Influenza vaccination and heart failure. A priority field for improvement

Montes-Santiago, J.; Blanco Rodicio, A.; Domínguez Erquicia, P.; Rey-García, G.

doi:10.1016/j.rceng.2017.11.003

array:23 ["pii" => "S2254887417301522" "issn" => "22548874" "doi" => "10.1016/j.rceng.2017.11.003" "estado" => "S300" "fechaPublicacion" => "2018-04-01" "aid" => "1452" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "copyrightAnyo" => "2017" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Rev Clin Esp. 2018;218:159-61" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2 "PDF" => 2 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0014256517302813" "issn" => "00142565" "doi" => "10.1016/j.rce.2017.11.003" "estado" => "S300" "fechaPublicacion" => "2018-04-01" "aid" => "1452" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Rev Clin Esp. 2018;218:159-61" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 50 "formatos" => array:2 [ "HTML" => 39 "PDF" => 11 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "Correspondencia" "titulo" => "Vacunación antigripal e insuficiencia cardiaca. Un prioritario campo de mejora" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "159" "paginaFinal" => "161" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Influenza vaccination and heart failure. A prioritary field of improvement" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1397 "Ancho" => 2516 "Tamanyo" => 241554 ] ] "descripcion" => array:1 [ "es" => "Cobertura vacunal antigripal anual en adultos >65 años en diversos ámbitos territoriales. IC: insuficiencia cardiaca. Fuente: elaborado a partir de: Servicio Gallego de Salud<a class="elsevierStyleCrossRef" href="#bib0090">3</a>; Ministerio de Sanidad, Seguridad Social e Igualdad<a class="elsevierStyleCrossRef" href="#bib0095">4</a>; European Centre for Disease Prevention and Control<a class="elsevierStyleCrossRef" href="#bib0100">5</a> y Centers for Disease Control<a class="elsevierStyleCrossRef" href="#bib0105">6</a>." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Montes-Santiago, A. Blanco Rodicio, P. Domínguez Erquicia, G. Rey-García" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Montes-Santiago" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Blanco Rodicio" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Domínguez Erquicia" ] 3 => array:2 [ "nombre" => "G." "apellidos" => "Rey-García" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2254887417301522" "doi" => "10.1016/j.rceng.2017.11.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887417301522?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256517302813?idApp=WRCEE" "url" => "/00142565/0000021800000003/v1_201803280442/S0014256517302813/v1_201803280442/es/main.assets" ] ] "itemAnterior" => array:18 [ "pii" => "S2254887417301558" "issn" => "22548874" "doi" => "10.1016/j.rceng.2017.10.010" "estado" => "S300" "fechaPublicacion" => "2018-04-01" "aid" => "1454" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Rev Clin Esp. 2018;218:158-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2 "PDF" => 2 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "Correspondence" "titulo" => "Regarding the 2016 European guidelines for heart failure" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "158" "paginaFinal" => "159" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Acerca de las guías europeas de insuficiencia cardiaca de 2016" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ò. Miró, V. Gil, P. Javaloyes, P. Llorens" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Ò." "apellidos" => "Miró" ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Gil" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Javaloyes" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Llorens" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887417301558?idApp=WRCEE" "url" => "/22548874/0000021800000003/v1_201803280546/S2254887417301558/v1_201803280546/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "Correspondence" "titulo" => "Influenza vaccination and heart failure. A priority field for improvement" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "159" "paginaFinal" => "161" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Montes-Santiago, A. Blanco Rodicio, P. Domínguez Erquicia, G. Rey-García" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Montes-Santiago" "email" => array:1 [ 0 => "julio.montes.santiago@sergas.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Blanco Rodicio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "Domínguez Erquicia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "G." "apellidos" => "Rey-García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Medicina Interna, Estructura Organizativa de Gestión Integrada, Vigo, Pontevedra, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Medicina de Familia, Estructura Organizativa de Gestión Integrada, Vigo, Pontevedra, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Documentación Clínica, Estructura Organizativa de Gestión Integrada, Vigo, Pontevedra, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Vacunación antigripal e insuficiencia cardiaca. Un prioritario campo de mejora" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1397 "Ancho" => 2517 "Tamanyo" => 242511 ] ] "descripcion" => array:1 [ "en" => "Annual influenza vaccine coverage of adults older than 65 years in various territories. Abbreviations: HF, Heart Failure. Source: Developed from Galician Health Service<a class="elsevierStyleCrossRef" href="#bib0090">3</a>; Ministry of Health, Social Security and Equality<a class="elsevierStyleCrossRef" href="#bib0095">4</a>; European Center for Disease Prevention and Control<a class="elsevierStyleCrossRef" href="#bib0100">5</a>; and the Centers for Disease Control.<a class="elsevierStyleCrossRef" href="#bib0105">6</a>" ] ] ] "textoCompleto" => "The annual influenza vaccination is one of the most effective measures for decreasing hospital readmissions and mortality, not only for patients with respiratory diseases but also for those with cardiovascular diseases and particularly, heart failure (HF).