[Choice of influenza vaccine in people over 65 years old. Analysis of reports from international vaccination advisory committees]. / Elección de vacuna antigripal en personas mayores de 65 años. Análisis de informes de comités asesores de vacunación internacionales.

OBJECTIVE: Annual recommendations on influenza vaccine use in different countries are developed by influenza-specific working groups within their Immunization Advisory Committees. Adults aged 65 years and over are included in the groups for which vaccination against influenza is particularly recommended due to the morbidity associated. A variety of influenza vaccines are available, some of which boosted immunity, are licensed for use only in this specific age group, where the immune response to traditional influenza vaccines may be suboptimal. We analyze the main annual recommendations on the use of the influenza vaccine issued by advisory committees on immunization for the population over 65 years of age. METHODS: The latest influenza vaccination guidelines have been selected and the recommendations for people over 65 years of age published by the main vaccination advisory committees have been reviewed. RESULTS: The UK Advisory Committee (JCVI) recommends the use of Quadruvalent Inactivated Influenza Vaccine with Adjuvant (aQIV) or High Dose Quadrivalent Inactivated Influenza Vaccine (QIV-HD). The US committee (ACIP) does not express a preference for any type of vaccine. The Australian committee (ATAGI) preferably recommends adjuvanted influenza vaccine. The advisory committees of Canada and Germany (NACI, STIKO) and the European Center for Disease Control (Ecdc) recommend using any of the age-appropriate flu vaccines available, although they bet on the The UK Advisory Committee (JCVI) recommends the use of Quadruvalent Inactivated Influenza Vaccine with Adjuvant (aQIV) or High Dose Quadrivalent Inactivated Influenza Vaccine (QIV-HD). The US committee (ACIP) does not express a preference for any type of vaccine. The Australian committee (ATAGI) preferably recommends adjuvanted influenza vaccine. The advisory committees of Canada and Germany (NACI, STIKO) and the European Center for Disease Control (Ecdc) recommend using any of the age-appropriate flu vaccines available, although they bet on the use of inactivated quadrivalent flu vaccine high dose at the individual level for those over 65 years.use of inactivated quadrivalent flu vaccine high dose at the individual level for those over 65 years. CONCLUSIONS: It is necessary further studies and improvement in their quality that analyze the different vaccines available and their comparability, although the use of reinforced immunity vaccines is generally recommended in the population over 65 years of age.

Adequacy of Usual Vitamin and Mineral Intake in Spanish Children and Adolescents: ENALIA Study.

Background: The National Dietary Survey on the Child and Adolescent Population in Spain (ENALIA) provides data to assess the usual micronutrient intake among Spanish infants, children, and adolescents. Methods: Cross-sectional survey (November 2012-July 2014) of a representative sample of Spanish children and adolescents (six months-17 years) (n = 1862). Dietary information was collected using two non-consecutive one-day food diaries (six months-10 years old) or two 24 h dietary recalls (11 years and older) separated by at least 14 days. Estimates were calculated using the Iowa State University method and PC-SIDE software (version 1.0, department of statistics, center for agricultural and rural development, Ames, IA, USA) to account for within- and between-person variation. Results: Usual intake of vitamin D was insufficient in practically all individuals. Vitamin E, folate, and calcium were insufficient, especially from nine years of age, and magnesium and iodine from 14 years of age. The percentage of subjects with insufficient intakes was higher among females. Sodium intake was excessive in a considerable percentage of the population, especially in males, and it increased with age. Finally, over half of children under four years of age had zinc usual intakes that exceeded the Tolerable Upper Level. Conclusion: Vitamin and mineral intake in Spain should be improved, especially in late childhood and adolescence. Nutritional intervention and educational strategies are needed to promote healthy eating habits and correct micronutrient inadequacies in Spanish children and adolescents.

Clinical value of morphine, pholcodine and poppy seed IgE assays in drug-abusers and allergic people.

