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Take Clomid is contraindicated in the presence of cysts in the ovaries, liver and kidney failure, the presence of pituitary tumors or genital organs Brand or Generic? The information is provided for informational purposes only and is not a guide for self .

Cialis ne doit pas être prise à tous. Il est important que cialis en ligne est prescrit par un médecin, bien se familiariser avec les antécédents médicaux du patient. Ich habe Probleme mit schnellen Montage. Lesen Sie Testberichte Nahm wie cialis rezeptfrei 30 Minuten vor dem Sex, ohne Erfolg. Beginn der Arbeiten nach 4 Stunden, links ein Freund ein trauriges Ja, und Schwanz in sich selbst nicht ausstehen, wenn es keinen Wunsch ist.

Main title


Influenza Update for
Iowa Long-Term Care Facilities
Iowa Department of Public Health
Center for Acute Disease Epidemiology
Webinar Information
 All participants will be muted during the presentation.  Questions can be submitted directly to the facilitator via the question feature located on your control panel  All questions submitted will be answered at the end of the  This session will be recorded and made available for reviewing  When available, you will receive a follow-up-email on how to access this recording Discussion Points
 Influenza Virus  Influenza Activity Nationally and in Iowa  Outbreak Management  Review of Antiviral Treatment and Prophylaxis Recommendations Presenters (In order of presentation)
 Ann Garvey, DVM, MPH, MA, Deputy State Epidemiologist  Kemi Oni, MPH, Influenza Surveillance Coordinator, IDPH  Chris Galeazzi, MPH, Field Epidemiologist Unit Lead, IDPH  Patricia Quinlisk, MD, MPH, Medical Director, IDPH


Influenza Virus
Influenza Virus
 Viral infection that mostly affects the respiratory system — your nose, throat and lungs  Symptoms include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue.  Some people may also have vomiting and diarrhea (they
will also have fever & respiratory symptoms)  Outbreaks of diarrhea and vomiting alone are frequently caused by Noroviruses (sometimes called Stomach flu)




Persons at Higher Risk for Severe Complications
 Children <5 years  And people with medical (especially <2 years) conditions like:  Adults >65 years  Pregnant women  Neurological conditions  American Indians &  Chronic lung disease  Heart disease  Blood disorders  Endocrine disorders  Kidney disorders  Liver disorders  Metabolic disorders  Weakened immune system


Influenza in persons > 65 years
 Greatest risk of serious complications  90% of influenza-related deaths  50% to 60% of influenza-related hospitalizations


How Influenza Spreads
 Droplets when people cough, sneeze, or talk
 Droplets land in the mouths or noses of people who are
 Also by touching surfaces with the virus on it and then touching your own mouth, eyes, or nose Usually spread from 1-day before symptoms start through 5-7days after becoming sick Influenza Activity Update
National Estimates
 Average of 300,000 Iowans get the flu every year
 Flu and its complication of pneumonia cause an average
of 1,000 deaths yearly in Iowa Peak Month of Flu Activity 1982-83 through 2013-14
Flu Activity Update - Iowa
Widespread Activity
 All three strains of influenza circulating
 Flu A(H3N2) – 92%  Flu A(H1N1)pdm09 – 1%  Flu B(both Yamagata and Victoria lineage) – 4%  Hospitalization rate increasing (especially > 65 yrs) This graph was generated using data collected from sentinel Flu Activity Update - Nationally
 46 states reporting widespread activity
 Flu A(H3N2) viruses most common (>99% of all subtyped flu A  H3N2-predominiated seasons associated with more severe illness and mortality, especially in children and older persons  Hospitalization rates in >65 increasing steeply  More than 2/3 of flu A(H3N2) viruses circulating are not well matched to this years vaccine LTC Outbreaks Reported to IDPH
 IDPH continues to receive reports of influenza-related outbreaks in long term care facilities  There have been 46 reported influenza outbreaks (since October 1, 2014) # of outbreaks
Region 1 (Central)
Region 2 (NE)
Region 3 (NW)
Region 4 (SW)
Region 5 (SE)
Region 6 (Eastern)


