By T. Taklar. Utah Valley State College. 2019.

The vaccine preventable diseases estimated to account for one third of infant and child disability and mortality in Ethiopia cheap pristiq 100mg fast delivery. Mental Retardation: If a child is significantly retarded in his psychomotor development (milestones) we suspect subnormal intelligence and speak of mental retardation purchase 100 mg pristiq otc. In very mild case there may be only minimal brain damage giving rise to slight delay only and less than optimal intelligence may only become obvious in school pristiq 100mg visa. He can not sit without support at age 9 months, can not stand at at age 15 months, can not walk at age 18 months b. He can not lough loudly at age 6 months, speak three words at age 2 years, and follow a few simple directions at age 3 years c. He can not grasp actively at age 6 months, and take small objects with thumb and finger at age 1 year. Inherited abnormalities or subnormalities of the brain like in microcephalus, hydrocephalus. An abnormality of chromosomes the carrier of inheritance in the cellular nucleus the feature of mongolism (Down’s syndrome) characteristic faces with slanting eyes, a small flat nose a protruding tongue, low set ears and small head. Perinatal problems (prematurity, asphyxia) , or disease acquired after the neonatal period (meningitis, encephalitis, cerebral malaria) may damage the brain d. Deafness can mimic mental retardation 182 Pediatric Nursing and child health care Management: Since there is no treatment of the cause 1. In moderate retardation habit training – eating, walking, and putting on cloths 2. In mild retardation special attention in schools or ideally special school can of value 3. It is a term used for all permanent, no-progressive, generalized brain damage in children irrespective of the cause. Usually some degree of spasticity symptoms are combined with mental retardation, but sometimes the mental retardation is minimal or even abscent. Prenatal: acquired disease such as congenital infection Perinatal: (shortly before or after delivery) : asphyxia, cerebral hemorrhage, b. After the first week of life: meningitis, encephalitis, cerebral malaria can also cause cerebral palsy 183 Pediatric Nursing and child health care Clinical Features: 1. Spastic paralysis if the lesion unilateral or spastic paraplegia if the lesion bilateral 2. Regular exercise under the guidance of physiotherapist help in preventing deformity and contracture 2. Parents of such children support and reassurance Prevention: • Proper antenatal and perinatal care, • early recognition of meningitis etc 13. Down’s Syndrome: Down’s syndrome is a chromosomal abnormality involving an extra chromosome (number 21) characterized by a typical physical appearance and mental handicap. Abnormal attachment of chrosomes inherited from parents 184 Pediatric Nursing and child health care Clinical Manifestations: 1. If diagnosed within the first month of life and substitution with thyroid hormone continued regularly the child will have a normal life 3. With late diagnosis and inadequate treatment the child will be severely retarded and handicapped 13. Polyuria, and polydipsia in young children are symptoms to make you think of diabetes mellitus which is not uncommon and is often overlooked Findings of sugar in urine, and an increased blood sugar prove the diagnosis. Addele Pilliteri (1987), Child health Nursing, care of the growing child, Little, Brown and Company. Addele Pilliteri (1992), Maternal and child health Nursing, care of the child bearing and child rearing family, J. A Tiu (1991), Essential Paediatric Nursing, Chelmstord, Kampala 189 Pediatric Nursing and child health care 12. Katharyn May, Laura Mahlmeister (1990), Comprehensive Maternity Nursing, nursing Process and the child bearing family, J. Maurice King, Felicity king (1978), Primary Child Care, a manual for health workers, Oxford University Press. Patricia Wiel and Cadewing, essentials of maternal and Newborn Nursing 2nd edition. Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Important Guidelines for Printing and Photocopying Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty. All copies must retain all author credits and copyright notices included in the original document. Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication. Except as expressly provided above, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission of the author or authors. This material is intended for educational use only by practicing health care workers or students and faculty in a health care field. We hope that it will be a good introduction to eye diseases for health science students working in Ethiopia. There are so many books about eye diseases available but hardly any, which are written from the perspective of Ethiopia, where more blind are live. The lecture note is basically focused on the community as well as clinical ophthalmology to introduce the students on the common causes and burden of blindness and their preventive aspect. So it is written for students who are intended to see patients and need to recognize each disease and recommend possible treatment. When looking at a patient with eye disease, the most important skill is to be able to recognize the appearance of each particular disease. In the management of diseases which are beyond their scope are recommended to refer as early as possible. Their main role is to pick problems early and to have an active role in the prevention of blindness. Selected pictures are used to illustrate some anatomical parts and common eye diseases to make note easier and understandable. There are several encouraging signs that there is an increasing awareness of the challenge of treatable and preventable blindness throughout the world. Our country is forming prevention of blindness to try to look realistically at the problem locally. In spite of all this, the number of avoidably blind people in Ethiopia continues to increase faster than the population. We would like to express our appreciation to The Carter Center, Atlanta Georgia for funding the activities in the development of this lecture note all the way through. We would like to thank Gondar University for helping us with different material in order to make this note feasible. Reviewers that highly contributed to the development of this material using their valuable time and experience include 1.