<a class="elsevierStyleCrossRef" href="#bib0080">1</a> However, there are scarce data, particularly in Spain, on the vaccine's coverage for patients hospitalized for HF. The aim of this study was to examine the electronic health record (EHR) for completion of recommendations on the coverage of influenza vaccinations for patients hospitalized for HF and to compare the changes in the rate of the vaccine's indication between 2014 and 2016, in the discharge reports of an internal medicine department.We analyzed the discharge reports and EHRs of a sample considered representative of patients hospitalized for HF in our hospital center's Department of Internal Medicine.<a class="elsevierStyleCrossRef" href="#bib0085">2</a> To this end, we examined the first 60 (2014) and 59 (2016) patients with a primary diagnosis of HF at discharge (diagnostic code 428.0, International Classification of Diseases-9th edition-Clinical Modification [ICD-9CM]). The patients were chosen starting in January to ensure that the periods for the influenza vaccination campaigns were completed. The explicit references in the discharge reports as to the advisability of the influenza vaccination were quantified. The EHRs were exhaustively searched for such references (made primarily by primary care) in all of their sections. The patient characteristics in 2014 and 2016 showed no significant variations, except in mean age and ischemic etiology (79±9 vs. 82±9 years and 20% vs. 41%, respectively; p<0.05 for both). To analyze the study objectives, we therefore grouped the samples selected in both periods (2014 and 2016) into one, resulting in a total of 119 patients. Fifty-eight percent of this group were women, with HF of hypertensive (83%) or valvular (31%) etiology. The left ventricular ejection fraction was measured in 92% of the patients and was >45% in 75% of the cases. The comorbidities were atrial fibrillation (78%), anemia (58%), chronic obstructive pulmonary disease (19%), neurological disease (dementia or previous stroke) (33%), diabetes (38%) and renal failure (43%). The hospital survival rate was 90%, and mortality at 12 months was 34%. Sixty-seven percent of the unvaccinated patients died during hospitalization, compared with 33% of those who were vaccinated (p=0.004). The advisability of an influenza vaccination was mentioned in 7% (4/60 in 2014) and 5% (3/59 in 2016) of the discharge reports.The coverage of the influenza vaccination in the medical history was 68% (41/60) in 2014 and 70% (41/59) in 2016. In the remaining reviewed medical histories, there was no reference to the state of vaccination. In comparison, the rate of vaccine coverage in the general population older than 65 years in Vigo, Galicia, Spain, England (the European country with the greatest vaccine coverage) and USA are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<a class="elsevierStyleCrossRefs" href="#bib0090">3–6</a> Vigo was the area in Galicia with the least influenza vaccination coverage. In any case, none of the previously mentioned populations, except for England, reached the >75% objective recommended by European organizations.<a class="elsevierStyleCrossRef" href="#bib0100">5</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>In Vigo, the influenza vaccination coverage in HF was greater than that of the rest of the population over 65 years of age. However, the 70% coverage needs substantial improvement because the specific recommendation for influenza advises a figure close to 100%. In addition to age, there are comorbidities for which the influenza vaccination is also recommended for patients with HF (chronic obstructive pulmonary disease, diabetes, etc.). Between 2014 and 2016, there was a slight improvement in the vaccine coverage. However, the low rate of vaccine recommendations in the discharge reports is worrying.Adults older than 65 years constitute 50–70% of all influenza-related hospitalizations and 85% of influenza-related deaths.<a class="elsevierStyleCrossRef" href="#bib0110">7</a> Respiratory infections are a common cause of exacerbation and hospitalization for patients with cardiovascular diseases.<a class="elsevierStyleCrossRef" href="#bib0115">8</a> Particularly in HF, respiratory infection is a common cause of readmission.<a class="elsevierStyleCrossRefs" href="#bib0120">9,10</a> However, in patients with HF, the rate of influenza vaccinations is still low. For example, in the recent PARADIGM study, the influenza vaccination rate among the more than 8000 participants from America, Asia and Europe was 21%, although among the patients included in Spain, the rate reached 52%.<a class="elsevierStyleCrossRef" href="#bib0130">11</a>The influenza vaccination can attenuate the worsening prognosis of the HF caused by these respiratory infections.<a class="elsevierStyleCrossRef" href="#bib0135">12</a> Even in a small series such as ours, the mortality among the patients with HF was lower among the vaccinated patients. It has recently been shown in Spain that the influenza vaccination prevents up to 36% of readmissions for diseases that are exacerbated or related to the influenza infection, including cardiovascular processes.<a class="elsevierStyleCrossRef" href="#bib0140">13</a> Therefore, the influenza vaccination represents a low-cost and highly effective measure for preventing the morbidity and mortality associated with HF, which is generally recommended in the clinical practice guidelines.<a class="elsevierStyleCrossRefs" href="#bib0145">14,15</a>Although the influenza vaccination rates have stabilized in our department and healthcare area, there is a certain relaxation in terms of its recommendation in the discharge reports. We need to increase efforts by patients and practitioners so that this measure can be increasingly widespread in the at-risk population. Our center's department of preventive medicine has therefore intensified the measures aimed at achieving practically universal coverage of the influenza vaccination for hospitalized patients." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Montes-Santiago J, Blanco Rodicio A, Domínguez Erquicia P, Rey-García G. Vacunación antigripal e insuficiencia cardiaca. Un prioritario campo de mejora. Rev Clín Esp. 2018;218:159–161." ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1397 "Ancho" => 2517 "Tamanyo" => 242511 ] ] "descripcion" => array:1 [ "en" => "Annual influenza vaccine coverage of adults older than 65 years in various territories. Abbreviations: HF, Heart Failure. Source: Developed from Galician Health Service<a class="elsevierStyleCrossRef" href="#bib0090">3</a>; Ministry of Health, Social Security and Equality<a class="elsevierStyleCrossRef" href="#bib0095">4</a>; European Center for Disease Prevention and Control<a class="elsevierStyleCrossRef" href="#bib0100">5</a>; and the Centers for Disease Control.<a class="elsevierStyleCrossRef" href="#bib0105">6</a>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Can vaccinations improve heart failure outcomes? Contemporary data and future directions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.S. Bhatt" 1 => "A.D. DeVore" 2 => "A.F. Hernandez" 3 => "R.J. Mentz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jchf.2016.12.007" "Revista" => array:6 [ "tituloSerie" => "JACC Heart Fail" "fecha" => "2017" "volumen" => "5" "paginaInicial" => "194" "paginaFinal" => "203" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28161238" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0085" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Medicina cardiovascular" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. García-Alegría" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:6 [ "titulo" => "Modelos organizativos y criterios de calidad en la asistencia al paciente con insuficiencia cardíaca." "fecha" => "2007" "paginaInicial" => "57" "paginaFinal" => "60" "editorial" => "Jarpyo" "editorialLocalizacion" => "Madrid" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0090" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Servicio Gallego de Salud. Campaña de vacunación antigripal. Available from: <a id="intr0010" class="elsevierStyleInterRef" href="http://www.sergas.es/Saude_publica/Documents/4692/Informe%20FINAL%20Campa%26ntilde;a%20Vacinaci%26oacute;n%20Antigripal%202016.pdf">http://www.sergas.es/Saude_publica/Documents/4692/Informe%20%20FINAL%20Campaña%20Vacinación%20Antigripal%202016.pdf</a> [accessed 5.11.17]." ] ] ] 3 => array:3 [ "identificador" => "bib0095" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Ministerio de Sanidad, Seguridad Social e Igualdad. Cobertura de vacunación. Available from: <a id="intr0015" class="elsevierStyleInterRef" href="http://www.mssi.go.es/profesionales/saludPublica/prevPromocion/vacunaciones/docs/CoberturasVacunacion/Tabla10.pdf">http://www.mssi.go.es/profesionales/saludPublica/prevPromocion/vacunaciones/docs/CoberturasVacunacion/Tabla10.pdf</a> [accessed 5.11.17]." ] ] ] 4 => array:3 [ "identificador" => "bib0100" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <a class="elsevierStyleInterRef" target="_blank" id="intr0020" href="http://www.ecdc.europa.eu/en/seasonal-influenza/prevention-and-control">http://www.ecdc.europa.eu/en/seasonal-influenza/prevention-and-control</a> [accessed 5.11.17]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Seasonal influenza vaccination and antiviral use in Europe – overview of vaccination recommendations and coverage rates in the EU Member States for the 2013-14 and 2014-15 influenza seasons" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "European Centre for Disease Prevention and Control" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2016" "editorial" => "ECDC" "editorialLocalizacion" => "Stockholm" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0105" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Centers for Disease Control. Available from: <a id="intr0025" class="elsevierStyleInterRef" href="http://www.cdc.gov/flu/fluvaxview/1617season.htm">http://www.cdc.gov/flu/fluvaxview/1617season.htm</a> [accessed 5.11.17]." ] ] ] 6 => array:3 [ "identificador" => "bib0110" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Influenza illness and hospitalization averted by influenza vaccination in the United States, 2005–2011" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Kostova" 1 => "C. Reed" 2 => "L. Finelli" 3 => "P.Y. Cheng" 4 => "P.M. Gargiullo" 5 => "D.K. Shay" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0066312" "Revista" => array:5 [ "tituloSerie" => "PLoS ONE" "fecha" => "2013" "volumen" => "8" "paginaInicial" => "e66312" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23840439" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0115" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.A. Udell" 1 => "R. Zawi" 2 => "D.L. Bhatt" 3 => "M. Keshtkar-Jahromi" 4 => "F. Gaughran" 5 => "A. Phrommintikul" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.2013.279206" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2013" "volumen" => "310" "paginaInicial" => "1711" "paginaFinal" => "1720" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24150467" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0120" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predictors and outcomes of infection related hospital admissions of heart failure patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D. Alon" 1 => "G.Y. Stein" 2 => "R. Korenfeld" 3 => "S. Fuchs" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0072476" "Revista" => array:5 [ "tituloSerie" => "PLoS ONE" "fecha" => "2013" "volumen" => "8" "paginaInicial" => "e72476" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24009684" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0125" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Influenza vaccine and survival in acute heart failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E. Kopel" 1 => "R. Klempfner" 2 => "I. Goldenberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ejhf.14" "Revista" => array:6 [ "tituloSerie" => "Eur J Heart Fail" "fecha" => "2014" "volumen" => "16" "paginaInicial" => "264" "paginaFinal" => "270" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24464586" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0130" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Influenza vaccination in patients with chronic heart failure: the PARADIGM-HF trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "O. Vardeny" 