Medical Monday: Breaking News from the World of Obstetrics and Gynecology

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I spent this week at Stanford MedX Conference. This conference covers some of my fondest professional interests. In particular, we covered various themes of technology in medicine, such as the use of devices and apps for patients to use to follow chronic disease conditions like diabetes. We covered the increasingly important role of apps in research. 

We explored the phenomenon of peer to peer connections among patients and discussed how it is especially helpful with rare or undiagnosed conditions. 

Another prominent theme at the conference was design in health care. We heard lectures and  participated in workshops in human centered design, or more particularly patient centered design. We used design thinking to create maps of the patient experience, then took that information forward to inform features as disparate as language used in phone notifications, seating in exam rooms, and interior decor. 

One theme of the conference was “everyone included”. I already knew this meant the voices of all genders. I also learned it meant all those in health care, not just patients and caregivers. Namely, it also included family members, medical researchers, device makers and all those who design and evaluate the health care experience. 

The genius of the conference in my mind was that it brought together those who were traditionally separate. In my two years of attending the conference it became readily apparent that fantastic synergies were possible by bringing together people from these varied  backgrounds. Patients, physicians, scientists, designers and computer scientists, sat around around common tables to learn methods to solve vexing problems in health care. And yes, we were given large sheets of paper, colored markers and sticky notes. 

But... the people ! This was the best part of all. I am here to report that there are plenty of good and brilliant people in the world with the ability to conceive of solutions to serious problems. At this conference, they came in all shape, sizes, ages, nationalities and genders. You could not pick them out at a grocery store. But if they had a conversation at your dinner table, you would quickly learn how special they were.  

On to policy. The Congressional Budget Office (CBO) continues to predict a 15 percent rise in premiums for policies under the Affordable Care Act (ACA). They have reported that this will likely be the case due to uncertainty over the Federal government’s willingness to pay subsidies to defray the cost of health care. Also likely contributing might be reduced  number of enrollees now that the individual mandate is not being enforced. 

GOP Senators have pared their efforts down to a one point bill. This final attempt to repeal and replace Obamacare basically takes Medicaid expansion money and shifts it to block grants administered by States. 

At the same time, Senator Bernie Sanders has proposed a near opposite. He has proposed retooling Medicare in the image of Obamacare and providing it to everyone. This is the so called “Medicare for all” proposal. While this has no likelihood of passing this Congress, it is espoused by most of the potential upcoming Democratic candidates for President. The rationale here is that such a plan would save money in the long run. The reasons for this being conceivable have been discussed before and elsewhere. In a nutshell, it has to do with people’s willingness to keep up on their prevention, screening, contraception and prenatal care, thus avoiding costlier more severe phenomena. 

The Senate Finance Committee has obtained an easy bipartisan agreement to refund CHIP, the children's health insurance program,

In another strikingly bipartisan move, Congress has rejected deep cuts to the National Institute of Health. Indeed lawmakers on both sides of the aisle have defied the Commander in Chief and increased spending on biomedical research. 

In medical news, HPV vaccination rates continue to be sub par. However new data shows that vaccinations that have been given may be conferring a herd immunity as HPV infections have decreased 32% between 2009 and 2014. 

Vaping is viewed as a safe alternative to smoking in pregnancy. There is NO data to support this. In fact, newer data show an association between maternal vaping and asthma in the offspring.

Marijuana is viewed as safe in pregnancy. However, it is associated with learning difficulties in grade school  offspring. The State of Nevada is beginning a program to educate about this. 

In concerning but unsurprising News, pregnant women’s exposure to pesticides appears to be associated with premature delivery and low birth weight. 

 A recent study shows a faint correlation between two flu shots in row and miscarriage. Ever hear of signal to noise ratio ? This is probably noise. ACOG continues to reiterate the real demonstrated need for flu vaccine in pregnancy. 