This test is sensitive and will detect therapeutic dosage with salicylic acid order pristiq with a visa, acetylsalicylic acid order pristiq on line amex, 4-aminosalicylic acid order discount pristiq online, methyl salicylate and salicylamide. Measure the absorbance of the supernatant at 540 nm against plasma blank Results Calculate the plasma salicylate concentration from the graph obtained on analysis of the salicylate standards. Some salicylate metabolites interfere, but plasma concentrations of these compounds are usually low. Oxalates, for example, from fluoride/ oxalate blood tubes, also interfere in this test. Toxic manifestations of barbiturates vary with the amount of ingestion, type of drug and time elapsed since ingestion. Phenobarbital) generally cause toxicity, but fatalities are more common with the latter. Moderate intoxication is characterized by greater depression of mental status and severe intoxication causes coma. Phenobarbital) levels are helpful for making a diagnosis but of little value when predicting the severity of the over dose. Specific laboratory tests Quantitative assay Specimen Whole blood, plasma or serum (5 ml) Reagents (see annex I) 1. Standards (see annex I) Solutions containing barbital at concentrations of 5, 10, 25 and 50 mg/l in blank human plasma 80 Toxicology Procedure 1. Add 5 ml of sample, 2 ml of hydrochloric acid and 60 ml of diethyl ether to a 250-ml separating funnel. Lubricate (with purified water) and insert the funnel and shake gently for 2 minutes. After standing for 5 minutes, and then discard the lower aqueous phase, add the diethyl ether extract to 10 ml of borate buffer in a second separating funnel and mix for 1 minute. Allow to stand for 5 minutes and again discard the lower, aqueous phase through the funnel tap. Wash round the funnel with 5 ml of purified water; allow standing for 5 minutes and again discarding the lower, aqueous phase through the funnel tap. Add about 4 g of sodium sulfate/charcoal mixture to the ether extract in the funnel, shake to disperse, and filter the extract through phase-separating filter-paper into a 150-ml conical flask. Add a further 20 ml of diethyl ether to the separating funnel, shake and add to the extract in the flask through the filter funnel. Evaporate the extract to dryness on a water-bath at 40°C under a stream of compressed air or nitrogen. Check the spectrophotometer zero at 240 nm using purified water in both sample and reference positions. Add 4 ml of filtrate from the test-tube to a clean, dry cell, add 50 µl of concentrated ammonium hydroxide and mix using a plastic paddle. If necessary, accurately dilute a portion of the extract with purified water to bring the reading on to the scale, and record the magnitude of the dilution. Results 1) To perform a quantitative measurement, measure the difference between absorbance at pH 10 and at pH 2, construct a calibration graph by analysis of the standard barbiturate solutions, and calculate the barbiturate concentration in the sample. Alternatively, use the following formula: ((absorbance at pH 10) - (absorbance at pH 2)) × Dilution factor (if any) × 25 = barbiturate (mg/l) 2) Sample volumes of less than 5 ml may be used, but there will be a corresponding loss of sensitivity unless "micro"- volume fused silica spectrophotometer cells are available. Environmental toxicants Exposure of biological systems to chemicals may occur through environmental pollution of the atmosphere, water or soil. Food born toxins derived from different microbes also can contribute in causing environmental intoxication. The possibility of carbon monoxide poisoning is