February-March: New Zealand Mass Killing is a Warning to U.S.!
New Zealand (NZ) is on my short list of places to visit. Everyone I know who has visited NZ has fallen in love with the serenity of this bucolic archipelago. Now comes a horrific
mass killing of Muslims at prayer
. The killer was a fanatical right wing separatist from Australia, a country that most Americans, myself included, embrace as a nation of immigrants like our own, rough and ready, brash and audacious, willing to fight for freedom no matter what the cost. The killer said the Muslim immigrants were invaders. Sound familiar?
The imminent danger is that we Americans fall into the same trap of separating "us" from "them". There is no "them". There is only "us", one species, one homo sapiens. All of the "terrorist" killings in the US last year were committed not by ISIS but by native born right wing separatists who are ideological descendants of
Adolf Hitler
, whom hundreds of thousands of Catholic, Jewish, Protestant, Muslim and Hindu patriots died to defeat. Hitler has been reincarnated and it is up to us to put his bastard genie back into the lamp where it belongs!!
John A. Schmidt, MD
Internist
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God Blessed the Irish!
As our nation continues to debate whether we should embrace or reject immigrants, we celebrate the greatest immigrant population of them all, the
American Irish
!
Given my German surname, I was certain that I was mainly German until we visited our youngest daughter during her semester abroad at the
University of Galway
. We visited a local Pub and, no exaggeration, I felt a vibe which told me immediately that I was among my kin. I knew I had some Irish heritage because my dear mom, who will turn 91 this May, and whose maiden name is Crumback, always talked about her great grandfather, James McKenna, who fought at
Gettysburg
as a member of the
Fighting 69th
. His name is emblazoned on the base of the Pennsylvania monument on the Gettysburg battlefield. He died in a ditch cave-in many years later and is buried at
Holy Cross Cemetery
outside of Philadelphia.
Still thinking that our
civil war
ancestor was just a tiny part of my heritage, my youngest brother, a urologist, visited mom while she was having a nose bleed. He collected a sample of blood and sent it to Twenty Three and Me. Two weeks later he called me in a panic and said, "Jack, Mom is 85 percent Irish!" Then he sent in a his own ample and found that he is also largely Irish! No doubt I am the same and proud of it!!
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St. Joseph, My Silent Hero and a Man for Others!
As we Irish celebrate
St. Patrick
, we must not forget to celebrate
St. Joseph
. As a
Jewish
father, he was the first teacher of
Jesus
. Regardless of your religious persuasion, there is no doubt that this humble man had a mighty impact on the course of human civilization because he imbued his Son with the Jewish value of charity, especially for strangers. I have a special devotion to St. Joseph. I am a graduate of
St. Joseph's Prep
and
St. Joseph's University
, both in Philadelphia, and I chose Joseph as my confirmation name. We have no quotations from St. Joseph. No matter. His actions speak volumes. As a father, husband, dreamer, worker, and teacher, he stands apart and is a model for men.
Carol Maloney joined Valerie in our front office in December and is a graduate of
Providence College
. She kindly gave me a key chain bearing the emblem of St. Joseph's University for Christmas. Notice the lily atop the SJU. If you are so inclined, read about the
Lily of St. Joseph
. That lily reveals so much about the good man that we honored on March 19th and the woman he loved!
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Know Your Coronary Artery Calcium Score!
We have learned through experience that the calculator is imperfect. It can over or underestimate your risk. Now comes a better approach called
coronary artery calcium scoring
. In about 5 seconds, a CT scanner can measure your
coronary artery calcium (CAC)
and generate a score and percentile rating comparing you to your age and gender matched peer group.
As reviewed in the
Annals of Internal Medicine
on February 19, by Cardoso and others, a calcium score of 0 carries an excellent prognosis essentially eliminating the need for
statin therapy
. The authors refer to this as the "Power of Zero CAC" and indeed Ms. Clark and I have had the pleasure of telling a number of our patients that their CAC score is zero. For a calcium score between 1 and 99, statins are probably indicated. For scores greater than 100 or above the 75th percentile, statins are definitely indicated. As a rule of thumb, every reduction of LDL cholesterol by 40 mg/dL reduces cardiovascular risk by 25 percent. The addition of
Vascepa®
to a potent statin, as reported in the recent
REDUCE-IT trial
, further reduces cardiovascular risk. Thus the rationale for measuring coronary artery calcium is stronger than ever.
For reasons that only they understand, most insurance companies do not pay for this simple non-invasive test. The cost varies widely with
JSUMC
charging hundreds of dollars while
Princeton Radiology
and Open MRI charge only $50-$60, very good value for your hard earned money. The test is standardized and we find the reports to be of high quality regardless of where the test is performed. The radiation exposure is about the same as a
screening digital mammogram
, that is, about one-third of the annual radiation exposure from the sun.
It is my experience that cardiologists are more likely to order a costly
nuclear stress test
than a coronary artery calcium score. However, it is important to realize that a negative nuclear stress test does not rule out coronary artery disease or the need for statins, not at all. Said differently, a negative nuclear stress test is not the same as a calcium score of zero. A negative nuclear stress test only rules out a hemodynamically significant plaque, that is, one that occludes 80 percent or more of a coronary lumen. In symptomatic patients, an exercise test is indeed the most appropriate choice. But for the majority of patients who have no chest pain or shortness of breath, a calcium score is far more appropriate and informative. Remember, even small plaques, once ruptured, can lead to a heart attack or stroke. The greater the calcium score, the greater the "plaque burden", and the greater the risk of a future cardiovascular event even if the nuclear stress test is negative.
