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Caring for the Critically Ill Patient |

Critically Ill Patients With 2009 Influenza A(H1N1) Infection in Canada FREE

Anand Kumar, MD; Ryan Zarychanski, MD; Ruxandra Pinto, PhD; Deborah J. Cook, MD, MSc; John Marshall, MD; Jacques Lacroix, MD; Tom Stelfox, MD, PhD; Sean Bagshaw, MD, MSc; Karen Choong, MD; Francois Lamontagne, MD; Alexis F. Turgeon, MD, MSc; Stephen Lapinsky, MD; Stéphane P. Ahern, MD; Orla Smith, MSc; Faisal Siddiqui, MD; Philippe Jouvet, MD, PhD; Kosar Khwaja, MD; Lauralyn McIntyre, MD, MSc; Kusum Menon, MD, MSc; Jamie Hutchison, MD; David Hornstein, MD; Ari Joffe, MD; Francois Lauzier, MD; Jeffrey Singh, MD, MSc; Tim Karachi, MD; Kim Wiebe, MD; Kendiss Olafson, MD; Clare Ramsey, MD; Sat Sharma, MD; Peter Dodek, MD, MHSc; Maureen Meade, MD, MSc; Richard Hall, MD; Robert A. Fowler, MD, MSc; for the Canadian Critical Care Trials Group H1N1 Collaborative
[+] Author Affiliations

Author Affiliations: Section of Critical Care Medicine, Health Sciences Centre and St Boniface Hospital, Winnipeg, Manitoba, Canada (Drs Kumar, Siddiqui, Wiebe, Olafson, Ramsey, and Sharma); Department of Medical Oncology and Hematology, Cancercare Manitoba, Winnipeg (Dr Zarychanski); Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Pinto and Fowler); Departments of Clinical Epidemiology and Biostatistics (Drs Cook and Meade) and Medicine (Dr Karachi), McMaster Children's Hospital (Dr Choong), McMaster University, Hamilton, Ontario, Canada; Department of Critical Care Medicine, St Michael's Hospital, Toronto, Ontario, Canada (Dr Marshall and Ms Smith); Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada (Drs Lacroix and Jouvet); Departments of Critical Care Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada (Dr Stelfox); Division of Critical Care Medicine, University of Alberta, Edmonton (Drs Bagshaw and Joffe); Department of Medicine, Centre Hospitalier, Université de Sherbrooke, Sherbrooke, Quebec, Canada (Dr Lamontagne); Centre de Recherche du CHA, Hôpital de l’Enfant-Jésus, Université Laval, Quebec City, Quebec, Canada (Drs Turgeon and Lauzier); Intensive Care Unit, Mount Sinai Hospital (Dr Lapinsky) and University Health Network (Dr Singh), University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Hôpital Maisonneuve-Rosemont, University of Montréal, Montréal, Quebec, Canada (Dr Ahern); Trauma Services, McGill University Health Centre, Montréal, Quebec, Canada (Dr Khwaja); Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa, Ontario, Canada (Dr McIntyre); Clinical Research Unit, Children's Hospital of Eastern Ontario, Ottawa (Dr Menon); Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada (Dr Hutchison); SMBD-Jewish General Hospital, Montréal, Québec, Canada (Dr Hornstein); University of British Columbia, Vancouver (Dr Dodek); and Department of Anesthesia, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada (Dr Hall).


JAMA. 2009;302(17):1872-1879. doi:10.1001/jama.2009.1496.
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Published online

Context Between March and July 2009, the largest number of confirmed cases of 2009 influenza A(H1N1) infection occurred in North America.

Objective To describe characteristics, treatment, and outcomes of critically ill patients in Canada with 2009 influenza A(H1N1) infection.

Design, Setting, and Patients A prospective observational study of 168 critically ill patients with 2009 influenza A(H1N1) infection in 38 adult and pediatric intensive care units (ICUs) in Canada between April 16 and August 12, 2009.

Main Outcome Measures The primary outcome measures were 28-day and 90-day mortality. Secondary outcomes included frequency and duration of mechanical ventilation and duration of ICU stay.

Results Critical illness occurred in 215 patients with confirmed (n = 162), probable (n = 6), or suspected (n = 47) community-acquired 2009 influenza A(H1N1) infection. Among the 168 patients with confirmed or probable 2009 influenza A(H1N1), the mean (SD) age was 32.3 (21.4) years; 113 were female (67.3%) and 50 were children (29.8%). Overall mortality among critically ill patients at 28 days was 14.3% (95% confidence interval, 9.5%-20.7%). There were 43 patients who were aboriginal Canadians (25.6%). The median time from symptom onset to hospital admission was 4 days (interquartile range [IQR], 2-7 days) and from hospitalization to ICU admission was 1 day (IQR, 0-2 days). Shock and nonpulmonary acute organ dysfunction was common (Sequential Organ Failure Assessment mean [SD] score of 6.8 [3.6] on day 1). Neuraminidase inhibitors were administered to 152 patients (90.5%). All patients were severely hypoxemic (mean [SD] ratio of PaO2 to fraction of inspired oxygen [FIO2] of 147 [128] mm Hg) at ICU admission. Mechanical ventilation was received by 136 patients (81.0%). The median duration of ventilation was 12 days (IQR, 6-20 days) and ICU stay was 12 days (IQR, 5-20 days). Lung rescue therapies included neuromuscular blockade (28% of patients), inhaled nitric oxide (13.7%), high-frequency oscillatory ventilation (11.9%), extracorporeal membrane oxygenation (4.2%), and prone positioning ventilation (3.0%). Overall mortality among critically ill patients at 90 days was 17.3% (95% confidence interval, 12.0%-24.0%; n = 29).

Conclusion Critical illness due to 2009 influenza A(H1N1) in Canada occurred rapidly after hospital admission, often in young adults, and was associated with severe hypoxemia, multisystem organ failure, a requirement for prolonged mechanical ventilation, and the frequent use of rescue therapies.

Conclusion Published online October 12, 2009 (doi:10.1001/jama.2009.1496).

Figures in this Article

The reemergence of pandemic influenza has been anticipated since the Hong Kong (H3N2) influenza pandemic of 1968. In recent years, there has been substantial concern that a pandemic would involve the novel H5N1 avian flu variant, which has demonstrated an ability to cause severe disease when transmitted to humans.1,2 However, this spring the US Centers for Disease Control and Prevention reported the occurrence of a 2009 influenza A(H1N1) in 2 children in southern California.3 Subsequently, infection with this virus has been reported in virtually every country.47 The World Health Organization declared the first phase 6 global influenza pandemic of the century on June 11, 2009.8

The largest numbers of confirmed cases have been documented in the United States, Mexico, Canada, Chile, and Australia.9 Mexico and Canada have both experienced large localized outbreaks of infection with severe illness requiring intensive care unit (ICU) admission and ventilator support. This report describes the epidemiological characteristics, clinical features, treatments, and outcomes of a multicenter cohort of critically ill adult and pediatric Canadian patients.

