical Sciences, University of Auckland Dr

More information

Novel H1N1 Influenza A Update. William Muth MD 2 Oct 2009

Novel H1N1 Influenza A Update. William Muth MD 2 Oct 2009 Novel H1N1 Influenza A Update William Muth MD 2 Oct 2009 Novel H1N1 Influenza A Update Epidemiology Treatment Chemoprophylaxis Vaccine Infection Prevention Novel H1N1 Influenza A International Epidemiology

More information

Diagnosis of Seasonal and Pandemic Influenza. Objectives. Influenza Infections 11/7/2014

Diagnosis of Seasonal and Pandemic Influenza. Objectives. Influenza Infections 11/7/2014 Diagnosis of Seasonal and Pandemic Influenza Michael Klepser, Pharm.D., FCCP Professor Ferris State University College of Pharmacy Objectives Given a patient case, be able to identify signs and symptoms

More information

CARDIAC PROBLEMS IN PREGNANCY

CARDIAC PROBLEMS IN PREGNANCY CARDIAC PROBLEMS IN PREGNANCY LAS VEGAS, NEVADA, USA 27 February 1 March 2016 SUCCESSFUL TREATMENT WITH RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR OF MASSIVE PULMONARY EMBOLISM IN THE 16 TH WEEK OF PREGNANCY

More information

AF in the ER: Common Scenarios CASE 1. Fast facts. Diagnosis. Management

AF in the ER: Common Scenarios CASE 1. Fast facts. Diagnosis. Management AF in the ER: Common Scenarios Atrial fibrillation is a common problem with a wide spectrum of presentations. Below are five common emergency room scenarios and the management strategies for each. Evan

More information

Protocol Identifier Subject Identifier Visit Description. [Y] Yes [N] No. [Y] Yes [N] N. If Yes, admission date and time: Day Month Year

Protocol Identifier Subject Identifier Visit Description. [Y] Yes [N] No. [Y] Yes [N] N. If Yes, admission date and time: Day Month Year PAST MEDICAL HISTORY Has the subject had a prior episode of heart failure? o Does the subject have a prior history of exposure to cardiotoxins, such as anthracyclines? URGENT HEART FAILURE VISIT Did heart

More information

Chapter. Severe Acute Respiratory Syndrome (SARS) Outbreak in a University Hospital in Hong Kong. Epidemiology-University Hospital Experience

Chapter. Severe Acute Respiratory Syndrome (SARS) Outbreak in a University Hospital in Hong Kong. Epidemiology-University Hospital Experience content Chapter Severe Acute Respiratory Syndrome (SARS) Outbreak in a University Hospital in Hong Kong 3 Nelson Lee, Joseph JY Sung Epidemiology-University Hospital Experience Diagnosis of SARS Clinical

More information

Case Report Respiratory Syncytial Virus Associated Myocarditis Requiring Venoarterial Extracorporeal Membrane Oxygenation

Case Report Respiratory Syncytial Virus Associated Myocarditis Requiring Venoarterial Extracorporeal Membrane Oxygenation Hindawi Case Reports in Infectious Diseases Volume 2017, Article ID 7074508, 4 pages https://doi.org/10.1155/2017/7074508 Case Report Respiratory Syncytial Virus Associated Myocarditis Requiring Venoarterial

More information

Infant and Pediatric Influenza. Mike Czervinske RRT-NPS University of Kansas Medical Center

Infant and Pediatric Influenza. Mike Czervinske RRT-NPS University of Kansas Medical Center Infant and Pediatric Influenza Mike Czervinske RRT-NPS University of Kansas Medical Center Influenza Infants and Influenza Acute infection of the respiratory tract Nose Throat Possibly lungs Pathophysiology

More information

Is it HF secondary to rheumatic heart disease???

