Risultati per: Indicazioni per la terapia domiciliare del COVID-19

Circulation, Volume 150, Issue Suppl_1, Page A4114220-A4114220, November 12, 2024. Background:It is still not well understood whether cardiac injury observed during acute COVID-19 infection extends after recovery from the initial viral infection. The purpose of this study was to determine the incidence of left and right ventricular dysfunction in patients hospitalized with acute COVID-19 and evaluate for cardiac recovery.Methods:A multicenter, retrospective cohort study was conducted. Adult patients were identified by hospitalizations using ICD-10 code U07.1 from March 2020 to October 2021. Patients were included if they had: 1) acute COVID-19 infection confirmed by RT-PCR and 2) a transthoracic echocardiogram (TTE) performed during their hospitalization. Clinical and echocardiographic data were collected and analyzed. Longitudinal TTE parameters were obtained from follow-up studies performed after discharge.Results:A total of 750 patients (mean age 64.3 ± 15.3 years, 60.0% male) were included. The average time to follow-up TTE was 8.7± 7.4 months. 133 patients (17.7%) had new LV dysfunction seen on TTE (Figure 1). LV recovery (defined as normalization of LVEF or improvement of LVEF by >10% from baseline) was observed in 28 of 74 (37.8%) survivors. 9 of 26 patients (34.6%) who had a follow-up TTE

Circulation, Volume 150, Issue Suppl_1, Page A4137878-A4137878, November 12, 2024. Background:The COVID-19 pandemic in 2020 was marked by a sharp decrease in out-of-hospital cardiac arrest (OHCA) survival. Whether OHCA survival has recovered to pre-pandemic levels, and whether changes in OHCA survival are similar across communities of different racial and ethnic composition, is unknown.Methods:We included adult patients with non-traumatic OHCA from 2015-2022 in the Cardiac Arrest Registry to Enhance Survival registry. Using hierarchical multivariable regression, we calculated risk-adjusted rates of survival to hospital discharge during 2015-2019 (reference period) and compared this to survival rates during 2020, 2021, and 2022. We also examined whether the trajectory of survival over this period differed based on the racial/ethnic composition of the community served by the emergency medical service (EMS) agency, defined as predominantly White ( >80% White residents), majority Black or Hispanic ( >50% Black or Hispanic residents), or integrated (neither).Results:Of 485,079 patients with OHCA, mean age was 61.9 years; 64% were male, and 22% were of Black race with 7% of Hispanic ethnicity. Overall, risk-adjusted survival rates to hospital discharge for OHCA decreased from 10.1% in 2015-2019 to 8.4% in 2020 (P

Circulation, Volume 150, Issue Suppl_1, Page A4140703-A4140703, November 12, 2024. Background:The mRNA vaccines against COVID-19 are highly effective but have been associated with a rare non-infective form of myocarditis, particularly in young males after receiving the second dose. Understanding the mediators of this adverse effect is crucial to enhance the safety of future mRNA vaccines.Hypothesis:Myocardial injury following COVID-19 mRNA vaccination is mediated by overproduced cytokines, and estrogens have a protective effect on this adverse effect.Approach:Candidate cytokine mediators were identified through analysis of proteomics data from plasma samples of vaccinated individuals. Human iPSC-derived macrophages and cardiomyocytes were used to model cytokine-induced effects. An in vivo mouse model of cytokine-induced myocardial injury was employed to assess the impact of the cytokine cocktail and estrogens.Results:CXCL10 and IFN-γ were consistently upregulated in vaccinated individuals on day 1 and further elevated in patients with myocarditis following mRNA vaccination. Consistently, iPSC-derived macrophages exposed to COVID-19 mRNA vaccines produced these cytokines. Next, iPSC-derived cardiomyocytes exposed to these cytokines showed impaired contractility, arrhythmogenicity, and pro-inflammatory gene expression. The phytoestrogen genistein mitigated these effects in vitro, reducing cytokine-induced proteasomal degradation of cardiac proteins and preserving contractile function. In vivo, genistein significantly decreased cardiac injury markers and immune cell infiltration in a mouse model of cytokine-induced myocardial injury.Conclusion:CXCL10 and IFN-γ are key mediators of myocardial injury post-mRNA vaccination. Genistein shows potential as a therapeutic agent to mitigate associated cardiovascular risks.

