Issue: 82

December: Tis the Season for Gratitude, Generosity, and Joy!
I write this newsletter after recently caring for two terminally ill, decorated, Normandy Invaders, both in their nineties.  Neither man wore his heroism on his sleave.  They lived long, productive, joyful lives, their heroism under wraps, no doubt hushed by their near-death experiences as twenty year olds! Only their devoted families brought their distinguished service to my attention. Though they never said so, they were grateful for their second chance and proved it with lives of service to others!

Too glum for the holidays, you say?  On the contrary!  Their lives of service teach us how to find joy this holiday season!

Christmas and Hannukah, for those who believe, mark the intervention of a generous God, willing to sacrifice His Kin to save His people. Both feasts celebrate a rescue mission, not unlike the invasion of France to liberate the peoples held hostage by the satanic Nazis. Hannukah and Christmas are about liberation and freedom! 

The only appropriate response to such heroism is gratitude. But gratitude is not enough. If we are truly grateful, we must be generous.  Generosity is the shortest route to joy!

The life of recently deceased president George H. W. Bush is an excellent model of how someone turned gratitude for salvation into generous, joyful service.  At the age of 22, he was shot down on his 24 th mission south of Japan.  His two copilots having perished, he was saved by a submarine.  He attended college and then emigrated to Texas to start an oil business.  What followed was a remarkable career of government service that spanned more than 40 years. 

I was particularly impressed with his conduct after his wrenching defeat to President Bill Clinton.  Instead of sulking, he left a handwritten note of encouragement on the desk of the Oval Office.  "I wish you great happiness here," he wrote.  It is well known that H.W. was not an eloquent man. Yet his sincerity and heartfelt best wishes for his successor's success were evident in that simple note. The two went on to form a lasting friendship and legend has it that H.W. always gave Bill Clinton a caramel candy whenever they met.  This is why it was so poignant when his son, President George W. Bush, gave a candy to First Lady, Michelle Obama, at his father's funeral in the National Cathedral.  With that simple gesture, he was imitating his dad's generous approach to life!  Let us do the same!!   

John A. Schmidt, MD 
Centennial of 1918 Influenza Cataclysm: Those who ignore history...!
As recounted in the December 13 issue of the New England Journal of Medicine, the 1918 influenza pandemic killed more than 50 million people worldwide, including 675,000 in the United States, a percentage of the population that would amount to 2.15 million Americans today.  Should such an outbreak recur, our EDs and ICUs would be overwhelmed, and the healthcare of all Americans would be severely compromised, directly or indirectly.

"Everyone lost a family member, friend, classmate, or workmate.  There were bodies stacked three deep in hospital corridors, corpses piled up at cemetery entrances, mass graves, and countless bewildered orphans."  The epidemic came on the heals of World War I, adding to the misery of families who lost loved ones in the killing fields of Europe.

The NIH and CDC have appropriately devoted huge resources to better understand the 1918 influenza virus.  Between 1995 and 2005, viral RNA sequences from preserved autopsy tissues and a frozen corpse were fully sequenced and used to stitch the extinct virus back together and bring it back to life.  Overcoming arguments that such information would be used for germ warfare, the reincarnated virus has been studied in numerous animal models.  This ongoing work has helped identify the viral genes responsible for the 1918 strain's deadly properties and which avian influenza viruses, currently infecting waterfowl, have the potential to "jump" from their wildlife reservoir to humans, just as the 1918 virus did.  There is no way to eradicate this reservoir of avian flu viruses and it is not fear mongering to say that one of them may someday lead to a flu epidemic on the scale of 1918.

Interestingly, all the influenza viruses responsible for pandemics since 1918 contain gene segments derived from the 1918 "founder" virus.  Consequently, the past 94 years can be considered a single "pandemic era" with the founding 1918 virus parenting the progeny that spread through the populace in 1957, 1968, and 2009.  Thus the 1918 virus has been called the genetic "mother of all influenza pandemics" making its further study critical to anticipating the next pandemic.  

One of the many lessons gleaned from the historical record is that the 1918 virus was highly "copathogenic" meaning that it paved the way for bronchopneumonias by commensal bacteria colonizing the human nasopharynx.  Thus the hallmark of a deadly flu virus is its ability to facilitate invasion by otherwise harmless bystander bacteria which rapidly destroy normal lung tissue, regardless of a patient's age or state of health.  This realization led to the early administration of antibiotics during the 2009 pandemic saving countless lives.

I remind my patients that the flu virus is not a cold virus.  It has the potential to kill you and the people you infect, some of whom will be pregnant women and infants.  Jersey Shore University Medical Center is now admitting patients with influenza and they are very ill.  Your best protection is to get vaccinated not only with a flu vaccine but with both pneumonia vaccines as well, keeping in mind that the flu virus paves the way for bacterial pneumonia, most commonly caused by strains of S. pneumonia blocked by Prevnar-13® and Pneumovax-23®.  Buy a digital thermometer and have your temperature ready when you call for help.  We have to work together to prevent the spread of influenza!!
Systolic Congestive Heart Failure (CHF)-New Treatment Paradigm to Get Rid of Excess Sodium!
Many of my patients suffer from Systolic Congestive Heart Failure (sCHF) also known as Heart Failure with Reduced Ejection Fraction (HFrEF).  They have to stop and catch their breath while ascending stairs.  They prop their heads up at night with two or more pillows to avoid waking up short of breath. They gain weight as their legs swell. Their hearts are enlarged.  Their left ventricular ejection fractions (LVEF) are less than 50 percent.  The sodium in salt is their mortal enemy!

The antidote is to restrict sodium consumption to less than 2 grams per day and treat with potent diuretics such as furosemide (Lasix®) and spironolactone (Aldactone®) to purge the body of excess sodium.  