obvious for the victim of fire and smoke inhalation; but accidental and suicidal exposures are also common. The gas is readily absorbed across the alveolus and combines with hemoglobin with high affinity than oxygen. This displacement of oxygen from hemoglobin leads to a decrease in oxygen transport and causes tissue hypoxia. Elimination of carbon monoxide is predominantly through respiration; only about 1% is 83 Toxicology metabolized to carbon dioxide. Laboratory analysis - Carboxyheamoglobin level – should be measured as early as possible to establish the diagnosis of carbon monoxide poisoning. Carboxyheamoglobin should be measured from blood sample using spectrophotometric methods. Although not as accurate, carboxyheamoglobin levels can be estimated from expired air using a breath analyzer for carbon monoxide. The PaO2 is often normal, as it is a measure of oxygen dissolved in plasma, not a measure of oxygen bound to hemoglobin. Specific laboratory tests Qualitative test Applicable to whole blood treated with heparin, edetic acid or fluoride/oxalate. Cyanide may give a similar tint, but acute cyanide poisoning is generally much less common than carbon monoxide poisoning. Add a small amount (about 20 mg) of sodium dithionite to each test solution (x, y and z) and also to 10 ml of ammonium hydroxide solution and mix well. Measure the absorbance of solutions x, y and z against the dithionite-treated ammonium hydroxide solution at 540 nm and 579 nm. Note that the hemoglobin content of blood varies from person to person, and thus the volume of diluents used may need to be altered. A dilution giving a maximum absorbance of about 1 absorbance unit at 540 nm is ideal. B - It is important to use sodium dithionite that has been freshly obtained or stored in a sealed container in desiccators, since this compound is inactivated by prolonged contact with moist air. Food poisoning syndromes result after ingestion of a wide variety of foods contaminated with pathogenic microorganisms or microbial toxins. The pathogenic organisms are Clostridium perferinges, Bacillus cereus, Escherichia coli, Closterdium botulinium and Vibrio cholerae. The illnesses produced usually are not associated with fever or blood, pus, or mucus in the stools because it doesn’t have tissue involvement. Except for botulism and cholera, the clinical course of most of these food-borne toxin related illnesses is self-limiting. However, in a common source outbreak, examination of food, gastric contents, or stool may be useful. However, confirmatory tests may be warranted in the case of a mass outbreak of food poisoning. Any use of a drug for non-medical purposes, usually for altering consciousness but also for body building is known as abuse of drug. Psychological dependence (drug seeking behavior in which the individual uses the drug repetitively for personal satisfaction), physiologic dependence (withdrawal of the drug produces symptoms & signs), &tolerance (necessitating large doses of the drug to achieve the same response) are the main features of drugs of abuse. Alcohols Alcohol, primarily in the form of ethyl alcohol (ethanol), has occupied an important place in the history of human kind for at least 8000 years. Young children, chronic alcoholics or suicidal persons may ingest toxic quantities of one or several of the alcohols. Whether intentional or accidental, alcohol ingestions remain one of the more common, yet potentially devastating, poisonings commonly encountered in the emergency 89 Toxicology department. Approximately 25% of ingested ethanol is absorbed unaltered from the stomach and the rest from the small intestine.

