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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