Issue: 73

February: Underdogs No More!!!
If you were losing sleep watching the highlights of the Winter Olympic Games as I was, there was no better reward than watching the U.S. Women's Ice Hockey Team  win the gold medal against Canada in a topsy-turvy, hard-hitting, double overtime finish! Having lost to the Canadians four straight times, and not having won the gold since 1998, the U.S. women proved, once again, that nothing succeeds like persistence.  I love that famous quotation of Calvin Coolidge , 30 th President of the United States: "Nothing in the world can take the place of persistence. Talent will not; nothing is more common than unsuccessful men/women with talent.  Genius will not; unrewarded genius is a proverb.  Education will not; the world is full of educated derelicts.  Persistence and determination alone are omnipotent.  The slogan "Press On" has solved, and always will solve, the problems of the human race."

There is a hidden truth here.  The underdog, perhaps out of necessity, perhaps out of desperation, perhaps both, must hang-on to succeed. The underdog must believe and have faith. What's more, the underdog must stay humble, knowing that to gain a place on the podium, he/she must sacrifice self for the good of the team.

Nowhere was this more evident than in Minneapolis on February 4 when the underdog Philadelphia Eagles , against all odds, narrowly defeated awesome Tom Brady and the New England Patriots in Super Bowl LII .  "Of course!", you say. Dr. Schmidt is crowing because he is from Philadelphia.  True! But as my clad-in-green Irish-twin sister observed, there was a serenity and humility about the Eagles back-up quarterback, Nick Foles , that defied belief.  There was no fist pumping, no shouting, just cool execution of the game plan he, his teammates, and coaching staff crafted during many hours of practice.  And who was on the sideline cheering him on?  The Eagles first string quarterback, Carson Wentz , his Most Valuable Player (MVP) season having been snuffed out by a torn cruciate ligament .  His selfless support of his teammate set the tone for the entire team.  Their all-for-one, one-for-all spirit nucleated an elusive victory and Rocky Balboa ascended the steep steps of the Philadelphia Art Museum once more!!

John A. Schmidt, MD 
Change in the Mission Statement of the U.S. Citizenship and Immigration Service!
As reported by Newsweek on February 22, the federal agency charged with processing immigration applications to the United States has slashed the phrase "nation of immigrants" from its mission statement. This is a travesty.  As Eleanor Acer , senior director for refugee protection at Human Rights First  said: "Our nation is one built by immigrants - removing this language does nothing to change that fact...President Trump and his hardline immigration extremists will stop at nothing to demonize and dehumanize immigrants and refugees, who have often fled violence and persecution in search for a better life for themselves and their children."

Listen to President John F. Kennedy's " Nation of Immigrants " address to the Anti-Defamation League  on January 31, 1963, when he beautifully enunciated the principles that make our country great.
Phosphorus in Patients with Chronic Kidney Disease!
Smokers need to stop smoking, diabetics and pre-diabetics need to avoid concentrated carbs , and persons with high blood pressure need to avoid salt!  Add one more to the list: patients with chronic kidney disease need to limit intake of phosphorus !

Phosphorus combines with calcium to form calcium phosphate , the mineral that makes our bones hard.  But if there is too much phosphorus, serum calcium  is depleted as calcium phosphate begins to deposit in our blood vessels and heart valves.  Vascular calcification  correlates with increased cardiovascular mortality and is therefore to be avoided.