Belly fat; it’s always the last weight to come off. However, it is well worth the effort. We’ve known for some time that belly fat was associated with increased rates of cardiovascular disease. However, new research indicates that central obesity is associated with increased rates of several cancers. Moreover, in the case of breast cancer, it is more closely associated with higher risk forms of hormone receptor negative cancer. 

As data science improves, so do our results. New research published in JAMA, the Journal of the American Medical  Association, constitutes the largest longest and best designed trials on the safety of postmenopausl a hormone replacement therapy. Happily, it does not increase the risk of premature death. This is medicine’s way of saying that the therapy is safe. 

 

Thanks for reading. Stay tuned next week for more exciting news from the world of Obstetrics and Gynecology. 

Medical Monday Special Edition : Hurricanes and Health

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I have lived through two hurricanes, Camille, and Agnes. I was a child, and when I lived for time in St. Petersburg, Florida, hurricanes were nothing but fun and games. We skipped school, had no power, and ate snacks. When it cleared, we rowed, paddled and boated all over the streets and the bayous which had become one. Harvey and Irma are another matter entirely. 

I encourage everyone everywhere to explore the internet or other news media to understand the gravity and breadth of the situation. See the radar, see the satellite video, see the webcams, news and personal videos, the photos, and hear the personal accounts. 

Put yourself in these people’s shoes. And then consider the ramifications of all of this on health. I will present some data and recommendations gathered by the CDC (Centers for Disease Control) in the wake of Hurricane Katrina. It is hard to say exactly how much of this could be generalized to other areas such as Houston or the Florida area, but I would suppose it is a reasonable starting place. 

Here are some key points from the CDC: 

  • Illnesses in the wake of a hurricane are predictable.
  • Long term displacement ( homelessness) poses treatment challenges. 
  • Medical system disruption poses treatment challenges. 

Here is a key recommendation: 

  • Unified registration for evacuees complete with medical history, treatment and vaccination records would assist with care. 

Consider that structures and infrastructure are damaged. This means not only homes and public buildings, but power plants, power lines, sewage treatment plants, and water lines. It means chemical plants and damaged. It also means that people in shelter are in close quarters with out adequate food or sanitation. Telecommunications are disrupted. Finally it means that hospitals, clinics and the movement of medical personnel are all disrupted. 

What illnesses are to be expected ? In the above described setting, infectious rashes are common, with near universal exposure to polluted floodwaters. Respiratory infections come next, followed by Gastrointestinal illness. Vibrio cholera played a large role in GI illness, and other forms of the waterborne vibrio bacteria accounted for the serious skin infections. 

Viruses also entered the picture, particularly the mosquito borne type. Remember that mosquitos reproduce in standing water. Human West Nile Virus had an uptake, but this year, officials anticipate Zika virus will be the major player. 

Trauma of all kinds counts for most presentations to hospitals. Cardiovascular causes are a far second, with medication refills being a third. These three accounted for the vast majority of presentations to hospitals in the wake of Katrina. 

Evacuees in the aftermath of hurricanes are at the most risk. Vaccinations are a key aspect of care for evacuees. For those evacuees in a group setting, the following are recommended: Influenza, varicella, MMR and Hepatitis A. 

Emergency responders are another special group requiring care. Vaccination recommendations for this group include Tetanus if not up to date, Hepatitis B, and the same vaccinations as are given to evacuees if responders are working in large group settings. 

reference : 

https://depts.washington.edu/einet/symposium/USA031210.pdf

For critical additional reading : 

https://www.cdc.gov/disasters/hurricanes/index.html

http://www.weather.gov

 

Please familiarize yourself with what is going on. Figure out how you can help. 

I have lived through two hurricanes, Camille, and Agnes. I was a child, and when I lived for time in St. Petersburg, Florida, hurricanes were nothing but fun and games. We skipped school, had no power, and ate snacks. When it cleared, we rowed, paddled and boated all over the streets and the bayous which had become one. Harvey and Irma are another matter entirely. 

