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SIGN Vol 20, Issue 5 Sept/Oct 2013

President's Message: A Leader Says Thank You
By Amy Cotton MSN, GNP-BC, FNGNA, FAAN

I am grateful.  How quickly the last two years have flown by.  As I think about the highlights of my NGNA Presidency, I am struck how much you, NGNA members, have influenced, encouraged and inspired me and I want to say “Thank You.” 
 
We have accomplished so much.  Strengthening partnerships, developing new collaborations and creating new member resources as a result of these relationships just to name a few.  Your Board leaders have boldly forged ahead with implementing strategies to support our mission, to improve nursing care for older adults.
 
I am excited as Mary Rita Hurley assumes NGNA’s presidency in October at our 2013 Annual Convention.  As the Executive Director for the Oregon Center for Nursing, she brings to NGNA  leadership expertise, expert knowledge of gerontological nursing and older adult health issues, strong skills in partnership cultivation as well as a genuine passion to improve nursing care for older adults.  With her leadership, and our outstanding Board of Directors and national office team, we are in good hands. 
 
It has been a privilege and honor to serve you.  I encourage each of you to continue to influence and improve older adult nursing care in whatever roles you have the opportunity to do so.  I shared with you my credo in an early President's message:  To value aging is to improve lives, not just the lives of older adults but their loved ones and those who work passionately to care for them.  
 
You have all improved my life and I thank you for the phenomenal work you do in gerontological nursing. I'll miss talking to you every few months.  Be good to yourselves and your nursing colleagues.  See you at convention!
 
Warmest regards and blessings to you,
 
     

 NGNA Convention Update

Submitted by Marilyn Daly Newton, RN, BC, CRRN, FNGNA, Co-Chair 2013 Convention
 
Clearwater, Florida
October 3-5, 2013
Hilton Clearwater Beach

Our time to celebrate is almost here!  The convention is planned, speakers and presenters have been chosen and by now, you should have all received your invitation to attend our 2013 convention!

A Clear Vision of Care for the Older Adult is a reality! Our presenters and speakers are from a wide variety of backgrounds in gerontological nursing.  The Concurrent Sessions on Friday, Oct 4th and Saturday, Oct 5th have so much knowledge to offer.   All the sessions are presented by nurses!  The research concurrent sessions are always interesting, featuring a variety of research projects presented by nurses. All the sessions guarantee to meet all nurses’ expectations.

Our Poster Presentation again will allow you to view the research and implementation of your fellow nurses’ work in their perspective fields.  The posters and their presenters will be available throughout most of the convention.   Students have an important role in our organization and this gives them the opportunity to perhaps present for the first time.  To view all the posters and meet the authors please check the hours in your brochure.  It’s amazing to see what is going on in our world of gerontology!

The 2013 Highlights of the Convention are many.   Networking, membership, continuing education, book signing event and just having a great time with your peers are just a few.

The Pre-convention Workshops are filling up fast! On Wednesday, Oct. 2nd, and Thursday, Oct 3rd, our own Deborah Conley, will prepare RN’s for the ANCC generalist Gerontological Nurse Certification exam.   Please refer to the brochure for further information including a separate registration fee.

Other Pre-Convention Workshops include Fall Prevention, Reducing Inappropriate Use of Anti-Psychotics, and Pain in the Older Adult. The workshops will take place on Thursday, Oct 3rd in the afternoon.  More information can be found in the brochure .Continuing Education Contact Hours will be presented for the convention including additional hours for the pre-convention workshops.

If you did not receive a brochure, you can download one from our website www.ngna.org   Hotel Information can also be found in the brochure.  Regular registration rates are available until the date of the convention.

NGNA is a great opportunity for nurses to develop skills, gain endless knowledge, form “forever” friendships and make a DIFFERENCE in the lives of our older population!

JOIN US IN CLEARWATER, FL TO CELEBRATE NGNA, 2013!


Celebrate National Gerontological Nursing Week with NGNA!
 


During the week of September 30 - October 5, 2013, the National Gerontological Nursing Association (NGNA) is celebrating National Gerontological Nursing Week, which coincides with the NGNA 2013 Annual Convention at the Hilton Clearwater Beach in Clearwater, Florida, from October 3 – 5, 2013. Click here for convention details.

The weeklong celebration is designed to recognize gerontological nurses, and make public their continual efforts to provide A Clear Vision of Care for the Older Adult.

