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November: Is America Possible?
Borrowing the title of the famous essay by
Vincent Harding, we should pause this Thanksgiving and ask ourselves, "Is America Possible?" When we travel abroad and someone asks us our nationality, we emphatically say, "I'm an American!" not "I am a citizen of the United States." Why do we prefer "American" when we know it is inclusive of immigrant Americans, Native Americans, Asian Americans, Canadians, Mexicans, Central Americans, Latin Americans, Caribbean Americans, and South Americans? I believe it's because "American" makes us part of something far greater than ourselves, as captured in the lyrics of our beloved anthem, "America the Beautiful." This Thanksgiving, let us give thanks to a generous God who has patiently blessed us time and time again despite our mean spiritedness. Then ask yourself what qualifies you to be an American and a member of, as Vincent Harding wrote, this "beloved community."
John A. Schmidt, MD
Internist
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Our Office is Moving
Pictured above is our new office located at:
2006 Highway 71, Suite 3
Spring Lake Heights, NJ 07762
We are excited to welcome you to your new Medical Home where we will start seeing patients on January 2, 2017. It's on the corner of Highway 71 and Church Street across from Hoffman's Ice Cream!
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Celebrating Our Veterans and What They Teach Us!
The best thing about being a doctor is the people I meet. From my earliest days as a medical student on the Pepper Ward of the Hospital of the University of Pennsylvania, I have met people, mostly older people, who have taught me much about life. "It's OK, sonny, don't you worry now." The detachment conveyed in these words made me pause. How was it that a person teetering on the brink of death displayed such calm? When I engaged such people in conversation, they had invariably experienced many "close calls." They had learned to rise above their trials and cultivated an inner strength.
I recently discharged a veteran from Jersey Shore University Medical Center who was seriously wounded in the
Bougainville Campaign in the South Pacific in 1944. He still had draining wounds requiring constant attention in the Wound Care Center. The radiology report mistakenly said, "shotgun victim." He had recently lost a large amount of weight. The album provided by his daughter showed that he had been a mountain of a man. He was still a Mountain of a Man!
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Individualizing Therapy: Who Gets the Drumstick?
Remember when your grandfather was carving the Thanksgiving turkey? Some got white meat, some dark, and some the thigh. How did he decide who would get the prized drumstick? As we learn more about medical therapy, we find that there is no "one size fits all." For maladies of daily life such as colds, simple therapeutic trials with over-the-counter remedies often suffice. But what about the more complex illnesses, where you may have to commit to months of expensive and sometimes risky therapy before knowing if the treatment worked? Insurance companies (the keepers of the drumsticks!) are increasingly focused on
a priori methods of identifying responders.
An interesting example was published in the
November 10 issue of the New England Journal of Medicine where investigators used an antibody (
pembrolizumab,
Keytruda
®)) targeting
PD-L1 in patients with advanced lung cancer (PD-L1 inactivates would-be killer lymphocytes invading the tumor). PD-L1 is expressed by some but not all lung cancers and the only way to find out is to biopsy the tumor and examine it under a microscope. In this study, "patients with expression of PD-L1 on at least 50% of tumor cells and treated with pembrolizumab had longer survival with fewer adverse events than patients treated with conventional chemotherapy."
As with the measurement of HER2 in breast cancers, measurement of PD-L1 in lung cancers serves to identify those patients with the greatest chance of benefiting from expensive antibody therapy.
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New Guidelines for the Management of Gout
Gout (or gouch! as some of my more colorful patients like to call it) appears suddenly as an inflammation of a joint and it really hurts!
Typically, the big toe or ankle becomes swollen, red, and exquisitely tender such that even the slightest pressure elicits terrific pain. Gouty attacks are caused by deposition of uric acid crystals. Medicines that combat gout fall into two categories: a) those that quickly reduce inflammation and pain, and b) those that interfere with the production and accumulation of uric acid crystals when used for many months to years (xanthine oxidase inhibitors).