I encourage everyone everywhere to explore the internet or other news media to understand the gravity and breadth of the situation. See the radar, see the satellite video, see the webcams, news and personal videos, the photos, and hear the personal accounts. 

Put yourself in these people’s shoes. And then consider the ramifications of all of this on health. I will present some data and recommendations gathered by the CDC (Centers for Disease Control) in the wake of Hurricane Katrina. It is hard to say exactly how much of this could be generalized to other areas such as Houston or the Florida area, but I would suppose it is a reasonable starting place. 

Here are some key points: 

  • Illnesses in the wake of a hurricane are predictable. 
  • Long term displacement ( homelessness) poses treatment challenges. 
  • Medical system disruption poses treatment challenges. 

Here is a key recommendation: 

  • Unified registration for evacuees complete with medical history, treatment and vaccination records would assist with care. 

A brief search on the Apple App store reveals several useful apps. Check out the ones from the Red Cross, FEMA, and the National Weather Service. As of yet there is no comprehensive evacuee app. 

Consider that structures and infrastructure are damaged. This means not only homes and public buildings, but power plants, power lines, sewage treatment plants, and water lines. It means chemical plants and damaged. It also means that people in shelter are in close quarters with out adequate food or sanitation. Telecommunications are disrupted. Finally it means that hospitals, clinics and the movement of medical personnel are all disrupted. 

What illnesses are to be expected ? In the above described setting, infectious rashes are common, with near universal exposure to polluted floodwaters. Respiratory infections come next, followed by Gastrointestinal illness. Vibrio cholera played a large role in GI illness, and other forms of the waterborne vibrio bacteria accounted for the serious skin infections. 

Viruses also enter the picture, particularly the mosquito borne type. Human West Nile Virus had an uptick in Katrina, but this year, officials anticipate Zika virus will be the major player. 

Trauma of all kinds counts for most presentations to hospitals. Cardiovascular causes are a far second, with medication refills being a third. These three accounted for the vast majority of presentations to hospitals in the wake of Katrina. 

Evacuees in the aftermath of hurricanes are at the most risk. Vaccinations are a key aspect of care for evacuees. For those evacuees in a group setting, the following are recommended: Influenza, varicella, MMR and Hepatitis A. 

Emergency responders are another special group requiring care. Vaccination recommendations for this group include Tetanus if not up to date, Hepatitis B, and the same vaccinations as are given to evacuees if responders are working in large group settings. 

reference : 

https://depts.washington.edu/einet/symposium/USA031210.pdf

For critical additional reading : 

https://www.cdc.gov/disasters/hurricanes/index.html

http://www.weather.gov

 

Please familiarize yourself with what is going on. Figure out how you can help. Click on the up to date radar image below to help. 

 

https://radar.weather.gov/Conus/full.php

https://radar.weather.gov/Conus/full.php

Medical Monday, Labor Day Version: Breaking News from the World of Obstetrics and Gynecology

The current administration continues to try to whittle away at the ACA (Affordable Care Act). This week, funding for the "advertising” for the ACA was cut. In particular, programs for health care enrollment were cut from 100 million to 10 million. 

At the same time, a bipartisan group of Governors has stepped up to craft and submit a proposal to stabilize existing insurance markets under the ACA. Their plan maintains several original ACA features, including the individual mandate, guaranteed subsidies payments, and funding to promote ACA enrollment. New features would include a 15 billion dollar fund to supplement the subsidies, as well as tax credits for insurance companies willing to enter markets with only one insurer. The bill also favors more State flexibility in the spending of their respective subsidies. 

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The most interesting news in policy is the Love Ernst Bill, also known as the “Allowing Greater Access to Safe and Effective Contraception Act” . It has been introduced by two Senators and two Representatives, all Republican, and all women. They are  Congresswomen Barbara Comstock (R-VA) and Mia Love (R-UT), U.S. House of Representatives to Senators Joni Ernst (R-IA) and Cory Gardner's (R-CO), in case you want to give them a shout out. 