BACKGROUND: The diagnosis of anaphylactic reactions due to opiates during anaesthesia can be difficult, since in most cases various drugs may have been administered. Detection of specific IgE to poppy seed might be a marker for sensitisation to opiates in allergic people and heroin-abusers. This study assessed the clinical value of morphine, pholcodine and poppy seed skin-prick and IgE determination in people suffering hypersensitivity reactions during anaesthesia or analgesia and drug-abusers with allergic symptoms. METHODS: We selected heroin abusers and patients who suffered severe reactions during anaesthesia and analgesia from a database of 23,873 patients. The diagnostic yield (sensitivity, specificity and predictive value) of prick and IgE tests in determining opiate allergy was analysed. RESULTS: Overall, 149 patients and 200 controls, mean age 32.9 ± 14.7 years, were included. All patients with positive prick to opiates showed positive prick and IgE to poppy seeds, but not to morphine or pholcodine IgE. Among drug-abusers, 13/42 patients (31%) presented opium hypersensitivity confirmed by challenge tests. Among non-drug abusers, sensitisation to opiates was higher in people allergic to tobacco (25%), P<.001. Prick tests and IgE against poppy seed had a good sensitivity (95.6% and 82.6%, respectively) and specificity (98.5% and 100%, respectively) in the diagnosis of opiate allergy. CONCLUSIONS: Opiates may be significant allergens. Drug-abusers and people sensitised to tobacco are at risk. Both the prick and specific IgE tests efficiently detected sensitisation to opiates. The highest levels were related to more-severe clinical profiles.

Allergic hypersensitivity to cannabis in patients with allergy and illicit drug users.

BACKGROUND: Cannabis is the illicit drug most widely used by young people in high-income countries. Allergy symptoms have only occasionally been reported as one of the adverse health effects of cannabis use. OBJECTIVES: To study IgE-mediated response to cannabis in drug users, atopic patients, and healthy controls. METHODS: Asthmatic patients sensitised to pollen, and all patients sensitised to tobacco, tomato and latex, considered as cross-reacting allergens, were selected from a data base of 21,582 patients. Drug users attending a drug-rehabilitation clinic were also included. Controls were 200 non-atopic blood donors. Specific IgE determination, prick tests and specific challenge with cannabis extracts were performed in patients and controls. RESULTS: Overall, 340 patients, mean age 26.9±10.7 years, were included. Males (61.4%) were the most sensitised to cannabis (p<0.001). All cannabis-sensitised patients were alcohol users. Eighteen (72%) of the patients allergic to tomato were sensitised to cannabis, but a positive specific challenge to cannabis was highest in patients sensitised to tobacco (13/21, 61.9%), (p<0.001). Pollen allergy was not a risk factor for cannabis sensitisation. Prick tests and IgE for cannabis had a good sensitivity (92 and 88.1%, respectively) and specificity (87.1 and 96%) for cannabis sensitisation. CONCLUSIONS: Cannabis may be an important allergen in young people. Patients previously sensitised to tobacco or tomato are at risk. Cannabis prick tests and IgE were useful in detecting sensitisation.

Adverse events associated with pandemic influenza vaccines: comparison of the results of a follow-up study with those coming from spontaneous reporting.

Prior to marketing of pandemic influenza vaccines, the only safety data were those from clinical trials. The objective of this study was to compare information coming from spontaneous reporting with that systematically collected in a formal observation study; this also permits to further evaluate safety of pandemic influenza vaccines in the targeted patients' population. Out of a sample of 507 vaccinated subjects, 103 (20.3%) developed some complication. In the same period 83 reports corresponding to all vaccinated people of Castilla y León (n=131,462) were collected. Severe cases were 1 (1%) and 7 (8.4%), respectively, with the two procedures. The spontaneous reporting rate was 322-fold lower than that identified through the follow-up study; when considered the severe cases, it was 37-fold lower. Under certain circumstances reporting might be performing better than usual due to strengthening of the surveillance system. Adverse events observed for the pandemic H1N1 vaccines lie within the expected safety profile for common events with influenza vaccines. An overall benefit-risk assessment of these vaccines should be done.

Clinical significance of cross-reactivity between tobacco and latex.

BACKGROUND: Allergen cross-reactivity between tobacco and other species of Solanaceae family (tomato, potato, aubergine and egg plant) have been reported. We have recently studied IgE response to tobacco in asthmatic patients sensitised to Lolium perenne (Perennial rye grass pollen) and have found that 30% of the tobacco responsive patients also have latex sensitisation. OBJECTIVE: The aim of our study was to investigate the possibility of cross-reactivity between tobacco and latex in asthmatic patients with IgE response to latex. METHODS: A study was performed on tobacco and latex exposure in 15 patients who suffered from asthma and latex sensitisation and who were randomly chosen from our database of latex-sensitive patients. To identify tobacco and latex as possible allergens that might cause clinical specific responses, all these patients were tested with prick-tests, specific IgE to tobacco, latex and related allergens, bronchial challenge, and patch tests with tobacco, latex and nicotine. Immunological response was evaluated with immunoblotting, immunoblotting-inhibition and EAST-inhibition tests. RESULTS: Positive prick and bronchial challenge with specific IgE>0.35 kU/L to tobacco was demonstrated in 11 asthmatics who were also sensitised to rye grass. Tobacco IgE level was related with sensitisation to latex (p<0.002), but not to other vegetables belonging to the Solanaceae family. EAST-inhibition and immunoblotting-inhibition showed the existence of cross-reactivity between tobacco and latex. CONCLUSIONS: Cross-reactivity exists between latex and tobacco allergens. Smoker patients with IgE response to tobacco may be a risk population for latex sensitisation.