Study Design

In response to an outbreak of 2009 influenza A(H1N1) in Mexico, members of the Canadian Critical Care Trials Group (CCCTG) designed a multicenter observational study of critically ill patients infected with 2009 influenza A(H1N1) (eAppendix). After several cycles of feedback and pilot testing, forms were widely disseminated to ICU physicians, and uploaded to the CCCTG and other critical care society Web sites on May 3, 2009.10 Data were collected retrospectively or prospectively on all patients with 2009 influenza A(H1N1)–related critical illness admitted to the ICU between April 16 and August 12, 2009. Research ethics board approval was granted by Sunnybrook Health Sciences Centre as the central coordinating center on April 30, 2009, and by each participating local research ethics board. The need for a priori informed consent was waived because of the noninterventional study design.

Data Collection

Eligible patients included all adult and pediatric critically ill individuals admitted to participating hospitals in Canada with confirmed, probable, or suspected 2009 influenza A(H1N1) infection, according to case definitions developed by the World Health Organization and the Canadian National Microbiology Laboratory.10,11 Critically ill patients were defined as (1) those admitted to a pediatric or adult ICU or those requiring mechanical ventilation (invasive or noninvasive), (2) those with a fraction of inspired oxygen (FIO2) concentration greater than or equal to 60%, or (3) those with the need for intravenous infusion of inotropic or vasopressor medication. Suspected cases of 2009 influenza A(H1N1) in the presence of a strong epidemiologic link were initially included because confirmatory testing was unavailable in some hospitals when diagnostic laboratories were overwhelmed with testing requests once the pandemic was under way.

Eligibility criteria were confirmed and data were recorded by research coordinators or site investigators at each center (eAppendix). Severity of illness was assessed in adults and children using the Acute Physiology and Chronic Health Evaluation (APACHE) II and Pediatric Risk of Mortality (PRISM) III scores.12,13 Comorbidities, including major comorbidities defined a priori, were recorded as the presence of 1 or more of the following chronic medical conditions: congestive heart failure; cerebrovascular, neoplastic, chronic liver or renal diseases; and use of immunosuppressant medications.14

The primary outcome measure was mortality at 28 days and 90 days after the onset of critical illness as defined by the eligibility criteria. Secondary outcomes included frequency and duration of mechanical ventilation and duration of ICU and hospital stay. Data were submitted to the coordinating center and checked for errors by manual inspection and electronic range limits.

Analysis

Descriptive statistics included frequency analysis (percentages) for categorical variables and means and standard deviations or medians and interquartile ranges (IQRs) for continuous variables. To test for differences in baseline characteristics between those with confirmed or probable and those with suspected disease, and those who survived vs those who died, a 2-sample t test or the Wilcoxon rank sum test was used for continuous variables as appropriate and the χ2 test or Fisher exact test was used for discrete variables. Daily variables are presented at days 1, 3, 7, and 14.

The Kaplan-Meier method in which patients discharged from the ICU alive were censored at the time of discharge was used to depict the probability of survival over the duration of follow-up and to generate survival curves. The discriminative ability of the day 1 APACHE II and SOFA scores on mortality were compared by testing the difference in C statistics (area under the receiver operating curve). The 95% confidence intervals (CIs) and P values were reported to reflect a 2-tailed α level of .05. The statistical analyses were conducted using SAS version 9.1 (SAS Institute Inc, Cary, North Carolina).

Characteristics of Study Patients and Hospitals

Between April 16 and July 13, 2009, 215 critically ill patients were admitted to 38 study ICUs (median of 16 ICU beds1534; median hospital size, 463 beds [IQR, 238-524 beds]) with confirmed (n = 162), probable (n = 6), or suspected (n = 47) 2009 influenza A(H1N1) infection. Patients having confirmed or probable 2009 influenza A(H1N1) infection were significantly younger, had a longer duration of mechanical ventilation and ICU stay, and higher mortality than those with suspected disease. Therefore, all analyses were restricted to the 168 patients with confirmed or probable 2009 influenza A(H1N1) infection (Table 1). The mean (SD) age was 32.3 (21.4) years; 113 patients were female (67.3%), 50 were children (29.8%), and there were 43 aboriginal Canadians (25.6%). There were 52 critically ill patients from the greater Winnipeg region, in the province of Manitoba, and 116 patients were from other provinces (Figure 1). Sixteen cases originated from nosocomial transmission; none of these were health care workers.

Table Graphic Jump LocationTable 1. Demographic Characteristics of Critically Ill Patients With Confirmed or Probable 2009 Influenza A(H1N1) Infection
Place holder to copy figure label and caption
Figure 1. Patients With 2009 Influenza A(H1N1) Admitted to the Hospital, Intensive Care Unit (ICU), or Who Died in Several Canadian Provinces (n = 116) and in the Greater Winnipeg Region, Manitoba, Canada (n=52) Between April 18, 2009, and August 15, 2009a
Graphic Jump Location

aUsed with permission, Centre for Immunization and Respiratory Infectious Diseases, Public Health Agency of Canada.
bMay indicate specimen collection date.

Among adults, the mean (SD) APACHE II score was 19.7 (8.7); and among pediatric patients, the mean (SD) PRISM III score was 9.1 (9.8). At presentation, comorbidities were present in 165 patients (98.2%) (Table 2). However, major comorbidities were present in only 51 patients (30.4%). The most common individual comorbidities were chronic lung disease (41.1%), obesity (33.3%), hypertension (24.4%), and ever smoking (22.6%). The mean (SD) body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) was 34.6 (11.0) and 28 patients (23.7%) were morbidly obese (BMI >40). The most common presenting symptoms were fever (90.5%), respiratory symptoms (94.6%), weakness (55.9%), and myalgias (40.1%). Concomitant presenting conditions included possible bacterial pneumonia (54 cases; 32.1%), hypotension requiring vasopressors (23 cases; 13.7%), asthma or chronic obstructive pulmonary disease exacerbation (23 cases; 13.7%), altered level of consciousness (17 cases; 10.1%), acute kidney injury (12 cases; 7.1%), and ischemic chest pain (5 cases; 3.0%).