Circulation, Volume 150, Issue Suppl_1, Page A4146890-A4146890, November 12, 2024. Background:COVID-19 has introduced new complexities in the management of patients undergoing the transcatheter edge-to-edge repair (TEER) procedure of the mitral valve. This study compares outcomes of mitral valve TEER in patients with and without COVID-19, utilizing data from the National Inpatient Sample (2020-2021).Methods:We conducted a retrospective cohort study on 23,465 patients without COVID-19 and 85 patients with COVID-19 undergoing mitral valve TEER. Multivariate logistic regression was employed to compare outcomes, adjusting for potential confounders. Primary outcomes included mortality and major complications, while secondary outcomes encompassed specific procedural complications.Results:Patients with COVID-19 were younger (mean age: 73.176 vs. 76.178 years, p-value

Circulation, Volume 150, Issue Suppl_1, Page A4141946-A4141946, November 12, 2024. INTRODUCTION:Mechanisms contributing to the post-acute sequelae of SARS-CoV-2 (PASC, aka Long COVID) and associated functional limitations are unclear.RESEARCH QUESTION:Determine cardiovascular, autonomic and exercise physiology among patients with Long COVID.METHODS:Twenty-one Long COVID patients (16 females, 41±12yrs) underwent cardiovascular assessment during head-up tilt at supine, 30oand 60o, a 10-minute upright standing orthostatic challenge and cardiopulmonary exercise testing (CPET). Baroreceptor sensitivity was determined with Valsalva maneuver. Heart rate (HR) and blood pressure (BP) were monitored continuously. Plasma norepinephrine (NE) was monitored during tilt.RESULTS:During tilt, HR increased with transition from supine to 30oand 60o(72±12 v. 80±14 v. 90±15bpm, P

Circulation, Volume 150, Issue Suppl_1, Page A4139757-A4139757, November 12, 2024. Background:The COVID-19 pandemic has significantly exacerbated sleep problems. Pandemic-related lockdowns and drastic changes in daily life have disrupted sleep patterns, resulting in a marked increase in sleep disturbances.Research questions:This study aims to investigate the primary factors contributing to the increase in sleep disturbances during the COVID-19 pandemic in Korea. By utilizing nationally representative data encompassing various variables, this study seeks to identify COVID-19-related factors associated with sleep disturbances during the pandemic.Method:We analyzed data from the nationally representative Korea Community Health Survey conducted in 2020, including 216,809 adults. Changes in daily life due to COVID-19 were assessed by asking participants to score their current situation compared to their pre-pandemic situation, ranging from 100 (no change) to 0 (complete cessation of daily activities). COVID-19 concerns were assessed with five questions: 1) fear of contracting the virus; 2) fear of mortality if infected; 3) fear of blame from others; 4) concerns about the health of vulnerable family members; and 5) concerns about economic impacts. Sleep disturbances were defined as sleeping 5 hours or less per night on average. Logistic regression analyses with a complex sample design were performed to examine the relationship between COVID-19-related factors and sleep disturbances, adjusting for socioeconomic and health-related variables.Results:A high level of lifestyle changes due to COVID-19 (OR = 1.15, 95% CI = 1.11–1.19) and high COVID-19 concerns (OR = 1.04, 95% CI = 1.01–1.08) were associated with an increased likelihood of sleep disturbances. Conversely, resting during COVID-19 symptoms (OR = 0.81, 95% CI = 0.76–0.87), having support during quarantine (OR = 0.93, 95% CI = 0.89–0.97), and trust in the government and neighbors (OR = 0.92, 95% CI = 0.89–0.96) were associated with a decreased likelihood of sleep disturbances.Conclusion:These findings suggest that sleep disturbances during the COVID-19 pandemic were mediated by lifestyle disruptions and high levels of concern. Social support and trust mitigated the impact of COVID-19-related risk factors. As part of preparedness, improving the environment to facilitate adequate rest during illness, ensuring strong social support, and fostering high levels of trust in the government and neighbors may be important to protect sleep health during future public health emergencies.

