Issue: 68

September: Mother Nature Brings Us Together
As if to send a strong message to the Divider-in-Chief  and his isolationist followers, Mother Nature has sent the oval office a strong missive to close ranks.  Natural disasters of unprecedented magnitude have struck North America including Houston, Florida, the Keys, Mexico City, and Puerto Rico.  Like you, I have friends, family, colleagues, and loved ones in at least two of these places and have struggled to find out if they are safe.  Having suffered the dire consequences of Super Storm Sandy, I am experiencing post-traumatic stress disorder (PTSD) for the first time. And because the World Trade Center Twin Towers also fell in September, it has been a double whammy.  But here's the question: The Trade Tower disaster brought us together, made us stronger and more united. Will we approach these recent natural disasters with the same integrity?  Our resolve for a unified nation, one for all and all for one, is being tested. Remember that the citizens of Puerto Rico are also citizens of our United States. They therefore deserve our full and unflinching support.  Please consider on-line contributions to the American Red Cross and Catholic Relief Services , both of whom are straining to provide services to these severely distressed areas. For those of you who are victims of these hurricanes and are in need of tax relief or government aid, you may find the newsletter on the subject from McCarthy & Company, PC helpful.
John A. Schmidt, MD 
The Public Health Consequences of Rescinding Deferred Action for Childhood Arrivals (DACA)
Imagine being brought to the United States by your undocumented parents before you could pronounce your name.  You master the English language, attend school, and enter the work force.  Some say you are a living example of the American Dream . Others say you are an imposter and deserve to be deported.

The Gospel on Sunday, September 24, was one of the most difficult for me to accept.  The owner of the vineyard paid the same wage to those who worked a full day, a half day, or a quarter day.  Clearly those who worked fewer hours should be paid less.  Except the owner of the vineyard disagreed and paid all the same wage.  Hmmm... Clearly the vineyard owner did not attend business school.  Will he no longer be able to attract full-time laborers or will he be flooded with grateful, talented, and committed workers to make his vineyard the best in the land? I suspect he didn't care.  His only goal was to give his workers a living wage so they could survive long enough to show up the next day.  Charity?  Enlightened self-interest?  You decide.  But know this.  The stress put on the Dreamers by the Divider-in-Chief will have consequences for our health care system in general and our mental health care system in particular. Read the editorial published online in the New England Journal of Medicine on September 13 for more. As your physician, I am interested in your blood pressure, not your immigration status.  Doctors' offices, hospitals, and clinics are, by definition, sanctuaries.     
Chimeric Antigen Receptor T-cell (CAR-T) Therapy: A Major Advance in the Battle Against Cancer!
You and I count on our immune systems to destroy invaders, including cancers. As discussed in previous newsletters, cancers have developed elaborate mechanisms to keep our immune systems in check.  Fortunately, medical investigators have now found new ways to empower our immune systems to target and destroy the cancers that would prematurely end our lives.

The latest episode in this great and evolving story comes from the University of Pennsylvania School of Medicine and the Children's Hospital of Philadelphia , where investigators, led by Dr. Carl June , have taken lymphocytes from persons dying of cancer and genetically engineered them to kill tumor cells.  Novartis , a drug company with facilities in New Jersey, worked closely with the UPenn physician-scientists, leading to the first FDA approval of CAR-T technology , in this case, for Acute Lymphoblastic Leukemia on August 31. 

The pharma industry is criticized for profiteering and rightly so. This, on the other hand, is a genuine advance born of decades of painstaking research.  Read the inspiring account in the September 17 online issue of the New England Journal of Medicine of how a five-year old, Emily Whitehead, was saved and is a thriving, tumor-free 12-year-old today.

