Issue: 42

U.S. Women Simply Amazing!

In what I believe will be a turning point in U.S. women's team sports, the U.S. Women's Soccer Team defeated No. 2 ranked Germany and then a very talented Japanese team to win the FIFA Women's World Cup Soccer Championship! I was particularly impressed with their lighting speed and pin-point accuracy! With four natives of New Jersey on the team, we have much to be proud of!!


John A. Schmidt, MD 


Coronary Artery Calcification (CAC)

Atherosclerosis (hardening of the arteries) results in calcium deposits in arteries that supply the brain, heart, and legs with life-sustaining blood.  Just as an X-ray can "see" the calcium deposited in healthy bones, an X-ray and computerized tomography (CT) can see and accurately measure the calcium deposited in arteries.  Whereas calcium deposition in bones is good and essential to preventing fractures, calcium deposition in blood vessels is known to be bad and a biomarker that predicts the likelihood of heart attack.


As reported in the July 7 issue of the Annals of Internal Medicine, Coronary Artery Calcification (CAC) score correlated with all-cause mortality after 15 years of follow up of almost 10,000 asymptomatic patients substantially increasing the value of what was already a very useful predictive biomarker.


Sadly, insurance companies do not pay for the performance of this simple test.  Why?  There are two main reasons.  First, studies conducted to date showed that patients were no more likely to modify cardiac risk factors (diabetes, smoking, hypercholesterolemia, hypertension, obesity, exercise routine) once informed of their CAC score. Presumably their behavior might change with better education. Second, and most importantly, there is no intervention trial to show that treating patients on the basis of CAC score improves outcomes.  Nevertheless, for patients who need extra motivation or who are on the fence regarding cholesterol lowering statins, paying out of pocket for a CAC score may be a good investment!  Let me know if you would like a prescription for this test.

MRI Imaging of the Brain Discriminates Vascular Dementia from Alzheimer's Dementia

Many of my patients fear Alzheimer's disease especially after having watched a family member or friend gradually lose their cognitive ability. Most have also witnessed the sudden neurological deficit that occurs after a stroke. Alzheimer's disease, by definition, is not the result of vascular disease. Strokes, on the other hand, are usually caused by blockage of a blood vessel by a ruptured atherosclerotic plaque or emboli released from the heart. (See last month's issue regarding exciting new progress in treating stroke!)


As reported in the July 7 issue of the Annals of Internal Medicine there is a more subtle process known as subclinical brain infarctions (SBIs).  Also known as "lacunar strokes," these can be asymptomatic and are often less than three mm in diameter. In a prospective study of almost 1,900 patients, the investigators found that these small lesions, though usually silent, put patients at significantly increased risk for subsequent stroke and stroke related death. These subclinical lesions were associated with hypertension, elevated hemoglobin A1c levels and smoking whereas larger lesions were associated with elevated LDL levels. An accumulation of these lesions can lead to Vascular Dementia with or without a clinical stroke.  Risk factor reduction (treatment of high blood pressure, prevention of diabetes, stopping smoking) may therefore not only serve to prevent heart attack and stroke, but vascular dementia as well.  Patients with lacunar strokes on MRI should be treated with a full dose aspirin (325 mg daily). Bottom Line: not all dementia is due to Alzheimer's disease for which we have no treatment.  Some dementias (about one-in-four) are the result of vascular disease and preventable with risk factor modification!


Gastroesophageal Reflux Disease (GERD)

As reported in the July 7 issue of the Annals of Internal Medicine, GERD results from retrograde passage of acidic gastric contents into the esophagus causing heart burn which can masquerade as heart pain (angina pectoris).  If gastric acid goes as far north as the oropharynx (back of the mouth), acid can be inhaled and cause hoarseness, cough, asthma, globus (a full sensation that makes you want to swallow again and again), dental erosions and/or throat pain. Thus, the diagnosis can be made by a dentist finding eroded dental enamel, or suggested by your Ear, Nose and Throat (ENT) specialist upon examination of your vocal cords with a fiber optic scope. A Reflux Disease Questionnaire (RDQ) has been developed to help patients and physicians make the diagnosis of GERD. A definitive diagnosis requires endoscopy or measurement of esophageal pH.  A therapeutic trial with a proton pump inhibitor (PPI; omeprazole, etc.) may be helpful in confirming the diagnosis without having to perform these invasive tests.  In patients who do not respond to PPIs or with "alarms symptoms" (weight loss, difficulty swallowing, recurrent vomiting, iron deficiency anemia due to blood loss, persistent complaints over several years, and/or history of Barrett's esophagus), an upper endoscopy is indicated.  Some patients may have to take PPI's indefinitely but many can use the medications as needed ("on-demand") after recovering from the initial episode. The best time to take a PPI is 30-60 minutes before breakfast. The vast majority of patients with GERD do not require an endoscopy and there is currently no evidence to show that such patients without alarm symptoms should be screened for Barrett's esophagus, an alteration in the lining of the lower esophagus that rarely develops into cancer.  