Table Graphic Jump LocationTable 2. Comorbidities of Critically Ill Patients With Confirmed or Probable 2009 Influenza A(H1N1) Infection
Course of Illness and Treatments Received

The median time from symptom onset to hospital admission was 4 days (IQR, 2-7 days)27 and from hospitalization to ICU admission was 1 day (IQR, 0-2 days) after presentation to the hospital. Only 10 patients (6%) had received a seasonal influenza vaccination in either of the past 2 years. Most patients (70.8%) had bilateral chest radiograph infiltrates (41.1% with 4-quadrant involvement) and 72.6% had acute lung injury at the onset of critical illness.

Of all patients, 136 (81.0%) were mechanically ventilated on the first day of ICU admission; 128 (76.2%) invasively and 55 (32.7%) noninvasively. Forty-seven patients (85.4%) who received noninvasive ventilation ultimately required invasive ventilation. The mean (SD) day 1 ratio of PaO2 to FIO2 was 147 (128) mm Hg (Table 3); the mean (SD) day 1 FIO2 value was 74% (26%) and the mean (SD) day 1 positive end-expiratory pressure (PEEP) was 9.8 (4.0) cm H2O (eTable).

Table Graphic Jump LocationTable 3. Organ Dysfunction Over Time Among 168 Critically Ill Patients

The mean daily PEEP was greater than 10 cm H2O for the first 2 weeks of mechanical ventilation. Over the first 2 weeks of critical illness, tidal volumes ranged from 8 to 9.1 mL/kg of ideal body weight; and carbon dioxide elimination was not substantially impaired. Barotrauma occurred in 14 patients (8.3%). Therapies for oxygenation failure included neuromuscular blockade (47 patients; 28.0%), inhaled nitric oxide (23 patients; 13.7%), high-frequency oscillatory ventilation (20 patients; 11.9%), extracorporeal membrane oxygenation (7 patients; 4.2%), and prone positioning ventilation (5 patients; 3.0%) (eTable).

Inotropes or vasopressors were used in 55 patients (32.7%) on day 1 after the onset of critical illness (Table 3), often with high levels of sedatives to facilitate patient-ventilator synchrony. Drug treatments included neuraminidase inhibitors (152 patients [90.5%] for a median of 5 days48), antibiotics (166 patients; 98.8%), and corticosteroids (85 patients; 50.6%).

Creatine kinase was moderately elevated over the first week of critical illness (median level, 580 U/L [IQR, 203-1728 U/L] by day 3; to convert creatine kinase to μkat/L, multiply by 0.0167) (Table 3). The mean leukocyte count was normal at admission and remained in the normal range for the first week. Clinical evidence of secondary bacterial pneumonia following ICU admission was found in 41 cases (24.4% of all patients) including 18 cases caused by Staphylococcus aureus and 5 cases caused by Streptococcus pneumoniae.

Outcomes

Among 168 critically ill patients with 2009 influenza A(H1N1) infection, 29 died (17.3%; 95% CI, 12.0%-24.0%). Eighteen patients died (10.7%; 95% CI, 6.6%-16.6%) within the first 14 days and 24 died (14.3%; 95% CI, 9.5%-20.7%) within 28 days from the onset of critical illness (Table 4 and Figure 2 and Figure 3). Twenty-one of those who died were female (72.4%) and 8 were male (27.6%). Of 50 children, only 4 died (8.0%). Of 9 health care workers, 5 required mechanical ventilation and none died. The median length of ICU stay was 12 days (IQR, 5-20 days)520; 12 days for survivors522 and 10 days for nonsurvivors.419 The median duration of ventilation was 12 days (IQR, 6-20 days) for both survivors620 and nonsurvivors.420 One patient died on a medical ward, while all others died in the ICU.

Table Graphic Jump LocationTable 4. Clinical Course and Outcomes of Patients With Confirmed or Probable 2009 Influenza A(H1N1) Infectiona
Place holder to copy figure label and caption
Figure 2. Age Distribution of 168 Critically Ill Patients With Confirmed or Probable 2009 Influenza A(H1N1)
Graphic Jump Location

Intervals on the x-axis are equal to the lower limit and less than the upper limit of that age category.

Place holder to copy figure label and caption
Figure 3. Survival Curves of Critically Ill Patients With 2009 Influenza A(H1N1)
Graphic Jump Location

Dashed lines represent 95% confidence intervals. One patient died beyond day 60.

The primary reported causes of death included severe acute respiratory distress syndrome and hypoxemia, or complications thereof5; secondary infection and sepsis6; multiorgan dysfunction syndrome,2 malignancy,2 chronic obstructive pulmonary disease,1 primary cardiac arrest1; tension pneumothorax,1 cerebral edema1; and undetermined etiologies. Pulmonary embolism was believed to be contributory but not causal in 1 death.

Comparison of Survivors With Nonsurvivors

Patients who died were more likely to have higher severity of illness at presentation and greater organ dysfunction (Table 5). Although this overall population was young, older patients were more likely to die. There were no statistically significant differences in female sex distribution or aboriginal vs nonaboriginal status. The APACHE II and day 1 SOFA scores were significantly associated with overall mortality (P<.001 and P = .002, respectively) and there was no difference between the predictive value of these 2 scores (C statistics: 0.757 and 0.688, respectively; P = .13). Because nearly all patients received early treatment with neuraminidase inhibitors, we were unable to investigate differences in outcome due to treatment or timing of these agents.

Table Graphic Jump LocationTable 5. Comparison of Survivors and Nonsurvivors
Comparison of All Patients

As of August 22, 2009, in the general Canadian population, among 7107 reported cases, 1441 required hospitalization (20.3%), 278 were admitted to the ICU (3.9%) (the 215 admitted by July 13, 2009, are reported in this series).15 In comparing characteristics of all patients infected with 2009 influenza A(H1N1) infection, patients hospitalized, those admitted to the ICU, and those who died, the median age of patients was progressively greater along this continuum and there was a progressively greater proportion of patients with at least 1 underlying medical condition. The proportion of females was greater among those admitted to the ICU and among those who died compared with those infected and those admitted to hospital. There were a greater proportion of pregnant women requiring admission to the hospital and who died compared with the proportion among all of those infected.15

The spring outbreak of 2009 influenza A(H1N1) infection in Canada affected primarily young, female, and aboriginal patients without major comorbidities, and conferred a 28-day mortality of 14.3% among critically ill patients. A history of lung disease or smoking, obesity, hypertension, and diabetes were the most common comorbidities. Critical illness occurred rapidly after hospital admission and was associated with severe oxygenation failure, a requirement for prolonged mechanical ventilation, and the frequent use of rescue therapies.

