Archive for September, 2012

Fitness and the Prevention of Chronic Disease

Saturday, September 29, 2012 // Uncategorized

Midlife Fitness and the Development of Chronic Conditions in Later Life

Benjamin L. Willis, MD, MPH; Ang Gao, MS; David Leonard, PhD; Laura F. DeFina, MD; Jarett D. Berry, MD, MS
[+-] Author Affiliations

Author Affiliations: The Cooper Institute (Drs Willis and DeFina), Division of Cardiology, Department of Internal Medicine (Ms Gao and Dr Berry), and Department of Clinical Science, Division of Biostatistics (Dr Leonard), The University of Texas Southwestern Medical Center, Dallas.


Arch Intern Med. 2012;172(17):1-8. doi:10.1001/archinternmed.2012.3400.
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Background  The association between cardiorespiratory fitness (fitness) and mortality is well described. However, the association between midlife fitness and the development of nonfatal chronic conditions in older age has not been studied.

Methods  To examine the association between midlife fitness and chronic disease outcomes in later life, participant data from the Cooper Center Longitudinal Study were linked with Medicare claims. We studied 18 670 healthy participants (21.1% women; median age, 49 years) who survived to receive Medicare coverage from January 1, 1999, to December 31, 2009. Fitness estimated by Balke treadmill time was analyzed as a continuous variable (in metabolic equivalents [METs]) and according to age- and sex-specific quintiles. Eight common chronic conditions were defined using validated algorithms, and associations between midlife fitness and the number of conditions were assessed using a modified Cox proportional hazards model that stratified the at-risk population by the number of conditions while adjusting for age, body mass index, blood pressure, cholesterol and glucose levels, alcohol use, and smoking.

Results  After 120 780 person-years of Medicare exposure with a median follow-up of 26 years, the highest quintile of fitness (quintile 5) was associated with a lower incidence of chronic conditions compared with the lowest quintile (quintile 1) in men (15.6 [95% CI, 15.0-16.2] vs 28.2 [27.4-29.0] per 100 person-years) and women (11.4 [10.5-12.3] vs 20.1 [18.7 vs 21.6] per 100 person-years). After multivariate adjustment, higher fitness (in METs) was associated with a lower risk of developing chronic conditions in men (hazard ratio, 0.95 [95% CI, 0.94-0.96] per MET) and women (0.94 [0.91-0.96] per MET). Among decedents (2406 [12.9%]), higher fitness was associated with lower risk of developing chronic conditions relative to survival (compression hazard ratio, 0.90 [95% CI, 0.88-0.92] per MET), suggesting morbidity compression.

Conclusions  In this cohort of healthy middle-aged adults, fitness was significantly associated with a lower risk of developing chronic disease outcomes during 26 years of follow-up. These findings suggest that higher midlife fitness may be associated with the compression of morbidity in older age


Figure. Prevalence of selected chronic conditions in men and women by attained age (N = 18 670). Prevalence of chronic conditions at ages 70, 75, 80, and 85 years was determined by classifying all participants alive at these age thresholds according to the presence or absence of each of the 8 chronic conditions. The presence of a condition required that the earliest indication of the condition occurred before or at the attained age among survivors. Because some participants survived across multiple age thresholds and are represented in more than 1 age category, the numbers listed for the age groups total more than 18 670. ALZ indicates Alzheimer disease; CA, cancer of the colon or lung; CHF, congestive heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; and IHD, ischemic heart disease.

+Image not available. 
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Preventing Diabetes With Exercise

Friday, September 28, 2012 // Uncategorized

Exercise is more powerful than any drug out there for the prevention of Type 2 diabetes.  What hasn’t been looked at is what effect the type of exercise has on the risk.  According to this prospective study, lifting weights is an important componet to diabetes prevention.
Original Investigation | Sep 24, 2012

A Prospective Study of Weight Training and Risk of Type 2 Diabetes Mellitus in Men

Anders Grøntved, MPH, MSc; Eric B. Rimm, ScD; Walter C. Willett, MD, DrPH; Lars B. Andersen, PhD, DrMED; Frank B. Hu, MD, PhD
[+-] Author Affiliations

Author Affiliations: Departments of Nutrition (Mr Grøntved and Drs Rimm, Willett, and Hu) and Epidemiology (Drs Rimm, Willett, and Hu), Harvard School of Public Health, Boston, Massachusetts; Institute of Sport Science and Clinical Biomechanics, Exercise Epidemiology Research Unit and Centre of Research in Childhood Health, University of Southern Denmark, Odense (Mr Grøntved and Dr Andersen); Channing Division of Network Medicine, Harvard Medical School and Brigham and Women’s Hospital, Boston (Drs Rimm, Willett, and Hu); and Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway (Dr Andersen).


Arch Intern Med. 2012;172(17):1-7. doi:10.1001/archinternmed.2012.3138.

Background  The role of weight training in the primary prevention of type 2 diabetes mellitus (T2DM) is largely unknown.

Methods  To examine the association of weight training with risk of T2DM in US men and to assess the influence of combining weight training and aerobic exercise, we performed a prospective cohort study of 32 002 men from the Health Professionals Follow-up Study observed from 1990 to 2008. Weekly time spent on weight training and aerobic exercise (including brisk walking, jogging, running, bicycling, swimming, tennis, squash, and calisthenics/rowing) was obtained from questionnaires at baseline and biennially during follow-up.

