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November
2006: VOLUME
1, NUMBER 2
Current
Perspectives on the Clinical
Diagnosis of Influenza
In this issue...
The
combination of influenza vaccine shortages in past years along with
the emergence of limited but lethal human infection with avian influenza
H5N1 strains have brought considerable medical and media attention to
the influenza virus. Somewhat lost among these important problems are
new reports documenting the difficulties healthcare providers have in
regularly diagnosing influenza in both the office and the hospital.
In this issue, we review the
growing body of data detailing differential diagnostic predictors of
influenza in a season of wintertime fevers and respiratory tract infections,
the limitations of both clinical diagnosis and laboratory testing, the
current state of rapid influenza diagnostics, and recently published
recommendations from professional associations regarding prevention
to avoid complications such as cardiopulmonary disease and stroke. |
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GUEST
EDITOR OF THE MONTH |
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Commentary
& Reviews:
Paul
G. Auwaerter, MD
Associate Professor
of Medicine
Clinical Director,
Division of Infectious Diseases
Johns Hopkins University
School of Medicine
Baltimore, MD |
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Guest
Faculty Disclosure
Paul
G. Auwaerter, MD, has disclosed that he has served on the
Speaker Bureau for
Sanofi Aventis and
Schering-Plough and as a consultant for Pfizer, Ortho-McNeil and
Schering-Plough. He also disclosed that he is a Stock Shareholder
for Johnson and Johnson.
Unlabelled /Unapproved Uses
The authors have indicated that there will be no reference
to unlabeled/ unapproved uses of drugs or products in this presentation. |
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LEARNING
OBJECTIVES |
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The
Johns Hopkins University School of Medicine and The Institute for
Johns Hopkins Nursing take responsibility for the content, quality,
and the scientific integrity of this CE activity.
At the conclusion of this activity, participants should be
able to: |
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Describe
the most accurate clinical predictors of influenza; |
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Discuss
the issues surrounding the under-diagnosis of influenza and the
current emphasis on preventative measures; |
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Identify
the limitations of current influenza diagnostics and the technological
improvements currently under development. |
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COMPLETE
THE POST TEST
Step 1.
Click on the appropriate link below.
This will take you to the post-test.
Step 2.
If you have participated in a Johns
Hopkins on-line course, login. Otherwise, please register.
Step 3.
Complete the post-test and course
evaluation.
Step 4.
Print out your certificate.
Pharmacy credit is only available via PDF mail-in form:
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COMMENTARY |
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With
more than 200,000 cases annually in the United States, and upwards
of an all-cause influenza-related mortality of more than 50,000 deaths
in some years[1], there is ample opportunity for all clinicians
to encounter influenza in medical offices, emergency departments, and
hospitals. These numbers raise the question: how well are healthcare
providers diagnosing influenza infection?
The answer appears to be: not
as well as we should. Poehling and colleagues recently reported on a
four-year prospective study of fevers and respiratory tract infections
in children under five who underwent diagnostic viral culture and influenza
polymerase chain reaction testing of respiratory specimens[2].
They found that, compared to study-confirmed influenza cases, only 28%
of hospitalizations and 17% of ambulatory visits were properly diagnosed
by clinicians. Others have also reported substantial under-reporting
of influenza when physician-ordered tests are solely used for generating
surveillance information[3,4]. These tests were least effective
in the very young, as well as in the elderly, with this latter group
often presenting with non-traditional symptoms of influenza such as
acute exacerbations of chronic obstructive lung disease, cardiovascular
events, stroke, or diabetic decompensations.
Part of the problem may lie in
our current conceptions of influenza infection. The common symptoms
of influenza are typically believed to be abrupt onset of fever, cough,
headache, myalgia, and malaise. Call et al reviewed the world literature
on the subject of syndromic diagnosis of influenza and found that no
sign or symptom alone could strongly lead to a diagnosis of influenza[5].
