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Original Article |

Recovery of Potential Pathogens and Interfering Bacteria in the Nasopharynx of Otitis Media–Prone Children and Their Smoking and Nonsmoking Parents FREE

Itzhak Brook, MD, MSc; Alan E. Gober, MD
[+] Author Affiliations

Financial Disclosure: None.


Arch Otolaryngol Head Neck Surg. 2005;131(6):509-512. doi:10.1001/archotol.131.6.509.
Text Size: A A A
Published online

Objective  To study the frequency of isolation of potential pathogens and interfering bacteria in the posterior nasopharynx of otitis media–prone (OMP) children and their smoking and nonsmoking parents to possibly explain why active and passive exposure to smoking is associated with carriage of potentially pathogenic bacteria and an increased risk of respiratory tract infection in both adults and children.

Setting  Outpatient clinic.

Participants  Twenty OMP children and their smoking parents (smoking group) and 20 OMP children and their nonsmoking parents (nonsmoking group).

Interventions  Posterior nasopharynx cultures were taken from 20 OMP children and their smoking parents and 20 OMP children and their nonsmoking parents.

Main Outcome Measure  Potential pathogens and aerobic and anaerobic bacteria with interfering capabilities against these organisms were identified.

Results  Fourteen potential pathogens were isolated from smoking parents, and 17 were recovered from their children. Concordance in isolation of a pathogen between a parent and child was noted in 11 instances. Three potential pathogens were isolated from nonsmoking parents (P<.001 compared with the parents and children in the smoking group and children in the nonsmoking group), and 16 were recovered from their children. Bacterial interference by normal flora isolates against potential pathogens was noted in 58 instances in smoking parents and in 55 instances in their children (P<.05). Bacterial interference was noted in 129 instances in nonsmoking parents (P<.05 compared with the parents and children in the smoking group and children in the nonsmoking group) and in 55 instances in their children.

Conclusions  A high recovery rate of potential pathogens and a low number of interfering organisms were observed in OMP children. This was not related to their parents’ smoking habits. The posterior nasopharynx flora of smoking parents contained more potential pathogens similar to the ones recovered from OMP children and fewer interfering organisms than nonsmoking parents.

Smoking is associated with an increased risk of respiratory tract infections in adults1 and also with oral colonization by some potentially pathogenic species of bacteria.24 In children, exposure to cigarette smoke is a risk factor for respiratory tract infections, including otitis media4 and meningococcal meningitis.5 Active smoking and passive exposure to cigarette smoke are also associated with carriage of some potentially pathogenic bacteria in both adults and children.6 This has been explained by (1) enhanced bacterial binding to epithelial cells of smokers7 and (2) the low number of alpha-hemolytic streptococci with inhibitory activity against Streptococcus pyogenes in the oral cavity of smokers.8 However, the rate of colonization with other aerobic and anaerobic organisms with interfering capabilities has not been evaluated. Furthermore, to our knowledge, the frequency of recovery of potential pathogens and interfering bacteria in the nasopharynx of pairs of otitis media–prone (OMP) children and their smoking parents has not been studied. The purpose of the present study was to compare the frequency of isolation of potential pathogens and aerobic and anaerobic interfering bacteria in the posterior nasopharynx of OMP children and their smoking parents (smoking group) with the isolation rate in OMP children and their nonsmoking parents (nonsmoking group).

PATIENTS

Included in the study were 40 OMP children consecutively seen for their annual physical examination in an outpatient clinic and 1 of each of their parents. Twenty of the parents were smokers (defined as smoking at least 10 cigarettes a day for the past 5 years), and 20 were nonsmokers. None of the parents had any chronic illness, received antimicrobial therapy, or had a respiratory tract infection in the 3 months prior to study enrollment. Parents varied in age from 25 to 44 years (average age, 33 years), and 22 were women. Age and sex distribution was similar in both groups.

The children’s ages ranged from 20 to 66 months (average age, 38 months), and 26 were boys. Age and sex distribution was similar in both groups. The OMP patients were defined as having at least 6 episodes of acute suppurative otitis media in the previous 2 years. None of the children had prior adenoidectomy or tonsillectomy, perforation of the tympanic membranes, treatment with antimicrobials or other medications, or any infections in the preceding 4 weeks, and none had chronic medical problems. The protocol was approved by the institutional review board.