Results  During 508 332 person-years of follow-up (18 years), we documented 2278 new cases of T2DM. In multivariable-adjusted models, we observed a dose-response relationship between an increasing amount of time spent on weight training or aerobic exercise and lower risk of T2DM (< .001 for trend). Engaging in weight training or aerobic exercise for at least 150 minutes per week was independently associated with a lower risk of T2DM of 34% (95% CI, 7%-54%) and 52% (95% CI, 45%-58%), respectively. Men who engaged in aerobic exercise and weight training for at least 150 minutes per week had the greatest reduction in T2DM risk (59%; 95% CI, 39%-73%).

Conclusions  Weight training was associated with a significantly lower risk of T2DM, independent of aerobic exercise. Combined weight training and aerobic exercise conferred a greater benefit.

Figures in this Article

Regular physical activity (PA) is a cornerstone in the prevention and management of type 2 diabetes mellitus (T2DM). Achieving a daily amount of moderate or vigorous PA of at least 30 minutes per day is associated with a substantial reduction in the risk of T2DM.1 – 4 This is broadly consistent with the current recommendations regarding PA in adults.5 More recently, evidence from randomized controlled trials6 has shown that resistance training can improve glycemic control in patients with T2DM, even in the absence of aerobic training. This has led to the recommendation for resistance training 3 times per week in individuals with T2DM.7 – 8 However, whereas the evidence that regular aerobic exercise can prevent T2DM is compelling, to our knowledge, no studies have examined the role of weight training in the primary prevention of T2DM.

In this study, we examined the association of weight training with the risk of T2DM in men observed biennially for 18 years in the Health Professionals Follow-up Study (HPFS). In particular, we examined whether the influence of weight training is independent of aerobic exercise and assessed the combined influence of weight training and aerobic exercise on T2DM risk.

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Influenzae Vaccine 2012-2013

Thursday, September 27, 2012 // Uncategorized

Influenza Vaccine for 2012-2013

 It is the flu vaccine season.  Here’s the summary on this season’s flu vaccine from an independent source, The Medical Letter.

The Medical Letter on Drugs and Therapeutics • October 1, 2012 (Issue 1400) p. 77

Important Copyright Message: The Medical Letter® publications are protected by US and international copyright laws. Forwarding, copying or any distribution of this material is prohibited. Sharing a password with a non-subscriber or otherwise making the contents of this site available to third parties is strictly prohibited. By accessing and reading the attached content I agree to comply with US and international copyright law and these terms and conditions of The Medical Letter, Inc.

Annual vaccination against influenza A and B viruses is the most effective method of preventing influenza and has been shown to decrease influenza illness and its complications. A new vaccine is available for the current season. Chemoprophylaxis and treatment of influenza was discussed in an earlier issue.1

VACCINE COMPOSITION — This year’s seasonal trivalent influenza vaccine contains the following three strains: A/California/7/2009 H1N1-like (derived from the pandemic 2009 influenza virus), A/Victoria/361/2011 H3N2-like, and B/Wisconsin/1/2010-like. The H1N1 strain is the same as in last year’s vaccine. The H3N2 and B strains are new this year.2

LIVE VS. INACTIVATED VACCINE — FluMist, the intranasal live attenuated influenza vaccine (LAIV), is recommended for use only in healthy, non-pregnant persons 2-49 years old. In children, the LAIV appears to be more effective than the trivalent inactivated vaccine (TIV).3 In adults, the TIV has been more effective.4

WHO SHOULD BE VACCINATED — The US Advisory Committee on Immunization Practices (ACIP) recommends annual influenza vaccination for everyone ≥6 months old who does not have a specific contraindication, including pregnant women.5 Vaccination of pregnant women not only protects them against influenza-associated illness, but also protects their newborn infants for up to the first 6 months of life.6,7

TIMING — Serum antibodies reach maximal levels in most adults about 2 weeks after influenza vaccination and generally persist for at least 6-8 months. The vaccine should be offered as soon as it becomes available through the end of the influenza season in May.

EFFECTIVENESS — The effectiveness of the seasonal vaccine in preventing influenza in healthy adults depends on the match between the vaccine and circulating strains. Vaccine effectiveness is highest when the match is close, but even when the match is poor, vaccination has been shown to reduce the risk of death from influenza.8 In addition, vaccination of children and adolescents can protect unvaccinated residents of the same community.9

ADVERSE EFFECTS — TIV – Except for soreness at the injection site, adverse reactions to TIV are uncommon. In clinical trials, Fluzone High-Dose and Fluzone Intradermal have caused more injection-site reactions than standard TIV vaccines.

During the 2010 influenza season in Australia, a vaccine formulation identical to Afluria was associated with an increased risk of fever and febrile seizures in children 6 months-4 years old and an increased risk of fever in children 5-8 years old. Afluria is licensed in the US for use in children ≥5 years old, but the ACIP recommends that it be used only in patients ≥9 years old.5

Rarely, influenza vaccination has been associated with Guillain-Barré syndrome, but the absolute risk is very low, and influenza infection itself has been associated with Guillain-Barré syndrome.10

LAIV – Rapid influenza diagnostic tests may be falsely positive if used within a week after FluMist vaccination. The intranasal LAIV is generally well tolerated, but can cause a runny nose, nasal congestion and a sore throat. It is not recommended for use in children <2 years old. Children <5 years old with recurrent wheezing and patients of any age with asthma may be at increased risk of wheezing after receiving FluMist.

Vaccinees may shed the vaccine-strain virus for a few days after vaccination, but person-to-person transmission has been rare, and serious illness resulting from transmission has not been reported. Healthcare workers and family members should avoid close contact with severely immunocompromised patients in protected environments for 7 days after vaccination with the live vaccine.

