San Antonio Express-News (Sunday)
What if the second shot of shingles vaccine is delayed?
Q: Three years ago, I turned 60 and received my first dose of Shingrix. I had a highly unpleasant reaction, with fever and flu-like symptoms. I did not return for the second dose until last week, so although I have had two doses, they are three years apart. Do I need to get another dose in a short window of my most recent vaccination, or will I be considered protected since I have had two doses, just significantly spaced apart? By the way, no reaction this round other than a sore arm!
A: The new two-dose shingles subunit vaccine (Shingrix) is a highly effective treatment to prevent shingles and its complications. It is recommended you get the second dose two to six months after the first dose. According to the Centers for Disease Control and Prevention:
“The vaccine series need not be restarted if more than 6 months have elapsed since the first dose; however, the efficacy of alternative dosing regimens has not been evaluated, data regarding the safety of alternative regimens are limited, and individuals might remain at risk for herpes zoster during a longer than recommended interval between doses 1 and 2.”
Despite that somewhat reassuring statement, three years seems to be pushing it to me, and I would really consider getting a third dose two to six months after the dose you just took. You may (or may not) have a reaction, but you would be surer about having protection against shingles.
Q: I had my thyroid removed in 2004 due to papillary carcinoma. I see an ear, nose and throat doctor once a year, at which time I have an ultrasound of my neck area. My primary care physician orders blood tests every three months to primarily determine if my levothyroxine dosage is correct. Please advise which thyroidrelated blood tests you would recommend to appropriately monitor my level of medication. My ENT told me that an incorrect dosage may result in heart issues.
A: Measuring the thyroid hormone itself, levothyroxine, and thyroid-stimulating hormone, made in the pituitary, are adequate to monitor the thyroid level in most people. There is a
fairly broad range of these hormones, but when both are in the normal range, that’s usually a good place to be. If the thyroxine level is low, the body responds by increasing the TSH level. If thyroxine is high, the TSH level goes way down. It’s when thyroxine is high that the heart can be damaged, particularly by the development of atrial fibrillation.
In most people with a history of thyroid cancer, experts recommend a thyroxine level just on the high side of normal. That means the TSH level will be low-normal, which is desired because some cancer cells can be stimulated by high levels of TSH. In patients with a higher risk of cancer recurrence, the TSH level may need to be suppressed even below the lower limit of normal.
Frequent checks of the thyroid are appropriate to be sure your thyroid levels are not so high that you are at increased risk for developing the heart problems of excess thyroid levels. Other health issues also may occur, such as bone loss. It’s a delicate balancing act between reducing cancer recurrence risk but not damaging the rest of the body.
Q: I read your recent column regarding asymptomatic atrial fibrillation. How does this differ from having a heart murmur? I have had a murmur for about 25 years, though it was not fully diagnosed until three years ago during an unrelated emergency room visit. Until recently, the murmurs
were getting worse. Other than limiting my intake of caffeine, is there anything I can do?
A: Atrial fibrillation is an abnormal heart rhythm, an electrical disturbance of the heart. A murmur is a mechanical issue.
A heart murmur is a sound that’s heard by the examiner, most commonly of blood flowing through one of the heart valves. Often, the murmur is not due to any problem: In a thin person, blood can sometimes be heard through a normal valve. Other times, a heart murmur may be the sign of a damaged valve. Either the valve isn’t opening all the way, called stenosis, or the valve fails to close properly and the blood flows the wrong way across the valve, called incompetence, insufficiency or regurgitation. Rarely, a murmur can be heard through a structure that
should no longer be open, such as a patent ductus arteriosus — necessary in fetal life to allow oxygenated blood from the placenta to flow into the developing fetal body.
Many times, a correct diagnosis of the underlying cause of a heart murmur can be made by examination. Other times, further evaluation is warranted. An echocardiogram uses sound waves to take pictures of the heart and measure the direction and velocity of flow. Severely diseased valves, from stenosis or incompetence, eventually may need valve replacement.
Most heart murmurs do not require treatment and shouldn’t make you worried. Your regular doctor or cardiologist should be able to tell you whether yours is the kind that needs to watched or if you can ignore it. Caffeine
intake is not a problem for people with heart murmurs.
Physicians hear heart murmurs so often that we can forget that the term can be concerning to people who are just hearing they have one and suspect it means a serious heart problem, which it usually does not.
Q: To listen to the heart or lungs, some practitioners place the stethoscope on the patient’s skin; others place it on the outside of the patient’s clothing. I would appreciate your comments on how the two techniques compare.
A: Directly on the patient’s skin allows for the best sound transmission. When listening to a very soft heart murmur, having a quiet room and the patient’s chest completely exposed is necessary.
However, a thin garment, such as a T-shirt or a hospital gown, doesn’t create a large loss of sound. Thicker garments make listening to the chest considerably less effective, so an examiner may only be able to hear very significant abnormalities.
I teach my students to have a patient disrobe entirely. Sometimes, physicians take shortcuts for the sake of time, but it does come at a cost of accuracy.