The immune system, once unleased, is a powerful warrior. CAR-T is not for the faint hearted. The potential for collateral damage is considerable.  As discussed in the article, the future success of CAR-T depends, in part, on minimizing damage to normal cells.  Fortunately, progress has been made in this area as well.
Patients with Mild to Moderate Chronic Obstructive Pulmonary Disease (COPD) Benefit from Daily Tiotropium
COPD , largely a disease of smokers, chips away at lung function eventually rendering a person breathless and dependent on supplemental oxygen . Tiotropium (Spiriva®) and similar muscarinic antagonists help patients with severe COPD by reducing mucus production and opening airways.  Now comes an important study in the September 7 issue of the New England Journal of Medicine showing that tiotropium is also useful in treating the early stages of the disease. The annual decline in the forced expiratory volume (FEV1, i.e., the amount of air one can forcefully exhale in one second) after bronchodilator use (e.g., Ventolin® , ProAir® ) was significantly less in the tiotropium group.  As is generally the case for most diseases I treat, early intervention is therefore the key to success.
Kidney Function in the Systolic Blood Pressure Intervention Trial (SPRINT)
As published in the September 19 issue of the Annals of Internal Medicine , "nearly two-thirds of U.S. adults aged 60 years or older have hypertension."  Hypertension is an important risk factor for stroke , heart attack , and chronic kidney disease and, because it is the " silent killer ," often goes untreated before it is too late.

The SPRINT trial examined the effects of intensive (< 120 mm Hg) versus standard (< 140 mm Hg) control of systolic blood pressure (the top number).  As reported in my August newsletter , recent analysis of patient reported outcomes showed that more aggressive control of systolic blood pressure was generally well tolerated.

One of the goals of blood pressure control is to prevent renal damage .  Paradoxically, aggressive control of blood pressure occasionally leads to an elevation in creatinine and a decrease in glomerular filtration rate (GFR) .  Does this mean that treatment of high blood pressure damages kidneys?  No, on the contrary.  Filtration pressure , of course, declines with falling blood pressure.  Thus, the observed changes in creatinine and GFR reflect normal physiology.  We know this because withdrawal of blood pressure medicines rapidly leads to a rebound in GFR.  

SPRINT showed that cardiovascular events  and, all-cause mortality was significantly lower in the aggressive treatment group. I agree with the SPRINT authors when they conclude that an elevation in creatinine is benign when compared with heart attack, stroke, or death. This is yet another example of how doctors and patients need to pay more attention to clinical outcomes than laboratory data.
Medicare Part D Open Enrollment
All Medicare patients are required by law to purchase medication coverage (Part D).  Unfortunately, many of my Medicare patients opt for cheap plans and then end up paying large out-of-pocket sums for the medicines they deserve. October 15th  marks the beginning of Medicare Open Enrollment.  I advise all Medicare recipients to visit  and click on the part D tab.  Enter your zip code and medications and sign-up for the plan that best meets your needs and your pocketbook!
Medication Reconciliation (Med-Rec)
Perhaps the greatest challenge I face is knowing what medicines you are taking, when you are taking them, and how often.  Most patients find this odd.  They say: "You prescribed them, so you must know."  Well, in some cases that is true.  However, most of my patients are also taking medicines prescribed by other physicians, nurses, and clinics.  Some pharmacies provide a "fill history," but most, unfortunately do not.  Thus, the only foolproof way for me to know what medicines you are taking is to read the labels of your medication bottles.  So please, please, please bring ALL of your medication bottles to each and every visit.
Patient Portal
We are now showing a short tutorial video in our waiting room describing our free online Patient Portal  called "Follow My Health." Please look up from your magazine and see how a few minutes of your time can improve your health care!!

Morgan, Valerie, Ms. Clark, and I wish you a wonderful autumn and a quick recovery from the recent storms!
In This Issue
September: Mother Nature Brings Us Together
The Public Health Consequences of Rescinding Deferred Action for Childhood Arrivals (DACA)
Chimeric Antigen Receptor T-cell (CAR-T) Therapy: A Major Advance in the Battle Against Cancer!
Patients with Mild to Moderate Chronic Obstructive Pulmonary Disease (COPD) Benefit from Daily Tiotropium
Kidney Function in the Systolic Blood Pressure Intervention Trial (SPRINT)
Medicare Part D Open Enrollment
Medication Reconciliation (Med-Rec)
Patient Portal Please!!
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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Click here to learn more about the benefits of our Follow My Health Patient Portal and register today! You can make appointments and get your lab results on the portal. Simply ask Valerie to send you an invitation. Call 732-282-8166.

"A good government may, indeed, redress the grievances of an injured people; but a strong people can alone build up a great nation."

- Thomas Francis Meagher


Dr. Schmidt's New Office in Spring Lake Heights
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.