Weekly Influenza Report
Posted weekly at IDPH website

To learn more about our Influenza surveillance, please contact Kemi Oni, MPH 515-725-2136 Oluwakemi.oni@idph.iowa.gov Outbreak Management
Public Health defines an outbreak as…
One laboratory confirmed case of influenza Another symptomatic patient (within 72 hours) Report to Public Health
 Review national recommendations
 Arranging specimen transportation
 Provide additional consultation/support
Confirm the Cause of Illness
 While Positive Rapid Test Results can help
guide outbreak decisions  Negative Rapid Test Results do not exclude influenza as the cause of the outbreak (limited sensitivity)  Confirmatory testing at SHL is recommended Implement Standard & Droplet Precautions
All residents with suspected or confirmed influenza
Standard Precautions
 Gloves with hand contact with respiratory secretions or contaminated  Gown if soiling of clothes with respiratory secretions anticipated  Changing gloves and gowns after each encounter and performing hand Droplet Precautions
In place for 7-days after onset or 24-hours after fever and symptoms resolve- whichever is longer  Ill patients in private room, if possible  Wear facemask when enter room CDC Antiviral Recommendations
 All long-term care facility residents who have confirmed or suspected influenza should receive antiviral treatment  Antiviral chemoprophylaxis is recommended for all non-ill residents, regardless of whether they received influenza vaccination during the previous fall Methods to Decrease Transmission
 Restrict common activities
 Limit large group activities  Consider serving meals in rooms  Avoid new admissions  Or transfers to wards with symptomatic residents  Limit visitation  Exclude ill persons from visiting  Post notices  Monitor personnel absenteeism due to respiratory illness  Exclude those with ILI for at least 24 hours after fever resolves  Restrict personnel movement from areas having illness to those not affected by outbreak Vaccination
 Routinely (every year) influenza vaccination should be provided to long term care residents and personnel  During outbreaks administer influenza vaccine to unvaccinated residents and personnel Daily Surveillance
 Conduct daily active surveillance for respiratory illness among ill residents, health care personnel and visitors to the facility  Until at least 1 week after the last confirmed influenza case occurred Antiviral Treatment and
Prophylaxis
Antiviral Agents for Influenza
 Neuraminidase inhibitors (primary agents for A and B influenza)  Oseltamivir (Tamiflu®)  Zanamivir (Relenza®)  Adamantanes (most A's resistant - not used)  Amantadines  Rimantanes  Peramivir (Rapivab®)  IV administration only General Treatment Efficacy of
Neuraminidase Inhibitors
 Reduces uncomplicated illness by 1 day when given within 48 hours of onset of illness  In young children, reduced illness by 3.5 days if given within 24 hours of onset of illness  No or minimal effect in healthy people if started after 48 hours after onset of illness  Secondary pneumonia decreased by 50% in adults with lab confirmed flu if treated  Risk of death reduced after treatment  Children studies showed variable but reduced secondary infections after treatment, less asthma impact CDC Antiviral Treatment Recommendations
All long-term care facility residents with
confirmed or suspected influenza should
receive antiviral treatment immediately
• Treatment should not wait for laboratory confirmation of
• Antiviral treatment works best when started within the first 2 days of symptoms. • However, these medications can still help when given after 48 hours to those that are very sick, such as those who are hospitalized, or those who have progressive illness. Antiviral Treatment Dosage
Duration for antiviral treatment is 5 days
Zanamivir (Relenza – inhaled powder)
2 inhalations of 10 mg twice daily, dose varies by child's weight
 Treatment – not approved in <7 years of age
Oseltamivir (Tamiflu – tablet)
 Children (under 40 Kg) dose varies by weight
 Adults (older children 40+ kg) 75 mg twice daily

CDC Antiviral Prophylaxis Recommendations
 All eligible residents in the entire long-term care facility (not just currently impacted wards) should receive antiviral chemoprophylaxis as soon as an influenza outbreak is determined  Regardless of whether they received influenza vaccination  Priority should be given to residents living in the same unit or floor as an ill resident  However, since staff and residents may spread influenza to residents on other units, floors, or buildings of the same facility, all non-ill residents are recommended to receive antiviral chemoprophylaxis to control influenza outbreaks Antiviral Prophylaxis Dosage
Zanamivir (Relenza – inhaled powder)
 2 inhalations (10 mg) once daily  Not approved for children <5 years of age  Oseltamivir (Tamiflu – tablet)
 Children one year and older (<40 kg) dose varies by weight  Older children and adult (40+ kg) 75 mg once daily  CDC recommends antiviral chemoprophylaxis for a minimum of 2 weeks, and continuing for at least 7 days after the last known case was identified. See Influenza Antiviral Drugs at
Antiviral Medications are Especially Important
this Season

 H3N2-predominant flu seasons have been associated with more hospitalizations and deaths in older people and young children in the past  High hospitalization rates are being observed  Hospitalization rates are especially high among people 65 years  2/3 of the H3N2 viruses that have been tested at CDC are not well matched to this years vaccine, suggesting vaccine effectiveness may be reduced this season Questions?

Source: http://www.iowahealthcare.org/UserDocs/Influenza_Update_for_LTC_012015.pdf

Microsoft word - sample questions

Clinical MCQs Assessment – Sample Questions The fol owing 20 clinical MCQs are representative of the style and format of MCQs that candidates wil receive as part of the AACP Stage 2 Clinical MCQ Assessment. The answers and explanatory notes are provided at the end of this document. SQ1. Which ONE of the following patients has the HIGHEST calculated creatinine clearance?

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Scottish Intercollegiate Guidelines NetworkPart of NHS Quality Improvement Scotland Autism spectrum disordersBooklet for parents and carers We would like to thank all the young people who took part in the focus groups to provide us with their ideas and illustrations for this booklet. © Scottish Intercollegiate Guidelines Network ISBN 978 1 905813 27 8