1 => "B. Claggett" 2 => "J.A. Udell" 3 => "M. Packer" 4 => "M. Zile" 5 => "J. Rouleau" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jchf.2015.10.012" "Revista" => array:6 [ "tituloSerie" => "JACC Heart Fail" "fecha" => "2016" "volumen" => "4" "paginaInicial" => "152" "paginaFinal" => "158" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26746371" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0135" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Influenza vaccination and risk of hospitalization in patients with heart failure: a self-controlled case series study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H. Mohseni" 1 => "A. Kiran" 2 => "R. Khorshidi" 3 => "K. Rahimi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehw411" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2016" "volumen" => "38" "paginaInicial" => "326" "paginaFinal" => "333" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27660378" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0140" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The effectiveness of influenza vaccination in preventing hospitalisations of elderly individuals in two influenza seasons: A multicentre case-control study" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "the Working Group of the Project PI12/02079" "etal" => true "autores" => array:6 [ 0 => "A. Dominguez" 1 => "N. Soldevila" 2 => "D. Toledo" 3 => "P. Godoy" 4 => "E. Espejo" 5 => "M.A. Fernandez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2807/1560-7917" "Revista" => array:4 [ "tituloSerie" => "Euro Surveill" "fecha" => "2017" "volumen" => "22" "paginaInicial" => "pii=30602" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0145" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Ponikowski" 1 => "A.A. Voors" 2 => "S.D. Anker" 3 => "H. Bueno" 4 => "J.G. Cleland" 5 => "A.J. Coats" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehw128" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J." "fecha" => "2016" "volumen" => "37" "paginaInicial" => "2129" "paginaFinal" => "2200" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27206819" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0150" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.W. Yancy" 1 => "M. Jessup" 2 => "B. Bozkurt" 3 => "J. Butler" 4 => "D.E. Casey Jr." 5 => "M.H. Drazner" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2013.05.019" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2013" "volumen" => "62" "paginaInicial" => "e147" "paginaFinal" => "e239" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23747642" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/22548874/0000021800000003/v1_201803280546/S2254887417301522/v1_201803280546/en/main.assets" "Apartado" => array:4 [ "identificador" => "71813" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Correspondence" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22548874/0000021800000003/v1_201803280546/S2254887417301522/v1_201803280546/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887417301522?idApp=WRCEE"]

 array:23 [
  "pii" => "S2254887417301522"
  "issn" => "22548874"
  "doi" => "10.1016/j.rceng.2017.11.003"
  "estado" => "S300"
  "fechaPublicacion" => "2018-04-01"
  "aid" => "1452"
  "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;"
  "copyrightAnyo" => "2017"
  "documento" => "simple-article"
  "crossmark" => 1
  "subdocumento" => "cor"
  "cita" => "Rev Clin Esp. 2018;218:159-61"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 2
    "PDF" => 2
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0014256517302813"
      "issn" => "00142565"
      "doi" => "10.1016/j.rce.2017.11.003"
      "estado" => "S300"
      "fechaPublicacion" => "2018-04-01"
      "aid" => "1452"
      "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;"
      "documento" => "simple-article"
      "crossmark" => 1
      "subdocumento" => "cor"
      "cita" => "Rev Clin Esp. 2018;218:159-61"
      "abierto" => array:3 [
        "ES" => false
        "ES2" => false
        "LATM" => false
      ]
      "gratuito" => false
      "lecturas" => array:2 [
        "total" => 50
        "formatos" => array:2 [
          "HTML" => 39
          "PDF" => 11
        ]
      ]
      "es" => array:11 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Correspondencia</span>"
        "titulo" => "Vacunaci&#243;n antigripal e insuficiencia cardiaca&#46; Un prioritario campo de mejora"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "159"
            "paginaFinal" => "161"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Influenza vaccination and heart failure&#46; A prioritary field of improvement"
          ]
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0005"
            "etiqueta" => "Figura 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr1.jpeg"
                "Alto" => 1397
                "Ancho" => 2516
                "Tamanyo" => 241554
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cobertura vacunal antigripal anual en adultos &#62;<span class="elsevierStyleHsp" style=""></span>65 a&#241;os en diversos &#225;mbitos territoriales&#46; IC&#58; insuficiencia cardiaca&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Fuente&#58; elaborado a partir de&#58; Servicio Gallego de Salud<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a>&#59; Ministerio de Sanidad&#44; Seguridad Social e Igualdad<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a>&#59; European Centre for Disease Prevention and Control<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> y Centers for Disease Control<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a>&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "J&#46; Montes-Santiago, A&#46; Blanco Rodicio, P&#46; Dom&#237;nguez Erquicia, G&#46; Rey-Garc&#237;a"
            "autores" => array:4 [
              0 => array:2 [
                "nombre" => "J&#46;"
                "apellidos" => "Montes-Santiago"
              ]
              1 => array:2 [
                "nombre" => "A&#46;"
                "apellidos" => "Blanco Rodicio"
              ]
              2 => array:2 [
                "nombre" => "P&#46;"