NGNA encourages all members and nursing professionals to become involved in this year’s National Gerontological Nursing Week. NGNA has launched a web page devoted entirely to National Gerontological Nursing Week and provides readers ideas on how to recognize outstanding gerontological nurses, send an article to a local publication and other promotional activities. Click here to visit this website and explore all the tools to celebrate this important week.

In honor of the dedication, commitment, and tireless effort of the nearly 15,000 nurses nationwide who specialize in caring for older adults, the members of NGNA are proud to recognize gerontological nurses everywhere during this week, for the quality care that they provide to the growing population of older Americans.

For more information, visit NGNA’s Web site by clicking here.
 


Bigger and Better: Geriatric Nursing

Submitted by Barbara Resnick, PhD, CRNP, FAAN, FAANP, Editor, Geriatric Nursing
 
I am thrilled to announce good news for the journal:
  • Geriatric Nursing's 2012 impact factor increased.
  • Because of font and format improvements, article content has increased 50%.
  • Geriatric Nursing has three articles among Elsevier's 25 top-selling articles in journals related to Geriatric Medicine.
Geriatric Nursing is dedicated to getting new and innovative information focused on care of older adults out to nurses and nurse researchers working across all levels of care.  The journal is read by those working in long term care settings, acute care hospitals, rehabilitation facilities, as well as the community and researchers interested in improving the care provided and lives of older adults internationally.  In addition to study and project outcome papers, please consider submitting manuscripts focused on methods related to research when working with older adults as well as specific aspects of projects and research studies.  This could include such topics as:  the theoretical support and description of an effective intervention, the development and testing of a new measure, or an innovative recruitment approach.  We invite and encourage student work and will provide some level of guidance through the publication process.  Please take the time to write up your work and share it with others so that we at Geriatric Nursing can help to improve the care and quality of life of our ever growing number of older adults in the United States and Internationally. 
 

 
Chapter Resource Corner

Submitted by Charlotte Radu, Don Dissinger and Linda Hassler
Chair, Co-Chair and Board Liaison, Chapter Resources Committee


Spring and summer have come and with these seasons comes new growth.  The Chapter Resource Committee (CRC) is looking to cultivate NEW growth as well.

For 2013, we are conducting every other month conference calls with chapter presidents, who will all be invited to join.  Our vision is to have all chapters represented on the conference calls.  The more chapters represented, the wider the data base of experts will be for others to tap into. 

Most members think of the CRC as a resource for newly forming chapters but we are more than that.  We are a resource group for all NGNA members and chapters old and new. 

The committee members recently sent out e-mails to all chapter presidents asking for basic chapter information.  “Why?” you may ask. We have been reviewing the national web site and realized that very few chapters have information on it.  We have taken on the task to be a resource to update information for all chapters.   Once the requested information had been received we can use it to update chapter web pages.  Or you can e-mail Chris Walls directly  at cwalls@ngna.org  with up-to-date chapter information.   We will also use the information on our calls to further share the activities of your chapter.  We are always looking for new and innovative ways to keep chapters fresh and growing.   Once you start using the web site you will see just how easy it is to keep your chapter news updated.  Chris is a great resource for helping with this task.  All chapters have valuable information to share.

While exploring our web page it was found that there were 3 different sections for the CRC making it difficult to find information.  We worked with Chris to combine the information and now have a one-stop shopping page.  On this updated page (click here to access) you’ll find all the links needed for Chapter Resources. 

One of the tabs “Find a Chapter in your area” (found here) will take you to a map of the U.S. that highlights all the states in purple that have chapters, making it easy to find a chapter in your state.  As you may notice there are many  states without chapters. Do we have any takers out there to form a new chapter?   This would be a great way to highlight your state and its contributions to improving nursing care of older adults (this is our purpose statement).

We will continue to work  on other projects such as  identifying the states within which  NGNA  Fellows reside, and if they have a local chapter of which  they are  a member.  Are there any state gerontological associations or other like-minded groups that a chapter can collaborate with?  We all have a common goal – Care of the Elderly. 

We want to be an all-inclusive CRC for our members,  not just for newly forming chapters.  Please join us in making this possible!
 