The body's response to systolic congestive heart failure is unfortunately maladaptive.  Instead of excreting excess sodium, the kidneys are instructed to retain sodium by a pathway known as the Renin-Angiotensin-Aldosterone System (RAAS).  This is why inhibitors of this pathway, especially Angiotensin Converting Enzyme inhibitors (ACEi, e.g. enalapril) and angiotensin receptor blockers (ARBs, e.g., valsartan) have proven to be especially beneficial.  

The atria and ventricles of the heart attempt to defend themselves against sodium retention by making natriuretic peptides (ANP and BNP) which instruct the kidneys to excrete sodium.  BNP levels provide a surrogate marker of CHF severity.  BNP (and NT-proBNP) rise as CHF worsens and decrease as CHF improves. 

Natiuretic peptides are unfortunately degraded by a protease known as Neutral Endopeptidase or neprilysin, thwarting the heart's attempt to get rid of sodium.  Now comes an inhibitor of neprilysin, sacubitril, that protects natriuretic peptides thereby increasing sodium excretion by the kidneys.  When combined with valsartan to form the combination medication known as Entresto®, the ill effects of RAAS are blocked and the beneficial effects of natriuretic and other vasoactive peptides are augmented.

The latest study showing the power of sacubitril-valsartan (Pioneer-HF) was published in the online issue of the New England Journal of Medicine on November 11.  Patients with Congestive Heart Failure with Reduced Ejection Fraction were randomized to sacubutril/valsartan (Entresto®) or enalapril twice daily.  NTpro-BNP levels were significantly lower in patients in the Entresto group indicating that the heart was having to make less BNP.  More importantly, the rate of rehospitalization for CHF was significantly lower in patients treated with Entresto® as compared to enalapril.  The safety profiles of Entresto and enalapril were comparable.

I recommend my patients with heart failure with reduced ejection fraction transition from ACE inhibitors (enalapril/lisinopril)to Entresto®.
Radical Prostatectomy vs. Watchful Waiting in Prostate Cancer--29 Year Follow-Up!  
Prostate cancer is common in my male patient population and men often ask: "What is the best therapeutic option?"  The options range from "watchful waiting" and "active surveillance" to radical prostatectomy.  

Prostate cancer begins to appear typically after age 50 and most men diagnosed with prostate cancer usually have at least ten years to live and often much longer.  They therefore want a durable treatment that will rid them of cancer for the rest of their lives.

An update of the famous Scandinavian Prostate Cancer Group Study published in the New England Journal of Medicine on December 13 helps address their questions. The study showed that men who had surgery were about half as likely to die of prostate cancer as compared to those who were randomized to watchful waiting. "A significantly lower overall mortality, lower mortality due to prostate cancer, and a lower risk of metastasis prevailed in the radical prostatectomy group." On average, 2.9 years of life were added.  Among men who underwent radical prostatectomy, extracapsular extension was associated with a five times higher risk of death due to prostate cancer.  A Gleason score higher than 7 was associated with a 10 times higher risk of death due to prostate cancer.  Thus, a high Gleason score and the presence of extracapsular extension were highly predictive of death from prostate cancer.

Fortunately, the tools we have available today make it possible to diagnose prostate cancer at an early stage when extracapsular extension and high Gleason score are far less likely.  As discussed in a previous newsletter, Magnetic Resonance Imaging and U.S. guided biopsies have made it possible to detect early prostate cancer with high sensitivity and specificity such that extracapsular extension and high Gleason scores can be avoided. Armed with this information, men with prostate cancer and their physicians are better able to make informed therapeutic decisions knowing that surgery provides a durable cure.
Other News!
As published online in the New England Journal of Medicine on November 10, treatment with dapagliflozin (Farxiga®), a selective inhibitor of sodium glucose transporter 2 (SGLT-2), significantly reduced the risk of hospitalization for heart failure in type 2 diabetics.  This study, known as DECLARE-TIMI, strengthens the case for the preferential use of this class of medicines in the treatment of DMII.  Jardiance® and Invokana® are also SGLT2 inhibitors with demonstrated cardiovascular benefits.
Now Hear This!
During the week of Christmas, the office will be open only on Thursday, December 27.  The office will reopen on Wednesday, January 2.  As usual, I can be reached by text messaging, mobile phone (908- 256-9439) or through my answering service. The patient portal and my regular email ( will be checked for messages daily.

Valerie, Carol, Ms. Clark, Ms. Catong and I wish you and yours a joyful holiday season and a prosperous and healthy New Year!!
In This Issue
December: Tis the Season for Gratitude, Generosity, and Joy!
Centennial of 1918 Influenza Cataclysm: Those who ignore history...!
Systolic Congestive Heart Failure (CHF)-New Treatment Paradigm to Get Rid of Excess Sodium!
Radical Prostatectomy vs. Watchful Waiting in Prostate Cancer--29 Year Follow-Up!
Other News!
Now Hear This!
John A. Schmidt Jr., M.D.
Board Certified Internist
Dr. Schmidt is one of the leading internists in Monmouth County offering  Medical Home services.  
He is an attending physician at Jersey Shore University Medical Center.
Dr. Schmidt is enrolled in the Maintenance of Certification Program of the American Board of Internal Medicine
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" In crucial things, unity. In important things, diversity. In all things, generosity."

- George H.W. Bush


Ms. Catong's children
John A. Schmidt Jr., MD
Meaningful Medicine in Your Medical Home
2006 Highway 71, Ste. 3, Spring Lake Heights, NJ 07762
Phone:  732-282-8166  
Fax:  732-280-0147 
Disclaimer: The articles in Healthy Living are for general information only and are not medical advice.
Discuss all medical concerns and treatment options with your physician.