PRECAUTIONS AND CONTRAINDICATIONS — A history of a severe allergic reaction to any influenza vaccine is a contraindication to vaccination. Since both the live and inactivated vaccines are made from virus grown in eggs, hypersensitivity reactions to egg protein could occur. Persons being vaccinated who report a history of having had only hives related to egg exposure should receive TIV rather than LAIV, and should be observed for 30 minutes following vaccine administration for signs of an allergic reaction. Persons with a history of a more severe reaction to eggs should be referred for allergy evaluation before vaccination.11

DOSAGE — A 0.5-mL IM dose of TIV is recommended for adults and children ≥3 years old; 0.25 mL IM is recommended for children 6-35 months old. FluMist is given as a 0.2-mL dose (0.1 mL in each nostril). Fluzone Intradermal is given intradermally as a 0.1-mL dose using the supplied microinjection system.

Children 6 months-8 years old being vaccinated for the first time should receive two doses of seasonal vaccine at least 4 weeks apart. Children 6 months-8 years old who received 2 or more doses of seasonal vaccine since July 1, 2010 need only one dose this year; all other previously vaccinated children <9 years old should receive two doses this year.5

CONCLUSION — Seasonal influenza vaccine is effective in preventing influenza and should be offered to everyone ≥6 months old who does not have a specific contraindication.

1. Antiviral drugs for influenza. Med Lett Drugs Ther 2012; 54:1.

2. CDC. Vaccine virus selection for the 2012-2013 influenza season. Available at Accessed September 16, 2012.

3. RB Belshe et al. Live attenuated versus inactivated influenza vaccine in infants and young children. N Engl J Med 2007; 356:685.

4. AS Monto et al. Comparative efficacy of inactivated and live attenuated influenza vaccines. N Engl J Med 2009; 361:1260.

5. CDC. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP) – United States, 2012-13 influenza season. MMWR 2012; 61:613.

6. K Zaman et al. Effectiveness of maternal influenza immunization in mothers and infants. N Engl J Med 2008; 359:1555.

7. AA Eick et al. Maternal influenza vaccination and effect on influenza virus infection in young infants. Arch Pediatr Adolesc Med 2011; 165:104.

8. KL Nichol et al. Effectiveness of influenza vaccine in the community-dwelling elderly. N Engl J Med 2007; 357:1373.

9. M Loeb et al. Effect of influenza vaccination of children on infection rates in Hutterite communities: a randomized trial. JAMA 2010; 303:943.

10. P Haber et al. Vaccines and Guillain-Barré syndrome. Drug Saf 2009; 32:309.

11. MJ Greenhawt et al. Administering influenza vaccine to egg allergic recipients: a focused practice parameter update. Ann Allergy Asthma

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Finding the Best Doctor for you

Wednesday, September 26, 2012 // Uncategorized

This is an article that was sent to me by a friend and patient.  There are some interesting ideas in it that highlight some of the new ways that primary care is being delivered  This is from The Wall Street Journal. 

September 24, 2012

Finding the Best Doctor for You


Sarah Morse recently sought out a new physician after moving to Annapolis, Md., to take a job as a college admissions official. She opted for a large medical practice that offers extended walk-in hours, email access and an online portal where she can make appointments, request prescription refills and get test results.

Ms. Morse’s previous doctor, a traditional solo practitioner in Baltimore, had no such amenities.

What should you look for in picking a primary-care doctor? The industry expects some movement among patients and doctors due to full implementation of the federal health overhaul. Anna Mathews has details on Lunch Break. Photo: Getty Images.

“In this day and age, people need to provide those kinds of services,” says Ms. Morse, 57 years old. She recently made use of the extended hours after coming down with a sudden case of poison ivy that needed treatment first thing in the morning.

Things are changing at the doctor’s office, giving people who need to find a new family doctor more options to choose from—and some things to watch out for.

A growing number of primary-care physicians, who traditionally provided basic checkups and treatment for everyday medical problems, are aiming to take on a more ambitious role overseeing all aspects of their patients’ health. Many are giving up self-employment and are going to work for big hospital systems, which might push up certain costs for patients. Other doctors are opting out of insurance-payment systems and asking patients to pay them directly, sometimes through monthly fees. And primary-care practices can increasingly be found in some nontraditional settings, including clinics in the workplace set up by employers.

Choosing a new doctor can be confusing, and many people rely on recommendations from friends or co-workers. Among other reasons, people may seek out new physicians if they move to a new city, or if their doctors relocate or stop accepting their insurance. Experts say it is increasingly important for patients to lock in a primary-care doctor soon because of expected increased demand for physicians starting in 2014, when the new federal health-overhaul law will add millions of people to the health-insurance rolls.

Primary-care practices that coordinate automatically with specialists, track patients to ensure they get the right tests and generally oversee patients’ broad health needs are commonly known as medical homes. Nonphysicians are taking on a greater role in this team-based approach, so patients should make sure they feel comfortable with a practice’s nurses and physician assistants. The number of medical-home practices is growing, according to the nonprofit National Committee for Quality Assurance, the biggest certifier of medical homes. The group recognized about 4,770 medical homes nationwide as of August, up from about 1,500 at the end of 2010.