Ultraviolet Radiation is the Cause of Skin Melanoma

As reported in the July 9 issue of the New England Journal of Medicine, 75,000 people in the United States are diagnosed with melanoma every year and 10,000 die from the disease.  Melanoma is the most serious form of skin cancer. The primary cause of melanoma is known: DNA damage resulting from exposure to ultraviolet radiation.  Melanoma rates have been increasing for decades.  It is the fifth leading cancer in men and seventh in women.  Among Caucasians, proximity to the equator correlates with incidence of melanoma.  Reducing exposure to UV radiation (UVA and UVB), from both the sun and artificial sources such as tanning beds, is therefore essential to prevention. Protecting children is especially important. The World Health Organization (WHO) has classified UV radiation from tanning beds as a carcinogen.  The notion that tanning protects against melanoma is a dangerous myth.  Coco Chanel, who popularized tanning in the 1920's was sadly wrong.


In 2013, advocates for patients with melanoma, dermatologists, and manufacturers of new ingredients came together in a coalition called Public Access to Sun Screens (PASS).  At the end of 2014, Congress passed and President Obama signed bipartisan legislation called the Sunscreen Innovation Act setting deadlines for FDA review of new over-the-counter sunscreen products.  However, no additional resources were provided to FDA.  In recent months, the FDA has declined to permit use of eight new sunscreen ingredients without additional data even though these have been used in Europe for five years.


I agree with the editorialist that FDA needs to be given more resources to work with manufacturers of potentially innovative sunscreen products.  In the meantime, you can do your part by wearing sun protective clothing and using high sun protective factor (SPF) and water-resistant sun screen creams, sprays, and lotions.  Reapply after bathing and, for goodness sake, avoid tanning salons!!  Patients who have had melanoma, individuals with more than 25 nevi, those with more than one first degree relative with melanoma, and transplant patients should have annual skin checks by a qualified dermatologist because of their increased risk.

Synthetic Cannabinoids

I have mentioned in past issues my serious misgivings about the legalization of marijuana because of its role in automobile accidents, negative effects on cognitive development in adolescents, and its ability to serve as a gateway to more serious intoxications and addictions.  Now there is yet another reason for alarm.  As discussed in the July 9 issue of the New England Journal of Medicine, chemists in a real life version of Breaking Bad have been surreptitiously making synthetic derivatives of tetrahydrocannabinol (THC), the active ingredient in marijuana.  Some of these are regulated by the Drug Enforcement Administration (DEA) but many are not. These potent chemicals are used to lace plant material such that they have the appearance of typical "weed." Some have found their way into e-cigarettes. Outbreaks of deaths due to the ingestion/inhalation of these compounds have been increasingly reported in the United States. Unlike opioids, there is no antidote or readily available diagnostic test available to ER physicians.  Municipalities and jurisdictions anxious to have the tax revenue from marijuana often do not provide the oversight necessary to keep these toxic chemicals out of the hands of unsuspecting users.  If you or someone you love decides to use marijuana, make sure it can be traced back to a safe and licensed grower.  Better yet, avoid the stuff altogether! 

Now Hear This!

The big day is rapidly approaching!  Our youngest daughter is about to be married to a wonderful guy on August 1 in the City of Brotherly Love!  But I'm not excited.  I'M VERY EXCITED!  So please submit your refill requests and other requests early.  The office will be closed except for emergencies beginning Wednesday, noon, July 29, and will reopen on Monday, August 3.  Thank you!


Valerie, Morgan, and I wish you a happy summer (in the shade!).

In This Issue
U.S. Women Simply Amazing!
Coronary Artery Calcification
MRI Imaging of the Brain Discriminates Vascular Dementia from Alzheimer's Dementia
Gastroesophageal Reflux Disease
UV Radiation is the Cause of Skin Melanoma
Synthetic Cannabinoids
Now Hear This!


John A. Schmidt Jr., M.D.


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 at Rutgers Robert Wood Johnson Medical School.



 Feel free to share this newsletter with your family and friends.



Register to receive our monthly newsletter



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.