Is it HF secondary to rheumatic heart disease??? Is it HF secondary to rheumatic heart disease??? Is mitral regurg. Is complication of CHF??? Cardiomyopathy Definition The term cardiomyopathy is purely descriptive, meaning disease of the heart muscle

More information

Influenza A 6/23/2010. Lisa Winston, MD UCSF / San Francisco General Hospital Divisions of Infectious Diseases and Hospital Medicine

Influenza A 6/23/2010. Lisa Winston, MD UCSF / San Francisco General Hospital Divisions of Infectious Diseases and Hospital Medicine Influenza Update in a Pandemic Year Nothing to disclose. Lisa Winston, MD UCSF / San Francisco General Hospital Divisions of Infectious Diseases and Hospital Medicine Influenza Biology Influenza Biology

More information

Takotsubo Cardiomyopathy

Takotsubo Cardiomyopathy Advances in Heart Disease 2008 Takotsubo Cardiomyopathy Mary O. Gray, MD, FAHA, FACC Associate Professor of Medicine University of California, San Francisco Staff Cardiologist and Training Faculty Divisions

More information

Severe Hypertension. Pre-referral considerations: 1. BP of arm and Leg 2. Ambulatory BP 3. Renal causes

Severe Hypertension. Pre-referral considerations: 1. BP of arm and Leg 2. Ambulatory BP 3. Renal causes Severe Hypertension *Prior to making a referral, call office or Doc Halo, to speak with a Cardiologist or APP to discuss patient and possible treatment options. Please only contact the patient's cardiologist.

More information

Cardiovascular Disorders Lecture 3 Coronar Artery Diseases

Cardiovascular Disorders Lecture 3 Coronar Artery Diseases Cardiovascular Disorders Lecture 3 Coronar Artery Diseases By Prof. El Sayed Abdel Fattah Eid Lecturer of Internal Medicine Delta University Coronary Heart Diseases It is the leading cause of death in

More information

Human infection with pandemic (H1N1) 2009 virus: updated interim WHO guidance on global surveillance

Human infection with pandemic (H1N1) 2009 virus: updated interim WHO guidance on global surveillance Human infection with pandemic (H1N1) 2009 virus: updated interim WHO guidance on global surveillance 10 July 2009 Background This document updates the interim WHO guidance on global surveillance of pandemic

More information

Myocarditis in Bronchiolitis Caused by Respiratory Syncytial Virus

Myocarditis in Bronchiolitis Caused by Respiratory Syncytial Virus Myocarditis in Bronchiolitis Caused by Respiratory Syncytial Virus Kazem Sakha, MD;* Hasan Sultani, MD** and Bahman Rastgar, MD*** Abstract Background- Bronchiolitis is one of the common respiratory infections

More information

Influenza vaccines. Cheryl Cohen

Influenza vaccines. Cheryl Cohen Influenza vaccines Cheryl Cohen cherylc@nicd.ac.za Overview Burden of influenza and risk groups Clinical presentation, diagnosis and treatment Influenza the virus Currently available influenza vaccines

More information

Supplementary material 1. Definitions of study endpoints (extracted from the Endpoint Validation Committee Charter) 1.

Supplementary material 1. Definitions of study endpoints (extracted from the Endpoint Validation Committee Charter) 1. Rationale, design, and baseline characteristics of the SIGNIFY trial: a randomized, double-blind, placebo-controlled trial of ivabradine in patients with stable coronary artery disease without clinical

More information

Fluzone High-Dose Vaccine and FIM12 Efficacy Trial Results

Fluzone High-Dose Vaccine and FIM12 Efficacy Trial Results Fluzone High-Dose Vaccine and FIM12 Efficacy Trial Results Corey A. Robertson, MD, MPH Director, Scientific and Medical Affairs, Sanofi Pasteur 1 Older Adults Suffer Disproportionately from Influenza-related

More information

HISTORY. Question: How do you interpret the patient s history? CHIEF COMPLAINT: Dyspnea of two days duration. PRESENT ILLNESS: 45-year-old man.

