Issue: 55

August Olympics: Simply Superlative!
My faith has been restored!  After so much naysaying and hand-ringing, the Rio Olympics were an unqualified success! There were so many highpoints but the image that will forever live in my memory is that of the U.S. Women's Gymnastics Team!  They were so poised, so cool under pressure, the epitome of a team: all for one and one for all!  I'll go further. I saw in them a metaphor for what we hopefully will become as a nation: diverse, confident, disciplined, joyful, gritty, and tireless in our pursuit of excellence!  There was another team competition worthy of mention - that of the U.S. women's eight rowing for gold! As recounted in the New York Times on August 13, the boat had fallen behind at 1,000 meters and it was up to the coxswain to inspire her team.  What did she say?  "This is the United States women's eight!" With pain searing in every muscle, the women reached down deep and won by two seats! I am so proud of the women and men and their families who have sacrificed, prepared, and, most of all, worked together to achieve unprecedented results!  With devotion like theirs, our future is bright!

John A. Schmidt, MD 
To Floss or Not to Floss: That is the Question!
As reported in the New York Times on August 2, the data supporting dental flossing is weak. So why do it? First, this could be said for many activities of daily living (ADLs). If you wait for a controlled randomized trial (CRT) before deciding to comb your hair, you could be waiting a very long time with your hair in a hopeless tangle!  Second, and more interestingly, flossing has to do with biofilms.  Biofilms are complex communities of bacteria that adhere to a surface. They cover rocks in ponds, the walls of your fish aquarium, your toilet bowl and bathroom sink, and your teeth!  By means of a process known as "quorum sensing," early colonizers reach a critical mass and then begin to secrete a matrix that provides a home for late colonizers, some of which produce substances damaging to teeth and the periodontal ligaments that attach teeth to bone. So while there is no rigorous proof, there is good scientific rationale for flossing.  Flossing prevents colonies of bacteria from reaching critical mass (aka, plaque), thereby preventing gingivitis and loss of teeth.  As my brother the dentist says, "Be true to your teeth and they won't be false to you!"  When asked about the lack of evidence supporting flossing, he said, "Just do it!" 
Autologous Stool Transplantation for Recurrent C. diff
Speaking of biofilms, one of the most complex thrives in our intestines. These bacteria produce important substances such as vitamin K, which is used by the liver to make clotting factors II, VII, IX and X.  Antibiotics, especially broad spectrum antibiotics used to treat serious infections, have the potential to disrupt this beneficial community. Vitamin K levels go down and "blood thinners" designed to block the activity of vitamin K such as warfarin (Coumadin®), suddenly become far more potent, increasing the risk of bleeding. Another unintended consequence may be the emergence of pathogens normally kept in check by normal gut flora.  One such pathogen is Clostridium difficile (C. diff) which has become a common hospital acquired infection.  Counterintuitively, C. diff is treated with antibiotics, but not always successfully. Instillation of feces into the colon (elegantly known as "fecal microbiota transplantation") is sometimes the only thing that works!  As reported in the Annals of Internal Medicine on August 23, not all feces are equally effective (but I suggest you take this up with your gastroenterologist!) 
Know Your Hip Bone Mineral Density (BMD) and T score!
Hip fractures are unfortunately common requiring immediate hospitalization, open surgical repair by a skilled orthopedist, and prolonged convalescence.  They are the result of osteoporosis or thinning of the femoral neck (aka, hip bone).  A simple X-ray, known as a DEXA scan, measures the bone mineral density (BMD) in the fracture-prone femoral neck(s) to give a "T score." Hips with T scores less than -2.5 are at increased risk of fracturing.  Entering your BMD into the FRAX calculator ( links) gives an estimate of your ten-year risk of suffering a hip fracture. According to the World Health Organization, an individual with a ten-year hip fracture risk greater than three percent should be treated, usually with a bisphosphonate, while staying active and consuming adequate amounts of calcium and vitamin D.
Now comes an important study in the July 19 issue of the Annals of Internal Medicine showing that it is important to measure the change in BMD during the first year of treatment. Why? Patients whose bone mineral density (BMD) increased on treatment had the lowest hip fracture rates whereas those whose BMDs continued to decrease had more fractures. About one in four women fell into this higher risk group. Given that there are now good alternatives to bisphosphonates, especially Prolia®, it is important to identify treatment failures and consider alternative treatments.
While the study focused on women, remember that men also develop osteoporosis and are equally susceptible to hip fractures as they age. Thus men should also have DEXA scans, probably beginning at 70 years of age.  It is also useful to remember that gravity is your hip bone's best friend as clearly demonstrated by the osteoporosis that rapidly occurs in male and female astronauts staffing the international space station.  A sedentary lifestyle, prolonged bedrest, prednisone, and aromatase inhibitors (Femara®, Arimidex®, Aromasin®) all serve to weaken hip bones whereas walking eight miles per week has been shown to reduce the incidence of hip fractures by two thirds! 
Boxing glove and word Flu isolated on white background
Flu Vaccination 2016-2017
To those who say, "Oh, I never get the flu." or "I got the flu after receiving the shot." I have several replies.  First, the virus is changing all the time so past experience provides no guarantee.  Second, the flu virus infects the young and the old, the well and the unwell, though pregnant women are at greatest risk. Third, the medicines we have to prevent and treat influenza, especially sometimes fatal flu pneumonia, are not very effective so prevention is the key. Fourth, the virus used in the injected vaccine has been thoroughly killed so it is impossible to contract the disease from the vaccine.  Fifth, even if not completely effective, you are likely to have a milder form of the infection having had the vaccine.
The Centers for Disease Control and Prevention (CDC) recommends that everyone 6 months of age and older should get an injectable flu vaccine starting now. The nasal spray flu vaccine (live attenuated) should not be used this season.  A high-dose trivalent vaccine is approved for patients 65 and older.  A recombinant, egg-free, trivalent shot is approved for people 18 and older.  If you had a reaction to past flu vaccinations, the recombinant vaccine is a good choice.
Use your other arm to catch up on your other vaccinations!
Now Hear This!
Based on your helpful survey feedback, the practice will be moving to a new, improved, more accessible location come January 1.  I will provide regular updates as we approach the date.
Valerie, Ms. Clark, and I wish you a rest from your labors this Labor Day weekend! The office will be closed on Monday, September 5.  As usual, for emergencies, I can be reached on my cell phone at (908) 256-9439.
In This Issue
August Olympics: Simply Superlative!
To Floss or Not to Floss
Autologous Stool Transplantation for Recurrent C. diff
Know Your Hip Bone Mineral Density (BMD) and T score!
Flu Vaccination 2016-2017
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 Associate Attending in the Department of Medicine, Jersey Shore University Medical Center, and  Clinical Assistant Professor in the Department of Medicine, Rutgers Robert Wood Johnson Medical School.

Dr. Schmidt is enrolled in the Maintenance of Certification Program of the American Board of Internal Medicine

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""Choose a job you love, and you will never have to work a day in your life" ." 

- Confucius

John A. Schmidt Jr., MD
Meaningful Medicine in Your Medical Home
709 Seventh Avenue
Belmar, NJ 07719
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.