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In women with early-stage hormone- receptor-positive breast cancer buy cheap pristiq 100mg on line, ophorectomy plus 5 years of tamoxifen can increase the chances of 10 year disease-free survival from 47-66% and 10 year overall survival from 49- 82% compared with surgery alone (Love et al buy generic pristiq 100 mg on line, 2008) buy generic pristiq 50mg line. Post-menopause: After menopause, the ovaries stop producing oestrogen, but it is still made by aromatase. Hormone therapy in these women therefore focuses on stopping this process from occurring by use of aromatase inhibitors, and by blocking the action of oestrogen at the breast tissue. Hormone Therapy and Obesity Ewertz et al (2010) in a large, retrospective study found hormone therapy was less effective in obese women than lean women who had breast cancer. Since oestrogen is synthesized in adipose tissue after menopause, there is an excess of oestrogen in obese post-menopausal women (Ket et al, 2003). Obesity is also correlated with decreased plasma levels of sex- hormone-binding globulin, which naturally restricts the biologic activity of oestrogen (Siniscrope & Dannenberg 2010). Side effects of Hormone Therapy Tamox Arimidex Aromasin Femara Evista Fareston Faslodex ifen Bone/joint yes yes yes yes yes pain Osteoporosis yes yes yes Bone yes yes yes thinning Nausea yes yes yes yes yes Vomiting yes yes yes Hot flashes yes yes yes yes yes yes yes Weakness yes yes Fatigue yes yes yes yes Headache yes yes yes Insomnia yes yes 40 Tamox Arimidex Aromasin Femara Evista Fareston Faslodex ifen Sweating yes yes Dizziness yes yes Drowsiness yes High yes cholesterol Weight gain yes Blood clots yes yes Stroke yes yes Endometrial yes yes cancer Increased yes yes bone / tumour pain Mood swings yes yes Depression yes Hair yes thinning Constipation yes yes Dry skin yes yes yes Loss of yes libido Leg cramps yes 41 Tamox Arimidex Aromasin Femara Evista Fareston Faslodex ifen Swelling yes yes Flu-like yes symptoms Hypercalce yes mia Rash yes Vaginal yes discharge / bleeding Vision yes problems Dry eyes yes Diarrhoea yes Sore throat yes Back pain yes Abdominal yes pain Injection site yes pain Psychological Impact  Premature menopause induced by adjuvant therapy is associated with poorer quality of life, decreased sexual functioning, menopausal symptom distress, psychosocial distress related to fertility concerns in premenopausal breast cancer patients 42  Psychosocial distress is common in women who experience loss of fertility; loss of choice to have more children, or any children. Multi-disciplinary team members involved in breast cancer care 44 Oncologist: There are three main types of oncologists in breast cancer care:  Medical oncologist: specializes in cancer drugs e. Healthy eating can reduce cancer risk, recurrence and help reduce lymphoedema volume (McNeely et al, 2011). Dieticians devise diet plans that aim to  Ensure patients are as lean as possible within the normal range of body weight  Avoid weight gain and increase in waist circumference This is achieved through:  Limiting consumption of energy-dense foods  Consuming ‘fast foods’ sparingly 45  Eating mostly foods of plant origin  Eating at least 5 portions of various non-starchy vegetables and fruit a day  Eating relatively unprocessed cereals(grains) and/or pulses(legumes) with every meal  Limiting refined starchy foods  Limiting intake of red meat and avoiding processed meat  Limiting consumption of salt (World Cancer Research Fund/American Institute for Cancer Research, 2007) Dieticians also treat and provide advice on side effects of breast cancer treatments: nausea, mouth soreness, taste changes, constipation, diarrhoea, weight gain/loss, bone health and other specific dietary considerations due to co morbidities (Breast Cancer Care 2009) Occupational Therapist: Role: To facilitate patients to achieve maximum functional performance, both physically and psychologically, in everyday living regardless of their life expectancy (Penfold 1996). Mentioned how this is treated with analgesics or in more severe cases referral to a specialist is required. Sinead Cobbe (Senior physiotherapist in palliative care in Milford Hospice) • Demonstrated how to perform lymphoedema bandaging on breast cancer patients. Lymph vessels: (Absorption) A network of thin vessels that transport lymph and lymphocytes (white blood cells that Figureht infection and the growth of tumours) throughout the body. Lymph nodes: (Filtration) Small, bean-shaped structures located along the lymph vessels. Lymph is filtered through several lymph nodes where it is inspected for foreign substances. Lymphatic Ducts: (Drainage) Eventually, the lymph vessels empty into the lymphatic ducts which drain into one of the two subclavian veins. The lymphatic vessels of the left arm drain into the left subclavian lymphatic trunk and lymph channels of the right arm drain into the right subclavian lymphatic trunk. If the lymph nodes are not successful in destroying cancer cells, the nodes may become sites of secondary