HISTORY. Question: How do you interpret the patient s history? CHIEF COMPLAINT: Dyspnea of two days duration. PRESENT ILLNESS: 45-year-old man. HISTORY 45-year-old man. CHIEF COMPLAINT: Dyspnea of two days duration. PRESENT ILLNESS: His dyspnea began suddenly and has been associated with orthopnea, but no chest pain. For two months he has felt

More information

Acute Coronary Syndromes Unstable Angina Non ST segment Elevation MI (NSTEMI) ST segment Elevation MI (STEMI)

Acute Coronary Syndromes Unstable Angina Non ST segment Elevation MI (NSTEMI) ST segment Elevation MI (STEMI) Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN Objectives Evaluate common abnormalities that mimic myocardial infarction. Identify

More information

Running head: INFLUENZA VIRUS SEASON PREPAREDNESS AND RESPONSE 1

Running head: INFLUENZA VIRUS SEASON PREPAREDNESS AND RESPONSE 1 Running head: INFLUENZA VIRUS SEASON PREPAREDNESS AND RESPONSE 1 Electron micrograph of H1N1 Virus (CDC, 2009) Influenza Virus Season Preparedness and Response Patricia Bolivar Walden University Epidemiology

More information

GoodPrognosisofALCAPAAnomalousOriginoftheLeftCoronaryArteryfromthePulmonaryArterySyndromewithearlyDiagnosisandSurgicalTreatment

GoodPrognosisofALCAPAAnomalousOriginoftheLeftCoronaryArteryfromthePulmonaryArterySyndromewithearlyDiagnosisandSurgicalTreatment Global Journal of Medical Research: I Surgeries and Cardiovascular System Volume 18 Issue 3 Version 1.0 Type: Double Blind Peer Reviewed International Research Journal Publisher: Global Journals Online

More information

Cardiovascular Images

Cardiovascular Images Cardiovascular Images Pulmonary Embolism Diagnosed From Right Heart Changes Seen After Exercise Stress Echocardiography Brian C. Case, MD; Micheas Zemedkun, MD; Amarin Sangkharat, MD; Allen J. Taylor,

More information

Late diagnosis of influenza in adult patients during a seasonal outbreak

Late diagnosis of influenza in adult patients during a seasonal outbreak ORIGINAL ARTICLE Korean J Intern Med 2018;33:391-396 Late diagnosis of influenza in adult patients during a seasonal outbreak Seong-Ho Choi 1, Jin-Won Chung 1, Tark Kim 2, Ki-Ho Park 3, Mi Suk Lee 3, and

More information

A DAYS CARDIOVASCULAR UNIT GUIDE DUE WEDNESDAY 4/12

A DAYS CARDIOVASCULAR UNIT GUIDE DUE WEDNESDAY 4/12 A DAYS CARDIOVASCULAR UNIT GUIDE DUE WEDNESDAY 4/12 MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY 3/20 - B 3/21 - A 3/22 - B 3/23 - A 3/24 - B 3/27 - A Dissection Ethics Debate 3/28 - B 3/29 - A Intro to Cardiovascular

More information

1/31/2013 DISEASE BASICS. Influenza; Implications for Public Health Professionals. Influenza: An Age-Old Disease, A Disease for All Ages

1/31/2013 DISEASE BASICS. Influenza; Implications for Public Health Professionals. Influenza: An Age-Old Disease, A Disease for All Ages Influenza; Implications for Public Health Professionals Phillip L. Barkley, M.D. Director of Student Health University of Florida DISEASE BASICS Influenza: An Age-Old Disease, A Disease for All Ages Epidemics

More information

XVth Balkan Congress of Radiology Danubius Hotel Helia, October 2017, Budapest, Hungary

XVth Balkan Congress of Radiology Danubius Hotel Helia, October 2017, Budapest, Hungary XVth Balkan Congress of Radiology Danubius Hotel Helia, 12-14 October 2017, Budapest, Hungary Ružica Maksimović MRI in Myocarditis Faculty of Medicine, University of Belgrade, Centre for Radiology and

More information

Pericardial diseases

Pericardial diseases Pericardial diseases Anatomy of the pericardium Consists of parietal and visceral membranes. The space between them(pericardial space is normally filled by a lymph like fluid. The fluid s normal quantity

More information

Weekly Influenza Surveillance Report. Week 11

Weekly Influenza Surveillance Report. Week 11 Weekly Influenza Surveillance Report Week 11 Report produced: 22/03/2001 Influenza activity in Ireland For the week ending the 18/03/01, week 11, influenza activity has increased. Sentinel general practices