Principles of Geriatric Surgery

Submitted by JoAnn Coleman, DNP, ACNP, AOCN, GCN

Surgical treatment of older, medically complex individuals is expected to increase over the next several decades (Anaya, Becker, & Abraham, 2011). Currently, older patients undergo nearly 40% of surgical procedures and constitute one third of hospital admissions for traumatic injury (Administration on Aging, 2010; Potter, et al., 2005). More opportunity for surgeries to be performed in the older person are now available as more is learned about aging along with improved medical technology, and better anesthetic, surgical, and monitoring techniques (Bailes, 2000).

The primary risk for older surgical candidates is not the surgery itself, but the postoperative recovery. Older patients do well with planned surgeries; emergency surgery in the very old patient is risky. The greatest change in the human body as one ages is the lack of reserve. Older patients tolerate operations, but not complications (Katlic, 2001).

The following six Principles of Geriatric Surgery are relevant to all who care for the older surgical patient (Katlic, 2001):
  1. The clinical presentation of surgical problems in the older patient may be subtle or different from that of the general population. This may lead to a delay in diagnosis.
  2. The older person handles stress well but severe stress is handled poorly due to lack of organ system reserve.
  3. Optimal preoperative preparation and attention to detail are essential (because of Principle II). When preparation is not optimal the perioperative risk of surgery dramatically increases.
  4. The results of elective surgery in the older patient are reproducibly good; the results of emergency surgery are poor though still better than nonoperative treatment for most conditions. The risk of emergency surgery may be many times that of similar elective surgery (because of Principles II and III).
  5. Scrupulous attention to detail intraoperatively and perioperatively is of great benefit, as the older patient tolerates complications poorly (because of Principle II). The results of elective surgery in the older patient are good and do not support prejudice against advanced age. Chronological age, of itself, is not a contradiction to surgery (because of Principle IV).
  6. The results of elective surgery in the older patient are good and do not support prejudice against advanced age. Chronological age, of itself, is not a contraindication to surgery (because of Principle IV).
Principle I: Clinical Presentation
The older patient, and possibly their health care providers, may become tolerant over the years to abdominal pain, loss of energy, and other symptoms, resulting in a delay in diagnosis or an emergency presentation. Clinicians must understand that classic presentations of surgical disease occur in a minority of older patients and to maintain a high index of suspicion to minimize delay in diagnosis.

Principle II: Lack of Reserve
Functional reserve may be considered the difference between basal and maximal function; it represents the capacity to meet increased demands imposed by disease and trauma (Deiner & Silverstein, 2012). For the most part, organ system reserves decline as a person’s age reaches seventies and older. With excellent anesthetic and perioperative care the older patient may tolerate the stress of even complex elective surgery but not the added stress of exceptional, unique, extended or emergency surgery (Katlic, 2001).

Principle III: Preoperative Preparation
A patient’s age is unchangeable but some factors can be improved preoperatively, with benefits to the older patient. Correction of anemia and dehydration assume greater importance in the older patient because of their general lack of reserve and, particularly, the physiology of the aged heart and kidney (Jankovic, et al., 2011). Pulmonary problems in the older patient are usually due to decreased respiratory muscle strength. Although few data exist to support the routine use of preoperative pulmonary conditioning or rehabilitation, it is strongly recommended that patients would benefit from smoking cessation and treatment of bronchitis and reactive airway disease (Story, 2011; Lo, 2010). Prophylaxis against deep vein thrombosis and pulmonary embolism should be routine in the older patient (Jankovic, et al., 2011).

Principle IV: Emergency Surgery
The results of elective surgery in the older patient are good, frequently indistinguishable from the results in younger patients. But the identical operations performed emergently in the older patient carry at least a threefold increased risk. A patient’s advanced age weighs in favor of commencing rather than deferring elective surgery (Katlic, 2001).

Principle V: Attention to Detail
Perioperative blood loss is what is most dreaded when performing surgery in the older patient, as they lack the resilient compensatory mechanisms necessary to restore equilibrium (Pang & Schrier, 2012). Blood loss is the one factor over which the surgeon has the most control. Prevention of infection is crucial in the older surgical patient (Bratzler & Houck, 2005). Meticulous surgical technique is important in any patient but it is critical in those with advanced age. Any anastomotic leak is a dreaded complication in any patient and embodies an exceptional risk of mortality in the older patient; yet this complication can be minimized by careful technique and attention to detail. Perioperative monitoring (intensive monitoring and critical care) is more important in the older patient since they may manifest few signs or symptoms of impending problems (Hughes, Leary, Zweizig, & Cain, 2013; White, Khan, & Smithham, 2011; Palmer, 2006).