tumours. Breast Cancer Related Lymphoedema is the build up 48 of fluid in the upper extremity due to impairment of the lymph vessels following removal of the axillary lymph nodes and possibly exacerbated by radiation treatment (Smith and Miller, 1998). Lymphoedema has been reported to occur within days and up to 30 years after breast cancer treatment but most commonly occurs within 12 months post-surgery. Staging of lymphoedema (classification of severity): Stage 0 Lymphatic function is reduced, lymphoedema is present but is not apparent on physical examination Stage 1 Early accumulation of fluid that is relatively high in protein content. Stage 3 A severe increase in irreversible swelling may develop, along with skin changes, such as thickening of the skin, fat deposits, and warty over-growths. In almost all cases an in-depth medical history and physical examination are enough to make a diagnosis. Lymphoedema Assessment Subjective Objective  Current symptoms: Daily pattern, (Always compare to other side) frequency, intensity, duration  Range of motion  Pain  Increase in upper limb  Functional Impairments, dominant volume/circumference hand  Skin condition:  History of Oedema, previous - broken/fragile/shiny/ulcerated/ treatment? Chen et al, (2008) found it a reliable measure for assessing arm volume in breast cancer patients. Technique to measure circumference of upper limb: Ensure the limb is supported and in a straight position. These should be of the appropriate class and size, and a choice of fabrics and colours should be available. It consists of light, rhythmical strokes performed in the direction of normal lymphatic flow. Usually, it is performed for 45-60 minutes, 4 days a week for 2-4 weeks (acute phase of treatment) (Chiefetz and Hanley, 2010). This is a precise and accurate procedure using specific bandages and interfacing materials that provide external support to the skin. The gradient compressive forces push the lymphatic fluid from the interstitium into the lymph vessels increasing lymph reabsorption and stimulating lymphatic transport. In the acute phase (0-5 days) short-stretch bandages are used to reduce limb volume. Their efficiency is increased when exercises are done in conjunction due to dual-action of muscle pump and compression. Once limb volume is reduced substantially, patient is fitted for a compression garment to maintain the achieved volume. Exercise should consist of both range of motion/flexibility and strengthening and should be specific to each individual. Options include direct anatomic plane movements, scapular plane movements, or functional and combined movements (e. Wear gloves when doing duties, shave with electric razor, treat cuts with antiseptic lotion. Chou et al, (2012) carried out a single case study on a patient with unilateral secondary malignant breast – cancer lymphoedema and found that kinesio taping could be another choice for contraindicating pressure therapy patients instead of compressive bandaging, however it should not replace it. Furthermore, 55 Tsai et al, 2009 found that there was no significant difference between kinesio taping and bandaging for the treatment of cancer-related lymphoedema. The network is always present in the axilla and extends along the medial face of the ipsilateral arm, frequently below the cubital cavity and occasionally until the base of the thumb. Altogether 56 out of 116 patients who underwent axillary lymph-node dissection were found to have axillary web syndrome (incidence of 48. It is unrelated to the number of lymph nodes compromised or with the stage of the illness. The management included manual therapy, mostly using soft tissue treatment techniques, combined with education and advice. Pre-morbid range of movement was achieved within 11 treatments, spread over 3 weeks and after 16 weeks the patient experienced no pain. Furthermore, the patient returned to full-time employment after the seventh treatment by a physiotherapist. This results in fibrosis of the vasa nervorum (small arteries supplying blood to peripheral nerves) (Ahmad et al, 1999). Radiation-induced brachial plexopathy can occur when radiotherapy is directed at the chest, axillary region, thoracic outlet, or neck. The radiation dose, treatment technique, and concomitant use of chemotherapy all demonstrate significant association with the development of radiation injury to the brachial plexus (Bajrovic et al, 2004). One third of patients deteriorate rapidly and exhibit significant weakness, lymphoedema, and pain (Johansson et al, 2002). Signs and Symptoms  Numbness  Paraesthesia  Dysesthesia  Swelling and weakness of the arm  Motor deficits of the ipsilateral upper extremity On Examination  Neurologic findings in the C5-C6 myotomes and dermatomes, as well as diminished deep tendon reflexes supplied by C5-C6. Fatigue has been noted to decrease in the first 2 weeks after localized treatment for breast cancer but then to increase as radiation therapy persists into week 4. Administration of chemotherapy and radiotherapy for malignancy causes a specific fatigue syndrome.