We identified unusual features of severe disease in the current pandemic compared with most previous well-characterized pandemics, including the (probable) H2N2 1890 Russian influenza pandemic, the H2N2 1957 Asian influenza pandemic, and the H3N2 1968 Hong Kong pandemic.1618 In these previous influenza pandemics, an increased predilection for infection among children and young adults has been documented,9,19 although mortality curves were U shaped with increased deaths in the very young and the aged.

Our data suggest that severe disease and mortality in the current outbreak is concentrated in relatively healthy adolescents and adults between the ages of 10 and 60 years, a pattern reminiscent of the W-shaped curve previously seen only during the 1918 H1N1 Spanish pandemic.2022 Few patients older than 60 years in this study were admitted to the ICU (Figure 1). A potential biological basis for this observation is that patients in this age group have a cross-reactive antibody to 2009 influenza A(H1N1) at much higher rates than younger patients.23

The increased fraction of the aboriginal community presenting with severe 2009 influenza A(H1N1) infection is notable but not unique. This finding is reflected in the history of the 1918 H1N1 Spanish influenza pandemic during which mortality in aboriginal communities in North America (3%-9%) was many times higher than nonaboriginal communities (generally <0.75%).2429 In 1918, mortality within Alaskan and Labrador Inuit populations was 30% to 90%.24,28,29 Although mortality was not substantially greater among aboriginal Canadians in this report, the number of patients with severe disease and knowledge of prior illness patterns in this community is cause for concern.

The tendency of females to develop severe 2009 influenza A(H1N1) infection in this series is striking. A general female susceptibility has not been observed in other influenza case series of variable severity including the initial reports of 2009 influenza A(H1N1) infections.30,31 In most infectious diseases and related conditions such as sepsis and septic shock, males represent a larger proportion of cases and have a higher mortality.32,33 The explanation for increased risk of severe disease and death among females in this report is unclear but the role of pregnancy as a risk factor has been noted in previous influenza pandemics.34,35

The most common comorbidities among critically ill patients in our study were lung disease, obesity, hypertension, and a history of smoking or diabetes, each occurring in 30% to 40% of patients. All these conditions are known to be increased in frequency in the aboriginal population that comprises a substantial portion of cases within this cohort.36 The extent to which these comorbidities contribute to severity of disease is unclear because a large portion of the aboriginal population (which may be a risk factor itself on the basis of genetic susceptibility) often have such comorbidities.

Among critically ill patients, obesity has been shown to be a risk factor for increased morbidity, but not consistently with mortality.37,38 The association of obesity with severe 2009 influenza A(H1N1) infection has been reported by others39 and may be a novel finding of this pandemic; however, even though obesity was more common in our series than in the general Canadian population (33% vs approximately 24%), we did not find a significant difference in BMI between survivors and nonsurvivors.40

Critically ill patients with diabetes and hyperglycemia also are known to be at increased risk of complications and death; similarly, alcohol abuse, which is known to be a risk factor for acute respiratory distress syndrome, may have been a risk factor some patients in our series.41 These relationships also have been reported with seasonal influenza.42 The relative absence of serious comorbidities emphasizes that young, relatively healthy adults were the primary population affected by severe 2009 influenza A(H1N1) infection during this outbreak.

Patients with 2009 influenza A(H1N1) infection–related critical illness experienced symptoms for an average of 4 days prior to hospital presentation, but rapidly worsened and required care in the ICU within 1 to 2 days. Apart from the usual symptoms seen in seasonal influenza, these cases stand out for the presence of gastrointestinal tract symptoms, dyspnea, purulent sputum production, and occasional frothy lung fluid on cough or endotracheal aspiration. Chest radiographs demonstrating bilateral mixed interstitial or alveolar infiltrates were found in three-quarters of the patients.

Approximately one-third of patients required vasopressor support on day 1 following ICU admission; however, in many cases this appeared temporally associated with the need for substantial sedation to optimize ventilation. Broad-spectrum antibacterial agents were initiated in almost all patients because of the initial suspicion of community-acquired bacterial pneumonia. However, actual bacterial lung infection was typically documented later in the course of critical illness.

In addition, approximately one-third of patients in our cohort required advanced ventilatory support and rescue therapies for profound hypoxemic respiratory failure, including high levels of inspired oxygen and PEEP, pressure control, and airway pressure release ventilation, high-frequency oscillatory ventilation, prone positioning ventilation, neuromuscular blockade, inhaled nitric oxide, and extracorporeal membrane oxygenation. The fact that severe illness arises in a young, previously healthy population with a high probability of survival given the availability of appropriate resources has important societal implications.

In Winnipeg, Manitoba, Canada, site of the largest pandemic cohort of patients, the capacity for the care of critically ill patients was seriously challenged at the outbreak peak in June (Figure 1) with full occupancy of all regional ICU beds, similar to the 2002 Toronto, Ontario, Canada, experience with severe acute respiratory syndrome.43 If, as expected, the prevalence of 2009 influenza A(H1N1) infection increases with the upcoming flu season, there will be an acutely increased demand for ICU care, including the need for rescue therapies that are not currently widely available.4446 Clinicians and policy makers will need to examine feasible methods to optimally expand and deploy ICU resources to meet this need.

This study has a number of strengths. It represents the largest series of patients with severe 2009 influenza A(H1N1) infection yet described, and includes both adults and children from geographically and racially diverse settings across Canada, which improves the generalizability of our results to other regions. These observations of the epidemiological risk factors, typical clinical features, response to therapy, and prognosis should aid in the recognition, diagnosis, and clinical management of such infections. Our finding that patients can often be supported through 2009 influenza A(H1N1) infection–related critical illness with prolonged, aggressive life support, and the expectation that the number of cases will likely increase substantially over the next 6 months, highlight important potential limitations in critical care capacity.

This study also has limitations. Our focus on severe disease requiring ICU admission may not reflect important presenting features in less severe cases. The ongoing deaths throughout the course of the study period suggest the possibility of late deaths after the observation period. This may result in a final hospital mortality rate that exceeds the mortality rate we are reporting. Although we describe cases in most regions of Canada, many were from an outbreak in a single province (Manitoba) and involved an aboriginal Canadian population near Winnipeg, which is Manitoba's largest city. This may lead to overrepresentation or underrepresentation of certain comorbidities and clinical features.

In conclusion, we have demonstrated that 2009 influenza A(H1N1) infection–related critical illness predominantly affects young patients with few major comorbidities and is associated with severe hypoxemic respiratory failure, often requiring prolonged mechanical ventilation and rescue therapies. With such therapy, we found that most patients can be supported through their critical illness.

Corresponding Author: Anand Kumar, MD, Section of Critical Care Medicine, Health Sciences Centre, JJ 399, 700 William Ave, Winnipeg, MB R3E-0Z3 Canada (akumar61@yahoo.com).

