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October: Halloween and the Goblins of Fear!
I have yet to meet a patient who is completely carefree. Cares lead to anxieties, anxieties to fear, and fears occasionally lead to panic and paralysis. Have you ever been so afraid you were unable to move? I have.
There are rational fears and irrational fears. The former we understand, the latter less so. Either way, it is useful to probe the cause. For instance, some of my patients have witnessed the suffering of a relative or dear friend and live in fear that the same terrible outcome will befall them (Guilt enters in here. Why should I be so lucky?). People who know and care for you can help you identify your fears and support you. The solution begins with introspection, seeking help from close friends, and then dealing with those goblins in a supportive environment.
Fear can lead to bad behaviors. For example, patients sometimes deal with fear by expressing anger, rage, and foul language. Rather than admitting their fear and receiving empathy from loved ones, they lash out and antagonize their caregivers. Reflection can help fearful patients engage those around them, thereby avoiding alienation of those they need most.
Another fear-driven phenomenon is the
somatization syndrome
. A patient may have, for example, heartburn, convince him/herself it's a
heart attack
and, fast forward, double their heart rate and blood pressure. Analyzing the steps that led to this downward spiral can help patients avoid fruitless trips to the ER.
Alcohol, tobacco, and narcotics are
maladaptive approaches
to dealing with fear. Exercise, yoga, prayer, and mindfulness exercises are healthier approaches to
anxiolysis
. Prescription medicines can be helpful but are best used in conjunction with these measures and/or psychotherapy. The two classes of medicines that work best are
benzodiazepines
and
selective serotonin reuptake inhibitors
(SSRIs). Benzodiazepines work quickly whereas SSRIs take time. I prescribe these medicines in combination, relying on benzodiazepines to buy time for SSRIs. Once the SSRI has reached full effect, typically three weeks, many patients no longer need benzodiazepines or only need them for
breakthrough anxiety
. The fast-acting benzodiazepine,
alprazolam
(
Xanax®
), has addictive potential so I reserve it for patients with
authentic panic disorder
. The benzodiazepines with longer duration of action,
clonazepam
(
Klonopin®
) and
lorazepam
(
Ativan®
), are usually the best choice and, if dosed properly, allow patients to function without sedation.
John A. Schmidt, MD
Internist
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Nobel Prize in Medicine or Physiology: What's Your Chronotype?
The
Nobel Prize in Medicine or Physiology for 2017
has been awarded to three American scientists who discovered the "
clock genes
," the genes which regulate
sleep-wake cycles
,
core body temperature
,
cortisol
, food intake,
cognitive performance
, mood and other critically important bodily functions, known collectively as
circadian rhythms
. The clock genes function as an
oscillator
. As the clock gene known as
Period
accumulates, it turns off its own synthesis. The degradation of Period starts the cycle over again to match the 24-hour cycle resulting from the earth spinning on its axis as it rotates around the sun. Most of the cells in the body have clock mechanisms. They obey signals generated by the "master clock," a group of about 20,000 nerve cells called the
suprachiasmatic nucleus
(SCN). The SCN is located in a part of the brain called the
hypothalamus
that receives direct input from the eyes.
The purpose of the clock is to prepare us for the start of the day.
Jet lag
results when we land in an eastern time zone before the clock genes turn on. We feel terrible and are unable to face the day. There are data suggesting that
seasonal affective disorder
(SAD) is related to genetic variation in the genes encoding
clock proteins
.
The most important circadian rhythm in my practice is blood pressure. For most of us, blood pressure peaks in the morning and declines in the evening. This is why I encourage my patients to focus on their morning blood pressure and take their blood pressure medicines first thing in the morning. Respect the clock in your brain, not the one on your wrist!
The chronotype of your surgeon may be important or so a study published online in
The Lancet
on October 26 would suggest!
Elective surgery
is best because your surgeon and his/her team are fully awake!
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Selecting the Best Medications for the Treatment of Type 2 Diabetes
As discussed in previous issues of this newsletter, the treatment of type 2 diabetes is changing dramatically for the better. The older, cheaper medicines do not have the same
cardiovascular
, kidney, and weight loss benefits provided by the newer medicines. Among the newer medicines there are two standouts.
As reported in the August 31 issue of the
New England Journal of Medicine
, Victoza® also resulted in lower rates and progression of
diabetic kidney disease
." This is an important added benefit because diabetes is the leading cause of
chronic renal failure
and
hemodialysis
in the United States. There is a competing once-a-week product called
Trulicity®
, but it has not yet demonstrated the same benefits as daily Victoza. Likewise,
Bydureon®
, a once weekly GLP-1 agonist, as reported in the September 28 issue of the
New England Journal of Medicine
, failed to show a cardiovascular benefit. Thus, until proven otherwise, Vicotoza® is the only injectable with a cardiovascular and renal benefit in patients with
type 2 DM
. Note that none of the insulins used in the treatment of type 2 diabetes (
Lantus®
,
Levemir®
,
Toujeo®
,
Tresiba®
,
Basaglar®)
have been demonstrated to have the same benefits. Thus, among injectables, insulin is no longer preferred! Take Victoza® instead.
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If you have type 2 diabetes, exercise vigorously, reduce intake of
concentrated carbs
, and check if your medication plan covers Jardiance®, Invokana®, and/or Victoza®. If not, change plans!!! Avoid
donut-holes
! If you are a
Medicare
patient, visit
Medicare.gov
, pull down the
part D tab
, and enter your current meds and zip code. Then enter Victoza® and Jardiance® and select the lowest cost plan for you without donut-holes!
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Strategy to Reduce Your Health Care Insurance Premiums in 2018!
If you are not a Medicare or
Medicaid
patient, your 2018 medical insurance premiums will probably be higher. But there is a good strategy to keep a lid on your out-of-pocket costs. Purchase a
high-deductible policy
and contribute to a
Health Savings Account
(HSA)! Your contributions to the HSA are tax deductible, your contributions stay with you and can be invested for growth, and any withdrawals are tax free. Call your bank and set up a HSA. If they don't offer one, find one that does.
Horizon
is offering a high-deductible policy with a built-in HSA. Check it out!
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It gives me great pleasure to welcome Ms. Amanda (Mandy) Sivits to my practice. Mandy will be working with Valerie to serve you as Morgan prepares to begin her nursing career at Hackensack-Meridian's Riverview campus. Please give her a warm welcome! Thank you!
Valerie, Morgan, Mandy, Ms. Clark and I wish you a Happy Halloween, reverent All Saints Day, hopeful All Souls Day, and joyous beginning to the Holiday Season!
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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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"Health is the greatest gift, contentment the greatest wealth, faithfulness the best relationship."
- Buddha
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