May/2016
Issue: 52

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MAY you always _______ (fill in the blank!)
 
"May" is one of the most important words in our language because it names the month we most closely associate with motherhood and new life.  The word "may" is also important because it simultaneously conveys hope and humility.  May I have your blessing?  May I have your hand in marriage?  May is also about wishing.  May you always have your health!  May we always be as happy as we are today! When I fill in the blank, it usually has something to do with relationships.  May you always have a best friend!  May is a special word!  Use it often!

John A. Schmidt, MD 
Internist
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Desperate for Shut Eye? Improve Your Sleep IQ!
Sleep is a critically important part of healthy living.  Scientists still wonder why we need it and dedicate so much time to it.  As reported by BBC Earth, some interesting observations have come from animals that sleep with one eye open!  They rest one side of the brain while keeping the other wide awake. "Rest" is, of course, a misnomer. During sleep the "resting" brain goes offline and busily sorts through all of the day's events deciding what to file, what to discard, and what to keep for review. That's why "sleeping on it" can sometimes be the easiest way to solve a problem. Conversely, ruminating on problems that have no ready solution can often wreck a good night's sleep. Techniques to put such problems "in the parking lot" before we slumber can therefore be very beneficial indeed (see below).
 
According to the Centers for Disease Control and Prevention, insufficient sleep is a public health epidemic.  "Sleep is increasingly recognized as important to public health, with sleep insufficiency linked to motor vehicle crashes, industrial disasters, and medical and other occupational errors."  To test your sleep IQ take the Sleep Quiz at the National Center on Sleep Disorders Research!
 
"Insufficiency" means not enough sleep.  The first step to maximizing "sleep efficiency" is practicing good sleep hygiene.  This means going to bed at the same time each night and rising at the same time each morning, avoiding large meals, caffeine and alcohol close to bedtime, avoiding nicotine, darkening the room, wearing an eye mask and ear plugs to shut out ambient light and noise, turning off distracting electronic devices, and putting the dog (and your snoring human with restless legs-JK!) on the floor! Exercise is conducive to sleep provided it was done earlier in the day!
 
If you observe good hygiene but still can't sleep, please take a few minutes to complete the famous Stop-Bang or Berlin questionnaires and bring the results to your next visit.  Ask your sleeping partner to do the same! Men should also complete the International Prostate Symptom Score questionnaire while those experiencing sadness should complete the PHQ-9 questionnaire.  These questionnaires test for Obstructive Sleep Apnea, Benign Prostatic Hypertrophy with Bladder Outlet Obstruction, and depression, all of which can drastically reduce sleep efficiency.
 
What if none of this helps?  As published in the Annals of Internal Medicine on May 3, the American College of Physicians, following the lead of the National Institutes of Health and American Academy of Sleep Medicine, recommended that people with long-term sleep troubles try a form of psychotherapy before taking sleeping pills.  The psychotherapy is known as Cognitive Behavioral Therapy for Insomnia (CBT-I).  Experts like Dr. Nathaniel Watson, president of the American Academy of Sleep Medicine, contend that CBT-I has long lasting benefits without the side effects of sleep medications.
 
Sleepio and Shuti are online programs that use CBT-I to help you sleep better.  If you are a person who uses sleep medications month after month, you should give one of them a try and hopefully end an unhealthy dependence on sleep medications.
 
Is there still a place for sleep medications?  In a review article published in the May 3 issue of the Annals of Internal Medicine entitled "Pharmacological Treatment of Insomnia Disorder," the authors found that zolpidem (Ambien), eszopiclone (Lunesta), and suvorexant (Belsomra) had the best short-term results. Evidence for benzodiazepine hypnotics (trazolam/Halcion), melatonin agonists (ramelteon/Rozerem), antihistamines (diphenhydramine/Benadryl) and antidepressants (trazodone/Oleptro), was insufficient or low strength." Another important consideration is cost. Consumer Reports rated generic zolpidem as the best buy. Yet another consideration is how fast the medicine is cleared from the body to minimize hangover and side-effects. Zolpidem is cleared quickly. Zolpidem-CR and Eszopiclone take longer while recently released Belsomra takes even longer probably accounting for the drowsiness listed as a significant adverse reaction in the FDA-approved label.
 