Ted Davidson, who lives in Washington, D.C., recently found a primary-care practice on the recommendation of a physician acquaintance. The 25-year-old likes how his new doctor has his medical information on a digital tablet during visits. After Mr. Davidson was recently referred to a cardiologist because of some incidents of dizziness, his primary-care doctor at his next visit had the specialist’s notes and test results available electronically. “Having someone there to guide me through the whole process was so much more reassuring than doing it all myself,” says Mr. Davidson, who works at a business-valuation firm.

[image] Kyle T. Webster

Choosing Wisely

Choosing Wisely

Here are five things to consider in selecting a primary-care doctor.

1. Does the physician make you feel comfortable and listen to your concerns and opinions?

2. Does the office seem to function smoothly? How easy is it to get an appointment or get care outside regular office hours?

3. Does the practice track your care and alert you to gaps?

4. Do specialists’ results automatically get sent back to your doctor and discussed with you?

5. Does the practice accept your insurance, or charge you directly? Will it help you keep costs down when possible?

Source: WSJ reporting

Some doctors say they can’t offer patients the best care under the current insurance-payment structure. This typically provides fees for visits but not always other services, such as drawing up a care plan for a person recently discharged from a hospital. As a result, some doctors are refusing to accept insurance, and are requiring patients to pay them directly. For instance, at Qliance Medical Management Inc., which doesn’t take part in traditional insurer networks, patients typically pay between $49 and $89 a month for care at the health provider’s five clinics in Washington state, says Erika Bliss, Qliance’s chief executive.

David Usher, a doctor in Menomonie, Wis., recently left the Mayo Clinic to start his own solo direct-pay practice. He now offers his patients longer visits, typically 30 minutes or more, for a charge of $55, he says. The prices of other services are posted in his waiting room and online. “Patients like the extra time, as do I,” he says.

Some practices cater exclusively to the well-heeled. So-called concierge physicians may offer house calls, constant cellphone access and personalized assistance navigating the health-care bureaucracy. Patients may pay a yearly fee of $1,500 to $5,000, and even as much as $20,000 or more, for these extras, in addition to the fees their insurers pay the doctors for treatment, says Tom Blue, executive director of the American Academy of Private Physicians, which represents direct-pay and concierge doctors. His group estimates there are 4,400 direct-pay and concierge practices, up about 25% from last year.

Hospitals  increasingly are hiring doctors and doctors and buying up practices. For patients, this can bring benefits, since hospitals often are better able to invest in technology such as electronic medical records. The hospital systems also may foster greater integration between primary care, specialists and hospitals own operations. But physicians employed by hospitals may be more likely to refer patients to hospital imaging departments and labs, where services are often more expensive than at independent facilities.

A growing number of employers are launching workplace clinics, aiming to reduce health-care costs, improve their workers’ health and offer convenient care that may reduce time away from work.

Oerlikon Fairfield, a Lafayette, Ind., maker of gears, hired a medical-management company called WeCare TLC LLC to set up a clinic at its factory in 2010. It includes three exam rooms and a small pharmacy, and has a doctor and a nurse practitioner on duty full-time. The manufacturer, which has about 1,225 employees, says patient visits at the clinic cost about half the amount Oerlikon Fairfield pays when its workers go to doctors at local practices and hospital systems that have contracts with its insurance carrier, says Jane Wolfe, the company’s employee benefits manager. The clinic also promotes preventive-care efforts such as a weight-loss program.

Some workers initially had privacy concerns about seeing a doctor at work, Ms. Wolfe says. Now, the clinic is usually booked up and recently added more hours and a physical therapist, she says.

Write to Anna Wilde Mathews at [email protected]

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Fall Newsletter 2012

Sunday, September 23, 2012 // Uncategorized

Fall Newsletter 2012

 West Nile is on the wane.  It’s been the topic of a couple of recent blog posts. Now it is time to concentrate on a more common, more easily preventable seasonal viral illness.   The CDC’s caption below is a little misleading.  It’s flu vaccine season.

Our vaccine has arrived and we have  started scheduling appointments for flu shots .  We like to have an appointment so that wait time is minimized and we don’t have everyone arrive at once.  For those who already have a routine fall appointment, we will give it then.   Vaccine is plentiful and the manufacturers are employing different marketing strategies to sell more vaccine.  We have not signed on for the higher dose vaccine for older patients.  While it may result in higher antibody levels, that has not been shown to reduce the risk of getting the flu.  Likewise, the intradermal vaccine is approved for 18-64 year olds is not a more effective vaccine.  We’ve chosen to stick with what has been proven to work. The intranasal form can be taken by those 49 and under.  It is actually a little less effective than the traditional injection and has a higher incidence of side effects.  But, it doesn’t involve a needle.  Trying to utilize multiple vaccines for patients in different age groups in physician’s offices also causes logistical challenges.

Flu Season Is Here- Vaccinate to Protect You and Your Loved Ones from Flu

Everyone 6 months and older should get an annual flu vaccine. It takes about 2 weeks after vaccination for your body to develop an immune response. Get vaccinated now so you’ll be protected all season long!

Now that kids are back in school, we are reminded of many things typical of this time of year—parent-teacher meetings, sporting events and extracurricular activities. This time of year should also serve as an important reminder that flu season is just around the corner. By getting a flu vaccine for yourself and your entire family every year, you can help prevent flu-related illness, missed school, and missed work.

Influenza (flu) is a contagious respiratory disease that infects the nose, throat, and lungs and can lead to serious complications, hospitalization, or even death. Pneumonia and bronchitis are examples of serious flu-related complications. The flu also can cause certain health conditions, like diabetes, asthma, and heart and lung disease, to become worse. Anyone can get sick from the flu and spread it to friends and loved ones—even if you consider yourself to be healthy. Getting a flu vaccine is the single best way to protect yourself and your family from this serious disease.