The best available information suggests that during influenza season,
the abrupt onset of fever and cough in individuals 60 years of age or
older did increase the likelihood ratio to 5.4 (95% CI 2.8-7.7), but
this finding did not hold for younger age groups. By contrast, the absence
of fever or cough made influenza diagnosis less likely. Perhaps the
best single study on this subject was performed by Monto et al, finding
that the clinical determination of epidemic influenza, fever and cough
yielded a sensitivity of 79%[6].
Will rapid viral diagnostics
be of help to the clinician in securing an influenza diagnosis? In hospitals,
direct fluorescent-antibody (DFA) staining of respiratory specimens
may offer a result within hours, but these tests are not practical in
office settings. Rapid diagnostic tests are available (such as the Directigen
Flu A+B, ZstatFlu, XPECT Flu A/B) that have been compared to viral culture
and DFA, yielding a sensitivity of 72-95% with a specificity of 76-84% [7].
The Quick Vue A + B test was studied recently and found to have a sensitivity
of 82% compared to culture[8]. Although these tests may help
secure an influenza diagnosis or rule it out if pretest probability
of infection is low, they have not been especially popular with physicians
since the accuracy of their own clinical influenza diagnosis appears
to be approximately equivalent to the performance of these rapid tests.
New methodologies may offer improved
diagnosis, including surveillance for emerging strains of influenza
that may pose a threat for pandemics such as H5N1. As discussed by Townsend
et al, a FluChip based upon microarray technology may offer promise
of improved diagnosis of type and subtype along with more rapid turn-around[9].
Commercial availability may come about within a year, and the FluChip
could offer both clinicians and public health officials more up-to-date
information on specific strains of influenza circulating in their communities.
Since clinical diagnosis of influenza
remains less than ideal, efforts at optimizing prevention continue to
yield a more substantial likelihood of impact. Unlike children and younger
adults, older individuals may present with non-respiratory illnesses
such as acute coronary syndrome, cerebrovascular disease or diabetic
decompensations as manifestations of influenza infection. One large
study examining >39,000 people in a United Kingdom general practice
found that respiratory tract infection appeared to predispose individuals
to myocardial infarction and stroke (incidence ratio 4.95, 95% CI 4.43-5.53
and 3.19, 95% CI 2.81-3.62 respectively) during the first three days
of diagnosis, falling thereafter in the ensuing weeks[10].
Another study concluded that influenza immunization protected at-risk
patients from acute coronary syndrome compared to placebo[11].
Since a majority of patients
at risk for cardiovascular disease remain unimmunized, new guidelines
have been published attempting to enlist the support of subspecialists
such as cardiologists and endocrinologists to administer influenza vaccination
to their patients[12,13]. Together with improved immunization
in children, this may well decrease the overall burden of influenza
infection in the United States in future years.
References
| 1. |
WW
Thompson, DK Shay and E Weintraub et al., Mortality
associated with influenza and respiratory syncytial virus in the
United States, JAMA 289 (2003), pp. 179–186. |
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| 2. |
Poehling
KA, Edwards KM, Weinberg GA, et al. The
underrecognized burden of influenza in young children. N Engl
J Med. Jul 6 2006;355(1):31-40. |
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| 3. |
Surveillance
for laboratory-confirmed, influenza-associated hospitalizations--Colorado,
2004-05 influenza season. MMWR Morb Mortal Wkly Rep. Jun 3
2005;54(21):535-537. |
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| 4. |
Grijalva
CG, Craig AS, Dupont WD, et al. Estimating
influenza hospitalizations among children. Emerg Infect Dis.