Published Online: October 12, 2009 (doi:10.1001/jama.2009.1496). This article was corrected on November 3, 2009.

Author Contributions: Drs Kumar and Fowler had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Kumar, Zarychanski, Cook, Marshall, Stelfox, Lamontagne, Lapinsky, Ahern, Hutchison, Joffe, Dodek, Hall, Fowler.

Acquisition of data: Kumar, Zarychanski, Cook, Marshall, Stelfox, Bagshaw, Choong, Lamontagne, Turgeon, Lapinsky, Ahern, Smith, Siddiqui, Khwaja, McIntyre, Menon, Hutchison, Hornstein, Joffe, Lauzier, Singh, Karachi, Ramsey, Sharma, Meade, Hall, Fowler.

Analysis and interpretation of data: Kumar, Zarychanski, Pinto, Cook, Lacroix, Stelfox, Ahern, Jouvet, Menon, Wiebe, Olafson, Ramsey, Sharma, Fowler.

Drafting of the manuscript: Kumar, Zarychanski, Pinto, Cook, Ahern, Hall, Fowler.

Critical revision of the manuscript for important intellectual content: Kumar, Zarychanski, Pinto, Cook, Marshall, Lacroix, Stelfox, Bagshaw, Choong, Lamontagne, Turgeon, Lapinsky, Smith, Siddiqui, Jouvet, Khwaja, McIntyre, Menon, Hutchison, Hornstein, Joffe, Lauzier, Singh, Karachi, Wiebe, Olafson, Ramsey, Sharma, Dodek, Meade, Fowler.

Statistical analysis: Kumar, Pinto, Fowler.

Obtained funding: Kumar, Ahern, Fowler.

Administrative, technical or material support: Cook, Marshall, Lacroix, Bagshaw, Lamontagne, Turgeon, Ahern, Smith, Siddiqui, Hutchison, Joffe, Lauzier, Sharma, Meade, Fowler.

Study supervision: Kumar, Cook, Lacroix, Siddiqui, Khwaja, Menon, Fowler.

Financial Disclosures: None reported.

Funding/Support: The Public Health Agency of Canada, the Ontario Ministry of Health and Long-term Care, the Heart and Stroke Foundation Canada, and the Canadian Institutes of Health Research provided support for this article.

Role of the Sponsor: The Public Health Agency of Canada, the Ontario Ministry of Health and Long-term Care, the Heart and Stroke Foundation Canada, and the Canadian Institutes of Health Research had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Canadian Critical Care Trials Group H1N1 Collaborative Writing Committee: Anand Kumar, Ryan Zarychanski, Ruxandra Pinto, Philippe Jouvet, Jacques Lacroix, John Marshall, Deborah J. Cook, Rob Fowler.

Canadian Critical Care Trials Group H1N1 Collaborative Clinicians: Nova Scotia:Halifax: Richard Hall, Rob Green, Dietrich Heinzler, Lisa Julien, Debra Wright (Queen Elizabeth II Health Sciences Centre). Québec:Québec City: François Lauzier, Alexis Turgeon, Caroline Roy (CHA-Hôpital de l’Enfant-Jésus); François Lellouche, Marie-Claude Ferland (Institut Universitaire de Cardiologie et de Pneumologie de Québec). Longueuil: Germain Poirier (Hôpital Charles-LeMoyne). Sherbrooke: François Lamontagne (Centre Hospitalier Universitaire de Sherbrooke). Montreal: Phillippe Jouvet, Jacques Lacroix (CHU Sainte-Justine); Denny Laporta, David Hornstein (SMBD-Jewish General Hospital); Kosar Khwaja, Laura Banici (McGill University Health Centre); Stéphane P. Ahern, Yoanna Skrobic, Johanne Harvey (Hôpital Maisonneuve Rosemont); Martin Albert, Isabelle Arsenault (Hôpital du Sacré-Coeur de Montréal). Ontario:Ottawa: Lauralyn McIntyre, Claude Gaudet, Ray Saginur, Joe Pagliarello, Irene Watpool, Tracy Mcardle (Ottawa Hospital); Kusum Menon, Dermot Doherty, Sonny Dhanani, Roxanne Ward (Children's Hospital of Eastern Ontario). Kingston: John Muscedere, Nicole Godfrey, Susan Fleury (Kingston General Hospital). Toronto: Robert Fowler, Ruxandra Pinto, Neill Adhikari (Sunnybrook Hospital); Stephen Lapinsky, Cheryl Ethier, Tom Stewart (Mount Sinai Hospital); Orla Smith, John Marshall, Jan Friedrich, Karen Burns (St Michael's Hospital); Jeffrey M. Singh, John Granton, Nancy Brockest, Niall Ferguson, Andrea Matte (University Health Network); Jamie Hutchison (Hospital for Sick Children); Rob Cirone (St Joseph's Health Centre). Hamilton: Deborah Cook, Ellen MacDonald, Kelly Wilton, Andrea Tkaczyk (St Joseph's Healthcare); Karen Choong, Mark Duffett (McMaster University Children's Hospital); Maureen Meade (Hamilton Health Sciences Center, general site); Andy Freitag (Hamilton Health Sciences Center, McMaster site); Tim Karachi (Hamilton Health Sciences Center, Henderson site). Guelph: Gerry Hollinger (Guelph General Hospital). London: Claudio Martin (London Health Sciences Centre). Windsor: Eli Malus, Maureen Hrytsyk (Hotel Dieu Grace Hospital). Thunder Bay: Ravi Agarwala (Thunderbay Regional Health Sciences Centre). Manitoba:Winnipeg: Anand Kumar, Ryan Zarychanski, Faisal Siddiqui, Duane Funk, Allan Garland, Wendy Janz, Nicole Marten, Kim Wiebe, Mandy Siddiqui, Clare Ramsey, Satendra Sharma, Kendiss Olafson, Stasa Veroukis, Murray Kesselman (Health Sciences Centre/St Boniface Hospital/Grace Hospital/Victoria Hospital/Concordia Hospital/Seven Oaks Hospital). Brandon: Charles Penner (Brandon Regional Health Authority). Alberta:Calgary: Tom Stelfox (Foothills Medical Centre). Edmonton: Sean M. Bagshaw (University of Alberta Hospital); Mark Heule (Misericordia Hospital); Curtis Johnston (Royal Alexandria Hospital); Marcia Johnson (Public Health Division, Alberta Health Services); Sean Norris (Sturgeon Hospital); Ari Joffe (Stollery Children's Hospital); Daniel E. Stollery (Grey Nuns Hospital). British Columbia:Vancouver: Peter Dodek (St Paul's Hospital); Peter Skippen (BC Children's Hospital); Donald E. G. Griesdale, Denise Foster (Vancouver General Hospital). New Westminster: Sean Keenan, Steven Reynolds (Royal Columbian Hospital).

