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A 37-Year-Old Man Trying to Choose a High-Quality Hospital [Clinical Crossroads]

Uniform Format for Disclosure of Competing Interests in ICMJE Journals [Editorial]

A 66-Year-Old Man With an Abdominal Aortic Aneurysm [Clinical Crossroads]

This Week in JAMA [This Week in JAMA]

Surgical Mask vs N95 Respirator for Preventing Influenza Among Health Care Workers: A Randomized Trial [Original Contribution]

Context Data about the effectiveness of the surgical mask compared with the N95 respirator for protecting health care workers against influenza are sparse. Given the likelihood that N95 respirators will be in short supply during a pandemic and not available in many countries, knowing the effectiveness of the surgical mask is of public health importance. Objective To compare the surgical mask with the N95 respirator in protecting health care workers against influenza. Design, Setting, and Participants Noninferiority randomized controlled trial of 446 nurses in emergency departments, medical units, and pediatric units in 8 tertiary care Ontario hospitals. Intervention Assignment to either a fit-tested N95 respirator or a surgical mask when providing care to patients with febrile respiratory illness during the 2008-2009 influenza season. Main Outcome Measures The primary outcome was laboratory-confirmed influenza measured by polymerase chain reaction or a 4-fold rise in hemagglutinin titers. Effectiveness of the surgical mask was assessed as noninferiority of the surgical mask compared with the N95 respirator. The criterion for noninferiority was met if the lower limit of the 95% confidence interval (CI) for the reduction in incidence (N95 respirator minus surgical group) was greater than –9%. Results Between September 23, 2008, and December 8, 2008, 478 nurses were assessed for eligibility and 446 nurses were enrolled and randomly assigned the intervention; 225 were allocated to receive surgical masks and 221 to N95 respirators. Influenza infection occurred in 50 nurses (23.6%) in the surgical mask group and in 48 (22.9%) in the N95 respirator group (absolute risk difference, –0.73%; 95% CI, –8.8% to 7.3%; P = .86), the lower confidence limit being inside the noninferiority limit of –9%. Conclusion Among nurses in Ontario tertiary care hospitals, use of a surgical mask compared with an N95 respirator resulted in noninferior rates of laboratory-confirmed influenza. Trial Registration clinicaltrials.gov Identifier: NCT00756574 Published online October 1, 2009 (doi:10.1001/jama.2009.1466).

Factors Associated With Death or Hospitalization Due to Pandemic 2009 Influenza A(H1N1) Infection in California [Original Contribution]

Context Pandemic influenza A(H1N1) emerged rapidly in California in April 2009. Preliminary comparisons with seasonal influenza suggest that pandemic 2009 influenza A(H1N1) disproportionately affects younger ages and causes generally mild disease. Objective To describe the clinical and epidemiologic features of pandemic 2009 influenza A(H1N1) cases that led to hospitalization or death. Design, Setting, and Participants Statewide enhanced public health surveillance of California residents who were hospitalized or died with laboratory evidence of pandemic 2009 influenza A(H1N1) infection reported to the California Department of Public Health between April 23 and August 11, 2009. Main Outcome Measure Characteristics of hospitalized and fatal cases. Results During the study period there were 1088 cases of hospitalization or death due to pandemic 2009 influenza A(H1N1) infection reported in California. The median age was 27 years (range, <1-92 years) and 68% (741/1088) had risk factors for seasonal influenza complications. Sixty-six percent (547/833) of those with chest radiographs performed had infiltrates and 31% (340/1088) required intensive care. Rapid antigen tests were falsely negative in 34% (208/618) of cases evaluated. Secondary bacterial infection was identified in 4% (46/1088). Twenty-one percent (183/884) received no antiviral treatment. Overall fatality was 11% (118/1088) and was highest (18%-20%) in persons aged 50 years or older. The most common causes of death were viral pneumonia and acute respiratory distress syndrome. Conclusions In the first 16 weeks of the current pandemic, the median age of hospitalized infected cases was younger than is common with seasonal influenza. Infants had the highest hospitalization rates and persons aged 50 years or older had the highest mortality rates once hospitalized. Most cases had established risk factors for complications of seasonal influenza.

Critically Ill Patients With 2009 Influenza A(H1N1) Infection in Canada [Caring for the Critically Ill Patient]

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

Critically Ill Patients With 2009 Influenza A(H1N1) in Mexico [Caring for the Critically Ill Patient]

Context In March 2009, novel 2009 influenza A(H1N1) was first reported in the southwestern United States and Mexico. The population and health care system in Mexico City experienced the first and greatest early burden of critical illness. Objective To describe baseline characteristics, treatment, and outcomes of consecutive critically ill patients in Mexico hospitals that treated the majority of such patients with confirmed, probable, or suspected 2009 influenza A(H1N1). Design, Setting, and Patients Observational study of 58 critically ill patients with 2009 influenza A(H1N1) at 6 hospitals between March 24 and June 1, 2009. Demographic data, symptoms, comorbid conditions, illness progression, treatments, and clinical outcomes were collected using a piloted case report form. Main Outcome Measures The primary outcome measure was mortality. Secondary outcomes included rate of 2009 influenza (A)H1N1–related critical illness and mechanical ventilation as well as intensive care unit (ICU) and hospital length of stay. Results Critical illness occurred in 58 of 899 patients (6.5%) admitted to the hospital with confirmed, probable, or suspected 2009 influenza (A)H1N1. Patients were young (median, 44.0 [range, 10-83] years); all presented with fever and all but 1 with respiratory symptoms. Few patients had comorbid respiratory disorders, but 21 (36%) were obese. Time from hospital to ICU admission was short (median, 1 day [interquartile range {IQR}, 0-3 days]), and all patients but 2 received mechanical ventilation for severe acute respiratory distress syndrome and refractory hypoxemia (median day 1 ratio of Pao2 to fraction of inspired oxygen, 83 [IQR, 59-145] mm Hg). By 60 days, 24 patients had died (41.4%; 95% confidence interval, 28.9%-55.0%). Patients who died had greater initial severity of illness, worse hypoxemia, higher creatine kinase levels, higher creatinine levels, and ongoing organ dysfunction. After adjusting for a reduced opportunity of patients dying early to receive neuraminidase inhibitors, neuraminidase inhibitor treatment (vs no treatment) was associated with improved survival (odds ratio, 8.5; 95% confidence interval, 1.2-62.8). Conclusion Critical illness from 2009 influenza A(H1N1) in Mexico occurred in young individuals, was associated with severe acute respiratory distress syndrome and shock, and had a high case-fatality rate. Published online October 12, 2009 (doi:10.1001/jama.2009.1536).

Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome [Caring for the Critically Ill Patient]

Context The novel influenza A(H1N1) pandemic affected Australia and New Zealand during the 2009 southern hemisphere winter. It caused an epidemic of critical illness and some patients developed severe acute respiratory distress syndrome (ARDS) and were treated with extracorporeal membrane oxygenation (ECMO). Objectives To describe the characteristics of all patients with 2009 influenza A(H1N1)–associated ARDS treated with ECMO and to report incidence, resource utilization, and patient outcomes. Design, Setting, and Patients An observational study of all patients (n = 68) with 2009 influenza A(H1N1)–associated ARDS treated with ECMO in 15 intensive care units (ICUs) in Australia and New Zealand between June 1 and August 31, 2009. Main Outcome Measures Incidence, clinical features, degree of pulmonary dysfunction, technical characteristics, duration of ECMO, complications, and survival. Results Sixty-eight patients with severe influenza-associated ARDS were treated with ECMO, of whom 61 had either confirmed 2009 influenza A(H1N1) (n = 53) or influenza A not subtyped (n = 8), representing an incidence rate of 2.6 ECMO cases per million population. An additional 133 patients with influenza A received mechanical ventilation but no ECMO in the same ICUs. The 68 patients who received ECMO had a median (interquartile range [IQR]) age of 34.4 (26.6-43.1) years and 34 patients (50%) were men. Before ECMO, patients had severe respiratory failure despite advanced mechanical ventilatory support with a median (IQR) Pao2/fraction of inspired oxygen (Fio2) ratio of 56 (48-63), positive end-expiratory pressure of 18 (15-20) cm H2O, and an acute lung injury score of 3.8 (3.5-4.0). The median (IQR) duration of ECMO support was 10 (7-15) days. At the time of reporting, 48 of the 68 patients (71%; 95% confidence interval [CI], 60%-82%) had survived to ICU discharge, of whom 32 had survived to hospital discharge and 16 remained as hospital inpatients. Fourteen patients (21%; 95% CI, 11%-30%) had died and 6 remained in the ICU, 2 of whom were still receiving ECMO. Conclusions During June to August 2009 in Australia and New Zealand, the ICUs at regional referral centers provided mechanical ventilation for many patients with 2009 influenza A(H1N1)–associated respiratory failure, one-third of whom received ECMO. These ECMO-treated patients were often young adults with severe hypoxemia and had a 21% mortality rate at the end of the study period. Published online October 12, 2009 (doi:10.1001/jama.2009.1535).

Respiratory Protection Against Influenza [Editorial]

Preparing for the Sickest Patients With 2009 Influenza A(H1N1) [Editorial]

Influenza in 2009: New Solutions, Same Old Problems [Editorial]

Gene-Environment Interactions and Depression [Letters]

Gene-Environment Interactions and Depression--Reply [Letters]

Postherpetic Neuralgia in Herpes Zoster [Letters]

Postherpetic Neuralgia in Herpes Zoster--Reply [Letters]

Rhabdomyolysis Associated With 2009 Influenza A(H1N1) [Research Letters]

CDC Updates Recommendations for Protecting Clinicians From Influenza [Medical News & Perspectives]

H1N1 Vaccine Urged for Health Workers, But Some Resist Getting on Board [Medical News & Perspectives]

Hand Washing, a Key Anti-Flu Strategy, Often Neglected by Health Care Workers [Medical News & Perspectives]

Bacterial Coinfections in Lung Tissue Specimens From Fatal Cases of 2009 Pandemic Influenza A (H1N1)--United States, May-August 2009 [From the Centers for Disease Control and Prevention]

Surveillance for Pediatric Deaths Associated With 2009 Pandemic Influenza A (H1N1) Virus Infection--United States, April-August 2009 [From the Centers for Disease Control and Prevention]

Notice to Readers: Annual Conference on Antimicrobial Resistance--February 1-3, 2010 [From the Centers for Disease Control and Prevention]

Evening Mood at Schlachtensee [The Cover]

Curtains [A Piece of My Mind]

Pantoun on Lines by William Osler [Poetry and Medicine]

VITAL STATISTICS FOR 1908 [JAMA 100 Years Ago]

Allergy Frontiers [Book and Media Reviews]

Rheumatoid Arthritis [Book and Media Reviews]

Building Healthy Communities Through Medical-Religious Partnerships [Book and Media Reviews]

Sleep Apnea and Snoring: Surgical and Non-Surgical Therapy [Book and Media Reviews]

The Mindful Medical Student: A Psychiatrist's Guide to Staying Who You Are While Becoming Who You Want to Be [Book and Media Reviews]

Inaccurate Statement in: A 70-Year-Old Woman With Shingles [Correction]

Incorrect Wording in a Table in: A 52-Year-Old Woman With Obesity [Correction]

Influenza [JAMA Patient Page]

About This Journal [About This Journal]