Everyone Needs a Flu Vaccine


While flu activity usually peaks in January or February, the flu itself is unpredictable. And although there are many different flu viruses, the yearly flu vaccine protects against the three viruses that research suggests will be most common that flu season.

Everyone 6 months and older should get a flu vaccine each year, especially if you are at high risk for complications or you live with or care for someone who is, including the following groups:

  • Pregnant women
  • Children younger than 5, but especially children younger than 2 years old
  • People 50 years of age and older
  • People of any age with certain chronic medical conditions
  • People who live in nursing homes and other long-term care facilities
  • People who live with or care for those at high risk for complications from flu, including:
    • Health care workers
    • Household contacts of persons at high risk for complications from the flu
    • Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated)

For a complete list of all people recommended for flu vaccination, as well as those who are not recommended for flu vaccination, visit Who Should Get Vaccinated.

Get a Flu Vaccine Every Flu Season

You should get vaccinated every year for two reasons. The first reason is that because flu viruses are constantly changing, flu vaccines may be updated from one season to the next to protect against the most recent and most commonly circulating viruses. The second reason is that a person’s immune protection from vaccination declines over time so annual vaccination is needed for optimal protection. So, yearly vaccination is recommended even for those who received the vaccine during the previous flu season.

A Reminder for Parents

Many children need two doses of flu vaccine this season to be fully protected. Some children 6 months through 8 years of age who are getting vaccinated for the first time will need two doses. Some children in this age group who have received a flu vaccine in prior seasons will also need two doses. Your child’s health care provider can tell you whether two doses are recommended for your child.

The 2009 H1N1 virus continues to circulate. It wasn’t added to the seasonal vaccine until the 2010-2011 flu season. This means that children who did not get the 2009 H1N1 vaccine in 2009-2010, or a seasonal flu vaccine in 2010-2011 or later, will not be fully protected from the 2009 H1N1 virus until they receive 2 doses of the 2012-2013 flu vaccine.

Everyone 9 years of age and older needs only one dose of 2012-2013 flu vaccine.

Vaccine Options

So what are your vaccine options? There are two types of vaccines- the flu shot and the nasal spray.

The viruses in the flu shot are killed, and the viruses in the nasal spray vaccine are weakened, so neither vaccine can cause the flu. A flu shot can have mild side effects, such as soreness or swelling where the vaccine was received, a mild fever, or aches. Mild side effects of the nasal spray can include runny nose, headache, sore throat, and cough. Any side effects you experience are not contagious to others and should disappear within 2 days.

The flu vaccine is safe. People have been receiving flu vaccines for more than 50 years. Vaccine safety is closely monitored annually by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). Hundreds of millions of flu vaccines have been given safely to people across the country for decades.


Pertussis is in the news lately.  The respiratory illness has been increasing due to the reduced effectiveness of the vaccine in current use. N Engl J Med 2012 Sep 13; 367:1012. (  Whooping cough vaccine had been recommended for older adults who will be in close contact with children under a year of age.  However, it appears that now the recommendation is for all older adults to receive the vaccine.  Unfortunately, Medicare will not pay for the vaccine unless it is accompanied by a diagnosis of wound management.  This puts us in the uncomfortable  position of being encouraged to use an incorrect diagnosis in order to have it covered by insurance.


Here are the present recommendations from the Advisory Committee for Immunization Practices:

Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis (Tdap) Vaccine in Adults Aged 65 Years and Older — Advisory Committee on Immunization Practices (ACIP), 2012


June 29, 2012 / 61(25);468-470

Since 2005, the Advisory Committee on Immunization Practices (ACIP) has recommended a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine booster dose for all adolescents aged 11 through 18 years (preferred at 11 through 12 years) and for those adults aged 19 through 64 years who have not yet received a dose (1,2). In October 2010, despite the lack of an approved Tdap vaccine for adults aged 65 years and older, ACIP recommended that unvaccinated adults aged 65 years and older be vaccinated with Tdap if in close contact with an infant, and that other adults aged 65 years and older may receive Tdap (3). In July 2011, the Food and Drug Administration (FDA) approved expanding the age indication for Boostrix (GlaxoSmithKline Biologicals, Rixensart, Belgium) to aged 65 years and older (4). In February 2012, ACIP recommended Tdap for all adults aged 65 years and older. This recommendation supersedes previous Tdap recommendations regarding adults aged 65 years and older.




Communication Update:

Our new patient portal should become functional this week.  It will allow you to log on to a secure portal and access critical parts of your medical records and current lab results.  If you wish to utilize it, send me an email and I will send you a super PIN number.  You will get an email from CGM Life eServices with instructions of how to log on using your PIN.   In the near future you will also be able to use this website for secure messaging.  Email can be used in the meantime for communication, but it is not secure and information in it should be kept general.

[email protected] is my personal email address.



Shingles or herpes zoster is a sometimes painful rash that is caused by a reawakening of the chicken pox virus which has been dormant for years.  While the rash is temporary, it can result in chronic inflammation of the nerve called postherpetic neuralgia.  The risk of shingles and its sometime sequelae can be reduced by a vaccine, Zostavax.