Healthy kidneys, under the control of parathyroid hormone (PTH) , do a good job of removing excess phosphorus.  When kidneys are no longer able to remove phosphorus, PTH goes up in a futile attempt to maintain serum calcium and lower serum phosphorus levels .  High levels of PTH deplete bones of calcium and increase fracture risk.  
What to do?    
As reported in the February 20 issue of the Annals of Internal Medicine , the Clinical Practice Guidelines (CPGs) for management of patients with Chronic Kidney Disease-Bone and Mineral Disorder  (CKD-BMD) have been updated.  Here are the highlights:
  1. Calcium, phosphorus, vitamin D and alkaline phosphatase should be monitored regularly.
  2. Vitamin D deficiency should be corrected.
  3. Bone mineral density should be assessed by DEXA scanning to estimate fracture risk.
  4. Vascular and valvular calcification should be assessed by X-ray and echocardiogram.
  5. Elevated phosphorus levels should be lowered with diet and, if necessary, phosphorus binders, preferably sevelamer (Renvela®).
  6. Though elevations in PTH may be useful in lowering phosphorus, steps should be taken to avoid excessive PTH (secondary hyperparathyroidism) to protect bones.  PTH should be lowered with calcimimetics (Cinacalcet/Sensipar®) and/or vitamin D supplements (Calcitriol/Rocaltrol®).
Phosphorus is found in protein rich foods .  Because protein is essential, the challenge is to maintain adequate protein intake while minimizing phosphorus intake.  Fortunately, there are foods like bean curd and cottage cheese, that deliver nutritious protein without excessive phosphorus. Your nutritionist can help!  If dietary modification is inadequate, phosphorus binders should be taken with meals.

Let's discuss your kidney function  at your next visit.  Avoid excessive use of over-the-counter pain relievers ( ibuprofen, naproxen, celecoxib, meloxicam , etc.) known collectively as nonsteroidal anti-inflammatory drugs (NSAIDs) that might damage your kidneys if taken chronically.  Kidneys hate high blood pressure and diabetes so make sure you take steps to avoid these kidney-killers. If you have kidney disease  as reflected by elevated serum creatinine  and reduced glomerular filtration rate  (GFR), adhere to a low phosphorus diet!
New Guidelines for Shingles Vaccination
As reported in the February 6 issue of the Annals of Internal Medicine , the Recommended Immunization Schedule for Adults, Age 19 or Older , in the United States has been updated.  The most important change has to do with shingles vaccination .  Until recently, only the live attenuated vaccine known as Zostavax® ( Merck ) was available.  As of October 20, 2017, a second vaccine known as Shingrix® ( Glaxo ) was approved by FDA.  Shingrix® is a conjugate vaccine , similar in design to Pneumovax® and Prevnar® . Fragments of the virus are attached (conjugated) to a polymer/carrier that improves the ability of the fragments to generate protective antibodies .  Conjugate vaccines have better efficacy in seniors than live virus vaccines .  The main disadvantage with Shingrix® is that it requires two injections. Zostavax® requires one. As with Zostavax®, the vaccine can be expensive depending on your insurance coverage.  

Here are the recommendations of the Advisory Committee on Immunization Practices (ACIP):
  1. Administer two doses of Shingrix® two to six months apart to adults aged 50 years or older regardless of past episode of shingles OR past immunization with Zostavax®.  Patients having received Zostavax® should wait at least two months before starting Shingrix®.
  2. Shingrix® is preferred over Zostavax® in adults 60 or older.
Dr. Schmidt's Wife Rita with Dr. David Johnson
Now Hear This!
As you may have heard, my dear wife, Rita, is slowly but surely recovering from open heart surgery.  Thanks to all of you who have cheered her on!!  The Olympics of Life require persistence and team work as well as the support of friends and colleagues.  I am very grateful to Dr. David Johnson  and his outstanding team at Jersey Shore University Medical Center  for restoring the life of a very special person!!

We wish Morgan well as she begins her nursing career at Riverview Medical Center!
In This Issue
February: Underdogs No More!!!
Change in the Mission Statement of the U.S. Citizenship and Immigration Service!
Phosphorus in Patients with Chronic Kidney Disease!
What to do?
New Guidelines for Shingles Vaccination
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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"You may encounter many defeats, but you must not be defeated. In fact, it may be necessary to encounter the defeats, so you can know who you are, what you can rise from, how you can still come out of it."

- Maya Angelou


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 
E-Mail:   [email protected] 
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.