Circulation, Volume 150, Issue Suppl_1, Page A4146939-A4146939, November 12, 2024. Background:New onset AF during acute illness has a high rate of AF recurrence within 5-yr. However, little is known about AF progression in patients with new onset AF during COVID illness. It is also unknown whether the time of COVID diagnosis (early vs late) impacts AF progression. More specifically, did the potentially different immune and inflammatory responses during early vs late COVID produce structural and electrical cardiac remodeling that would increase the likelihood of AF progression.Objective:We sought to compare AF progression in patients with new onset AF during early vs late COVID and hypothesized that early COVID was associated with increased AF progression compared to late COVID.Methods:From Apr 2020 to Feb 2024, patients receiving a SARS-2-CoV test without a history of AF with new onset AF and at least 3-mo of follow up were included (N=11,767). Patients were subdivided based on pos vs neg SARS-2-CoV test and time of diagnosis. Early COVID diagnosis (n=3052) included Apr 2020-Aug 2021 and late COVID (n=8715) included Sep 2021-Feb 2024. AF progression endpoints at 3-, 6- and 12-mo included AF hospitalization, AF emergency department (ED) visit, cardioversion and AF ablation.Results:Patients with late COVID were more likely females with hypertension, coronary artery disease and hyperlipidemia compared to early COVID patients. At 3- and 6-mo follow-up there was no difference in AF progression between the early and late COVID groups for any endpoint. In contrast, at 12-mo follow up there was in increase in late diagnosis group AF ED visits (11% vs 7.6%,p

Circulation, Volume 150, Issue Suppl_1, Page A4134935-A4134935, November 12, 2024. Introduction:Recent data demonstrated that the COVID-19 pandemic adversely affected cardiovascular fellows in training (cFIT) and faculty in terms of educational disruption and search for job prospects, respectively. However, less is known about the pandemic’s effect on cFIT and faculty in terms of general well-being, shifts in personal and professional priorities, quantitative measures of stress levels, and research productivity.Methods:A national survey targeting cFIT and faculty was developed to assess the effect of the pandemic two years later on these parameters. Fifty-four participants, including 21 cFIT and 33 faculty, responded to the survey. The survey was distributed between October 2021 and May 2022 to program directors of ACGME-accredited general cardiology fellowship programs in the United States.Results:30% of cFITs perceived impaired clinical training during the pandemic; 36% of fellows experienced a decline in their clinical skills in the cardiac catheterization lab, while 27% experienced a decrease in their echocardiographic skills. Additionally, a significant percentage of cFIT reported negative interference in their competencies in nuclear cardiology (27%) and electrophysiology (12%). Most participants (76%), including faculty and fellows, reported several health issues such as sleep problems, low energy, changes in appetite, difficulty concentrating, and restlessness due to the pandemic. 43% of the faculty and 61% of cFIT reported high rates of impaired short-term productivity (Figure).Conclusion:In this national survey, we found that two years after the onset of the COVID-19 pandemic, cardiology fellows and faculty continued to experience significant concerns for decreased hands-on training and diminished research productivity. While faculty were not distressed regarding decreased clinical competencies, concerns about short-term and long-term research productivity persisted. Faculty and fellows all experienced increased stress levels and impaired productivity. Although limited by a small sample size, which can introduce bias, these results signal the importance of performing a follow-up study on the impact of COVID-19 on wellness as well as the impact on career.

Circulation, Volume 150, Issue Suppl_1, Page A4127513-A4127513, November 12, 2024. Background:SARS-CoV-2 infection affects the cardiopulmonary system in both the acute and long-term phase. This study aimed to comprehensively assess symptoms and potential long-term impairments 6, 18 and 30 months in patients previously hospitalized for severe Covid-19 infection.Methods:This prospective registry included patients hospitalized for PCR-confirmed Covid-19 infection. Approximately 6 months post-discharge, follow-up examination included patient history, clinical examination, echocardiography, electrocardiogram, cardiac magnetic resonance imaging (cMRI), chest computed tomography (CT) scan, pulmonary function test (PFT), six-minute walk test (6MWT) and a comprehensive laboratory panel. Patients with pathologic findings during the first visit underwent a second (at 18 months) and third (at 30 months) follow-up examination. Those without pathologic findings or who refused further medical examinations were contacted via phone to inquire about symptoms.Results:Between July 2020 and April 2022, 200 patients (91% general ward, 9% intensive care unit) were recruited. Due to dropouts, the second visit was conducted in 170 patients, and the third visit in 139 (74 in person, 65 via telephone). Long Covid criteria were fulfilled by 73% at 6 months, 52% at 18 months and 49% at 30 months post-discharge, with fatigue being the most common symptom (Figure 1). Echocardiography at 6 months showed impaired left ventricular function in 15 patients, with normalization in 80% at 18 months and further 66% at 30 months (Figure 2). cMRI revealed pericardial effusions in 28 patients at 6 months, which resolved in 47% at 18 months and in further 60% at 30 months. Signs of peri- or myocarditis were present in 7 patients at 6 months and were resolved in all 4 patients who attended control studies at 18 months. Chest CT scans at 6 months identified post-infectious residues in 41 patients, with full recovery in 20% at 18 months without further normalization after 30 months.The length of in-hospital stay was identified as a significant predictor for persisting Long Covid 6 months after discharge (95% CI: 1.005 – 1.12, p=0.03).Conclusion:While the prevalence of Long Covid decreased over time, a significant symptom burden persisted at 6, 18 and even 30 months after severe Covid-19 infection. Structural and functional abnormalities were less frequent compared to reported symptoms, posing a challenge in substantiating the causes of these symptoms.