Update on Herpes Zoster Vaccine: Licensure for Persons Aged 50 Through 59 Years

MMWR Weekly

November 11, 2011 / 60(44);1528-1528

Herpes zoster vaccine (Zostavax, Merck & Co., Inc.) was licensed and recommended in 2006 for prevention of herpes zoster among adults aged 60 years and older (1). In March 2011, the Food and Drug Administration (FDA) approved the use of Zostavax in adults aged 50 through 59 years (2). In June 2011, the Advisory Committee on Immunization Practices (ACIP) declined to recommend the vaccine for adults aged 50 through 59 years and reaffirmed its current recommendation that herpes zoster vaccine be routinely recommended for adults aged 60 years and older.

FDA approved the expanded indication for Zostavax in March 2011, based on a study of approximately 22,000 adults aged 50 through 59 years in the United States and four other countries. Half the study subjects received Zostavax, and half received a placebo. Study participants were then monitored for at least 1 year for the development of herpes zoster. Compared with placebo, Zostavax reduced the risk for developing herpes zoster by 69.8% (95% confidence interval = 54.1–80.6) (3).

At the February and June 2011 ACIP meetings, published and unpublished data were presented relating to the epidemiology of herpes zoster and its complications, and regarding herpes zoster vaccine safety, effectiveness, long-term protection, cost-effectiveness, and supply. Limited data are available on long-term protection afforded by herpes zoster vaccine administered to adults aged 60 years and older and those aged 50 through 59 years.

Merck is the only U.S. supplier of varicella zoster virus (VZV)-containing vaccines (Zostavax, varicella vaccine [Varivax], and combined measles, mumps, rubella and varicella vaccine [MMR-V, ProQuad]). Beginning in 2007, Merck has experienced production shortfalls of the bulk product used to manufacture VZV-based vaccines (4,5), leading to prioritized production of Varivax over Zostavax since 2008. As a result, filling of Zostavax orders has been delayed intermittently.

Considering all available evidence and the supply issues, ACIP declined to recommend the use of herpes zoster vaccine among adults aged 50 through 59 years and reaffirmed its existing recommendation that herpes zoster vaccine be routinely recommended for adults aged 60 years and older (1). ACIP will continue to monitor supply issues and might update recommendations regarding vaccination of adults aged 50 through 59 years when an adequate and stable supply of the vaccine is assured. Planned improvements by Merck in its production processes and the addition of new manufacturing facilities are expected to increase the supply of the vaccine during the next several years.

With the FDA approval, Zostavax is available in the United States for indicated use among adults aged 50 years and older. Contraindications to the use of Zostavax remain unchanged. Zostavax should not be given to pregnant women, persons with a primary or acquired immunodeficiency, or to persons with a history of anaphylactic reaction to gelatin, neomycin, or any other component of the vaccine. Herpes zoster vaccine can be administered simultaneously with other indicated vaccines (1,6).

For vaccination providers who choose to use Zostavax among certain patients aged 50 through 59 years despite the absence of an ACIP recommendation, factors that might be considered include particularly poor anticipated tolerance of herpes zoster or postherpetic neuralgia symptoms (e.g., attributable to preexisting chronic pain, severe depression, or other comorbid conditions; inability to tolerate treatment medications because of hypersensitivity or interactions with other chronic medications; and occupational considerations). No data are available regarding the effectiveness of herpes zoster vaccine in adults who become immunosuppressed subsequent to vaccination. Questions regarding the supply of these Merck products should be addressed to Merck’s Vaccine Customer Center by telephone (877-829-6372).



I can attest to the fact that it is not 100% effective.  I took the vaccine a year ago when it became apparent that shingles was on the rise.  This was based on my experience as well as national data.  Last week I notice an intensely itchy patch on the back of the leg which I knew could not be the result of a squadron of kamikaze mosquitoes.  I didn’t even have to take my trousers off to know the cause.  Fortunately, there was no pain and I elected not to take any antiviral medication.  There are a number of approved antiviral  drugs which  may help to reduce the risk of postherpetic neuralgia if taken within 72 hours of developing a rash.

Since no pain was involved, it didn’t seem to make sense to take a weeks’ worth of medication to prevent that problem when my symptoms were minimal.




An Apple A Day…by Kerry Green, Registered Dietitian

Fall is here… And so are the apples! Did you know there are over 600 different varieties of apples? Apples have been grown for thousands of years in Asia and Europe, and were brought to North America by European colonists. Apples have been present in the mythology and religions of many cultures, including Norse, Greek and Christian traditions. We typically choose the same types of apples every time we grocery shop.  But I encourage you to look through this list and pick a new one to try and experience different flavors these ancient fruits can provide.

Apples varieties similar to: Golden Delicious.  Gala is probably the most well-known of its offspring.  Some other apple varieties which are quite similar are:

  • Elstar – similar but with more depth of flavor
  • Freyberg – very similar
  • Gala – a major supermarket variety and with a bit more flavor than Golden Delicious, still very sweet
  • Jonagold – slightly sharper
  • Scrumptious – more complex flavors but still sweet
  • Sonya – even sweeter than Golden Delicious and in many ways a much nicer apple

Apples varieties similar to: McIntosh / Empire

McIntosh was widely grown in North America but has proved more successful as the parent of a number of newer apple varieties of which Spartan is perhaps the most well-known. Apples of this type are always popular with children.  Some other apple varieties which are quite similar are Empire and Spartan. Although Empire keeps well, these varieties are at their best when eaten as fresh as possible. Their refreshing flavor is enhanced by eating them straight from the fridge.