  • It incentivizes oral contraceptives (OCPS) to be sold over the counter (OTC) in several ways. 1. It hastens the FDA approval process and waives the fees to do so. It would then provide for OTC OCPS for women 18 and older. 
  • It has also repealed the ACA’s provisions on using health medical and flex savings accounts (FSAs) on OTC medications. 
  • Finally it has repealed the ACA’s annual limits on flex contributions. 

This represents great progress in the national conversation, and I applaud these forward thinking brave Republican lawmakers. At the same time, I fully understand the position of ACOG, the American College of Obstetricians and Gynecologists, of which I am a card carrying member. ACOG does not support the Love Ernst Bill. That is not because it is wrong, but rather because it does not go far enough. 

ACOG has stated that the available evidence shows that cost is a significant barrier to contraception. They state that the ACA’s strategy of birth control without copay is therefore the best strategy. ACOG also objects to the artificial age restriction of 18, and rightly points to the need to continue to curb the teen pregnancy rate, especially among those under the age of 18. Finally ACOG supports the provision of all forms of birth control, not just the birth control pill. 

At the present time, the use of IUDs ( intrauterine devices) is on the upswing. The developers of IUDs have come out with more brands and more sizes to meet the current demand and the particular needs of those who have not yet borne children. Nonetheless IUD use in the US lags behind our cohorts globally at 8% prevalence, while Belgium,for example is at 20% and South Korea at 70%. 

Egypt’s government is taking steps which show understanding of the relationship of contraception to prosperity. The government would like to employ contraception to control overpopulation, which they consider a threat to national development. They are deploying 12,000 family planning advocates to 18 rural provinces to address conservative beliefs on the matter. Perhaps they can also visit the United States as well. 

It is once again time to highlight the significant prevalence of post partum mood disorders. Time with a new baby is hard. Moreover, immense hormone changes are not always well tolerated. A new study published in the Maternal and Child Health Journal has shown that 21% of new mothers who have post partum mood disorders do NOT tell their physician. 

It should not be surprising then that a 14 year study out of Ontario has revealed that suicide is one of the leading causes of death in the pregnant and recently pregnant women. The study revealed that 5 % of deaths in pregnancy or the first year of motherhood were due to suicide. The study shows a clear need for comprehensive prenatal and post natal care with assessment for mood disorders and suicide prevention included. 

Let us not forget that Houston after Hurricane Harvey is a medical disaster. Several hospitals were just lost, and many had to be evacuated for repairs.  Beyond that, ambulances could scarcely travel, and caregivers had trouble getting to work at all. Much of the floodwater is polluted and the water supply is unsafe. All this spells a second wave of potential disaster from the threat of infectious disease. 

Polycystic Ovarian syndrome (PCOS) is a actually a cluster of conditions that involve problem with ovulation (egg production) and with carbohydrate metabolism. It turns out that those with PCOS not only have trouble getting pregnant, they have a higher complication rates in pregnancy, especially for gestational diabetes. 

A new global study has shown that perhaps we should all be eating fewer carbohydrates. The PURE study, which was published in the Lancet and presented at the European Society of Cardiology, showed that people who eat a high quantity of carbohydrates have a 30% higher change of dying compared to those eating a low carb diet. 

And in the truly awesome department, we look to the FDA approval of Kymriah, a new therapy for childhood leukemia. This is not actually a drug, per se. It is a technique, whereby the patient’s own white cells are extracted, genetically modified to kill cancer cells, then re-injected to do their job. It is being called a “living drug”. It produces remission in 83 % of cases. 

Gentle readers, you have work to do. Keep giving feedback to your elected officials, and even to those exceptional ones outside your district. 

And consider doing what you can for the those affected by Hurricane Harvey. Click on the satellite photo of the hurricane to donate via the Red Cross. 

Belated Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Actual patient care through the weekend prevented a timely publication of Medical Monday. Thanks for your patience ! 