Circulation, Volume 150, Issue Suppl_1, Page A4138301-A4138301, November 12, 2024. Background:Hyperlipidemia (HLD) is a major risk factor for cardiovascular disease (CVD). Little is known regarding temporal variation in CVD mortality related to HLD. The COVID-19 pandemic added complexity to factors influencing CVD mortality.Question:What are the yearly trends and impact of the COVID-19 pandemic on HLD-related CVD mortality in the United States?Methods:Mortality and demographic data for adults were obtained from CDC repository from 1999-2020, using ICD-10 codes HLD (E78.0-E78.5) and CVD (I00-I99). Age adjusted mortality rates (AAMR) per 1,000,000 population was standardized to the 2000 US population. Log-linear regression models evaluated mortality shifts. Average annual percentage change (AAPC) from 1999-2019 was used to calculate projected AAMR in 2020, subsequently compared to actual 2020 death rates to estimate pandemic-attributed excess deaths.Results:A total of 483,155 HLD-related CVD deaths were recorded between 1999-2020. Despite the CVD mortality decline in general population, HLD-related CVD AAMR rose from 36.33 [95% CI, 35.52-37.13] in 1999 to 99.77 [98.67-100.87] in 2019. Ischemic heart diseases (AAMR 49.39) were the most common causes of death while hypertension had the highest annual mortality increase (AAPC +10.23%) in populations with HLD. Higher HLD-related CVD mortality was observed in males (AAMR 104.87) than females (AAMR 61.93), in those ≥75 years (AAMR 646.45) than 35-75 years (AAMR 54.11), in non-Hispanic (NH) (AAMR 82.49) than Hispanic (AAMR 58.98) populations, and in rural (AAMR 89.98) than urban (AAMR 78.94) regions. NH Black populations (AAMR 84.35) and Western US regions (AAMR 96.88) had the highest HLD-related CVD. The first year of COVID-19 pandemic resulted in 10.55% excess HLD-related CVD death, with the most prominent increase in the 35-75 years age group (14.23%), Hispanic (17.96%), Black (14.82%), and urban (11.68%) populations.Conclusions:Our study revealed an increase in HLD-related CVD mortality which was exacerbated by the COVID-19 pandemic. Higher CVD mortality disproportionately affected males, Black, elderly (≥75 years), and rural populations with HLD. Further research is needed to validate our findings and identify contributing factors.