Cultures were obtained using sterile calcium alginate swabs. Specimens were collected from the posterior nasopharynx (through the mouth) and were immediately plated into media supportive of the growth of aerobic and anaerobic bacteria.

MICROBIOLOGIC EXAMINATION

Sheep’s blood (5%), chocolate, and MacConkey agar plates were inoculated for the isolation of aerobic organisms. The culture plates were incubated aerobically at 37°C (MacConkey agar) and under 5% carbon dioxide (blood and chocolate agars), and they were examined at 24 and 48 hours. For the recovery of anaerobic bacteria, the specimens were inoculated onto prereduced Brucella blood agar enriched with phytonadione (vitamin K1), blood agar that contained kanamycin and vancomycin, and an aerobic blood plate that contained phenylethyl alcohol and enriched thioglycolate broth. These media were immediately incubated in BBL Microbiology GasPack jars (Becton, Dickinson and Company, Franklin Lakes, NJ) at 37°C and examined after 48 and 96 hours of incubation at 37°C. All types of colonies on each plate were isolated. The total number of aerobic and anaerobic bacterial isolates processed from each individual varied from 4 to 17 (average, 7.8). Aerobic and anaerobic bacteria were identified by previously described methods.9,10

TESTING FOR INTERFERENCE

The inhibitory activity was tested in a blind fashion against 1 strain each of a recent clinical isolate of Streptococcus pneumoniae, Haemophilus influenzae (non–type b), Moraxella catarrhalis, and S pyogenes. Inhibitory activity of 5 separate colonies of all aerobic and anaerobic isolates was evaluated. The inhibitory activity of each isolate was individually tested against the test organisms, using the Steer steel pin replicator as previously described.11 In brief, minidrops of log-phase broth cultures of the isolates were transferred with the pin replicator to vitamin K1–enriched Brucella blood or chocolate (for H influenzae) agar plates and allowed to dry for 15 minutes at room temperature. A sample of a log-phase broth culture of the target strain was applied adjacent to each of the isolated strains, and the plates were incubated in 5% carbon dioxide or anaerobically at 37°C for 48 hours. Bacterial interference was defined as any reproducible inhibition of growth. Degrees of inhibition varied from complete absence of growth to a narrow zone of poor growth along the proximal area of the colony. Statistical significance was calculated using the χ2 test with Yates correction.

RECOVERY OF PATHOGENS

In the smoking group, 14 potential pathogens were isolated from 12 parents (0.7 per parent), and 17 potential pathogens were recovered from 15 of their children (0.85 per child). Concordance in isolation of a pathogen between a parent and child was noted in 11 instances (Table 1). In the nonsmoking group, 3 potential pathogens were isolated from 3 parents (0.15 per parent; P<.001 compared with the parents and children in the smoking group and children in the nonsmoking group), and 16 potential pathogens were recovered from 14 of their children (0.8 per child). Concordance in isolation of a pathogen between a parent and child was noted in 2 instances (Table 1).

Table Graphic Jump LocationTable 1. Pathogens Found in the Retropharynx of Smoking and Nonsmoking Parents and Their Children
BACTERIAL INTERFERENCE

Bacterial interference between 2 aerobic (alpha and nonhemolytic streptococci) and 2 anaerobic species (Prevotella and Peptostreptococcus species) and 4 potential pathogens (S pneumoniae, H influenzae, M catarrhalis, and S pyogenes) was observed. In the smoking group, bacterial interference was noted in 58 instances against the 4 potential pathogens by 21 normal flora isolates that were recovered from the parents and in 55 instances by 18 isolates from the children (Table 2). In the nonsmoking group, bacterial interference was noted in 129 instances against the 4 potential pathogens by 44 normal flora isolates that were recovered from the parents (P<.05 compared with the parents and children in the smoking group and children in the nonsmoking group) and in 55 instances by 20 isolates from the children (Table 3).