Jan 2006;12(1):103-109. |
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| 5. |
Call
SA, Vollenweider MA, Hornung CA, Simel DL, McKinney WP. Does
this patient have influenza? Jama. Feb 23 2005;293(8):987-997. |
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| 6. |
Monto
AS, Gravenstein S, Elliott M, Colopy M, Schweinle J. Clinical
signs and symptoms predicting influenza infection. Arch Intern
Med. Nov 27 2000;160(21):3243-3247. |
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| 7. |
Rodriguez
WJ, Schwartz RH, Thorne MM. Evaluation
of diagnostic tests for influenza in a pediatric practice. Pediatr
Infect Dis J. Mar 2002;21(3):193-196. |
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| 8. |
Poehling
KA, Zhu Y, Tang YW, Edwards K. Accuracy
and impact of a point-of-care rapid influenza test in young children
with respiratory illnesses. Arch Pediatr Adolesc Med. Jul 2006;160(7):713-718. |
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| 9. |
Townsend
MB, Dawson ED, Mehlmann M, et al. Experimental
evaluation of the FluChip diagnostic microarray for influenza virus
surveillance. J Clin Microbiol. Aug 2006;44(8):2863-2871. |
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| 10. |
Smeeth
L, Thomas SL, Hall AJ, Hubbard R, Farrington P, Vallance P. Risk
of myocardial infarction and stroke after acute infection or vaccination.
N Engl J Med. Dec 16 2004;351(25):2611-2618. |
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| 11. |
Gurfinkel
EP, Leon de la Fuente R, Mendiz O, Mautner B. Flu
vaccination in acute coronary syndromes and planned percutaneous
coronary interventions (FLUVACS) Study. Eur Heart J. Jan 2004;25(1):25-31. |
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| 12. |
Davis
MM, Taubert K, Benin AL, et al. Influenza
vaccination as secondary prevention for cardiovascular disease:
a science advisory from the American Heart Association/American
College of Cardiology. J Am Coll Cardiol. Oct 3 2006;48(7):1498-1502. |
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| 13. |
Association
AD. Standards
of medical care in diabetes -- 2006. Diabetes Care. 2006;29(Suppl.
1):S4-S42. |
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INFLUENZA
IN CHILDREN: AN UNDIAGNOSED BUT COMMON CAUSE OF OUTPATIENT
VISITS |
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Poehling
KA, Edwards KM, Weinberg GA, Szilagyi P, Staat MA, Iwane MK,
Bridges CB, Grijalva CG, Zhu Y, Bernstein DI, Herrera G, Erdman
D, Hall CB, Seither R, Griffin MR; New Vaccine Surveillance Network. The
underrecognized burden of influenza in young children.
N Engl J Med. 2006 Jul 6;355(1):31-40.
(For non-journal subscribers, an additional fee may apply
for full text articles.) |
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Poehling
et al report on a multi-site study that prospectively evaluated children
less than 5 years of age presenting with an acute respiratory tract
infection or fever in both ambulatory and inpatient settings. Over
a four year period (2000-2004) 3359 children were enrolled, with
about 50% under six months of age, and 80% less than two years of
age. Most common presenting symptoms included fever (93%), cough
(87%), and rhinorrhea (83%), although infants under 6 months of age
had fever and cough less commonly. All children were evaluated for
influenza by nasal/throat swab for viral culture and PCR.
Significantly, of
the influenza confirmed cases found in the study, only 28% of hospitalized
children and 17% of ambulatory visits had a correct diagnostic impression
of influenza by their providers. Commonly reported diagnoses instead
of influenza included bronchiolitis, pneumonia, asthma flare, seizure,
fever/sepsis, and viral illness. About 35% of children presented
within 48 hours of symptom onset, making them potentially eligible
for antiviral administration if influenza were considered at the
time. Between 11%-26% of children had received influenza immunization,
with the higher percentages in those children with recommendations
specifically for receiving vaccine.
As the above data
show, a substantial majority of outpatient visits for febrile or
respiratory illness in children were due to influenza without apparent
clinical recognition by their providers. The authors estimate that
influenza-related outpatients visits are 10 times (for ages 0-5 months)
to 250 times (for ages 24-59 months) as common as hospitalizations.