Why can patients with baker's asthma tolerate wheat flour ingestion? Is wheat pollen allergy relevant?

Diagnosis in patients sensitised to multiple pollens is difficult due to the relationship between pollen and food allergens. Misdiagnosis is often a cause for unsuccessful specific immunotherapy. Wheat is a potent allergen source and is one of the causes of baker's asthma, food and pollen allergy. Recently, we have performed a study on pollen sensitisation in our area, where cereal crops are very important. The clinical data from 19718 patients reviewed showed that grass pollen was the main source of clinical symptoms (6369 patients, 32.30% of asthmatics). However, wheat and cereal crop pollen showed very low prevalence. On the other hand, patients with wheat flour allergy after ingestion and/or with baker's asthma were not sensitised to wheat pollen, despite it containing some common allergens. In the same way, all our asthmatic bakers (135 patients) tolerated the ingestion of bread. Here we try to explain the reason for these surprising observations.

Effects of simvastatin on systemic inflammatory responses after cardiopulmonary bypass.

AIM: Cardiopulmonary bypass is associated with a complex systemic inflammatory response and the extent of their increase has been correlated with the development of postoperative complications. Recent studies suggest that treatment with statins is associated with a significant and marked decrease in inflammation-associated variables such as cytokines. Therefore, we investigated the effects of preoperative simvastatin treatment on systemic inflammatory response and perioperative morbidity after cardiopulmonary bypass. METHODS: A prospective, randomized study, was designed. Forty-four subjects undergoing elective coronary artery bypass grafting who fulfilled the inclusion criteria were randomized to treatment with simvastatin (20 mg/day, group A, N. 22) or control (group B, N. 22) before surgery. Plasma levels of interleukins (IL-6, IL-8, TNF-alpha), and systemic inflammatory response score (SIRS) were measured during the surgical intervention and over the following 48 postoperative hours. Cytokine levels were measured by enzyme-linked assays from plasma samples obtained at specific time points pre- and post-operation. RESULTS: In both groups the serum levels of the proinflammatory cytokines (IL-6, IL-8, TNF-alpha), and leukocytes, and the SIRS score increased significantly over the baseline, though no significant differences were observed between the two groups. The preoperative and postoperative course did not differ between both groups. CONCLUSIONS: In patients undergoing coronary artery bypass grafting with cardiopulmonary bypass, the administration of simvastatin doses not produce any changes in the inflammatory response as measured by the levels of IL-6, IL-8, TNF-alpha and SIRS score, nor does it reduce the complications after cardiac surgery.

Nasopharyngeal aspirate cytokine levels 1 yr after severe respiratory syncytial virus infection.

Respiratory syncytial virus (RSV) infection is an important cause of recurrent wheezing in infants. Nevertheless, the link between RSV infection and wheezing has yet to be elucidated at the molecular level. Here, we present a preliminary study on the evolution of the immune response in the respiratory tract at long-term after RSV infection. Twenty-seven immune mediators were profiled in nasopharyngeal aspirates (NPAs) obtained from 20 children hospitalized due to a severe infection by RSV at discharge from hospital and again 1 yr later. The same mediators were profiled in parallel in NPAs from 12 healthy controls. In the year following discharge, 85% (17/20) of children of the RSV group suffered at least one episode of wheezing documented by the pediatrician. On the contrary, wheezing episodes were observed only in 25% (3/12) of children in the control group. While most of the mediators profiled returned to normal levels by 1 yr after discharge from hospital, RSV children showed a persistent nasal hyper-secretion of VEGF, G-CSF, IL-10, IL-6, IFN-gamma, IL-7 and IL-13. In previous works VEGF, IL-10 and IFN-gamma have been put in relation with the pathogenesis of post-virus induced asthma. G-CSF, IL-6, IL-7 and IL-13 are increased in respiratory and plasma samples of asthmatic patients. Here, we evidence for the first time a persistent elevation of these mediators as late as 1 yr after severe RSV disease resolution, reinforcing their possible implication in the pathogenesis of wheezing.