Table Graphic Jump LocationTable 2. Isolates With Interfering Capabilities Recovered in the Retropharynx of Smoking Parents and Their Children
Table Graphic Jump LocationTable 3. Isolates With Interfering Capabilities Recovered in the Retropharynx of Nonsmoking Parents and Their Children

We observed a high recovery rate of potential pathogens and a low number of interfering organisms in OMP children. This was not related to their parents’ smoking habits. The prevalence of potentially pathogenic bacteria and interfering organisms in the respiratory tract of OMP children did not depend on whether the parents smoked. The study also illustrates that the posterior nasopharyngeal flora of smoking parents was similar to that recovered from their OMP children and contained more potential pathogens and fewer interfering organisms than in the nonsmoking parents. These findings confirm previous observations in smokers.68

The association between passive exposure to smoking and recurrent otitis media is well established.4 Since smoking parents harbor more potential pathogens and fewer interfering organisms, they may serve as a source of pathogens that can colonize and/or infect their children. Conversely, organisms that originated from their own children could have colonized these parents. It is possible that the exposure to second-hand smoke also contributes to better adherence of pathogens to the nasopharyngeal mucosa. Furthermore, children of smoking parents are exposed to more pathogenic bacteria that colonize their parents. It is also possible that pathogens may be shared between smoking parents and their children, since horizontal spread of organisms in the family setting can occur.12 A cycle can therefore exist in families of OMP children whose parents smoke such that potential microbial pathogens circulate between parents and children. Support for this explanation will come if future studies of smoking parents of non-OMP children show the presence of similar patterns of colonization in them as was observed in smoking parents of OMP children. Of interest is that such a situation does not seem to exist in families where the parents do not smoke, since pathogenic bacteria do not colonize the parents. However, without confirmation by a serologic or nucleic-acid typing procedure, it cannot be ruled out that the concordance of organisms in a parent and a child represents unrelated serotypes.

Previous studies have demonstrated a high recovery rate of potential pathogens (H influenzae, S pneumoniae, and M catarrhalis) and a lower number of interfering organisms in OMP children than in non-OMP children.1316 Bernstein et al13 and Fujimori et al15 documented a higher recovery of interfering alpha-hemolytic streptococci in non-OMP than in OMP children. Brook and Gober16 illustrated that the nasopharyngeal flora of non-OMP children contains more aerobic and anaerobic organisms with interfering capability and fewer potential pathogens than that of OMP children.

The presence of organisms with interfering potential may play a role in the prevention of upper respiratory tract infection. It is possible that the prior frequent use of antibiotics in infection-prone individuals may have reduced the number of organisms inhibitory to the growth of pathogens. However, since we studied only children who had not received antibiotics in the past month and adults who did not get antibiotics in the past 3 months, prior antibiotic use does not explain the bacterial discrepancies.

The ability of indigenous normal nasophayrngeal flora to inhibit colonization with potential pathogens has been studied in several types of upper respiratory tract infection.1722 Alpha-hemolytic streptococci were found to inhibit the colonization in patients and in vitro growth of a variety of pathogenic bacteria. These include S pneumoniae, S pyogenes, and Staphylococcus aureus.1722 The production of bacteriocin and other inhibitory substances that suppresses some bacterial growth or the use of nutrients in the nasopharyngeal environment essential for the potential pathogens may explain this phenomenon.23

Therapeutic colonization of the nasopharynx with interfering bacteria was recently studied by Roos et al,24 who inoculated children with repeated tonsillitis to either alpha-hemolytic streptococci or placebo spray. Clinical recurrences occurred in 2% of the alpha-hemolytic streptococci group (1/51) and 23% of the placebo-treated group (14/61). Similarly, these investigators showed that recolonization with alpha streptococci with the ability to inhibit the growth of pathogens reduced the recurrence of acute otitis media and the frequency of otitis media with effusion in susceptible children.25 Three months after colonization with alpha-hemolytic streptococci, 22 (42%) of the children given the streptococcal spray were otitis media free and had normal tympanic membranes compared with 12 (22%) of those given placebo.