More information

DEPARTMENT OF HEALTH AND MENTAL HYGIENE. nyc.gov/health

DEPARTMENT OF HEALTH AND MENTAL HYGIENE. nyc.gov/health THE CITY OF NEW YORK DEPARTMENT OF HEALTH AND MENTAL HYGIENE Michael R. Bloomberg Mayor Thomas R. Frieden, M.D., M.P.H. Commissioner nyc.gov/health 2009 New York City Department of Health and Mental Hygiene

More information

In Case of Technical Difficulties

In Case of Technical Difficulties In Case of Technical Difficulties If you hear an echo: -- Make sure you are only logged in once on your computer -- Select one form of audio only (either computer speakers or telephone connection) If the

More information

Influenza Update for Iowa Long-Term Care Facilities. Iowa Department of Public Health Center for Acute Disease Epidemiology

Influenza Update for Iowa Long-Term Care Facilities. Iowa Department of Public Health Center for Acute Disease Epidemiology Influenza Update for Iowa Long-Term Care Facilities Iowa Department of Public Health Center for Acute Disease Epidemiology Webinar Information All participants will be muted during the presentation. Questions

More information

Swine Flu; Symptoms, Precautions & Treatments

Swine Flu; Symptoms, Precautions & Treatments Swine Flu; Symptoms, Precautions & Treatments What is the swine flu? Swine flu, also known as the H1N1 virus, is a relatively new strain of an influenza virus that causes symptoms similar to the regular

More information

The Heart of the Matter

The Heart of the Matter The Heart of the Matter Is the Heart the Matter? --Chest pain in the Pediatric Patient-- 19th Interregional Symposium November 2, 2018 Session A, 9:35-10:50 am John-Charles Loo, MD Pediatric Cardiology,

More information

Clinical Features of the Initial Cases of 2009 Pandemic Influenza A (H1N1) virus infection in China

Clinical Features of the Initial Cases of 2009 Pandemic Influenza A (H1N1) virus infection in China Clinical Features of the Initial Cases of 2009 Pandemic Influenza A (H1N1) virus infection in China Naim Mahroum, MD Internal Medicine B Sheba Medical Center NEJM December 24, 2009 H1N1 Pandemic April

More information

Antiviral Therapy 10:

Antiviral Therapy 10: Antiviral Therapy 10:901 910 Efficacy and tolerability of the oral neuraminidase inhibitor peramivir in experimental human influenza: randomized, controlled trials for prophylaxis and treatment Luis Barroso

More information

INTERNATIONAL SOCIETY FOR HEART AND LUNG TRANSPLANTATION a Society that includes Basic Science, the Failing Heart, and Advanced Lung Disease

INTERNATIONAL SOCIETY FOR HEART AND LUNG TRANSPLANTATION a Society that includes Basic Science, the Failing Heart, and Advanced Lung Disease International Society of Heart and Lung Transplantation Advisory Statement on the Implications of Pandemic Influenza for Thoracic Organ Transplantation This advisory statement has been produced by the

More information

: Provide cardiovascular preventive counseling to parents and patients with specific cardiac diseases about:

: Provide cardiovascular preventive counseling to parents and patients with specific cardiac diseases about: Children s Hospital & Research Center Oakland Cardiology Primary Goals for this Rotation 5.13 GOAL: Prevention, Counseling and Screening (Cardiovascular). Understand the role of the pediatrician in preventing

More information

Influenza Therapies. Considerations Prescription influenza therapies require prior authorization through pharmacy services.

Influenza Therapies. Considerations Prescription influenza therapies require prior authorization through pharmacy services. Influenza Therapies Policy Number: 5.01.515 Last Review: 10/2017 Origination: 10/2002 Next Review: 10/2018 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for influenza

More information

ESCMID Online Lecture Library. by author

ESCMID Online Lecture Library. by author INFLUENZA IN CHILDREN Cristian Launes Infectious Diseases Unit. Department of Paediatrics. Hospital Sant Joan de Déu (Universitat de Barcelona) Innovation in Severe Acute Respiratory Infections (SARI),