                "apellidos" => "Dom&#237;nguez Erquicia"
              ]
              3 => array:2 [
                "nombre" => "G&#46;"
                "apellidos" => "Rey-Garc&#237;a"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2254887417301522"
          "doi" => "10.1016/j.rceng.2017.11.003"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887417301522?idApp=WRCEE"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256517302813?idApp=WRCEE"
      "url" => "/00142565/0000021800000003/v1_201803280442/S0014256517302813/v1_201803280442/es/main.assets"
    ]
  ]
  "itemAnterior" => array:18 [
    "pii" => "S2254887417301558"
    "issn" => "22548874"
    "doi" => "10.1016/j.rceng.2017.10.010"
    "estado" => "S300"
    "fechaPublicacion" => "2018-04-01"
    "aid" => "1454"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Medicina Interna &#40;SEMI&#41;"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "cor"
    "cita" => "Rev Clin Esp. 2018;218:158-9"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 2
      "PDF" => 2
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Correspondence</span>"
      "titulo" => "Regarding the 2016 European guidelines for heart failure"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "158"
          "paginaFinal" => "159"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Acerca de las gu&#237;as europeas de insuficiencia cardiaca de 2016"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "&#210;&#46; Mir&#243;, V&#46; Gil, P&#46; Javaloyes, P&#46; Llorens"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "&#210;&#46;"
              "apellidos" => "Mir&#243;"
            ]
            1 => array:2 [
              "nombre" => "V&#46;"
              "apellidos" => "Gil"
            ]
            2 => array:2 [
              "nombre" => "P&#46;"
              "apellidos" => "Javaloyes"
            ]
            3 => array:2 [
              "nombre" => "P&#46;"
              "apellidos" => "Llorens"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887417301558?idApp=WRCEE"
    "url" => "/22548874/0000021800000003/v1_201803280546/S2254887417301558/v1_201803280546/en/main.assets"
  ]
  "en" => array:15 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Correspondence</span>"
    "titulo" => "Influenza vaccination and heart failure&#46; A priority field for improvement"
    "tieneTextoCompleto" => true
    "saludo" => "Dear Editor&#44;"
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "159"
        "paginaFinal" => "161"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "J&#46; Montes-Santiago, A&#46; Blanco Rodicio, P&#46; Dom&#237;nguez Erquicia, G&#46; Rey-Garc&#237;a"
        "autores" => array:4 [
          0 => array:4 [
            "nombre" => "J&#46;"
            "apellidos" => "Montes-Santiago"
            "email" => array:1 [
              0 => "julio&#46;montes&#46;santiago&#64;sergas&#46;es"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "A&#46;"
            "apellidos" => "Blanco Rodicio"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "P&#46;"
            "apellidos" => "Dom&#237;nguez Erquicia"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "G&#46;"
            "apellidos" => "Rey-Garc&#237;a"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:3 [
          0 => array:3 [
            "entidad" => "Medicina Interna&#44; Estructura Organizativa de Gesti&#243;n Integrada&#44; Vigo&#44; Pontevedra&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Medicina de Familia&#44; Estructura Organizativa de Gesti&#243;n Integrada&#44; Vigo&#44; Pontevedra&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Documentaci&#243;n Cl&#237;nica&#44; Estructura Organizativa de Gesti&#243;n Integrada&#44; Vigo&#44; Pontevedra&#44; Spain"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Vacunaci&#243;n antigripal e insuficiencia cardiaca&#46; Un prioritario campo de mejora"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1397
            "Ancho" => 2517
            "Tamanyo" => 242511
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Annual influenza vaccine coverage of adults older than 65 years in various territories&#46; Abbreviations&#58; HF&#44; Heart Failure&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Developed from Galician Health Service<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a>&#59; Ministry of Health&#44; Social Security and Equality<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a>&#59; European Center for Disease Prevention and Control<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a>&#59; and the Centers for Disease Control&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a></p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The annual influenza vaccination is one of the most effective measures for decreasing hospital readmissions and mortality&#44; not only for patients with respiratory diseases but also for those with cardiovascular diseases and particularly&#44; heart failure &#40;HF&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> However&#44; there are scarce data&#44; particularly in Spain&#44; on the vaccine&#39;s coverage for patients hospitalized for HF&#46; The aim of this study was to examine the electronic health record &#40;EHR&#41; for completion of recommendations on the coverage of influenza vaccinations for patients hospitalized for HF and to compare the changes in the rate of the vaccine&#39;s indication between 2014 and 2016&#44; in the discharge reports of an internal medicine department&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We analyzed the discharge reports and EHRs of a sample considered representative of patients hospitalized for HF in our hospital center&#39;s Department of Internal Medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> To this end&#44; we examined the first 60 &#40;2014&#41; and 59 &#40;2016&#41; patients with a primary diagnosis of HF at discharge &#40;diagnostic code 428&#46;0&#44; International Classification of Diseases-9th edition-Clinical Modification &#91;ICD-9CM&#93;&#41;&#46; The patients were chosen starting in January to ensure that the periods for the influenza vaccination campaigns were completed&#46; The