Since high hospitalization rates led to the CDC recommendations to
universally immunize children 6-23 months of age[1], this
new information would further support recommendations for wider and
improved influenza immunization in children. Such broad immunization
would likely translate into substantial prevention and potentially
significant economic benefits with reduced illness, office visits,
and hospitalizations. Findings of this nature have supported efforts
to more highly target childhood influenza immunization (in addition
to the usual high risk groups), and have added to the growing sense
that childhood influenza may very well be the most important driver
of influenza in any given season.
References
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HOW
CAN CLINICIANS BEST IDENTIFY PATIENTS WITH INFLUENZA? |
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Call
SA, Vollenweider MA, Hornung CA, Simel DL, McKinney WP. Does
this patient have influenza? JAMA. 2005 Feb 23;293(8):987-97.
Review. PMID: 15728170.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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Call
et al provide a case-based scenario, including a review of 915 articles
published since 1966 pertaining to the clinical assessment of influenza.
The authors’ main objective was to gauge the precision of influenza
diagnosis based upon presenting signs and symptoms, with a secondary
objective to assess the performance of rapid diagnostic tests for influenza.
This study used a typical MEDLINE structured search strategy, with subsequent
data extraction and analysis by two independent reviewers.
The reviewers’ inclusion criteria required study designs that were prospective
(cohort or randomized control trials), that included primary clinical
signs for assessment of diagnosis, that had primary data available for
independent analysis, and that provided laboratory evidence of influenza
infection. They identified only ten studies that met these standards,
and, after additional review, were able to base their final data on
only six studies that included a total of 7105 patients.
Studies looking at patients regardless
of age found that the likelihood of influenza was less (defined as a
likelihood ratio <0.5) if there was an absence of a) fever, b) cough,
or c) nasal congestion. Subjective symptoms often associated with influenza – such
as complaints of feverishness, myalgia, malaise, sneezing or sore throat – provided
no discrete diagnostic value.
For patients aged 60 or older,
the combination of both fever and cough with an acute onset appeared
to be diagnostically useful, with likelihood ratios of 1.9 and 5.0 in
two of the studies meeting inclusion criteria.
The authors further report that
for diagnostic testing, direct fluorescent-antibody testing of respiratory
samples is the method many hospitals use to render a diagnosis within
hours. Polymerase chain reaction (PCR) tests may offer better sensitivity
and specificity, but are not widely available. Point-of-care rapid testing
(tests such as the QuickVue A+B Test, Directigen Flu A+B, and others)
are available, but given reduced sensitivity and specificity (ranges
59%-81% and 70%-99% respectively) they offer little additional information
if there is a substantial probability of influenza diagnosis based upon
acknowledged presence of epidemic influenza in the local community.
Not unexpectedly, no individual
clinical finding was strong enough to either rule-in or rule-out a diagnosis
of influenza. Subjective symptoms such as feverishness, headache, and
myalgia are notoriously difficult to base precise diagnoses upon, and
it appears influenza is no different in this regard. While healthcare
providers have been taught that fever, headache, myalgia and cough are
the classic components of an influenza infection, these same symptoms
can be seen with a myriad of other infections during the respiratory
season, especially in children and younger adults.
While the authors provide a careful
analysis of the data, their findings were limited in that diagnostic
confirmation for influenza was required as a gold standard against which
to compare syndromic presentations; however, the studies that met this
inclusion criterion used different testing methods. One included study
used only viral culture data, which may be less sensitive in the detection
of influenza virus than polymerase chain reaction methods or careful
serological studies using acute and convalescent samples. Other potentially
confounding considerations include that many patients in these studies
came from vaccine studies which may not be representative of patients
in primary care practices, and that these multinational data may be
less cohesive due to the introduction of language and cultural differences.
While the best clinical predicators
remain the acute onset of fever and cough during the influenza season,
the data supported this finding only in populations aged 60 or older.