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Cytopathic effects are non-specific and influenza A virus infection of cells can be detected by immunofluorescence for nucleoprotein buy 50mg pristiq with amex. Serology: A fourfold rise in titre from acute to convalescent specimens is also diag- nostic of infection in patients that recovered (Yuen 2005) 50 mg pristiq with visa. Other laboratory findings Leucopenia and especially lymphopenia (which has been shown to be a sign of poor prognosis in patients from Thailand) buy 50 mg pristiq free shipping, thrombocytopenia and moderately elevated transaminase levels are common findings (Beigel 2005). New developments and the future of influenza di- agnostics A few trends in influenza diagnosis have been observed. Yet these tests’ value is limited by their relatively low sen- sitivity especially for the diagnosis of avian influenza. The only remaining hurdle remains its relative high cost; but the highly competitive market has already made these tests more affordable. Conclusion Molecular diagnostic techniques play a more and more prominent role in laboratory diagnosis of influenza. Influenza serology’s main value lies in epidemiological investigations of yearly epidemics, avian to human transmissions and drug and vaccine trials. We can thus conclude that virological diagnosis for influenza has value for the in- dividual patient, epidemiological investigations and infection control. The appropri- ate selection of a particular test will is determinded by the test characteristics and the specific diagnostic or public health needs. A positive diagnostic test is the difference between someone with flu-like illness and a definite diagnosis of influenza or between a suspected human case of avian influenza and a confirmed case. Enzyme-linked immunosorbent assay for detection of antibodies to influenza A and B and parainfluenza type 1 in sera of patients. Surveillance of childhood influenza virus infection: what is the best diagnostic method to use for archival samples? Enzyme immunoassay, complement fixation and hemagglu- tination inhibition tests in the diagnosis of influenza A and B virus infections. Comparison of complement fixation and hemagglutination inhibition assays for detecting antibody responses following influenza virus vaccination. Rapid identification of viruses by indirect immunofluorescence: standardization and use of antiserum pool to nine respiratory viruses. Diagnosis of influenza in the com- munity: relationship of clinical diagnosis to confirmed virological, serologic, or molecular detection of influenza. In rare cases, the initial presentation may be atypical (febrile seizures, Ryan- Poirier 1995; bacterial sepsis, Dagan 1984). Typical symptoms of uncomplicated influenza Abrupt onset Systemic: feverishness, headaches, myalgias (extremities, long muscles of the back; eye muscles; in children: calf muscles), malaise, prostration Respiratory: dry cough, nasal discharge – may be absent in elderly people who may pres- ent with lassitude and confusion instead Hoarseness, dry or sore throat often appear as systemic symptoms diminish Croup (only in children) Table 2: Frequency of baseline symptoms* Symptom (%) Fever ≥ 37. Fever and systemic symptoms typically last 3 days, occasionally up to 4–8 days, and gradually diminish; however, cough and malaise may persist for more than Complications of Human Influenza 161 2 weeks. Physical findings of uncomplicated influenza Fever: rapidly peaking at 38–40°C (up to 41°C, especially in children), typically lasting 3 days (up to 4–8 days), gradually diminishing; second fever spikes are rare. Face: flushed Skin: hot and moist Eyes: watery, reddened Nose: nasal discharge Ear: otitis Mucous membranes: hyperaemic Cervical lymph nodes: present (especially in children) Adults are infectious from as early as 24 hours before the onset of symptoms until about seven days thereafter. Children are even more contagious: young children can shed virus for several days before the onset of their illness (Frank 1981) and can be infectious for > 10 days (Frank 1981). Severely immunocompromised persons can shed influenza virus for weeks or months (Klimov 1995, Boivin 