Circulation, Volume 150, Issue Suppl_1, Page ASa907-ASa907, November 12, 2024. Background:Different from the negative impact of COVID-19 pandemic on outcomes after out-of-hospital cardiac arrest (OHCA) collapsed before emergency medical service (EMS) arrival, there was a report suggested that COVID-19 pandemic did not affect outcomes after OHCA witnessed by EMS personnel. However, no large-scale studies have examined the impact of COVID-19 pandemic after EMS-witnessed OHCA, focusing on favorable neurological outcomes.Research Questions:Does COVID-19 pandemic affect favorable neurological outcomes after EMS-witnessed OHCA?Aims:To assess COVID-19’s impact on favorable neurological outcomes after EMS-witnessed OHCA.Methods:We performed an interrupted time series analysis (ITSA) with a prospective, nationwide, population-based registry in Japan to assess trends of incidence and favorable neurological outcome (Cerebral Performance Category 1 or 2) at 30 days with adult EMS-witnessed OHCA between pre-pandemic (January 2016-March 2020) and pandemic (April 2020-December 2021) periods. Subgroup analyses were performed by stratifying regions by infection spread status defined by whether a state of emergency has been declared. To assess whether there are differences in trends between areas with and without COVID-19 spread, we performed a controlled ITSA between the two areas.Results:We identified 58,315 patients with adult EMS-witnessed OHCA, 41,112 during the pre-pandemic period and 17,203 during the pandemic period. There was no significant increase in the incidence of EMS-witnessed OHCA during the pandemic period (0.03 per 100,000 person-years; 95% confidence interval [CI], –0.02 to 0.08; p = 0.21). Favorable neurological outcome significantly decreased (relative risk [RR], 0.80; 95% CI, 0.71 to 0.91; p < 0.01). In subgroup analysis, favorable neurological outcome significantly decreased in areas with COVID-19 spread (RR, 0.67; 95% CI, 0.56 to 0.81; p < 0.01), while there was no significant difference in areas without COVID-19 spread (RR, 0.91; 95% CI, 0.77 to 1.07; p = 0.24). A controlled ITSA showed that favorable neurological outcome significantly decreased in areas with COVID-19 spread compared to without COVID-19 spread (RR, 0.77; 95% CI, 0.60 to 0.98; p = 0.04).Conclusion:Unlike previous studies, our research with a nationwide, population-based registry showed that COVID-19 pandemic influenced favorable neurological outcome in EMS-witnessed OHCA. This trend appears to be more pronounced in areas with widespread infection.

Circulation, Volume 150, Issue Suppl_1, Page A4142337-A4142337, November 12, 2024. Background:We previously demonstrated a significantly increased inpatient mortality of COVID-19 infection-induced male Takotsubo (TTS) patients during the early pandemic period. Since then, our management of COVID-19 prevention and treatment have evolved significantly, reducing both hospitalization and mortality rates. With these advancements, we have analyzed the clinical characteristics and outcomes of reported COVD-19-associated TTS patients since the initial pandemic.Research Question:What are the clinical characteristics and mortality outcomes of COVID-19-associated TTS patients especially in the context of improved prevention and treatment?Aims:To identify clinical characteristics and outcome correlates in patients with COVID-19-associated TTS.Methods:We completed a systematic review of 191 patients with TTS from 95 published case reports, 13 case series, and 4 observational cross-sectional/cohort studies published from April 1, 2020 to May 1, 2024 (PubMed). We performed clustering analysis using the clinical, imaging, and inpatient mortality data of 78 patients, which categorized groups of patients based on how closely associated or similar they are relative to other groups. Following this, we applied feature analysis to identify which features contributed the most to the clustering results.Results:Of all TTS cases, the mean age was 64.2±16.1 with 32.9% males. A total of 122 (63.9%) had COVID-19 infection, 21 (11.0%) had COVID-19 vaccination, and 50 (26.2%) patients had other triggers (2 patients had both COVID-19 infection and a non-infectious trigger). In-hospital mortality was 28.6% (16 of 56) for males and 13.2% (15 of 114) for females (p-value = 0.01). There was no association between COVID-19 vaccine administration and in-hospital mortality (0%, 0 of 21). There were notable differences in the clinical and demographic characteristics of TTS patients before and after September 2021 based on clustering analysis. Feature analysis indicated that COVID-19-induced TTS strongly correlated with in-hospital mortality and long-term adverse outcome in male patients.Conclusion:More male TTS patients were found during the pandemic than is expected of the traditional TTS archetype. A triad of “male, COVID-19 infection and TTS” appears to predict higher inpatient mortality. Compared to our prior study, inpatient mortality rates for TTS COVID patients have declined for all groups. Vaccine-induced TTS is associated with a benign clinical phenotype.