Diagnostic rapid point of care testing may be helpful if positive (increasing
likelihood five-fold) or negative (virtually ruling out influenza as
a diagnosis if prior clinical probability is low), but generally does
not offer substantial benefit to healthcare providers evaluating patients
in ambulatory settings. The authors recommend, therefore, that practitioners
are best served using their own clinical assessment for diagnosing influenza
in the general population, especially since therapeutic intervention
is most efficacious if started within 48 hours of symptom onset. If
influenza is known to be circulating in the community, then abrupt onset
of fever and cough may be an imperfect but best available measure. |
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NEW
TECHNOLOGIES TO AID IN THE RAPID DIAGNOSIS OF INFLUENZA |
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Townsend
MB, Dawson ED, Mehlmann M, Smagala JA, Dankbar DM, Moore CL, Smith
CB, Cox NJ, Kuchta RD, Rowlen KL. Experimental evaluation
of the FluChip diagnostic microarray for influenza virus surveillance.
J Clin Microbiol. 2006 Aug;44(8):2863-71.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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Townsend
et al report on the use of a microarray (FluChip-55) following viral
RNA extraction and amplification to rapidly identify the H1N1, H3N2,
and H5N1 strains of influenza types A and B. In this study, a total
of 72 influenza virus isolates were analyzed, with the FluChip correctly
identifying 95% of isolates with 72% accuracy for subtyping. The investigators
examined viral RNA which bypassed the traditional generation of complimentary
DNA for reverse-transcriptase PCR, thereby greatly abbreviating the
time required for testing. The lower subtyping accuracy was attributed
to problems with traditional nucleic acid amplification rather that
difficulty with the microarray. False positive rates were judged as
1% and false negative rates as 4% of isolates.
Robotic laboratory machines using
microarray chip technology hold great promise for the rapid diagnosis
of infectious diseases: this study was able to evaluate influenza samples
within 11 hours as opposed to 4 or more days by traditional methods.
The FluChip could help evaluate respiratory samples for the presence
of seasonal influenza as well as emerging strains of potentially pandemic
influenza such as avian influenza H5N1.
The investigators have stated
that they hope to have a commercially available product within one year
with an eventual target of less than 2-7 hours turnaround time. Although
they note that the amount of RNA present in a patient sample is inadequate
to achieve this goal by the present methodology, they expect novel detection
techniques currently in development to overcome this existing limitation.
They anticipate the more immediate use of this technology will likely
be for public health laboratories to track influenza strains rapidly,
so clinicians can be informed more quickly about what pathogens are
circulating in their communities. |
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INFLUENZA
IMMUNIZATION AND CARDIOVASCULAR
DISEASE |
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Davis
MM, Taubert K, Benin AL, Brown DW, Mensah GA, Baddour LM, Dunbar
S, Krumholz HM; American Heart Association; American College of
Cardiology; American Association of Cardiovascular and Pulmonary
Rehabilitation; American Association of Critical Care Nurses; American
Association of Heart Failure Nurses; American Diabetes Association;
Association of Black Cardiologists, Inc; Heart Failure Society of
America; Preventive Cardiovascular Nurses Association; American
Academy of Nurse Practitioners; Centers for Disease Control and
Prevention and the Advisory Committee on Immunization. Influenza
vaccination as secondary prevention for cardiovascular disease:
a science advisory from the American Heart Association/American
College of Cardiology. J Am Coll Cardiol. 2006 Oct 3;48(7):1498-502.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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American
Diabetes Association. Standards of medical care in diabetes – 2006.
Diabetes Care 2006;29(Suppl. 1):S4-S42.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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Both
the AHA/ACC and the ADA have recently issued guideline statements reviewing
the rationale behind supporting annual influenza immunization with inactivated
vaccine in those with coronary and other atherosclerotic diseases.
With influenza-related death
more common in people with cardiovascular disease (CVD), the Journal
of the American College of Cardiologists report presented the best evidence
for supporting immunization as protective. Of key interest is the FLUVACS
(FLU Vaccination in Acute Coronary Syndromes) study, the only randomized
clinical trial available that addresses this question prospectively.