Additional Contributions: We thank our patients and the health care professionals who have delivered exemplary care to these patients in the face of uncertain risks. We also thank the following research assistants, who have worked tirelessly in the last several months: Davie Wong, Joel Braun, Aaron Guinn, Allison Stasiuk, Joan Tien, Raji Kaler, Alyson Mahar, Phil Hebert, MD, PhD, Blair Henry, MSc, Richard Mraz, PEng, Barry McLellan, MD, Michael Christian, MD, Steve Webb, MD, Simon Finfer, MD, Jamie Cooper, MD, Allison McGeer, MD, Tex Kissoon, MD, Brian Cuthbertson, MD, Mark Crowther, MD, MSc, Cathy Tansey, PhD, Craig Coopersmith, MD, and Arthur Slutsky, MD; Muhammad Mamdani, PharmD, MA, MPH, Judith Hall, MSc, Magda Melo, MSc, Bryan Boodhoo, MSc (University of Toronto Interdepartmental Division of Critical Care Medicine); and Rachel Rodin, MD (Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital); and the National Microbiology Laboratory of Canada, Winnipeg, the American Thoracic Society, and the Society of Critical Care Medicine. The persons listed in this section were not financially compensated for their work.

Tran TH, Nguyen TL, Nguyen TD,  et al; World Health Organization International Avian Influenza Investigative Team.  Avian influenza A (H5N1) in 10 patients in Vietnam.  N Engl J Med. 2004;350(12):1179-1188
PubMed   |  Link to Article
McFee RB. Avian influenza: the next pandemic?  Dis Mon. 2007;53(7):348-387
PubMed   |  Link to Article
Centers for Disease Control and Prevention (CDC).  Swine influenza A (H1N1) infection in two children—Southern California, March-April 2009.  MMWR Morb Mortal Wkly Rep. 2009;58(15):400-402
PubMed
Centers for Disease Control and Prevention (CDC).  Outbreak of swine-origin influenza A (H1N1) virus infection—Mexico, March-April 2009.  MMWR Morb Mortal Wkly Rep. 2009;58(17):467-470
PubMed
Editorial Team.  Pandemic phase level 4: human cases of the novel influenza A/H1N1 strain confirmed in Scotland and Spain: April 30, 2009.  Euro Surveill. 2009;14(17):1-2
 New influenza A(H1N1) virus infections: global surveillance summary, May 2009.  Wkly Epidemiol Rec. 2009;84(20):173-179
PubMed
 New influenza A(H1N1) virus—update.  Wkly Epidemiol Rec. 2009;84(19):171-172
PubMed
Chan M. World now at the start of 2009 influenza pandemic. http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/index.html. Accessed July 20, 2009
Public Health Agency of Canada.  Flu watch: July 5, 2009 to July 11, 2009 (week 27). http://www.phac-aspc.gc.ca/fluwatch/08-09/w27_09/index-eng.php. Accessed July 20, 2009
Canadian Critical Care Trials Group.  Case report form. http://www.ccctg.ca/news_events.php. Accessed July 15, 2009
Public Health Agency of Canada.  Case definitions for national surveillance H1N1 flu virus. http://www.phac-aspc.gc.ca/alert-alerte/swine-porcine/hp-ps-info_definition-eng.php. Accessed July 15, 2009
Knaus WA, Draper EA, Wagner DP, Zimmerman  JE. APACHE II: a severity of disease classification system.  Crit Care Med. 1985;13(10):818-829
PubMed   |  Link to Article
Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated pediatric risk of mortality score.  Crit Care Med. 1996;24(5):743-752
PubMed   |  Link to Article
Lee N, Chan PK, Hui DS,  et al.  Viral loads and duration of viral shedding in adult patients hospitalized with influenza.  J Infect Dis. 2009;200(4):492-500
PubMed   |  Link to Article
Public Health Agency of Canada.  Flu watch: August 16-23, 2009 (week 33). http://www.phac-aspc.gc.ca/fluwatch/08-09/w33_09/index-eng.php#t2. Accessed September 11, 2009
Cunha BA. Influenza: historical aspects of epidemics and pandemics.  Infect Dis Clin North Am. 2004;18(1):141-155
PubMed   |  Link to Article
Patterson KD. Pandemic Influenza, 1700-1900: A Study in Historical Epidemiology. Totowa, NJ: Rowman & Littlefield; 1986
Chu CM. The etiology and epidemiology of influenza: an analysis of the 1957 epidemic.  J Hyg Epidemiol Microbiol Immunol. 1958;2(1):1-8
PubMed
Simonsen L, Clarke MJ, Schonberger LB, Arden NH, Cox NJ, Fukuda K. Pandemic versus epidemic influenza mortality: a pattern of changing age distribution.  J Infect Dis. 1998;178(1):53-60
PubMed   |  Link to Article
Oxford JS. Influenza A pandemics of the 20th century with special reference to 1918: virology, pathology and epidemiology.  Rev Med Virol. 2000;10(2):119-133
PubMed   |  Link to Article
Morens DM, Fauci AS. The 1918 influenza pandemic: insights for the 21st century.  J Infect Dis. 2007;195(7):1018-1028
PubMed   |  Link to Article
Cox NJ, Subbarao K. Global epidemiology of influenza: past and present.  Annu Rev Med. 2000;51:407-421
PubMed   |  Link to Article
Centers for Disease Control and Prevention (CDC).  Serum cross-reactive antibody response to a novel influenza A (H1N1) virus after vaccination with seasonal influenza vaccine.  MMWR Morb Mortal Wkly Rep. 2009;58(19):521-524
PubMed
Markham N. The north coast of Labrador and the Spanish influenza of 1918. Them Days. 1986;11:4-5
Johnson NP, Mueller J. Updating the accounts: global mortality of the 1918-1920 “Spanish” influenza pandemic.  Bull Hist Med. 2002;76(1):105-115
PubMed   |  Link to Article
 Influenza among the American Indians.  Public Health Rep. 1919;34:2298-2300
Graham-Cumming G. Health of the original Canadians, 1867-1967.  Med Serv J Can. 1967;23(2):115-166
PubMed
Crosby AW. Epidemic and Peace, 1918. Wesport, CT: Greenwood Press; 1976
Kleivan H. The Eskimos of Northeast Labrador: A History of the Eskimo-White Relations, 1771-1955.  139 ed. Oslo, Norway: Norsk Polarinstitutt; 1966
Dawood FS, Jain S, Finelli L,  et al; Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team.  Emergence of a novel swine-origin influenza A (H1N1) virus in humans.  N Engl J Med. 2009;360(25):2605-2615
PubMed   |  Link to Article
Thompson WW, Shay DK, Weintraub E,  et al.  Influenza-associated hospitalizations in the United States.  JAMA. 2004;292(11):1333-1340
PubMed   |  Link to Article
Kumar A, Roberts D, Wood KE,  et al.  Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.  Crit Care Med. 2006;34(6):1589-1596
PubMed   |  Link to Article
Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000.  N Engl J Med. 2003;348(16):1546-1554
PubMed   |  Link to Article
Abramowitz LJ. The effect of Asian influenza on pregnancy.  S Afr Med J. 1959;32:1155-1156
Beigi RH. Pandemic influenza and pregnancy: a call for preparedness planning.  Obstet Gynecol. 2007;109(5):1193-1196
PubMed   |  Link to Article
MacMillan HL, MacMillan AB, Offord DR, Dingle JL. Aboriginal health.  CMAJ. 1996;155(11):1569-1578
PubMed
Goulenok C, Monchi M, Chiche JD, Mira JP, Dhainaut JF, Cariou A. Influence of overweight on ICU mortality: a prospective study.  Chest. 2004;125(4):1441-1445
PubMed   |  Link to Article
Sakr Y, Madl C, Filipescu D,  et al.  Obesity is associated with increased morbidity but not mortality in critically ill patients.  Intensive Care Med. 2008;34(11):1999-2009
PubMed   |  Link to Article
Napolitano LM, Park PJ, Sihler KC,  et al.  Intensive-care patients with severe novel influenza A (H1N1) virus infection—Michigan, June 2009.  MMWR Morb Mortal Wkly Rep. 2009;58:1-4
World Health Organization.  Infobase: BMI/overweight/obesity. https://apps.who.int/infobase/compare.aspx?dm=5&countries=124&year=2005&sf1=cd.0701&sex=all&agegroup=15-100. Accessed September 11, 2009
Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients.  Mayo Clin Proc. 2003;78(12):1471-1478
PubMed   |  Link to Article
Valdez R, Narayan KM, Geiss LS, Engelgau MM. Impact of diabetes mellitus on mortality associated with pneumonia and influenza among non-Hispanic black and white US adults.  Am J Public Health. 1999;89(11):1715-1721
PubMed   |  Link to Article
Fowler RA, Lapinsky SE, Hallett D,  et al; Toronto SARS Critical Care Group.  Critically ill patients with severe acute respiratory syndrome.  JAMA. 2003;290(3):367-373
PubMed   |  Link to Article
OSCAR Trial Website.  High frequency oscillation in ARDS. http://duncanyoung.net/index.php. Accessed July 20, 2009
Meade MO, Cook DJ, Mehta S,  et al.  A multicentre pilot randomized trial of high frequency oscillation in acute respiratory distress syndrome.  Am J Respir Crit Care Med. 2009;179:A1559
Adhikari NK, Burns KE, Friedrich JO, Granton JT, Cook DJ, Meade MO. Effect of nitric oxide on oxygenation and mortality in acute lung injury: systematic review and meta-analysis.  BMJ. 2007;334(7597):779-782
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1. Patients With 2009 Influenza A(H1N1) Admitted to the Hospital, Intensive Care Unit (ICU), or Who Died in Several Canadian Provinces (n = 116) and in the Greater Winnipeg Region, Manitoba, Canada (n=52) Between April 18, 2009, and August 15, 2009a
Graphic Jump Location