Most patients do not require a nuclear stress test even if their calcium score is positive. Rarely, we will refer an asymptomatic patient for exercise stress testing if they have a large amount of calcium in a critical vessel such as the
left main coronary artery
. One of our sedentary patients with a high calcium score had a strongly positive nuclear stress test and was referred for coronary artery bypass surgery. He is alive and well today. There is no doubt in my mind that the calcium score saved his life. We have also had the unfortunate experience of an asymptomatic patient with a negative nuclear stress test dying suddenly of a massive myocardial infarction. Had we performed a calcium score, we would have better understood the extent and location of her calcified plaque and performed life saving surgery before it was too late.
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Calculator vs Coronary Calcium Score
Calculators use population data to estimate your cardiovascular risk. However, each patient is a unique individual whose risk for ASCVD may or may not be adequately estimated by the calculator. Said differently, the population used to build the calculator may not be representative of your unique attributes. Calculators are also indirect, using blood tests and other data to estimate the likelihood of ASCVD. Now we finally have a simple quantitative tool that directly measures what we really want to know. Is there coronary disease or not? How much is there? Where is it located? We also get a look at your lungs which is especially important for smokers.
Before your next appointment, estimate your ten year cardiovascular risk using the calculator. Then let's discuss whether a coronary artery calcium score is appropriate for you.
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Driving Retirement
The day will come when most of us will have to stop driving to protect ourselves, passengers, pedestrians, cyclists, and other motorists. New Jersey statute says,
"Physicians are required by law to notify the NJ Motor Vehicle Commission if a patient suffers from a recurrent seizure, recurrent periods of unconsciousness or for impairment or loss of motor coordination due to conditions such as, but not limited to, epilepsy. (
NJSA 39:3-10.4
)."
As discussed in a beautifully written Perspective article by
Louise Aronson, MD
, published in the February 21 issue of the
New England Journal of Medicine
, driving is liberating for all of us, especially seniors. Most of us still remember how empowered we felt after receiving our first driver's license. This is even more true for seniors with physical disabilities. Once in their car, the shackles imposed by physical disability are suddenly removed enabling them to remain connected to friends, run errands, shop, go to church, receive out-patient physical therapy, and keep their doctors' appointments without imposing on others. In short, driving helps a person remain independent and independence leads to better health outcomes.
I will never forget the day when my dear wife, a retired cardiologist, lay very ill on NW6 of Jersey Shore University Medical Center on oxygen and barely able to use the bathroom as she was awaiting open heart surgery for a ruptured mitral valve. Who walks in but the salesperson from Seabreeze Ford!! Rita had notified security to let him in so she could sign the contract for her new Ford Focus!! With a stick shift no less!! With four weeks of hospitalization and many weeks of recuperation in front of her, she dreamed about driving that car and no person or operation was going to stop her, including me!! By now she has driven that car more than 15,000 miles, just a few more than her golf cart!!!
The goal is therefore to continue driving, which may sound odd to my risk averse readers living in a state as litigous as New Jersey. Having said this, we must be prudent. Vision and hearing need to be optimized by removing
cataracts
and wearing hearing aides. Medicines that might slow reflexes should be avoided. Persons should use familiar routes, drive at off-peak hours, minimize night-time driving, and avoid harsh driving conditions. Patients with
sleep apnea
need to be compliant with their
CPAP
. Patients with diabetes must take steps to avoid
hypoglycemia
. Pacemakers need to be checked and cell phones should be turned off. No alcohol!
Having said this, the day will come when driving retirement is essential to guaranteeing your safety, my highest priority. As Dr. Aronson advises, the transition should be gradual if at all possible taking care to avoid statements that might dishearten and demotivate the patient. My mom, who complains about almost nothing, often says how much she misses driving and how she hates to impose on others. It was the right decision and intellectually she knows it. But as Dr. Aronson writes so poignantly, she "knew instantly that the suggestion...to stop driving was not a single loss but the outermost figure in a Russian nesting doll of degradations what would steadily shrink her life until she, like the final doll, was a small, hidden version of her former self."
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Now Hear This!
As I pedal around Fairway Mews, I keep looking for Florida plates. None have arrived so far. When they do, Spring will have officially arrived!
March Madness: Regrets to the gallant Pirates of Seton Hall, the brave Knights of Fairleigh Dickenson, and Villanova Wildcats! Go Zags!
Phillies open on March 28th against the Braves with Bryce Harper in their lineup! Sorry, Val!
Valerie, Carol, Ms. Clark, Ms. Catong and I wish you a glorious springtime full of warmth and new life. Flonase users, please start now! Thank you!
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In This Issue
February-March: New Zealand Mass Killing is a Warning to U.S.!
God Blessed the Irish!
St. Joseph, My Silent Hero and a Man for Others!
Know Your Coronary Artery Calcium Score!
Calculator vs Coronary Calcium Score
Driving Retirement
Now Hear This!
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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 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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"We are born to love, we live to love, and we will die to love still more."
-attributed to Saint Joseph
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