More information

Cardiology Competency Based Goals and Objectives

Cardiology Competency Based Goals and Objectives Cardiology Competency Based Goals and Objectives COMPETENCY 1. Patient Care. Provide family centered patient care that is developmentally and age appropriate, compassionate, and effective for the treatment

More information

Persistent PR segment change in malignant pericardial disease

Persistent PR segment change in malignant pericardial disease Ahluwalia et al. Cardio-Oncology (2016) 2:6 DOI 10.1186/s40959-016-0015-1 RESEARCH Open Access Persistent PR segment change in malignant pericardial disease M. Ahluwalia 1*,R.O Quinn 2,B.Ky 2, D. Callans

More information

Restrictive Cardiomyopathy in Cats (a Type of Heart-Muscle Disease) Basics

Restrictive Cardiomyopathy in Cats (a Type of Heart-Muscle Disease) Basics Restrictive Cardiomyopathy in Cats (a Type of Heart-Muscle Disease) Basics OVERVIEW The heart of the cat is composed of four chambers; the top two chambers are the left and right atria and the bottom two

More information

UPDATE ON THE MANAGEMENTACUTE CORONARY SYNDROME. DR JULES KABAHIZI, Psc (Rwa) Lt Col CHIEF CONSULTANT RMH/KFH 28 JUNE18

UPDATE ON THE MANAGEMENTACUTE CORONARY SYNDROME. DR JULES KABAHIZI, Psc (Rwa) Lt Col CHIEF CONSULTANT RMH/KFH 28 JUNE18 UPDATE ON THE MANAGEMENTACUTE CORONARY SYNDROME DR JULES KABAHIZI, Psc (Rwa) Lt Col CHIEF CONSULTANT RMH/KFH 28 JUNE18 INTRODUCTION The clinical entities that comprise acute coronary syndromes (ACS)-ST-segment

More information

Cardiac Pathology & Rehabilitation

Cardiac Pathology & Rehabilitation Cardiac Pathology & Rehabilitation Which of the following best describes the physical activity performed in my leisure time? A. I perform vigorous physical activity 3X/week for 20 minutes each time B.

More information

IDSA GUIDELINES EXECUTIVE SUMMARY

IDSA GUIDELINES EXECUTIVE SUMMARY IDSA GUIDELINES Seasonal Influenza in Adults and Children Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management: Clinical Practice Guidelines of the Infectious Diseases Society

More information

Chapter 5: Influenza Lynnette Brammer, MPH; Nancy Arden, MN; Helen Regnery, PhD; Leone Schmeltz; Keiji Fukuda, MD; and Nancy Cox, PhD

Chapter 5: Influenza Lynnette Brammer, MPH; Nancy Arden, MN; Helen Regnery, PhD; Leone Schmeltz; Keiji Fukuda, MD; and Nancy Cox, PhD VPD Surveillance Manual Chapter 5 (v. 1999) 5 1 Chapter 5: Influenza Lynnette Brammer, MPH; Nancy Arden, MN; Helen Regnery, PhD; Leone Schmeltz; Keiji Fukuda, MD; and Nancy Cox, PhD I. Disease description

More information

ARIC HEART FAILURE HOSPITAL RECORD ABSTRACTION FORM. General Instructions: ID NUMBER: FORM NAME: H F A DATE: 10/13/2017 VERSION: CONTACT YEAR NUMBER:

ARIC HEART FAILURE HOSPITAL RECORD ABSTRACTION FORM. General Instructions: ID NUMBER: FORM NAME: H F A DATE: 10/13/2017 VERSION: CONTACT YEAR NUMBER: ARIC HEART FAILURE HOSPITAL RECORD ABSTRACTION FORM General Instructions: The Heart Failure Hospital Record Abstraction Form is completed for all heart failure-eligible cohort hospitalizations. Refer to

More information

INFLUENZA VIRUS. INFLUENZA VIRUS CDC WEBSITE

INFLUENZA VIRUS. INFLUENZA VIRUS CDC WEBSITE INFLUENZA VIRUS INFLUENZA VIRUS CDC WEBSITE http://www.cdc.gov/ncidod/diseases/flu/fluinfo.htm 1 THE IMPACT OF INFLUENZA Deaths: PANDEMICS 1918-19 S p a n is h flu 5 0 0,0 0 0 U S 2 0,0 0 0,0 0 0 w o rld