The health care sector’s initial responses to the Trump administration’s approach to health care policy ranged from shock to anger. Now people and corporations are starting to take action, especially in the face of the administration’s disarray and impotence. 

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The Trump administration through the Department of Health and Human Services slashed $200 million from the Teen Pregnancy and Prevention Program. (Can anybody tell me the process that made this possible, or does the President just decide like a dictator ? ) The spokesperson of the National Campaign to Prevent Teen and Unplanned Pregnancy has spoken out and disputed the administration’s position which stated that there is “ very weak evidence of positive impact of these programs. “  Experts everywhere are dismayed since the programs are believed to have produced a 41% drop in the teen pregnancy rate since 2010. The CDC (Centers for Disease Control) and ACOG ( American College of Obstetricians and Gynecologists) both credit the declining teen birth rate to these programs. 

The Trump administration is bit by bit, trying to dismantle the ACA’s protections on reproductive health care. Most recently, the contraceptive mandate for employer sponsored programs is on the chopping block. ACOG has stated that the contraceptive mandate has driven the unintended pregnancy rate to a 30 year low, and eliminating this feature would be a threat to public health. 

The Trump administration has indicated its support for abstinence only sex education, which has no evidence to support its efficacy. However, the CDC has produced two meta-analyses which indicate that comprehensive sex education results in reduced overall levels of sexual activity and increased levels of protection among those that are sexually active. 

Indiana law classified the use of aborted fetal tissue as a felony. A group of Indiana researchers has challenged this legislation with a federal lawsuit. The group bringing the suit is from the National Institute of Health funded Alzheimers Disease Center where they do study brain tissue from aborted fetuses. 

A recent article in the Dallas Morning News has highlighted the new voice of corporate American in social policy. Corporate America needs a diverse and inclusive workforce, and it understand that inclusiveness is good for business. Accordingly, it has begun to stand up for diversity. From various quarters, highly placed business leaders have spoken out and defied the current administration’s divisive policies. Recent examples of these divisive policies and positions include the President’s reaction to the Charlottesville violence, as well as recent controversy regarding LGBT rights, i.e. the so-called bathroom bill. 

The writer of the Dallas Morning News editorial, Dr. Daniel Grossman of the Department of Obstetrics and Gynecology University of California, San Francisco, has called upon the business community to begin speaking out on women’s reproductive rights as well. He cites the fact that fully 70% of Americans support women’s access to full reproductive services including abortion, and this is also the position of the American College of Obstetrics and Gynecology and the American Medical Association. A broad based field of research has shown time and again that access to comprehensive and affordable reproductive health care for women leads to better health, higher levels of educational attainment, and improved economic stability for women, families and society at large. To learn more see https://www.ansirh.org, Advancing New Standards in Reproductive Heath, a division of the UCSF Bixby Center for Global Reproductive Health, http://bixbycenter.ucsf.edu

As mentioned in several past posts, States are starting to take matters into their own hands. They are, on their own State legislative calendars, enacting various bills that safeguard the requirements for insurance to cover various benefits such as birth control or prenatal care. The latest is Arkansas, which has passed a law which will require insurers in the State to cover indicated mammograms. 

In the good news department, we have word that there are bipartisan meetings planned in the first part of September, which will include Governors as well as State Insurance Commissioners. The goal of the meetings will be to stabilize existing insurance markets under the ACA. Things may actually start to get real. 

In medical news, the truth is starting to come out, as truth eventually does. New data published in a recent study shows that yearly mammograms starting at 40 (rather than every other year at 50) would prevent the most deaths due to breast cancer. According to this study out of Cornell and New York Presbyterian, for those aged 40-80, screening at 40 reduces breast cancer deaths by 40 % beyond current protocols. Those who read this column regularly already know that a whole segment of the health care world including ACOG, the American Cancer Society and the American College of Breast Surgeons among others, have always taken this view. They have taken serious issue with the short sighted recommendations of the US Preventive Services Task Force (USPTF) which has taken the position that mammograms in the 40s confer no benefit. 