aUsed with permission, Centre for Immunization and Respiratory Infectious Diseases, Public Health Agency of Canada.
bMay indicate specimen collection date.

Place holder to copy figure label and caption
Figure 2. Age Distribution of 168 Critically Ill Patients With Confirmed or Probable 2009 Influenza A(H1N1)
Graphic Jump Location

Intervals on the x-axis are equal to the lower limit and less than the upper limit of that age category.

Place holder to copy figure label and caption
Figure 3. Survival Curves of Critically Ill Patients With 2009 Influenza A(H1N1)
Graphic Jump Location

Dashed lines represent 95% confidence intervals. One patient died beyond day 60.

Tables

Table Graphic Jump LocationTable 1. Demographic Characteristics of Critically Ill Patients With Confirmed or Probable 2009 Influenza A(H1N1) Infection
Table Graphic Jump LocationTable 2. Comorbidities of Critically Ill Patients With Confirmed or Probable 2009 Influenza A(H1N1) Infection
Table Graphic Jump LocationTable 3. Organ Dysfunction Over Time Among 168 Critically Ill Patients
Table Graphic Jump LocationTable 4. Clinical Course and Outcomes of Patients With Confirmed or Probable 2009 Influenza A(H1N1) Infectiona
Table Graphic Jump LocationTable 5. Comparison of Survivors and Nonsurvivors