More information

Estimating RSV Disease Burden in the United States

Estimating RSV Disease Burden in the United States Estimating RSV Disease Burden in the United States Brian Rha, MD, MSPH Medical Epidemiologist, Division of Viral Diseases Centers for Disease Control and Prevention Severe Acute Respiratory Infection Surveillance

More information

Cardiovascular and Respiratory Disorders

Cardiovascular and Respiratory Disorders Cardiovascular and Respiratory Disorders Blood Pressure Normal blood pressure is 120/80 mmhg (millimeters of mercury) Hypertension is when the resting blood pressure is too high Systolic BP is 140 mmhg

More information

Skin reactions in patients with influenza treated with oseltamivir: a retrospective cohort study

Skin reactions in patients with influenza treated with oseltamivir: a retrospective cohort study Antiviral Therapy 9:187-195 Skin reactions in patients with influenza treated with oseltamivir: a retrospective cohort study Beth L Nordstrom 1 *, Kelly Oh 1, Susan T Sacks 2 and Gilbert J L Italien 1

More information

Pediatric influenza-associated deaths in Arizona,

Pediatric influenza-associated deaths in Arizona, Pediatric influenza-associated deaths in Arizona, 2004-2012 (Poster is shared here as an 8.5 x11 document for easier viewing. All content is identical, though graphs and tables are formatted differently.)

More information

Wolff-Parkinson-White Syndrome

Wolff-Parkinson-White Syndrome Wolff-Parkinson-White Syndrome www.consultant360.com /articles/wolff-parkinson-white-syndrome A 37-year-old woman presented to the office with intermittent dizziness, palpitations, and multiple syncopal

More information

INFLUENZA AND OTHER RESPIRATORY VIRUSES

INFLUENZA AND OTHER RESPIRATORY VIRUSES INFLUENZA AND OTHER RESPIRATORY VIRUSES Lung Foundation Australia Patient Seminar 21 st October 2017 Lynette Reid Respiratory Clinical Nurse Specialist, RHH What is influenza (the flu )? Influenza (flu)

More information

The impacts of pericardial effusion on the heart function of infants and young children with respiratory syncytial virus infection

The impacts of pericardial effusion on the heart function of infants and young children with respiratory syncytial virus infection The impacts of pericardial effusion on the heart function of infants and young children with respiratory syncytial virus infection Author(s): Muslim M. Al Saadi, Abdullah S. Al Jarallah Vol. 13, No. 1

More information

PHARMACOTHERAPY Volume 27, Number 5, 2007

PHARMACOTHERAPY Volume 27, Number 5, 2007 Pharmacist-Managed Vaccination Program Increased Influenza Vaccination Rates in Cardiovascular Patients Enrolled in a Secondary Prevention Lipid Clinic Susan M. Loughlin, Pharm.D., Ali Mortazavi, M.D.,

More information

Clinical Policy: Holter Monitors Reference Number: CP.MP.113

Clinical Policy: Holter Monitors Reference Number: CP.MP.113 Clinical Policy: Reference Number: CP.MP.113 Effective Date: 05/18 Last Review Date: 04/18 Coding Implications Revision Log Description Ambulatory electrocardiogram (ECG) monitoring provides a view of

More information

Viral Threat on Respiratory Failure

Viral Threat on Respiratory Failure Viral Threat on Respiratory Failure Younsuck Koh, MD, PhD, FCCM Department of Pulmonary and Critical Care Medicine Asan Medical Center University of Ulsan College of Medicine Seoul, Korea No Conflict of

More information

Influenza Infection In Human. Dr. Zuhaida A. Jalil Surveillance Sector Disease Control Division, MOH Malaysia 3 May 2018

Influenza Infection In Human. Dr. Zuhaida A. Jalil Surveillance Sector Disease Control Division, MOH Malaysia 3 May 2018 Influenza Infection In Human Dr. Zuhaida A. Jalil Surveillance Sector Disease Control Division, MOH Malaysia 3 May 2018 Objective of the session: After completing this session, you will be able to: Understand

More information