Further studies are warranted to investigate the colonization patterns in nonsmoking parents and whether colonization of the posterior nasopharynx with interfering organisms and/or cessation of smoking by parents would be beneficial to them as well as their children in allowing for the return of the normal inhibitory flora and the reduction in the number of pathogens and subsequent infections. This would be beneficial if the smoking parents were the source of the potential pathogens in the household setting.

Correspondence: Itzhak Brook, MD, MSc, 4431 Albemarle St NW, Washington, DC 20016 (ib6@georgetown.edu).

Submitted for Publication: August 18, 2004; accepted February 19, 2005.

Aronson  MDWiss  STBen  RLKomaroff  AL Association between cigarette smoking and acute respiratory tract illness in young adults. JAMA 1982;248181- 183
PubMed Link to Article
Musher  DMFainstein  V Adherence of Staphylococcus aureus to pharyngeal cells from normal subjects, smokers, staphylococcal carriers and patients with viral infections.  In: Jeljaszewicz  J, ed.Staphylococci and Staphylococcal Infections. New York, NY: Gustav Fischer Verlag; 1981:1011-1116
Blackwell  CCWeir  DMJames  VS  et al.  Secretor status, smoking and carriage of Neisseria meningitidis. Epidemiol Infect 1990;104203- 209
PubMed Link to Article
Gryczynska  DKobos  JZakrzewska  A Relationship between passive smoking, recurrent respiratory tract infections and otitis media in children. Int J Pediatr Otorhinolaryngol 1999;49(suppl 1)S275- S278
PubMed Link to Article
Stuart  JMCartwright  KADawson  JARickard  JNoah  ND Risk factors for meningococcal disease: a case control study in south west England. Community Med 1988;10139- 146
PubMed
Pershagen  G Review of epidemiology in relation to passive smoking. Arch Toxicol Suppl 1986;963- 73
PubMed
El Ahmer  OREssery  SDSaadi  AT  et al.  The effect of cigarette smoke on adherence of respiratory pathogens to buccal epithelial cells. FEMS Immunol Med Microbiol 1999;2327- 36
PubMed Link to Article
Fujimori  IGoto  RKikushima  K  et al.  Isolation of alpha-streptococci with inhibitory activity against pathogens, in the oral cavity and the effect of tobacco and gargling on oral flora. Kansenshogaku Zasshi 1995;69133- 138
PubMed
Summanen  PBaron  EJCitron  DMStrong  CAWexler  HMFinegold  SM Wadsworth Anaerobic Bacteriology Manual. 5th ed. Belmont, Calif: Star Publishing Co; 1995
Murray  PRBarron  EJPfaller  MATenover  FCYolken  RH Manual of Clinical Microbiology. 6th ed. Washington, DC: ASM Press; 1995
Grahn  EHolm  SEEkedahl  CRoos  K Interference of alpha-hemolytic streptococci isolated from tonsillar surface on beta-hemolytic streptococci (Streptococcus pyogenes): a methodological study. Zentralbl Bakteriol Mikrobiol Hyg A 1983;254459- 468
PubMed
Brook  IGober  AE Emergence of beta lactamase producing aerobic and aerobic bacteria in the oro-pharynx of children following penicillin chemotherapy. Clin Pediatr (Phila) 1984;23338- 341
PubMed Link to Article