2002). During non-epidemic periods, respiratory symptoms caused by influenza may be difficult to distinguish from symptoms caused by other respiratory pathogens (see Laboratory Findings). However, the sudden onset of the disease, fever, malaise, and fatigue are characteristically different from the common cold (Table 4). Symptoms Influenza Cold Fever Usually high, lasts 3–4 days Unusual Headache Yes Unusual Fatigue and/or weakness Can last up to 2–3 weeks Mild Pains, aches Usual and often severe Slight Exhaustion Early and sometimes severe Never Stuffy nose Sometimes Common Sore throat Sometimes Common Cough Yes Unusual Chest discomfort Common and sometimes severe Mild to moderate Complications Bronchitis, pneumonia; in severe Sinus congestion cases life-threatening Complications of Human Influenza The most frequent complication of influenza is pneumonia, with secondary bacte- rial pneumonia being the most common form, and primary influenza pneumonia the most severe. Influ- enza infection has also been associated with encephalopathy (McCullers 1999, Morishima 2002), transverse myelitis, myositis, myocarditis, pericarditis, and Reye’s syndrome. Secondary Bacterial Pneumonia Secondary bacterial pneumonia is most commonly caused by Streptococcus pneu- moniae, Staphylococcus aureus, and Haemophilus influenzae. Typically, patients may initially recover from the acute influenza illness over 2 to 3 days before having rising temperatures again. Clinical signs and symptoms are consistent with classical bacterial pneumonia: cough, purulent sputum, and physical and x-ray signs of con- solidation. Institution of an appropriate antibiotic regimen is usually sufficient for a prompt treatment response. Primary Viral Pneumonia Clinically, primary viral pneumonia presents as an acute influenza episode that does not resolve spontaneously. Primary influenza pneumonia with pulmonary haemorrhages was a prominent fea- ture of the 1918 pandemic. In addition, pregnant women and individuals with car- diac disease (mitral stenosis) and chronic pulmonary disorders were found to be at increased risk during the 1957 pandemic. Mixed Viral and Bacterial Pneumonia Mixed influenza pneumonia has clinical features of both primary and secondary pneumonia. Some patients have a slowly progressive course, others may show a transient improvement in their condition, followed by clinical exacer- bation. Exacerbation of Chronic Pulmonary Disease Infectious pathogens have long been recognised as playing an important role in the pathogenesis of chronic respiratory disease (Monto 1978). In patients with chronic bronchitis, clinical influenza infection may lead to a permanent loss of pulmonary function. In children, influenza-induced asthma may continuously deteriorate dur- ing the first two days of illness and reconvalescence is typically longer (at least seven days) (Kondo 1991). Complications of Human Influenza 163 Croup Croup is a typical complication of influenza infection in children. The clinical pic- ture of croup caused by influenza viruses may be more severe than that caused by parainfluenza viruses (Peltola 2002). Failure of Recovery In epidemic influenza outbreaks, severely compromised elderly people are at par- ticular risk. Pneumonia and influenza death rates have ranged from fewer than ten to more than 600 per 100,000 among healthy versus chronically ill adults. In one study, the highest death rates (870 per 100,000) occurred in individuals with both cardiovascular and pulmonary disease (Barker 1982). More importantly, the risk of death may extend well beyond the first weeks after influenza complications. Some people may simply never recover from influenza complications – and eventually die from deterioration of underlying pulmonary, cardiovascular, or renal function (Saah 1986). Myositis Myositis is a rare complication of influenza B virus infection, and to a lesser extent influenza A. The median interval between the onset of influenza and the onset of benign acute childhood myositis is 3 days (Agyeman 2004). The calf muscles are involved alone or together with other muscle groups in 69 % and 31 % of cases, respectively.

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