All parties concerned recognize that this earlier and more frequent approach mammograms produces a higher number of false positives. However, actual clinicians ( doctors, nurses and nurse practitioners who see patients) do not take the position of the USPSTF(statisticians and epidemiologists largely)  that fear of mammograms, pain of mammograms, breast biopsies with benign results constituting a false positive, or even infected or bruised breast biopsies compare with a breast cancer death as a harm. In fact no number of these types of “harms” could ever add up to even one breast cancer death. 

The next item is in both the good news department and the we-already-knew-this department. A recent analysis published in the journal Menopause has indicated that vaginal estrogen does NOT confer increased cardiovascular risk. Vaginal estrogen does not appreciably enter systemic circulation. It stays local to the vagina, and does its job to relieve postmenopausal vaginal dryness. Vaginal estrogen was found to NOT increase risk for breast cancer or for any of these: colon cancer, uterus cancer, stroke, clots in the lung (pulmonary embolus) or deep vein thrombosis. Sheepish gynecologists should prescribe with confidence. 

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A concerning new report published in the journal Pediatrics has brought to light that less than half of new moms are consistently putting their babies on their backs to sleep. Not doing so raises the risk of SIDS (sudden infant death syndrome). Three quarters state they “ usually" do so. Current guidelines clearly state that babies should be in their parents room, in their own bed, and on their back to sleep for the first six months of their life. 

Breast and ovarian cancer patients are not getting genetic testing at adequate rates. Genetic testing for these patients informs the care of their children. Moreover, it can also provide insight into their own treatment. Finally, it may ultimately provide information that could help us screen for and treat cancer in new and better ways. I look forward to the day when disease is understood and treated at a genetic level. To get there, we must as a society, contribute our personal genetic information in a meaningful way. 

That’s it for this week; Stay tuned next week for more news from the exciting world of Obstetrics and Gynecology. 

Medical Monday: Breaking News from the World of Obsterics and Gynecology

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As expected, the Trump administration is planning to roll back the contraceptive mandate. The contraceptive mandate requires that insurers cover costs for contraception without copay. The proposed change in regulation would allow employers to refuse to cover contraception because of religious or moral objections. This change will not go unchallenged, Numerous lawsuits will likely be initiated if this change takes place. 

Those objecting to the contraceptive mandate often cite their objection to certain birth control methods which prevent implantation. However, mainstream authorities focus on the fact that increased contraceptive availability is associated with plummeting incidence of abortion and unplanned pregnacy. 

In other policy news Texas plans to continue funding their task force to determine the causes of their alarming rate of maternal mortality. It is really a shame that Texan’s don’t just save their money and acknowledge the obvious: that increased maternal mortality is directly related to their gutting of health care services to women. At this time, one quarter of Texas women lack health insurance. Data from many quarters tells us that this is a sure fire way to ensure poverty and high maternal mortality for many generations to come. 

Arkansas is racing to the bottom as well. A Federal Appellate court in St. Louis has ruled that Arkansas can block Medicaid funding to Planned Parenthood. 

Winning the race to the bottom, is of course the the Trump administration, who has resolved to cut Teen Pregnancy Prevention program funding. The American College of Obstetricians and Gynecologists (ACOG) came out with a swift condemnation of this plan. The current administration supports abstinence only programs, and yet asserts they favor “ evidence based” programs. Sling that medical jargon. 

Lawmakers have prevailed upon the Trump administration to make the Federal Government insurance subsidy payment for August. In fact, it is Republican members of Congress together with Democrats who have convinced the administration to continue payments, fearing a collapse of insurance markets. They believe this will buy time for a bipartisan solution to stabilize the markets. The CBO (Congressional Budget Office ) continues to warn that ending subsidies with cause premiums to rise by 20% by 2018. 