Bottom Line: Everyone has a bad night's sleep from time to time-it's normal. Those with persistent insomnia, defined as three nights per week for at least three months, should consider CBT-I as their first option using one of the on-line tools mentioned above or seek the help of a sleep therapist trained in CBT-I. Medications are useful for short term use, as a bridge to CBT-I, or for those failing CBT-I.
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Spinal Fusion in Patients with Spinal Stenosis
The spinal cord and its roots travel inside the spinal column in a channel called the spinal canal. The spinal column is made of bone and flanked by joints. Because bone is hard, many think of it as a static tissue. Nothing could be further from the truth!  Bone is constantly remodeling and it can grow, even in adulthood. Bone grows in response to excessive mechanical stress. It is nature's way of buttressing arthritic joints. You can easily convince yourself of this by feeling those bumps that often develop around finger joints from years of opening vacuum sealed containers! Those bony outgrowths are called osteophytes. When osteophytes grow in the direction of the spinal cord, the canal narrows (stenosis) and the soft spinal cord becomes compressed resulting in wicked back, buttock, and leg pain.
 
Surgery for spinal stenosis is popular in the United States. The surgery, called laminectomy, removes some of the bony osteophytes pressing on the spinal cord and its roots.  The surgery has been increasingly combined with spinal fusion where hardware (rods and screws) is used to immobilize the lumbar spine, adding to the cost, complications, and post-operative recovery time.
 
Now come two landmark studies in the April 14 issue of the New England Journal of Medicine, one from the United States and the other from Sweden, showing that laminectomy and fusion were no better than laminectomy alone. For most patients with symptomatic spinal stenosis contemplating surgery the results are clear: laminectomy yes, fusion no!
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Expanding the Definition of Chronic Obstructive Pulmonary Disease (COPD)
Chronic Obstructive Pulmonary Disease (emphysema) results from inhalation of cigarette, cigar, and e-cigarette smoke from you and/or the people around you. Doctors have traditionally made the diagnosis when pulmonary function tests (spirometry) show delayed exit of air from the lungs on forced expiration (FEV1).  But all practicing internists, myself included, have encountered severely symptomatic smokers whose pulmonary function tests are normal. Do they have COPD? Yes, because as shown in the May 12 issue of the New England Journal of Medicine, such individuals suffer the same symptoms and adverse outcomes even though they have preserved pulmonary function.  The authors used a questionnaire called the COPD Assessment Test which is available on line. If you or a loved one is a smoker and have been lulled into a false sense of security based on normal pulmonary function testing, take the questionnaire, find out if you have COPD, and take corrective measures to preserve your life!  
Now Hear This!
The office will be closed on Monday, May 30, in observance of Memorial Day. On behalf of myself and my dedicated staff, we extend our utmost gratitude to those men and women who have served our country and preserved our freedoms! Thank you! You are our heroes! 
 
In case you hadn't noticed, Ms. Clark is an Air Force veteran.  Thank you, Ms. Clark, for your service!
 
I also wish to extend my deepest gratitude to those of you who have sent cards and Mass Cards celebrating my dad.  He was a veteran and he will be remembered in a special way this Memorial Day!
 
On a happy note, my mom celebrated her 88th on May 25 along with our son, John III. Sixty-one years apart, they have a special relationship made all the more so by dad's passing.
 
May you have a wonderful holiday weekend with the ones you love! 
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In This Issue
MAY You Always
Desperate for Shut Eye? Improve Your Sleep IQ!
Spinal Fusion in Patients with Spinal Stenosis
Expanding the Definition of COPD
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.

  
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"As full of spirit as the month of May, and as gorgeous as the sun 
in Midsummer." 

William Shakespeare

Congratulations to our patient, Mrs. Mildred Piechota, now more than 100 years old and still going strong!



 
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.