Here 301 patients were randomized after myocardial infarction or angioplasty
to receive immunization or placebo. At one year, cardiovascular mortality
in the vaccinated group was 2% compared to 8% in the unvaccinated group
(relative risk 0.25 compared to the unvaccinated, 95% CI 0.30-0.86)[1].
In addition, other literature cited, based on cohort or case-control
studies, supports vaccine-associated reductions in stroke, heart failure,
and cardiovascular hospitalizations[2-5].
Importantly, no higher rate of
cardiovascular complications appeared to occur as a consequence of influenza
immunization, including a >39,000 CVD patient cohort in the United Kingdom
examined for 90 days after vaccination[6].
This advisory statement, endorsed
by multiple disciplines, has been directed toward cardiologists, neurologists,
and endocrinologists, specialists who do not typically view themselves
as important in the decision to recommend or to give influenza immunization
(a province usually of primary care providers). Since only 1 of every
3 adults with heart disease received influenza immunization in 2005
(CDC, unpublished data cited in the article), outpatient visits to cardiology
practices may be a prime opportunity to vaccinate. Only 50% of cardiology
practices are thought to stock influenza vaccine.
Synopsizing the recommendations:
- The
AHA and ACC advise that inactivated influenza vaccine be given to
all individuals with CVD as a component of secondary prevention of
coronary and atherosclerotic diseases unless contraindications exist.
- Influenza
immunization remains below-target in CVD groups and preventative benefits
are not what they could be.
- Providers
who care for CVD patients should stock vaccine and promote immunizations
with strong recommendations and/or standing orders.
The
American Diabetes Association has likewise added an influenza immunization
statement to their newly published practice guidelines. They recommend
annual vaccination for all diabetics over the age of 6 months, based
in part on case-control information suggesting a 79% decrease in hospitalization
rates among diabetics during an influenza epidemic[7].
Together, these guideline statements
urge specialists to strongly advise and/or administer annual influenza
vaccine, with the objective of increasing immunization coverage beyond
what is currently accomplished through primary care directives.
References
| 1. |
Gurfinkel
EP, Leon de la Fuente R, Mendiz O, Mautner B. Flu
vaccination in acute coronary syndromes and planned percutaneous
coronary interventions (FLUVACS) Study. Eur Heart J. Jan 2004;25(1):25-31. |
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| 2. |
Davis
JW, Lee E, Taira DA, Chung RS. Influenza
vaccination, hospitalizations, and costs among members of a Medicare
managed care plan. Med Care. Dec 2001;39(12):1273-1280. |
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| 3. |
Nichol
KL, Wuorenma J, von Sternberg T. Benefits
of influenza vaccination for low-, intermediate-, and high-risk
senior citizens. Arch Intern Med. Sep 14 1998;158(16):1769-1776. |
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| 4. |
Naghavi
M, Barlas Z, Siadaty S, Naguib S, Madjid M, Casscells W. Association
of influenza vaccination and reduced risk of recurrent myocardial
infarction. Circulation. Dec 19 2000;102(25):3039-3045. |
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| 5. |
Lavallee
P, Perchaud V, Gautier-Bertrand M, Grabli D, Amarenco P. Association
between influenza vaccination and reduced risk of brain infarction.
Stroke. Feb 2002;33(2):513-518. |
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| 6. |
Smeeth
L, Thomas SL, Hall AJ, Hubbard R, Farrington P, Vallance P. Risk
of myocardial infarction and stroke after acute infection or vaccination.
N Engl J Med. Dec 16 2004;351(25):2611-2618. |
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| 7. |
Colquhoun
AJ, Nicholson KG, Botha JL, Raymond NT. Effectiveness
of influenza vaccine in reducing hospital admissions in people with
diabetes. Epidemiol Infect. Dec 1997;119(3):335-341. |
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CME/CNE/CPE
INFORMATION |
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activity has been planned and implemented in accordance with the
Essential Areas and Policies of the Accreditation Council for Continuing
Medical Education through the joint sponsorship of the Johns Hopkins
University School of Medicine and The Institute for Johns Hopkins
Nursing. The Johns Hopkins University School of Medicine is accredited
by the ACCME to provide continuing medial educaiton for physicians.