explicit references in the discharge reports as to the advisability of the influenza vaccination were quantified&#46; The EHRs were exhaustively searched for such references &#40;made primarily by primary care&#41; in all of their sections&#46; The patient characteristics in 2014 and 2016 showed no significant variations&#44; except in mean age and ischemic etiology &#40;79<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9 vs&#46; 82<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9 years and 20&#37; vs&#46; 41&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 for both&#41;&#46; To analyze the study objectives&#44; we therefore grouped the samples selected in both periods &#40;2014 and 2016&#41; into one&#44; resulting in a total of 119 patients&#46; Fifty-eight percent of this group were women&#44; with HF of hypertensive &#40;83&#37;&#41; or valvular &#40;31&#37;&#41; etiology&#46; The left ventricular ejection fraction was measured in 92&#37; of the patients and was &#62;45&#37; in 75&#37; of the cases&#46; The comorbidities were atrial fibrillation &#40;78&#37;&#41;&#44; anemia &#40;58&#37;&#41;&#44; chronic obstructive pulmonary disease &#40;19&#37;&#41;&#44; neurological disease &#40;dementia or previous stroke&#41; &#40;33&#37;&#41;&#44; diabetes &#40;38&#37;&#41; and renal failure &#40;43&#37;&#41;&#46; The hospital survival rate was 90&#37;&#44; and mortality at 12 months was 34&#37;&#46; Sixty-seven percent of the unvaccinated patients died during hospitalization&#44; compared with 33&#37; of those who were vaccinated &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#46; The advisability of an influenza vaccination was mentioned in 7&#37; &#40;4&#47;60 in 2014&#41; and 5&#37; &#40;3&#47;59 in 2016&#41; of the discharge reports&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The coverage of the influenza vaccination in the medical history was 68&#37; &#40;41&#47;60&#41; in 2014 and 70&#37; &#40;41&#47;59&#41; in 2016&#46; In the remaining reviewed medical histories&#44; there was no reference to the state of vaccination&#46; In comparison&#44; the rate of vaccine coverage in the general population older than 65 years in Vigo&#44; Galicia&#44; Spain&#44; England &#40;the European country with the greatest vaccine coverage&#41; and USA are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3&#8211;6</span></a> Vigo was the area in Galicia with the least influenza vaccination coverage&#46; In any case&#44; none of the previously mentioned populations&#44; except for England&#44; reached the &#62;75&#37; objective recommended by European organizations&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In Vigo&#44; the influenza vaccination coverage in HF was greater than that of the rest of the population over 65 years of age&#46; However&#44; the 70&#37; coverage needs substantial improvement because the specific recommendation for influenza advises a figure close to 100&#37;&#46; In addition to age&#44; there are comorbidities for which the influenza vaccination is also recommended for patients with HF &#40;chronic obstructive pulmonary disease&#44; diabetes&#44; etc&#46;&#41;&#46; Between 2014 and 2016&#44; there was a slight improvement in the vaccine coverage&#46; However&#44; the low rate of vaccine recommendations in the discharge reports is worrying&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Adults older than 65 years constitute 50&#8211;70&#37; of all influenza-related hospitalizations and 85&#37; of influenza-related deaths&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> Respiratory infections are a common cause of exacerbation and hospitalization for patients with cardiovascular diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> Particularly in HF&#44; respiratory infection is a common cause of readmission&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">9&#44;10</span></a> However&#44; in patients with HF&#44; the rate of influenza vaccinations is still low&#46; For example&#44; in the recent PARADIGM study&#44; the influenza vaccination rate among the more than 8000 participants from America&#44; Asia and Europe was 21&#37;&#44; although among the patients included in Spain&#44; the rate reached 52&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The influenza vaccination can attenuate the worsening prognosis of the HF caused by these respiratory infections&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> Even in a small series such as ours&#44; the mortality among the patients with HF was lower among the vaccinated patients&#46; It has recently been shown in Spain that the influenza vaccination prevents up to 36&#37; of readmissions for diseases that are exacerbated or related to the influenza infection&#44; including cardiovascular processes&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> Therefore&#44; the influenza vaccination represents a low-cost and highly effective measure for preventing the morbidity and mortality associated with HF&#44; which is generally recommended in the clinical practice guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Although the influenza vaccination rates have stabilized in our department and healthcare area&#44; there is a certain relaxation in terms of its recommendation in the discharge reports&#46; We need to increase efforts by patients and practitioners so that this measure can be increasingly widespread in the at-risk population&#46; Our center&#39;s department of preventive medicine has therefore intensified the measures aimed at achieving practically universal coverage of the influenza vaccination for hospitalized patients&#46;</p></span>"
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Montes-Santiago J&#44; Blanco Rodicio A&#44; Dom&#237;nguez Erquicia P&#44; Rey-Garc&#237;a G&#46; Vacunaci&#243;n antigripal e insuficiencia cardiaca&#46; Un prioritario campo de mejora&#46; Rev Cl&#237;n Esp&#46; 2018&#59;218&#58;159&#8211;161&#46;</p>"
      ]
    ]
    "multimedia" => array:1 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1397
            "Ancho" => 2517
            "Tamanyo" => 242511