Effect of postoperative restrictive fluid therapy in the recovery of patients with abdominal vascular surgery.

OBJECTIVE: To compare the outcome of the postoperative administration of a restricted or standard intravenous fluid regimen in patients who underwent elective abdominal vascular surgery. The primary end point was postoperative hospital stay. DESIGN: Prospective observer-blinded, randomised controlled trial. MATERIAL AND METHODS: Patients were considered eligible if they underwent transperitoneal aorto-iliac approach with infrarenal graft repair. During the operation and intensive care unit stay, fluids were prescribed by the anaesthetists who were unaware of the details of the study. In the vascular surgical ward, patients in the standard group (SG) received 2500ml of fluids per day, whereas patients in the restricted group (RG) received 1500ml of fluids per day. All the patients were evaluated on an intention-to-treat basis. RESULTS: Forty patients were randomised to the RG (n=20) or SG (n=20). No significant differences were observed in the recovery of gastrointestinal function. However, the postoperative hospital stay was shorter in the RG (8 days) than in the SG (12 days) (p=0.003). CONCLUSIONS: The use of a restrictive postoperative fluid protocol significantly reduces the duration of hospital stay in patients who have undergone major elective abdominal vascular surgery.

The inflammatory response to colloids and crystalloids used for pump priming during cardiopulmonary bypass.

BACKGROUND: Systemic inflammatory response frequently occurs after coronary artery bypass surgery and is strongly correlated with the risk of postoperative morbidity and mortality. This study tests the hypothesis that the priming of the extracorporeal circuit with colloid solutions results in less inflammation in patients undergoing cardiac surgery than priming with crystalloid solutions. METHODS: A prospective, randomized study was designed. Forty-four patients undergoing elective coronary artery bypass grafting were randomly allocated to one of two groups: 22 patients primed with Ringer's lactate (RL) solution and 22 patients primed with gelatin-containing solution during the surgery. Plasma levels of interleukin (IL)-6, IL-8, tumor necrosis factor (TNF)-alpha, C-reactive protein (CRP) and, complement 4 were measured during the surgical intervention and over the following 48 postoperative hours. Cytokine levels were measured by enzyme-linked assays from plasma samples obtained at specific time points pre- and post-operatively. RESULTS: In both groups the serum levels of the pro-inflammatory cytokines (IL-6, IL-8, TNF-alpha), CRP, complement 4, and leukocytes increased significantly over the baseline, although no significant differences were observed between the two groups. The operation time, blood loss, need for inotropic support, extubation time, and length of intensive care unit stay did not differ significantly between the two groups. CONCLUSION: Priming with gelatin vs. RL produces no significant differences in the inflammatory response in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.

[Central venous pressure, rewarming time, and total fluid replacement volume are predictors of mortality and complications after cardiac surgery]. / Presión venosa central, tiempo de recalentamiento y líquidos totales son factores postoperatorios de morbi-mortalidad en cirugía cardiaca.

OBJECTIVE: To analyze the influence of early (first day) postoperative factors on postoperative course in patients who have undergone heart surgery. PATIENTS AND METHODS: A cross-sectional study of consecutively enrolled heart surgery patients was designed. We recorded central venous pressure, time required for rewarming to a core temperature of 35.5degrees C, and total fluids administered in 24 hours. We then analyzed their influence on mortality and cardiac, pulmonary, and renal complications. RESULTS: Two hundred thirty-six patients were included. Central venous pressure over 18 mm Hg, time to rewarming over 6 hours, and administration of more than 5 L of fluids in the first 24 hours were factors associated with increased mortality and the development of cardiovascular, pulmonary, and renal complications. CONCLUSIONS: Central venous pressure, rewarming time, and fluid replacement volume required on the first day are predictors of postoperative course.

[Evaluation of the appropriateness of stays in a third level hospital]. / Evaluación de la adecuación de las estancias en un hospital de tercer nivel.