In encouraging news, Oregon has passed law budgeting half a million dollars to expand comprehensive reproductive health care coverage for all its citizens. The law also requires insurers to cover such services with no out of pocket cost. Available evidence tells us that, as a direct result, they should expect decreased rates of unplanned pregnancy and abortion, with increased levels of educational attainment among women, decreasing unemployment statewide, and increased standards of living. 

https://www.cdc.gov/obesity/data/prevalence-maps.html

https://www.cdc.gov/obesity/data/prevalence-maps.html

On to the medical news. 

It is time for us to start thinking about obesity in more sophisticated ways. Obesity is a devastating and widespread medical problem. It is also very personal and for that reason it is challenging to discuss and treat. We are now beginning to understand that the causes of obesity include but are not limited to individual habits. For example, poverty and its many causes factor in strongly. We can graph the incidence of obesity on maps and thus understand obesity is part of culture as culture spreads across geography. New research out of the National Institute of Health has revealed that the “ origins of obesity lie as much in early childhood - even prenatally and intergenerational- as it does in an individual’s current behavior. “ Obesity is closely tied to many forms of human suffering and disease, from heart disease and diabetes, hypertension and cancer, to poor self esteem and depression. Further research is necessary, by all means. However to effectively address this serious problem, both patients and physicians are going to have to do better at mustering their courage and talk about obesity in frank and accurate terms. 

You might have noticed my mention of obesity as having a role in increasing cancer risk. Maybe you were not aware of this, since there is not an obvious connection. However, we have always know that obesity is associated with many types of cancers. However, new research from the Journal of the Academy of Nutrition and Dietetics sheds more light on the subject. It turns out that “ women who eat a lot of high calorie foods may face a slightly higher risk of obesity related cancers - even if they remain thin” The study went on to elaborate that “ women who favored low nutrient high calorie foods had a 10% higher risk of cancer linked to obesity. “ Cancers related to obesity include cancer of breast, colon, ovary, kidney, and endometrium (uterine lining). 

A new study from the Canadian Medical Association has shown that oral cancers related to the HPV are on the rise. Between 2000 and 2012 it is believed that the incidence of such cancers has risen by 50 %. 

Smoking in pregnancy is still a big problem. It turns out that depression in pregnancy makes smoking more likely. This tendency of smoking during depression in pregnancy is on the rise, according to new research published online in the October issue of Drug and Alcohol Dependence. 

HPV and smoking are a bad combination. Did you know smoking greatly accelerates the progress of HPV related disease ? 

HPV has an effective vaccine against it. However, new research indicates that less than half of girls and a quarter of boys are vaccinated. HPV ( Human papilloma virus ) has a vaccine. Humans papilloma virus causes genital warts, precancerous and cancerous lesions of the genitalia and mouth. Vaccines are available for young people from the ages of 9-26 years of age. They have little in the way of known side effects. 

In other virus news, there have been no locally transmitted cases of Zika viruses in Florida yet this year. The same encouraging trend has also been seen in Latin America and the Caribbean. Authorities now believe that those infected develop immunity to reinfection. However, authorities are also concerned that Zika may now be getting transmitted sexually. Work on a Zika vaccine is underway. 

Again, I encourage you all to contact your elected officials about your views on women’s health. Tell them the American people are willing to shoulder their collective responsibility for people's health care and the good of the future. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

In policy news we find more of the same. Texas again figures prominently, so much so that I have decided to create a new category: Texas news. Texas is an unmitigated perinatal disaster and is an embarrassment to this country, particularly to its medical establishment. But make no mistake, if current trends in law and politics are any indication, women's healthcare in every state will be like Texas.

To wit: a new study through the Commonwealth Fund has shown that one quarter of working age Texas women still lack insurance of any kind. A significant percentage of those who are insured struggle to pay medical bills and admit to having skipped needed care because of cost. Texas did chose not to expand its Medicaid, and this is believed to be one of the causes for these phenomena.

Also in Texas, ordinary standard insurance does not cover abortion. A new bill passing the Texas House will require women to buy supplemental insurance coverage for this procedure. It also increases reporting on complications after abortion and on the incidence of minors receiving the procedure. 