References

Tran TH, Nguyen TL, Nguyen TD,  et al; World Health Organization International Avian Influenza Investigative Team.  Avian influenza A (H5N1) in 10 patients in Vietnam.  N Engl J Med. 2004;350(12):1179-1188
PubMed   |  Link to Article
McFee RB. Avian influenza: the next pandemic?  Dis Mon. 2007;53(7):348-387
PubMed   |  Link to Article
Centers for Disease Control and Prevention (CDC).  Swine influenza A (H1N1) infection in two children—Southern California, March-April 2009.  MMWR Morb Mortal Wkly Rep. 2009;58(15):400-402
PubMed
Centers for Disease Control and Prevention (CDC).  Outbreak of swine-origin influenza A (H1N1) virus infection—Mexico, March-April 2009.  MMWR Morb Mortal Wkly Rep. 2009;58(17):467-470
PubMed
Editorial Team.  Pandemic phase level 4: human cases of the novel influenza A/H1N1 strain confirmed in Scotland and Spain: April 30, 2009.  Euro Surveill. 2009;14(17):1-2
 New influenza A(H1N1) virus infections: global surveillance summary, May 2009.  Wkly Epidemiol Rec. 2009;84(20):173-179
PubMed
 New influenza A(H1N1) virus—update.  Wkly Epidemiol Rec. 2009;84(19):171-172
PubMed
Chan M. World now at the start of 2009 influenza pandemic. http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/index.html. Accessed July 20, 2009
Public Health Agency of Canada.  Flu watch: July 5, 2009 to July 11, 2009 (week 27). http://www.phac-aspc.gc.ca/fluwatch/08-09/w27_09/index-eng.php. Accessed July 20, 2009
Canadian Critical Care Trials Group.  Case report form. http://www.ccctg.ca/news_events.php. Accessed July 15, 2009
Public Health Agency of Canada.  Case definitions for national surveillance H1N1 flu virus. http://www.phac-aspc.gc.ca/alert-alerte/swine-porcine/hp-ps-info_definition-eng.php. Accessed July 15, 2009
Knaus WA, Draper EA, Wagner DP, Zimmerman  JE. APACHE II: a severity of disease classification system.  Crit Care Med. 1985;13(10):818-829
PubMed   |  Link to Article
Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated pediatric risk of mortality score.  Crit Care Med. 1996;24(5):743-752
PubMed   |  Link to Article
Lee N, Chan PK, Hui DS,  et al.  Viral loads and duration of viral shedding in adult patients hospitalized with influenza.  J Infect Dis. 2009;200(4):492-500
PubMed   |  Link to Article
Public Health Agency of Canada.  Flu watch: August 16-23, 2009 (week 33). http://www.phac-aspc.gc.ca/fluwatch/08-09/w33_09/index-eng.php#t2. Accessed September 11, 2009
Cunha BA. Influenza: historical aspects of epidemics and pandemics.  Infect Dis Clin North Am. 2004;18(1):141-155
PubMed   |  Link to Article
Patterson KD. Pandemic Influenza, 1700-1900: A Study in Historical Epidemiology. Totowa, NJ: Rowman & Littlefield; 1986
Chu CM. The etiology and epidemiology of influenza: an analysis of the 1957 epidemic.  J Hyg Epidemiol Microbiol Immunol. 1958;2(1):1-8
PubMed
Simonsen L, Clarke MJ, Schonberger LB, Arden NH, Cox NJ, Fukuda K. Pandemic versus epidemic influenza mortality: a pattern of changing age distribution.  J Infect Dis. 1998;178(1):53-60
PubMed   |  Link to Article
Oxford JS. Influenza A pandemics of the 20th century with special reference to 1918: virology, pathology and epidemiology.  Rev Med Virol. 2000;10(2):119-133
PubMed   |  Link to Article
Morens DM, Fauci AS. The 1918 influenza pandemic: insights for the 21st century.  J Infect Dis. 2007;195(7):1018-1028
PubMed   |  Link to Article
Cox NJ, Subbarao K. Global epidemiology of influenza: past and present.  Annu Rev Med. 2000;51:407-421
PubMed   |  Link to Article
Centers for Disease Control and Prevention (CDC).  Serum cross-reactive antibody response to a novel influenza A (H1N1) virus after vaccination with seasonal influenza vaccine.  MMWR Morb Mortal Wkly Rep. 2009;58(19):521-524
PubMed
Markham N. The north coast of Labrador and the Spanish influenza of 1918. Them Days. 1986;11:4-5
Johnson NP, Mueller J. Updating the accounts: global mortality of the 1918-1920 “Spanish” influenza pandemic.  Bull Hist Med. 2002;76(1):105-115
PubMed   |  Link to Article
 Influenza among the American Indians.  Public Health Rep. 1919;34:2298-2300
Graham-Cumming G. Health of the original Canadians, 1867-1967.  Med Serv J Can. 1967;23(2):115-166
PubMed
Crosby AW. Epidemic and Peace, 1918. Wesport, CT: Greenwood Press; 1976
Kleivan H. The Eskimos of Northeast Labrador: A History of the Eskimo-White Relations, 1771-1955.  139 ed. Oslo, Norway: Norsk Polarinstitutt; 1966
Dawood FS, Jain S, Finelli L,  et al; Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team.  Emergence of a novel swine-origin influenza A (H1N1) virus in humans.  N Engl J Med. 2009;360(25):2605-2615
PubMed   |  Link to Article
Thompson WW, Shay DK, Weintraub E,  et al.  Influenza-associated hospitalizations in the United States.  JAMA. 2004;292(11):1333-1340
PubMed   |  Link to Article
Kumar A, Roberts D, Wood KE,  et al.  Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.  Crit Care Med. 2006;34(6):1589-1596
PubMed   |  Link to Article
Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000.  N Engl J Med. 2003;348(16):1546-1554
PubMed   |  Link to Article
Abramowitz LJ. The effect of Asian influenza on pregnancy.  S Afr Med J. 1959;32:1155-1156
Beigi RH. Pandemic influenza and pregnancy: a call for preparedness planning.  Obstet Gynecol. 2007;109(5):1193-1196
PubMed   |  Link to Article
MacMillan HL, MacMillan AB, Offord DR, Dingle JL. Aboriginal health.  CMAJ. 1996;155(11):1569-1578
PubMed
Goulenok C, Monchi M, Chiche JD, Mira JP, Dhainaut JF, Cariou A. Influence of overweight on ICU mortality: a prospective study.  Chest. 2004;125(4):1441-1445
PubMed   |  Link to Article
Sakr Y, Madl C, Filipescu D,  et al.  Obesity is associated with increased morbidity but not mortality in critically ill patients.  Intensive Care Med. 2008;34(11):1999-2009
PubMed   |  Link to Article
Napolitano LM, Park PJ, Sihler KC,  et al.  Intensive-care patients with severe novel influenza A (H1N1) virus infection—Michigan, June 2009.  MMWR Morb Mortal Wkly Rep. 2009;58:1-4
World Health Organization.  Infobase: BMI/overweight/obesity. https://apps.who.int/infobase/compare.aspx?dm=5&countries=124&year=2005&sf1=cd.0701&sex=all&agegroup=15-100. Accessed September 11, 2009
Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients.  Mayo Clin Proc. 2003;78(12):1471-1478
PubMed   |  Link to Article
Valdez R, Narayan KM, Geiss LS, Engelgau MM. Impact of diabetes mellitus on mortality associated with pneumonia and influenza among non-Hispanic black and white US adults.  Am J Public Health. 1999;89(11):1715-1721
PubMed   |  Link to Article
Fowler RA, Lapinsky SE, Hallett D,  et al; Toronto SARS Critical Care Group.  Critically ill patients with severe acute respiratory syndrome.  JAMA. 2003;290(3):367-373
PubMed   |  Link to Article
OSCAR Trial Website.  High frequency oscillation in ARDS. http://duncanyoung.net/index.php. Accessed July 20, 2009
Meade MO, Cook DJ, Mehta S,  et al.  A multicentre pilot randomized trial of high frequency oscillation in acute respiratory distress syndrome.  Am J Respir Crit Care Med. 2009;179:A1559
Adhikari NK, Burns KE, Friedrich JO, Granton JT, Cook DJ, Meade MO. Effect of nitric oxide on oxygenation and mortality in acute lung injury: systematic review and meta-analysis.  BMJ. 2007;334(7597):779-782
PubMed   |  Link to Article
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