Now come four recommendations from the American College of Physicians, as published in the November 1 issue of the Annals of Internal Medicine, regarding the best treatment approach: 1) acute episodes should be treated with generic medicines from one of three classes: a) colchicine, b) NSAIDs (e.g. naproxen/Aleve
®
), or c) corticosteroids (e.g. prednisone). Your best option depends on side effects, preexisting conditions (e.g. kidney disease), and cost; 2) if colchicine is selected for symptomatic relief, the regimen is simple: 1.2 mg followed by 0.6 mg one hour later; 3) long-term therapy with uric acid lowering medications (allopurinol or febuxostat) should be reserved for patients who have recurrent episodes, at least two per year; and 4) physicians should discuss the pros and cons before initiating long-term treatment. In other words, some patients may prefer to treat individual episodes rather than take medications on a daily basis.
For most patients, this is a viable, less costly, and safer approach.
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Calcium: Is it harmful?
Everyone has heard the phrase, "Milk builds strong teeth and strong bones," a motto coined by the dairy industry decades ago. But there has been an unfortunate backlash against calcium supplements and calcium rich foods based on the observation that calcium accumulates in the arteries of patients with atherosclerotic cardiovascular disease. In fact, I often recommend that at-risk patients have a CT scan to measure their "coronary calcium score," an excellent predictor of heart attack risk. But is calcium the culprit?
Now comes an important review in the October 25 issue of the Annals of Internal Medicine funded by the National Osteoporosis Foundation addressing this important question. The conclusion was unequivocal: "Intake of elemental calcium, in the form of food and/or supplements, up to 2500 mg/day is not associated with cardiovascular disease risk in generally healthy adults." In other words, calcium is not the culprit! Hypertension, diabetes, smoking, positive family history, and elevated cholesterol are the villains! Calcium deposition is a convenient measure of the accumulated detrimental effects of these major risk factors on vascular heath. So don't shoot the messenger!
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Oxygen Therapy in Patients with Emphysema and Moderate Desaturation
When you come to my office, Valerie often places a pulse oximeter on one of your fingers to measure your "oxygen saturation." Oxygen saturation measures the percentage of hemoglobin carrying oxygen. In healthy individuals who have never smoked, the value is typically between 98 and 100% ("fully saturated"). Pulse oximeters can be purchased on line or at Campbell's Pharmacy in Sea Girt for about $50. You can send a message to a smoker you love by putting one in their stocking this Christmas!
Resting oxygen saturation typically declines as patients continue to smoke. Exertion in such individuals leads to a further reduction because their damaged lungs cannot keep up with the oxygen requirements of hungry muscles. Oxygen therapy for patients with resting oxygen saturations less than or equal to 88% has been proven to increase quality of life and prolong survival. But what about individuals with levels that have not yet declined to 88%?
As reported in the October 27 issue of the New England Journal of Medicine, the "prescription of long-term supplemental oxygen for patients with resting or exercise-induced oxygen saturations between 89% and 93% did not result in a longer time to death or first hospitalization." Thus, costly oxygen therapy will continue to be reserved for those with severe disease. Moral of the story: Don't smoke and if you do, please stop!
I can help!
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Open Enrollment Is in Full Swing
Medicare open enrollment is from October 15 to December 7. Please visit Medicare.gov to find an economical part D plan for your medications.
You can now enroll in healthcare insurance programs offered under Obamacare at Healthcare.gov.
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Now Hear This!
Here are the little persons for whom Ms. Clark and I are thankful this Thanksgiving! Our youngest grandchild was born on October 5
th
at Cornell Weill Medical Center in NYC where his mother, our wonderful second daughter, is a third-year fellow in the Pediatric Intensive Care Unit. She spent many on-call nights caring for critically ill children wondering if the baby she was carrying inside would be healthy. The other two adorables are growing up in Austin, TX, and will be spending Thanksgiving with us!
Valerie, Ms. Clark, and I wish our patients and all Americans a wonderful Thanksgiving!
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| Ms. Clark's Children Ryan & Sean |
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| Dr. Schmidt's Grandchildren Parker, Alida & James |
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Board Certified Internist
Dr. Schmidt is one of the leading internists in Monmouth County offering
Medical Home
services.
He is an Associate Attending in the Department of Medicine, Jersey Shore University Medical Center, and Clinical Assistant Professor in the Department of Medicine, Rutgers Robert Wood Johnson Medical School.
Dr. Schmidt is enrolled in the Maintenance of Certification Program of the American Board of Internal Medicine
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"Gratitude can transform common days into thanksgivings, turn routine jobs into joy, and change ordinary opportunities into blessings."
- William Arthur Ward
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