Principle VI: Age is a Scientific Fact
Great biologic variability exists among older persons and older persons may even have better health than young persons (Katlic, 21001). Many studies have shown ageism or prejudice against the older person (Kydd & Wild, 2013).  Selection bias in the older patient may also lead to delay in referral for major surgical procedures. For most patients, general medical condition and associated medical problems are more important than age. Studies have shown that the severity of illness on admission is a much better predictor of outcome than age; comorbidities have a greater influence on survival than age; and the stage of malignancy influences outcomes more than age for the older patient having surgery for cancer (Zbar, Gravitz, & Audisio, 2012).

Incorporating principles of geriatric surgery with the focus of improving outcomes for the older patient by carefully considering the implications and consequences of age-related changes on surgical recovery are needed to:
  • Improve patient outcomes
  • Improve patient satisfaction
  • Allow early detection of the needs of the older patient
  • Institute interventions
  • Identify high risk events or potential problems not detected by routine history and physical examination
  • Implement preventive measures or interventions
  • Communicate information to all health care providers
Surgery is a viable, therapeutic option for many older patients. Surgical and anesthetic advances have reduced mortality of older surgical patients while also presenting risks and complications to challenge health care providers daily. Although age should not be ignored, the individual patient must be assessed for his or her functional level, unique characteristics, and risk factors (Doerflinger, 2009). Surgery has much to offer the older patient but the patient must be treated with appropriate knowledge and attention to detail.

References
Administration on Aging (2010). A Profile of Older Americans: 2010. Retrieved from http://www.aoa.gov/AoARoot/Aging_Statistics/Profile/2012/

Anaya, D.A., Becker, N.S., & Abraham, N.S. (2011). Global graying, colorectal cancer and liver metastasis: New implications for surgical management. Critical Reviews in Oncology Hematology, 77, 100-108.

Bailes, B.K. (2000). Perioperative care of the elderly surgical patient. AORN Journal, 72, 185-207.

Bratzler, D.W., & Houck, P.M. (2005). Antimicrobial prophylaxis for surgery; An advisory statement from the National Surgical Infection Prevention Project. American Journal of Surgery, 189, 395-404.

Deiner, S., & Silverstein, J.H. (2012). Long-term outcomes in elderly surgical patients. Mount Sinai Journal of Medicine, 79, 95-106. doi: 10.1002/msj.21288.
Doerflinger, D.M.C. (2009). Older adult surgical patients: Presentation and challenges. AORN Journal, 90, 223-240.

Hughes, S., Leary, A., Zweizig, S., & Cain, J, (2013). Surgery in elderly people: Preoperative, operative and postoperative care to assist healing. Best Practice & Research. Clinical Obstetrics and Gynaecology, pii: S1521-6934(13)00028-X.doi: 10.1016/j.bpobgyn.2013.02.006.

Janković, R., Bogićević, A., Stosić, B., Pavlović, A., Petrović, A., Marković, D., & Vucetić, C. (2011). Preoperative preparation of geriatric patients. Acta Chiurgica Iugoslavica, 58, 169-175.

Katlic, M.R. (2001). Principles of Geriatric Surgery. In R.A. Rosenthal, M.E. Zenilman, & M.R. Katlic (Eds.), Principles and Practice of Geriatric Surgery (pp. 92-104). New York: Springer-Verlag, Inc.

Kydd, A, & Wild, D. (2013). Attitudes towards caring for older people: Literature review and methodology. Nursing Older People, 25, 22-27.

Lo, I.L., Siu, C.W., Tse, H.F., Lau, T.W., Leung, F., & Wong, M. (2010). Pre-operative pulmonary assessment for patients with hip fracture. Osteoporosis International, 21, S579-S586. doi: 10.1007/s00198-010-1427-7.

Palmer, R.M. (2006). Perioperative care of the elderly patient. Cleveland Clinic Journal of Medicine, 73 Suppl 1, S106-S110.

Pang, W.W., & Schrier, S.L. (2012). Anemia in the elderly. Current Opinion in Hematology, 19,133-140. doi: 10.1097/MOH.0b013e3283522471.