BACKGROUND: Appropriateness Evaluation Protocol (AEP) has proved to be a useful tool for reviewing the utilisation of hospital resources. The aim of this article is to determine the proportion of inappropriate admissions and stays, as well as their causes, in patients hospitalised in the Hospital Clínico Universitario de Valladolid (HCUV). MATERIAL AND METHODS: A retrospective, analytical, observational, cohort study. The period of study was one year (2004). A sample of 1,630 admissions was gathered. Case definition, variables of interest and the model of data gathering were carried out in accordance with the AEP. The principal variables were analysed by means of a basal analysis and the possible relations between them. RESULTS: Fifty-four percent of the admissions showed at least one day of inappropriate stay, with the global rate of inappropriateness being 34.17%. Amongst the causes responsible for inappropriateness, 68.9% of admissions showed at least one criterion falling under the responsibility of the doctor or the hospital, and 51.3% were due to delays in the development of study or treatment. CONCLUSIONS: The utilisation of methods of identification of inappropriate use such as AEP show applications both in planning and in hospital management, by making it possible to identify hospital problems causing delays, principally problems of an organisational type, making it possible to develop interventions aimed at reducing inappropriate use.

Prevalence of positive prick test to anaesthetic drugs in the surgical population.

Prevalence of patients with positive prick tests to anaesthetics occurred in 4.7% of the surgical population.

Prick-test evaluation to anaesthetics in patients attending a general allergy clinic.

BACKGROUND AND OBJECTIVES: To analyse the prevalence of positive prick-tests to all medicaments normally checked in allergy units when a patient is suspected of being allergic to anaesthetics. To establish the degree of agreement between the antecedents of a previous history of an allergic reaction to a medicament and the positive result, or not, to the specific prick-test for the said medicament. METHODS: This was a prospective study, during 2003 and 2004, which analysed 473 patients referred by their doctors to allergy units to make retrospective diagnoses of an allergy to a drug. The prick-test was done using the undiluted drug. All patients were tested for 41 drugs. These include antibiotics, trimethoprim-sulphamethoxazole, non-steroidal anti-inflammatory drugs (NSAIDs) and perioperative drugs (PD): neuromuscular blocking drugs, latex, iodine, local anaesthetics, hypnotics, opioids and coadjuvants. Cohen's Kappa Index was used to determine the degree of agreement. RESULTS: 71.5% of patients studied presented a positive prick-test. The largest number of positive cases was found in antibiotics (56.4%), followed by PD (15.6%), NSAIDs (14.4%) and trimethoprim-sulphamethoxazole (12.7%). Among PD, the highest prevalence of positive prick-tests was found for neuromuscular blocking drugs (5.3%). Agreement between the substance suspected of causing the allergic reaction and the positive prick-test was excellent for penicillin (Kappa = 0.74) and other antibiotics (Kappa = 0.721) and good for NSAIDs (Kappa = 0.47) and iodine (Kappa = 0.54). CONCLUSIONS: The prevalence of patients with positive prick-tests to PD occurred in 15.6% in this prospective cohort. Neuromuscular blocking drugs were found to have the highest prevalence of positive prick-tests. There is positive agreement when the substance responsible for the allergic reaction is suspected, otherwise agreement is low.

[Postoperative analgesia in cardiac surgery: spinal versus intravenous morphine]. / Analgesia postoperatoria en cirugía cardiaca: comparación de morfina intratecal versus morfina intravenosa.

OBJECTIVE: To compare the effects of spinal and intravenous administration of morphine to supplement anesthesia with remifentanil in terms of analgesia during early postoperative recovery and considering time until extubation. MATERIAL AND METHODS: This prospective, randomized, blinded trial enrolled 59 patients scheduled for cardiac surgery. The patients were assigned to receive either a spinal infusion of morphine (15 microg x Kg(-1)) or an intravenous infusion (0.3 mg x Kg(-1)). Anesthesia was maintained with 0.15 to 0.50 microg x Kg(-1) x min(-1) of remifentanil and 2 to 4 mg x Kg(-1) x h(-1) of propofol in perfusion. After the period of extracorporeal circulation, all patients were given an intravenous infusion of 30 mg of ketorolac. Later intravenous ketorolac was ministered at a dose of 30 mg per 8 hours; intravenous morphine (bolus dose of 3 mg) was also administered until pain was relieved. RESULTS: The same quality of postoperative analgesia and anesthetic recovery was achieved with both spinal and intravenous administration. The incidence of side effects was also similar. Likewise, the extubation times were similar in the 2 groups (spinal infusion group: 294.5 [SD, 150.5] minutes; intravenous group: 325.0 [139.9] minutes; P>0.05). Less postoperative intravenous morphine was administered in the first 24 hours to patients in the spinal morphine group (P<0.05) and fewer patients in that group required intravenous morphine boluses (P<0.05). CONCLUSIONS: Our study suggests that spinal morphine does not offer advantages over intravenous morphine with regard to postoperative analgesia, hemodynamic stability and respiratory parameters, time until extubation, or adverse effects.