Circulation, Volume 150, Issue Suppl_1, Page A4143723-A4143723, November 12, 2024. Introduction:Thrombocytosis, sometimes extreme, after acute Kawasaki disease (KD) is common and felt to be pathognomonic of this diagnosis, although has also been reported after multisystem inflammatory syndrome in children (MIS-C), a clinically similar condition. We sought to determine differences in factors associated with thrombocytosis for each condition.Methods:From 01/2020 to 10/2023 across 41 sites in 8 countries from the International KD Registry, 1674 MIS-C and 1290 contemporaneous KD patients with adequate laboratory data were included in the analysis. Age-related cutpoints (derived from the CALIPER Study of normal children/adolescents; AJCP 2020; 154:342) were applied to peak platelet counts to define thrombocytosis (age 647 x109/L; age 1 to 434; age 12 to 371). Associations of demographic, clinical, laboratory and outcome factors with thrombocytosis were determined for each diagnosis group.Results:Thrombocytosis was more prevalent after KD (57%) than MIS-C (49%; p

Circulation, Volume 150, Issue Suppl_1, Page A4144056-A4144056, November 12, 2024. Background:COVID-19 infections have been associated with cardiovascular autonomic dysfunction (AD). Clinical findings include fatigue, cognitive impairment, and postural intolerance. However, quantitative post-COVID AD assessments are lacking.Objective:Compare autonomic testing measures of post-COVID-19 subjects to controls and those with pure autonomic failure (PAF).Methods:Autonomic testing included 1) change in heart rate (HR) and blood pressure (BP) with active standing (AS) and tilt table testing (TT), 2) time to BP nadir and recovery during AS and TT, 3) Valsalva ratio (VR), and 4) respiratory sinus arrhythmia (RSA). Comparisons between two groups were made using t-tests, Kruskal-Wallis, or chi-square tests. Multivariable linear regression was used to adjust findings for age and sex. A p-value of

Circulation, Volume 150, Issue Suppl_1, Page A4142506-A4142506, November 12, 2024. Introduction:Myocarditis has been reported after mRNA-based COVID-19 vaccination, but the immune mechanisms remain unclear. This study aimed to identify the proteome-based immunopathogenesis of post-vaccination myocarditis compared to viral myocarditis in the pre-COVID-19 era.Methods:Proteomic analysis of right ventricle (RV) biopsy specimens was performed in myocarditis patients (pre-pandemic viral myocarditis: n=3, post-vaccination myocarditis: n=3) and controls (normal endomyocardial biopsy specimens of heart transplant recipients, n=4) using mass spectrometry. Differentially expressed proteins were analyzed with CIBERSORTx, Gene Ontology (GO) analysis, and Ingenuity Pathway Analysis (IPA). To examine the relationship between the SARS-CoV-2 spike protein and post-vaccination myocarditis, immunohistochemistry (IHC), mass spectrometry analysis of spike protein, and activation-induced marker (AIM) assay in T cells from RV samples were conducted.Results:In the proteomic analysis, 6,861 proteins were identified. Post-vaccination myocarditis showed increased extracellular matrix formation and cardiac fibrosis. Both pre-pandemic and post-vaccination myocarditis had elevated pro-inflammatory cytokine activities. However, post-vaccination myocarditis exhibited higher expression of interferon-alpha (IFNα) and pattern recognition receptor activation, including TLR3 and TLR7. Pre-pandemic myocarditis showed higher activation of the complement system, neutrophils, and NK cells, whereas post-vaccination myocarditis showed increased Th2 cell activation and classical macrophage activation. Spike protein and related T-cell activation were not detected.Conclusion:The immune activation in myocarditis after COVID-19 mRNA vaccination may be triggered by the mRNA in the vaccine via an IFNα-driven immune response, leading to autoimmune-like features. Further studies are necessary to validate whether these proteins correlate with clinical characteristics.

Circulation, Volume 150, Issue Suppl_1, Page A4143094-A4143094, November 12, 2024. Background:Peripartum cardiomyopathy (PPCM) is defined as a dilated form of cardiomyopathy that occurs within the last month of pregnancy and up to 5 months postpartum. The etiology is likely multifactorial and viral infections may account for up to a third of PPCM cases. We aimed to examine the impact of concurrent COVID-19 infection on in-hospital outcomes of women with PPCM.Methods:National Inpatient Sample was queried to identify women admitted with PPCM with COVID-19 (group A) between the years 2020-2021 and without (group B) concurrent COVID-19 infection between the years 2016-2019.Results:A total of 19135 women were admitted with PPCM between the years 2016-2021, of whom 420 (2%) had concurrent COVID-19 infection. Group A PPCM followed a seasonal pattern with peak incidence in fall (43%) followed by winter (31%), spring (13%) and summer (13%) [p=0.002]. Group A was more often Hispanic (20.3% -vs- 10.8%, p