Story, D.A. (2011). Postoperative mortality and complications. Best Practice & Research. Clinical Anaesthesiology, 25, 319-327. doi: 10.1016/j.bpa.2011.05.003.

White, J.J., Khan, W.S., & Smitham, P.J. (2011). Perioperative implications of
surgery in elderly patients with hip fractures: An evidence-based review. Journal of Perioperative Practice, 21, 192-197.

Zbar, A.P., Gravitz, A., & Audisio, R.A. (2012). Principles of surgical oncology
in the elderly. Clinics in Geriatric Medicine, 28, 51-71.


 

NGNA Needs You! Call for Volunteers is Open!

It’s that time of year again! Before we know it, NGNA’s committees, comprised entirely of volunteer members, will begin working to achieve goals for 2014. In order to meet our objectives for another successful year, we need your help!
 
If you are interested in contributing your skills for the good of the organization, and you are an active member of NGNA, please fill out the information on the online form for consideration of a committee appointment.
 
2014 NGNA committees include:
 
Awards Committee
Convention Planning Committee
Chapter Resources Committee
Education & Evidence-Based Practice Committee
Finance Committee
Nominating Committee
Research Committee
Gerontological Advance Practice Nurse Special Interest Group (GAPN SIG)
Long Term Care Special Interest Group (LTC SIG)
 
Click here to access the volunteer form. Please complete and submit by October 25, 2013.
 
We appreciate your commitment and look forward to your participation!



Influenza Vaccination: Is It Useful in Older Adults?

The following article was provided courtesy of The Gerontological Society of America. It is featured in their most recent What’s Hot newsletter, published in collaboration with Sanofi Pasteur.

Click here to visit GSA’s website, which offers the opportunity to download the entire newsletter.

Evidence indicates that seasonal influenza mortality ranges from
3000 to 49 000 deaths per year, either directly or indirectly, and more
than 225 000 hospitalizations.11,12,13 After age 65, risk of flu-related death increases exponentially, with this group incurring more than 90% of the overall influenza-related mortality annually. 13 Individuals residing in nursing homes are highly susceptible to influenza, given the high exposure risk through close living quarters and shared caregivers. Comorbidities, frailty, and nutritional deficiencies often exacerbate vulnerability to infection and cause typically unrecognized excess morbidity in activities of daily living, strokes, and heart attacks.14,15 Vaccination is considered the cornerstone of influenza prevention.

There is some concern over the effectiveness of influenza vaccine in older adults from an immunological standpoint. Most studies agree that standard-dose influenza vaccines are less immunogenic and less effective in the older adult population than in younger, healthier adults. This outcome may be due, at least in part, to immunosenescence, which impairs the ability to respond to newly encountered antigens. However, in spite of waning immunity, vaccination remains the most cost-effective method for reducing the morbidity and mortality associated with influenza infection in older adults.

The standard-dose influenza vaccine has proven to be 50% effective in reducing laboratory-confirmed influenza compared with placebo in healthy adults.16 In this same study, the vaccine was found to be only 23% effective for those over 70 years of age, but a small sample size limits the generalizability of this finding.16 Other researchers, however, have found similar results.15,17 A Cochrane review published in 2010 showed that according to all the published evidence at the time, effectiveness of trivalent inactivated influenza vaccines in older adults, regardless of setting or outcomes, is modest. The review concluded that efforts should be focused on high vaccination coverage in long-term care facilities, including caregiver vaccination, as a strategy to reduce transmission.18

Higher-Dose Influenza Vaccine
Higher-dose influenza vaccine is an injected flu vaccine approved for use in individuals 65 years of age and older. Like the regular vaccine, the higher-dose vaccine is trivalent, with each component selected to protect against 1 of the 3 main groups of influenza viruses circulating in humans in a particular season. However, the higher-dose vaccine contains 4 times the amount of antigen from each of the 3 strains contained in the regular vaccine. The strategy for the higher-dose vaccine is that the increased antigen dose is 1 possible way to compensate for immunosenescence. Data from clinical trials comparing Fluzone® to Fluzone High- Dose among individuals age 65 years or older indicate that those receiving the higher-dose product mounted higher antibody levels than those receiving the lower dose.