Apples varieties similar to: Braeburn

Braeburn is undoubtedly one of the most successful commercial apple varieties. It keeps well in storage and it is also a well-flavored crisp juicy apple which will appeal to almost anyone. Some other apple varieties which are quite similar are:

If you are shopping for apples in North America or Europe, check the country of origin to make sure you are buying the freshest possible apples:

In Spring buy apples from Australia, New Zealand, Brazil, Chile, South Africa

In Autumn buy apples from: USA, Canada, England, France, Italy, Austria, Netherlands

Excerpts taken from: and



My new volunteer job is that I have been asked to be head of the Department of Medicine and Family Practice and Metropolitan Methodist Hospital which is coping with growing pains since the sudden closure Santa Rosa Hospital.

I will be attending the annual meeting of the Texas Club of Internists (

 from October 13th through the 18th.  It’s one of the two continuing medical education courses that I take annually.  Between the courses and online CME, I get over 100 hours of CME a year.

The office will be open during regular hours during that time and I expect that they will be giving quite a few flu shots in addition to answering calls.

Best wishes to Dr. Andy Diehl, O. Roger Hollan Professor of Medicine, friend, colleague and patient who is retiring from his position of Chief of the Division of General Internal Medicine at the UTHSC at San Antonio, a position that he has held for 31 years.

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The Emergence of West Nile Virus: Online First from theAnnals of Internal Medicine

Tuesday, September 11, 2012 // Uncategorized

Note:  It doesn’t mention the status of the vaccine.

The Resurgence of West Nile Virus FREE ONLINE FIRST

Catherine M. Brown, DVM, MSc, MPH; and Alfred DeMaria, MD

Ann Intern Med. 11 September 2012
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Over the past several decades, public health officials have worked to alert the public to the threat of emerging infections, and the idea has captured the imagination of the American public; consider The Andromeda Strain, Outbreak, and Contagion. However, these theatrical portrayals—in which a scary, mysterious disease emerges but is investigated and controlled by the time the credits roll—fail to reveal the true drama, the ecological complexity of the world where real and deadly diseases occur. Over the years, public health professionals and the public alike have gotten excited about such pathogens as hantavirus, H5N1 avian influenza, the severe acute respiratory syndrome (SARS), monkeypox, and West Nile virus (WNV). Whereas H5N1, SARS, and monkeypox are only vague memories for most Americans because the ecosystem that fostered disease transmission exists overseas and not in our own backyards, WNV and hantavirus are different. While the public and professionals may have become somewhat complacent about both diseases, 2012 is reminding us that perhaps we shouldn’t have.

West Nile virus has become endemic in North America. It is here to stay because we have the right combination of birds and mosquitoes. But this very endemicity has been driving complacency. After all, up to 80% of infected persons have few or no symptoms. However, WNV still causes life-threatening encephalitis and meningoencephalitis in some patients, and we are learning more about long-term sequelae (1), including flaccid paralysis (2). Although no vaccine or effective treatment is available, clinicians must maintain clinical suspicion of infection under the right circumstances of season and mosquito exposure to arrive at the correct diagnosis in a presenting patient. In addition, WNV remains a significant concern for blood collection organizations and transfusion services, requiring screening of donors, either individually or in pooled samples, on the basis of virus activity indicators.

Cases of WNV infection in 2012 in the United States have already exceeded that of any other year—with 1590 cases, 65 deaths, and 303 viremic blood donors as of 28 August 2012 (3)—including the earliest years after the introduction of WNV in 1999 when the U.S. population, both bird and human, was immunologically naive to the virus. The problem this year is so dramatic that cities, such as Dallas (4), have resorted to aerial pesticide application to kill adult mosquitoes (adulticiding) for the first time in 45 years. Texas, South Dakota, Mississippi, Oklahoma, Louisiana, and Michigan have been particularly hard hit. Could this be a new strain of the virus, a reintroduction, or a mutation? Is a long-term temporal cycle of WNV infection emerging? Or, and perhaps most likely, is this year’s experience related to unusual weather patterns? Temperature does have a role in WNV amplification.

This year we have been hearing from local health departments, wildlife rehabilitators, and other observers about an increase in dead bird sightings compared with recent years, which is similar to what had been seen earlier in the WNV experience. This might suggest a new WNV strain, either by natural selection or introduction. A new strain could also account for a change in human epidemiology. Alternatively, the reservoir of infection in birds might be substantial—some species experienced considerable mortality when the virus first arrived, but studies indicate that most populations have at least stabilized, if not recovered (5). But we cannot discount the possibility of increased numbers of the Culex species of mosquitoes that are the prime vectors. C. pipiens, C. restuans, and C. tarsalis are abundant and ubiquitous puddle- and container-breeding mosquitoes broadly distributed geographically in overlapping ranges in urban, suburban, and rural settings. These mosquitoes thrive and reproduce in stagnant, dirty, putrid collections of water in puddles and containers, sewers, storm drains, and catch basins, all of which are part of our residential infrastructure. The drought that has gripped much of the country this year has caused contraction of water sources, creating excellent breeding conditions for these mosquitoes. The record-breaking heat is known to speed up both the reproductive rate of mosquitoes and the rate of virus development within them (6). The interplay of heat, drought, human habitats, increased mosquito populations, and enhanced viral development all act in concert to increase the force of transmission. At least, that’s the theory. The truth of what lies behind the resurgence of WNV activity this year will take time to uncover.

