Undernutrition and function: another piece in the jigsaw [commet

The stomach, small intestine and pancreas share in the progressive bodily dysfunction associated with undernutrition and weight loss. All these changes are reversed by nutritional support whether given enterally or parenterally, emphasizing that parenteral and enteral nutrition are the treatment of gastrointestinal failure as dialysis is of renal failure or ventilation is of respiratory failure. The observations described by Winter and colleagues have important implications for our understanding of the relationship between nutrition and physiology. They also have important implications for the care of patients with gastrointestinal disease.     

Cost-effective analysis of influenza vaccination in the elderly

We analyzed the cost-effectiveness of vaccinating all elderly persons against influenza A on an annual basis. Our model included direct cost attributable to implementing the vaccination program and the cost of medically treating those who remained vulnerable despite vaccination (30%) and later required treatment for disease-related complications in either the hospital or ambulatory setting. Ten and 30% of those susceptible to influenza A were assumed to be infected with the virus of which 30% were considered to require medical treatment. This was compared to a model where no vaccination was given assuming the same rates of infection and required treatment. We found significant potential savings resulting from the implementation of an influenza control program in both the community and nursing home setting. Savings were most significant when vaccination prevented hospitalization. When vaccination cost was kept to a minimum, however, savings were also noted when medical treatment was able to be accomplished at least in part outside of the hospital.     

An illuminating piece in the jigsaw of Hodgkin lymphoma risk stratification

The management strategy of classical Hodgkin lymphoma in children is focussed on maximising therapeutic efficacy while minimising treatment-related toxicity via a risk-adapted and response-based approach. By using volumetric PET parameters, the report of Milgrom and her colleagues shows that combining pretreatment volumetric quantitative PET data with the early response assessment PET2 scan improved risk stratification in children with high-risk classical Hodgkin lymphoma treated on the COG AHOD0831 trial. Commentary on: Milgrom et al. Baseline metabolic tumor burden improves risk stratification in Hodgkin lymphoma: A Children's Oncology Group Study. Br J Haematol 2023;201:1192–1199.     

Pneumonia and influenza: vaccination of elderly is justified

With the availability of today's immunogenic agents, there is no excuse for the physician not to attempt to routinely vaccinate his or her elderly patients.     

The intradermal vaccination route – an attractive opportunity for influenza vaccination in the elderly

An age-related decline in functioning of the innate and adaptive immune systems results in increased susceptibility to infections (e.g. influenza) and decreased responses to vaccination in elderly people. A satellite symposium held during the xixth IAGG World Congress of Gerontology and Aging in Paris, 5–9 July 2009, considered the potential of intradermal vaccination to enhance immune responses in the elderly. The rich supply of capillary blood and lymphatic vessels in the dermis, along with its resident population of dendritic cells, make the skin an attractive site for vaccine delivery. Intanza^® 15 μg is a purified, inactivated, trivalent, split-virus influenza vaccine containing 15 μg haemagglutinin/strain/0.1 ml dose that is administered using a novel intradermal microneedle injection system. A randomised, open-label phase III trial in 3695 people aged 60–95 years found that antibody responses to the intradermal influenza vaccine were superior to those for the same vaccine administered intramuscularly. The systemic safety profile of the intradermal vaccine was comparable with that of the intramuscular vaccine, but rates of injection-site reactions were higher with the intradermal vaccine, reflecting the close proximity of injected vaccine to the skin surface. The increased immunogenicity of Intanza^® 15 μg in the elderly compared with the standard intramuscular influenza vaccine supports the concept of intradermal vaccination to enhance immune responses in elderly people.     

The effect of influenza vaccination on IL2 production in healthy elderly: implications for current vaccination practices.

Age-related senescence of T-cell mediated responses is well recognized. This study was designed to determine how aging affects the T-cell mediated Interleukin 2 (IL2) response to influenza vaccination. A group of healthy elderly individuals were compared to a control group of healthy young adults for their response to the 1990 influenza vaccine. Cultures of peripheral blood mononuclear cells (PBMC) were prepared from venous blood samples taken prevaccination (pre) and 8 and 12 weeks post-vaccination (post). PBMC cultures stimulated with inactivated A/Shanghai/16/89 (contained in the 1990 vaccine) and A/Philippine/2/82 (not contained in the vaccine) were assayed for peak IL2 activity. We find that after influenza vaccination, there was an insignificant increase in IL2 activity when PBMC from the young control group were stimulated with A/Shanghai/16/89 (pre, 5.14 U/mL/10(6) PBMC; post, 6.64 U/mL/10(6) PBMC) but there was a significant increase in IL2 activity when stimulated with A/Phillippine/2/82 (pre, 1.5 U/mL/10(6) PBMC; post, 8.3 U/mL/10(6) PBMC). In similar cultures of PBMC from the elderly group, there was a significant increase in IL2 response to both A/Shanghai/16/89 (pre, 1.6 U/mL/10(6) PBMC; post, 3.5 U/mL/10(6) PBMC) and A/Philippine/2/82 (pre, 0.86 U/mL/10(6) PBMC; post, 8.3 U/mL/10(6) PBMC). Measurements of CD4+/CD8+ populations were not affected by vaccination and were not significantly different in the two groups. Subgroup analysis of the elderly group revealed that previous influenza vaccination in 1989 did not significantly affect IL2 levels measured in the present study. This study shows that in healthy elderly, influenza vaccination effectively restores IL2 activity to normal. There appears to be an age-related decrease in the duration of T-cell memory.(ABSTRACT TRUNCATED AT 250 WORDS)     

Mortality benefits of influenza vaccination in elderly people: an ongoing controversy

Influenza vaccination policy in most high-income countries attempts to reduce the mortality burden of influenza by targeting people aged at least 65 years for vaccination. However, the effectiveness of this strategy is under debate. Although placebo-controlled randomised trials show influenza vaccine is effective in younger adults, few trials have included elderly people, and especially those aged at least 70 years, the age-group that accounts for three-quarters of all influenza-related deaths. Recent excess mortality studies were unable to confirm a decline in influenza-related mortality since 1980, even as vaccination coverage increased from 15% to 65%. Paradoxically, whereas those studies attribute about 5% of all winter deaths to influenza, many cohort studies report a 50% reduction in the total risk of death in winter--a benefit ten times greater than the estimated influenza mortality burden. New studies, however, have shown substantial unadjusted selection bias in previous cohort studies. We propose an analytical framework for detecting such residual bias. We conclude that frailty selection bias and use of non-specific endpoints such as all-cause mortality have led cohort studies to greatly exaggerate vaccine benefits. The remaining evidence base is currently insufficient to indicate the magnitude of the mortality benefit, if any, that elderly people derive from the vaccination programme.