The US Food and Drug Administration (FDA) approved the higher-dose vaccine in 2009 based on results of clinical trials. Sanofi Pasteur sponsored a multicenter, randomized, double-blind, controlled trial of the higher-dose vaccine. The overall study goal was to confirm the improved immunogenicity and safety profile of the new higher-dose vaccine compared with the standard licensed influenza vaccine for use in older adult patients.4

The primary outcome was assessed by geometric mean titers (GMTs), as well as seroconversion and seroprotection rates. Hemagglutination inhibition (HAI) is currently considered the best surrogate measure of efficacy in vaccine clinical trials. Baseline blood samples were collected at randomization, and follow-up samples were collected at day 28 after vaccination. Participants were observed for 30 minutes following vaccine administration and were asked to record oral temperature, injection site symptoms, and systemic symptoms for 7 days; they were contacted 6 months after vaccination to ascertain all serious adverse events.

A total of 3851 volunteers with a mean age of 73 (range 65–97) received the higher-dose or standard dose vaccine and were not withdrawn prior to the end of study. Pre-vaccination HAI GMTs were similar in both vaccination groups. The 28-day post-vaccination HAI GMTs were higher in the higher-dose vaccine group than in the standard dose vaccine group for all 3 influenza strains. With respect to percentage of participants who experienced seroconversion, the absolute difference between the higherdose group and the standard dose group was 25.4% for the A/H1N1 strain, 18.4% for the A/H3N2 strain, and 11.8% for the B strain. Seroprotective titers for all 3 virus strains were also achieved in a significantly greater proportion of participants who received higher-dose vaccine than in participants who received standard dose vaccine.

As for vaccine safety, higher-dose vaccine recipients reported higher rates of local reactions than did standard dose vaccine recipients during the first 7 days after vaccination. Pain, mostly mild intensity, was the most commonly reported reaction in both groups, reported in 36% of the higherdose group and 24% of the standard dose group. Although local reactions were significantly more common in the higher-dose group, the actual mean difference in erythema or swelling was modest. Systemic reactions (ie, fever, headache, malaise, or myalgia) in the 7 days after vaccination were not significantly different between higher-dose and standard dose vaccine recipients.

A large (26 000 subjects >65 years of age) multicenter trial comparing the efficacy of Fluzone High-Dose vaccine and Fluzone vaccine against laboratoryconfirmed influenza is under way, with results expected in 2014-2015. Subjects were randomized to receive Fluzone High-Dose vaccine or Fluzone vaccine in a 1:1 ratio.

Despite age-related waning of immune response to immunizations, vaccination is still a cornerstone of preventive medicine for older adults. Table 1 lists selected FDA-recommended vaccinations for individuals 65 years of age and older and highlights efficacy data in this population.

Table 1. Selected FDA-Approved Vaccines Recommended for Individuals ≥65 Years of Age

Vaccine Recommendationa Efficacy data
Influenza 1 dose annually Significant reductions in risk of hospitalization for heart disease (19%, p < .001) cerebrovascular disease (23%, p < .001), pneumonia, or influenza (29%, p < .001) and death from all causes (50%, p < .001) during the 1999–2000 season.8
Influenza (higher-dose) 1 dose annually Significantly higher antibody titers and seroconversion rates in adults 65 years and older compared with regular-dose vaccine for influenza A (GMT ratios 1.7–1.8). Rates for influenza B strains were higher (GMT 1.3), but not significantly so. Clinical correlations are currently under study. 4
Zoster 1 dose, for adults > 50 years of age, regardless of previous herpes zoster history Reduced the risk for developing zoster by 51.3% (95% CI = 44.2–57.6; p < .001)in healthy adults ages 60 years and older; 66.5% (95% CI = 47.5– 79.2; p < .001) efficacious for preventing post-herpetic neuralgia. 19
Pneumococcal polysaccharide 1 dose; individuals should receive a dose of vaccine at age 65 if at least 5 years have passed since the previous vaccination Associated with significant reductions in the risk of hospitalization for pneumonia (hazard ratio [HR], 0.74; 95% CI = 0.59-0.92) and in the overall pneumonia rate (HR, 0.79; 95% CI = 0.64–0.98) in adults ages 65 years and older. 20

a = Source: CDC Recommended Adult Immunization Schedule


NGNA Convention Attendees: To learn more about the higher dose flu vaccine, please plan to attend the onsite luncheon on Friday, October 4th. Dr. Marvin Bittner from the VA will be presenting on this topic. You will receive further details regarding this luncheon in your registration materials.