Bernstein  JMSagahtaheri-Altaie  SDryja  DMWactawski-Wende  J Bacterial interference in nasopharyngeal bacterial flora of otitis-prone and non-otitis-prone children. Acta Otorhinolaryngol Belg 1994;481- 9
PubMed
Faden  HZaz  MJBernstein  JMBrodsky  LStamievich  JOgra  PL Nasopharyngeal flora in the first three years of life in normal and otitis-prone children. Ann Otol Rhinol Laryngol 1991;100612- 615
PubMed
Fujimori  IHisamatsu  KKikushima  KGoto  RMurakami  YYamada  T The nasopharyngeal bacterial flora in children with otitis media with effusion. Eur Arch Otorhinolaryngol 1996;253260- 263
PubMed Link to Article
Brook  IGober  AE In vitro bacterial interference in the nasopharynx of otitis media-prone and non-otitis media-prone children. Arch Otolaryngol Head Neck Surg 2000;1261011- 1013
PubMed Link to Article
Brook  IGober  AE Bacterial interference in the nasopharynx and nasal cavity of sinusitis prone and non-sinusitis prone children. Acta Otolaryngol 1999;119832- 836
PubMed Link to Article
Brook  IGober  AE Interference by aerobic and anaerobic bacteria in children with recurrent group A beta-hemolytic streptococcal tonsillitis. Arch Otolaryngol Head Neck Surg 1999;125552- 554
PubMed Link to Article
Crowe  CCSandera  WE  JrLongley  S Bacterial interference, II: role of the normal throat flora in prevention of colonization by group A Streptococcus. J Infect Dis 1973;128527- 532
PubMed Link to Article
Brook  IGober  AE Role of bacterial interference and beta-lactamase-producing bacteria in the failure of penicillin to eradicate group A streptococcal pharyngotonsillitis. Arch Otolaryngol Head Neck Surg 1995;1211405- 1409
PubMed Link to Article
Johanson  WG  JrBlackstock  RPearce  AKSanford  JP The role of bacterial antagonism in pneumococcal colonization of the human pharynx. J Lab Clin Med 1970;75946- 951
PubMed
Sanders  E Bacterial interference, I: its occurrence among the respiratory tract flora and characterization of inhibition of group A streptococci by viridans streptococci. J Infect Dis 1969;120698- 707
PubMed Link to Article
Patek  MHochmannova  JNesvera  JStransky  J Glutamicin CB II, a bacteriocin-like substance produced by Corynebacterium glutamicum. Antonie Van Leeuwenhoek 1986;52129- 140
PubMed Link to Article
Roos  KHolm  EGrahn-Hakansson  ELagergren  L Recolonization with selected α-streptococci for prophylaxis of recurrent streptococcal pharyngotonsillitis: a randomized placebo-controlled multicenter study. Scand J Infect Dis 1996;28459- 462
PubMed Link to Article
Roos  KHakansson  EGHolm  S Effect of recolonisation with “interfering” alpha streptococci on recurrences of acute and secretory otitis media in children: randomised placebo controlled trial. BMJ 2001;322210- 212
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Pathogens Found in the Retropharynx of Smoking and Nonsmoking Parents and Their Children
Table Graphic Jump LocationTable 2. Isolates With Interfering Capabilities Recovered in the Retropharynx of Smoking Parents and Their Children
Table Graphic Jump LocationTable 3. Isolates With Interfering Capabilities Recovered in the Retropharynx of Nonsmoking Parents and Their Children