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Annual influenza vaccine coverage of adults older than 65 years in various territories&#46; Abbreviations&#58; HF&#44; Heart Failure&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Developed from Galician Health Service<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a>&#59; Ministry of Health&#44; Social Security and Equality<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a>&#59; European Center for Disease Prevention and Control<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a>&#59; and the Centers for Disease Control&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a></p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:15 [
            0 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Can vaccinations improve heart failure outcomes&#63; Contemporary data and future directions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46;S&#46; Bhatt"
                            1 => "A&#46;D&#46; DeVore"
                            2 => "A&#46;F&#46; Hernandez"
                            3 => "R&#46;J&#46; Mentz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jchf.2016.12.007"
                      "Revista" => array:6 [
                        "tituloSerie" => "JACC Heart Fail"
                        "fecha" => "2017"
                        "volumen" => "5"
                        "paginaInicial" => "194"
                        "paginaFinal" => "203"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28161238"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Medicina cardiovascular"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46; Garc&#237;a-Alegr&#237;a"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:6 [
                        "titulo" => "Modelos organizativos y criterios de calidad en la asistencia al paciente con insuficiencia card&#237;aca&#46;"
                        "fecha" => "2007"
                        "paginaInicial" => "57"
                        "paginaFinal" => "60"
                        "editorial" => "Jarpyo"
                        "editorialLocalizacion" => "Madrid"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Servicio Gallego de Salud&#46; Campa&#241;a de vacunaci&#243;n antigripal&#46; Available from&#58; <a id="intr0010" class="elsevierStyleInterRef" href="http://www.sergas.es/Saude_publica/Documents/4692/Informe%20FINAL%20Campa%26ntilde;a%20Vacinaci%26oacute;n%20Antigripal%202016.pdf">http&#58;&#47;&#47;www&#46;sergas&#46;es&#47;Saude&#95;publica&#47;Documents&#47;4692&#47;Informe&#37;20&#37;20FINAL&#37;20Campa&#241;a&#37;20Vacinaci&#243;n&#37;20Antigripal&#37;202016&#46;pdf</a> &#91;accessed 5&#46;11&#46;17&#93;&#46;"
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Ministerio de Sanidad&#44; Seguridad Social e Igualdad&#46; Cobertura de vacunaci&#243;n&#46; Available from&#58; <a id="intr0015" class="elsevierStyleInterRef" href="http://www.mssi.go.es/profesionales/saludPublica/prevPromocion/vacunaciones/docs/CoberturasVacunacion/Tabla10.pdf">http&#58;&#47;&#47;www&#46;mssi&#46;go&#46;es&#47;profesionales&#47;saludPublica&#47;prevPromocion&#47;vacunaciones&#47;docs&#47;CoberturasVacunacion&#47;Tabla10&#46;pdf</a> &#91;accessed 5&#46;11&#46;17&#93;&#46;"
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "Available from&#58; <a class="elsevierStyleInterRef" target="_blank" id="intr0020" href="http://www.ecdc.europa.eu/en/seasonal-influenza/prevention-and-control">http&#58;&#47;&#47;www&#46;ecdc&#46;europa&#46;eu&#47;en&#47;seasonal-influenza&#47;prevention-and-control</a> &#91;accessed 5&#46;11&#46;17&#93;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Seasonal influenza vaccination and antiviral use in Europe &#8211; overview of vaccination recommendations and coverage rates in the EU Member States for the 2013-14 and 2014-15 influenza seasons"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "European Centre for Disease Prevention and Control"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2016"
                        "editorial" => "ECDC"
                        "editorialLocalizacion" => "Stockholm"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Centers for Disease Control&#46; Available from&#58; <a id="intr0025" class="elsevierStyleInterRef" href="http://www.cdc.gov/flu/fluvaxview/1617season.htm">http&#58;&#47;&#47;www&#46;cdc&#46;gov&#47;flu&#47;fluvaxview&#47;1617season&#46;htm</a> &#91;accessed 5&#46;11&#46;17&#93;&#46;"
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Influenza illness and hospitalization averted by influenza vaccination in the United States&#44; 2005&#8211;2011"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46; Kostova"
                            1 => "C&#46; Reed"
                            2 => "L&#46; Finelli"
                            3 => "P&#46;Y&#46; Cheng"
                            4 => "P&#46;M&#46; Gargiullo"
                            5 => "D&#46;K&#46; Shay"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0066312"
                      "Revista" => array:5 [
                        "tituloSerie" => "PLoS ONE"
                        "fecha" => "2013"
                        "volumen" => "8"
                        "paginaInicial" => "e66312"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23840439"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association between influenza vaccination and cardiovascular outcomes in high-risk patients&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;A&#46; Udell"
                            1 => "R&#46; Zawi"
                            2 => "D&#46;L&#46; Bhatt"
                            3 => "M&#46; Keshtkar-Jahromi"
                            4 => "F&#46; Gaughran"
                            5 => "A&#46; Phrommintikul"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jama.2013.279206"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA"
                        "fecha" => "2013"
                        "volumen" => "310"
                        "paginaInicial" => "1711"
                        "paginaFinal" => "1720"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24150467"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Predictors and outcomes of infection related hospital admissions of heart failure patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "D&#46; Alon"