A frequently cited publication states that three quarters of emerging infections are zoonotic, that is, shared in nature by humans and animals (7). West Nile virus is first and foremost a bird virus. But it is spread within the avian reservoir by mosquitoes. And humans live in the same ecosystem as both birds and mosquitoes. So, to truly understand WNV and its manifestations, including the causes of increased incidence, we need to understand the virus and its cycle in nature, including the reservoir and the vector, and how the human-built environment contributes. Similar questions about hantavirus may eventually help explain the concerns about that disease that have also arisen this year (8). This integration of environmental science and veterinary medicine with human medicine is the essence of the One Health initiative (, an international effort toward inclusive collaboration across disciplines. Fully understanding a disease like WNV, with its strong environmental component, will require work on all 3 fronts.

In the meantime, mosquito-prevention messages must be unrelenting, directed at personal protective behaviors (avoidance, repellents, and clothing) and reduction of breeding sites. The public must be constantly prodded, with a balance of sensible precautions and serious awareness of the possibility for severe disease. Reduction of mosquitoes requires an integrated pest-management approach, and we must come to grips with the sometimes controversial issue of pesticide application to kill adult mosquitoes, when benefit outweighs risk, and objectively determine efficacy under various conditions. For the long term, perhaps modifying the way we create our own environment will be an important part of reducing the impact of the disease.


Klee AL, Maidin B, Edwin B, Poshni I, Mostashari F, Fine A, et al.  Long-term prognosis for clinical West Nile virus infection. Emerg Infect Dis. 2004;10:1405-11. [PMID: 15496241]
Jeha LE, Sila CA, Lederman RJ, Prayson RA, Isada CM, Gordon SM.  West Nile virus infection: a new acute paralytic illness. Neurology. 2003;61:55-9. [PMID: 12847156]
Centers for Disease Control and Prevention.  West Nile virus. Accessed at on 4 September 2012.
Kuta S.  West Nile virus: Dallas, Texas attack plan includes aerial insecticide spray assault. Huffington Post. 16 August 2012. Accessed at on 5 September 2012.
Foppa IM, Beard RH, Mendenhall IH.  The impact of West Nile virus on the abundance of selected North American birds. BMC Vet Res. 2011;7:43. [PMID: 21831324]
Brault AC.  Changing patterns of West Nile virus transmission: altered vector competence and host susceptibility. Vet Res. 2009;40:43. [PMID: 19406093]
Taylor LH, Latham SM, Woolhouse ME.  Risk factors for human disease emergence. Philos Trans R Soc Lond B Biol Sci. 2001;356:983-9. [PMID: 11516376]
Centers for Disease Control and Prevention.  Hantavirus: August 2012—Yosemite National Park outbreak notice. Updated 29 August 2012. Accessed at on 5 September 2012.

This article was published at on 11 September 2012.

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Does Yellow Fever Vaccine Protect Against West Nile Virus?

Thursday, September 6, 2012 // Uncategorized

West Nile Virus is in the news a lot these days:


West Nile Virus Cases Up 25% in Past Week


Nearly 2000 human cases of West Nile virus have been reported to the CDC so far this year, representing an increase of about 25% in the past week, the agency reports in its weekly update. Nearly 90 people have died from the disease in 2012.


There is currently no commercially available vaccine against the virus for humans, although one is available for animals (horses and geese).  Since West Nile Virus and Yellow Fever virus belong to the same family, Flaviviruses, there was interest several years ago as to whether being vaccinated against Yellow Fever virus protected against West Nile virus.  the answer seems to be no.

West Nile virus infection and serologic response among persons previously vaccinated against yellow fever and Japanese encephalitis viruses.


Division of Vector-Borne Infectious Diseases (DVBID), National Center for Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado 80521, USA. [email protected]


It is hypothesized that previous heterologous flaviviral exposure may modulate clinical illness among persons infected with West Nile virus (WNV). Little is known about the serological response in such persons. In summer 2003, a WNV outbreak occurred in Colorado, the location of the Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases (DVBID). DVBID employees, most previously vaccinated with yellow fever virus (YFV) or Japanese encephalitis virus (JEV) vaccines, were studied to determine whether previous vaccination affected symptom development among those subsequently infected with WNV during the outbreak, as well as their serological response. Serum samples collected in December 2003 and previously banked samples were tested using the plaque reduction neutralization test (PRNT) against WNV, Saint Louis encephalitis virus, dengue- 4 virus, JEV, and YFV. Specimens shown to have WNV antibody by PRNT were tested by IgM and IgG enzymelinked immunosorbent assays (ELISAs). Ten (9%) of 113 serosurvey participants had WNV neutralizing antibody titers in December 2003. PRNT titers from previous specimens showed that one of the ten had seroconverted to WNV before 2003. Of the remaining nine participants, seven reported illness in the summer of 2003, two of which were unvaccinated and five previously vaccinated. In the December 2003 specimens, five persons previously unvaccinated or vaccinated only against YFV had a fourfold or greater neutralizing titer with WNV than with other flaviviruses, whereas no persons previously vaccinated against JEV or JEV and YFV showed a similar difference in neutralizing titers. Eight of nine persons infected in 2003 had negative or indeterminate WNV MAC-ELISA results in the December 2003 sample; the ninth person was vaccinated against YFV one month previously, and was also YFV positive by MAC-ELISA. We conclude that previous flaviviral vaccination does not markedly affect the development of WNV fever and that the IgM antibody response in patients without neuroinvasive WNV disease is transient.

[PubMed – indexed for MEDLINE]
 There is no more recent information available, but human vaccines are being tested.  Whether they will be effective and whether the economics of a new vaccine development will make it feasible remains to be seen. 



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