References

Aronson  MDWiss  STBen  RLKomaroff  AL Association between cigarette smoking and acute respiratory tract illness in young adults. JAMA 1982;248181- 183
PubMed Link to Article
Musher  DMFainstein  V Adherence of Staphylococcus aureus to pharyngeal cells from normal subjects, smokers, staphylococcal carriers and patients with viral infections.  In: Jeljaszewicz  J, ed.Staphylococci and Staphylococcal Infections. New York, NY: Gustav Fischer Verlag; 1981:1011-1116
Blackwell  CCWeir  DMJames  VS  et al.  Secretor status, smoking and carriage of Neisseria meningitidis. Epidemiol Infect 1990;104203- 209
PubMed Link to Article
Gryczynska  DKobos  JZakrzewska  A Relationship between passive smoking, recurrent respiratory tract infections and otitis media in children. Int J Pediatr Otorhinolaryngol 1999;49(suppl 1)S275- S278
PubMed Link to Article
Stuart  JMCartwright  KADawson  JARickard  JNoah  ND Risk factors for meningococcal disease: a case control study in south west England. Community Med 1988;10139- 146
PubMed
Pershagen  G Review of epidemiology in relation to passive smoking. Arch Toxicol Suppl 1986;963- 73
PubMed
El Ahmer  OREssery  SDSaadi  AT  et al.  The effect of cigarette smoke on adherence of respiratory pathogens to buccal epithelial cells. FEMS Immunol Med Microbiol 1999;2327- 36
PubMed Link to Article
Fujimori  IGoto  RKikushima  K  et al.  Isolation of alpha-streptococci with inhibitory activity against pathogens, in the oral cavity and the effect of tobacco and gargling on oral flora. Kansenshogaku Zasshi 1995;69133- 138
PubMed
Summanen  PBaron  EJCitron  DMStrong  CAWexler  HMFinegold  SM Wadsworth Anaerobic Bacteriology Manual. 5th ed. Belmont, Calif: Star Publishing Co; 1995
Murray  PRBarron  EJPfaller  MATenover  FCYolken  RH Manual of Clinical Microbiology. 6th ed. Washington, DC: ASM Press; 1995
Grahn  EHolm  SEEkedahl  CRoos  K Interference of alpha-hemolytic streptococci isolated from tonsillar surface on beta-hemolytic streptococci (Streptococcus pyogenes): a methodological study. Zentralbl Bakteriol Mikrobiol Hyg A 1983;254459- 468
PubMed
Brook  IGober  AE Emergence of beta lactamase producing aerobic and aerobic bacteria in the oro-pharynx of children following penicillin chemotherapy. Clin Pediatr (Phila) 1984;23338- 341
PubMed Link to Article
Bernstein  JMSagahtaheri-Altaie  SDryja  DMWactawski-Wende  J Bacterial interference in nasopharyngeal bacterial flora of otitis-prone and non-otitis-prone children. Acta Otorhinolaryngol Belg 1994;481- 9
PubMed
Faden  HZaz  MJBernstein  JMBrodsky  LStamievich  JOgra  PL Nasopharyngeal flora in the first three years of life in normal and otitis-prone children. Ann Otol Rhinol Laryngol 1991;100612- 615
PubMed
Fujimori  IHisamatsu  KKikushima  KGoto  RMurakami  YYamada  T The nasopharyngeal bacterial flora in children with otitis media with effusion. Eur Arch Otorhinolaryngol 1996;253260- 263
PubMed Link to Article
Brook  IGober  AE In vitro bacterial interference in the nasopharynx of otitis media-prone and non-otitis media-prone children. Arch Otolaryngol Head Neck Surg 2000;1261011- 1013
PubMed Link to Article
Brook  IGober  AE Bacterial interference in the nasopharynx and nasal cavity of sinusitis prone and non-sinusitis prone children. Acta Otolaryngol 1999;119832- 836
PubMed Link to Article
Brook  IGober  AE Interference by aerobic and anaerobic bacteria in children with recurrent group A beta-hemolytic streptococcal tonsillitis. Arch Otolaryngol Head Neck Surg 1999;125552- 554
PubMed Link to Article
Crowe  CCSandera  WE  JrLongley  S Bacterial interference, II: role of the normal throat flora in prevention of colonization by group A Streptococcus. J Infect Dis 1973;128527- 532
PubMed Link to Article
Brook  IGober  AE Role of bacterial interference and beta-lactamase-producing bacteria in the failure of penicillin to eradicate group A streptococcal pharyngotonsillitis. Arch Otolaryngol Head Neck Surg 1995;1211405- 1409
PubMed Link to Article
Johanson  WG  JrBlackstock  RPearce  AKSanford  JP The role of bacterial antagonism in pneumococcal colonization of the human pharynx. J Lab Clin Med 1970;75946- 951
PubMed
Sanders  E Bacterial interference, I: its occurrence among the respiratory tract flora and characterization of inhibition of group A streptococci by viridans streptococci. J Infect Dis 1969;120698- 707
PubMed Link to Article
Patek  MHochmannova  JNesvera  JStransky  J Glutamicin CB II, a bacteriocin-like substance produced by Corynebacterium glutamicum. Antonie Van Leeuwenhoek 1986;52129- 140
PubMed Link to Article
Roos  KHolm  EGrahn-Hakansson  ELagergren  L Recolonization with selected α-streptococci for prophylaxis of recurrent streptococcal pharyngotonsillitis: a randomized placebo-controlled multicenter study. Scand J Infect Dis 1996;28459- 462
PubMed Link to Article
Roos  KHakansson  EGHolm  S Effect of recolonisation with “interfering” alpha streptococci on recurrences of acute and secretory otitis media in children: randomised placebo controlled trial. BMJ 2001;322210- 212
PubMed Link to Article

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