                            1 => "G&#46;Y&#46; Stein"
                            2 => "R&#46; Korenfeld"
                            3 => "S&#46; Fuchs"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0072476"
                      "Revista" => array:5 [
                        "tituloSerie" => "PLoS ONE"
                        "fecha" => "2013"
                        "volumen" => "8"
                        "paginaInicial" => "e72476"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24009684"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Influenza vaccine and survival in acute heart failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "E&#46; Kopel"
                            1 => "R&#46; Klempfner"
                            2 => "I&#46; Goldenberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ejhf.14"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Heart Fail"
                        "fecha" => "2014"
                        "volumen" => "16"
                        "paginaInicial" => "264"
                        "paginaFinal" => "270"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24464586"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Influenza vaccination in patients with chronic heart failure&#58; the PARADIGM-HF trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "O&#46; Vardeny"
                            1 => "B&#46; Claggett"
                            2 => "J&#46;A&#46; Udell"
                            3 => "M&#46; Packer"
                            4 => "M&#46; Zile"
                            5 => "J&#46; Rouleau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jchf.2015.10.012"
                      "Revista" => array:6 [
                        "tituloSerie" => "JACC Heart Fail"
                        "fecha" => "2016"
                        "volumen" => "4"
                        "paginaInicial" => "152"
                        "paginaFinal" => "158"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26746371"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Influenza vaccination and risk of hospitalization in patients with heart failure&#58; a self-controlled case series study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "H&#46; Mohseni"
                            1 => "A&#46; Kiran"
                            2 => "R&#46; Khorshidi"
                            3 => "K&#46; Rahimi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/eurheartj/ehw411"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2016"
                        "volumen" => "38"
                        "paginaInicial" => "326"
                        "paginaFinal" => "333"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27660378"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effectiveness of influenza vaccination in preventing hospitalisations of elderly individuals in two influenza seasons&#58; A multicentre case-control study"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "the Working Group of the Project PI12&#47;02079"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Dominguez"
                            1 => "N&#46; Soldevila"
                            2 => "D&#46; Toledo"
                            3 => "P&#46; Godoy"
                            4 => "E&#46; Espejo"
                            5 => "M&#46;A&#46; Fernandez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2807/1560-7917"
                      "Revista" => array:4 [
                        "tituloSerie" => "Euro Surveill"
                        "fecha" => "2017"
                        "volumen" => "22"
                        "paginaInicial" => "pii&#61;30602"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure&#58; The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology &#40;ESC&#41; developed with the special contribution of the Heart Failure Association &#40;HFA&#41; of the ESC"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Ponikowski"
                            1 => "A&#46;A&#46; Voors"
                            2 => "S&#46;D&#46; Anker"
                            3 => "H&#46; Bueno"
                            4 => "J&#46;G&#46; Cleland"
                            5 => "A&#46;J&#46; Coats"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/eurheartj/ehw128"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J&#46;"
                        "fecha" => "2016"
                        "volumen" => "37"
                        "paginaInicial" => "2129"
                        "paginaFinal" => "2200"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27206819"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2013 ACCF&#47;AHA guideline for the management of heart failure&#58; a report of the American College of Cardiology Foundation&#47;American Heart Association Task Force on practice guidelines"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;W&#46; Yancy"
                            1 => "M&#46; Jessup"
                            2 => "B&#46; Bozkurt"
                            3 => "J&#46; Butler"
                            4 => "D&#46;E&#46; Casey Jr&#46;"
                            5 => "M&#46;H&#46; Drazner"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2013.05.019"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2013"
                        "volumen" => "62"
                        "paginaInicial" => "e147"
                        "paginaFinal" => "e239"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23747642"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/22548874/0000021800000003/v1_201803280546/S2254887417301522/v1_201803280546/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "71813"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Correspondence"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/22548874/0000021800000003/v1_201803280546/S2254887417301522/v1_201803280546/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887417301522?idApp=WRCEE"
]

Indexed in:

Follow us:

Subscribe:

Article

Indexed in:

Follow us:

Subscribe:

Article

Subscribe to our newsletter