The Institute for
Johns Hopkins Nursing is accredited as a provider of continuing nursing
education by the American Nursing Credentialing Center's Commission
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The Johns Hopkins University School of Medicine designates this educational activity
for a maximum of 1.0 AMA PRA Category 1 Credit(s)TM. Physicians
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This 1.2 contact hour Educational Activity (Provider Directed/Learner Directed) is
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program is approved
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take the post-test for eInfluenza Review you will need to visit The
Johns Hopkins University School of Medicine's CME website or The
Institute for Johns Hopkins Nursing. If you have already registered
for another Hopkins CME program at these sites, simply enter the
requested information when prompted. Otherwise, complete the registration
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Johns Hopkins University School of Medicine and The Institute for
Johns Hopkins Nursing takes responsibility for the content, quality,
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activity has been developed for the Primary Care Physician, Internist,
Infectious Disease Specialists and Nurse. There are no fees or prerequisites
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The
Johns Hopkins University School of Medicine and The Institute
for Johns Hopkins Nursing take responsibility for the content,
quality, and the scientific integrity of this CE activity.
At the
conclusion of this activity, participants should be able to: |
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Describe
the most accurate clinical predictors of influenza; |
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Discuss
the issues surrounding the under-diagnosis of influenza and the
current emphasis on preventative measures; |
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Identify
the limitations of current influenza diagnostics and the technological
improvements currently under development. |
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The
Offices of Continuing Education (CE) at The Johns Hopkins University
School of Medicine and The Institute for Johns Hopkins Nursing are
committed to protect the privacy of its members and customers. The
Johns Hopkins University maintains its Internet site as an information
resource and service for physicians, other health professionals
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The Johns Hopkins
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Nursing will keep your personal and credit information confidential
when you participate in a CE Internet based program. Your information
will never be given to anyone outside The Johns Hopkins University
program. CE collects only the information necessary to provide you
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It
is the policy of The Johns Hopkins University School of Medicine
and The Institute for Johns Hopkins Nursing that the faculty and
provider disclose real or apparent conflicts of interest relating
to the topics of this educational activity, and also disclose discussions
of unlabeled/unapproved uses of drugs or devices during their presentation(s).
Johns Hopkins School of Medicine OCME and The Institute for Johns
Hopkins Nursing has established policies in place that will identify
and resolve all conflicts of interest prior to this educational
activity. Detailed disclosures will be made in the course handout
materials.
The presenting faculty
reported the following:
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John
G. Bartlett, MD, has disclosed that he has served on the HIV
Advisory Board for Glaxo Smith Kline, Abbott and Bristol-Myers
Squibb. |
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Jason
E. Farley, PhD(c), MPH, NP has disclosed that he has no relationship
with commercial supporters. |
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Statement · back
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opinions and recommendations expressed by faculty and other experts
whose input is included in this program are their own. This enduring
material is produced for educational purposes only. Use of Johns
Hopkins University School of Medicine name implies review of educational
format design and approach. Please review the complete prescribing
information of specific drugs or combination of drugs, including
indications, contraindications, warnings and adverse effects before
administering pharmacologic therapy to patients. |
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COMPLETE
THE POST TEST
Step 1.
Click on the appropriate link below. This
will take you to the post-test.
Step 2.
If you have participated in a Johns Hopkins
on-line course, login. Otherwise, please register.
Step 3.
Complete the post-test and course evaluation.
Step 4.
Print out your certificate.
Pharmacy credit is only available via PDF mail-in form:
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Copyright
© JHUSOM, IJHN, and eInfluenza Review
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