Finally in the Texas news, the Texas physician Dr. Brett Giroir, a Pediatrician, has been nominated for assistant Secretary of Health at the Department of Health and Human Services. However, Democratic Senators have delayed his confirmation on concerns that he would not support women's health programs. And they wonder why Texas is in the state it's in.

The Trump administration has cut funding for the Texas Teen Pregnancy and Prevention Program. Now it proposes eliminating funding for all such programs across the country. Moreover the fundamental research for the Teen Pregnancy Prevention Project is situated at Texas A&M University and theses researchers have recently been notified that their funding has been cut.

In Texas, Planned Parenthood has been barred from receiving Medicaid reimbursement. As a result the number of comments coming in to the Center for Medicaid Services (CMS) have doubled from 9,000 per week to 18,000 per week. According to the Center for Public Policy Priorities this will remove healthcare access from 45,000 people.

In the good news department, a bipartisan group of high ranking Senators are trying to strengthen existing law regarding health care. They are recommending that the Federal government continue paying subsidies, and that all Americans enroll in coverage. They also recommend renewal of the Children’s Health Insurance Program. Even Senate Majority Leader Mitch McConnell has said that he would consider such a bipartisan effort to shore up subsidy payments to insurers to stabilize current insurance markets.

In the medical news, one is seven women experience anxiety or depression in the first year after giving birth. This remains vastly under-diagnosed untreated with only 15% of those affected seeking help. Obstetricians have been alerted to increase screening for these debilitating conditions. 

In other concerning news, the team suicide rate among girls has reached a 40 year high. This is according to a new report from the Centers for Disease Control and Prevention published this last week in the Morbidity and Mortality Weekly Report. As of 2015 it sits at about 5 per 100,000. 

Preterm birth has continued to be a significant perinatal problem and one that has been resistant to explanation and treatment. However, new research published in Obstetrics and Gynecology has indicated that sleep disorders may play a role in some cases. Data from over three million birth was studied, with conditions like apnea and insomnia being tied to preterm birth. 

New research indicates that risk of stroke is decreasing for men but not women. Stroke risk is related to the incidence of several medical conditions, including obesity, smoking, high blood pressure, diabetes, and high cholesterol. These conditions are on the rise among women. 

Physicians and patients, listen up: Physicians are doing a BAD Job at educating patients about marijuana use in pregnancy. Increasing State legalization has led many to believe marijuana is entirely safe under varied conditions. (Since when do we believe what politicians have to say about science and medical care ? ) This has not been substantiated. According to researchers at the University of Colorado in Denver, the data available is limited, and sometimes flawed. However, there is “ moderate evidence that the use of marijuana in pregnancy is associated with increased risk of reduced fetal growth, lower IQ scores in young children, adverse effects on a child's cognitive functioning and academic ability, an increase in attention problems” There may also be associations with low birth weight and preterm birth. Patients need to be honest with their caregivers, and caregivers have to help patients to meet their needs some other way than to use marijuana.

Stay tuned form more fascinating and important news from the word of Obstetrics and Gynecology, next week, on Medical Monday. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

In policy news, it is no secret that Senate Republican bill to repeal the Affordable Care Act was a failure. Their proposals included many measures that would curtail health care for women in the form of either provision of contraception, for health screening for condition such as sexually transmitted diseases, breast cancer or cervical cancer and access to prenatal and maternity care. The failure of this bill led many of us who care for women to breathe a sigh of relief. 

However there is a new threat to women's healthcare. The House Appropriations Committee is responsible for setting the federal governments spending priorities for the upcoming year. These budgetary items come in the form of bills. Most of the bills concern essential services such as the military but included with these budgetary plans are several add on provisions or riders which contain potential law related to women's healthcare and it's funding. For example, the bland and harmless sounding "Financial Services and General Government Bill" would prevent people from purchasing insurance through the Affordable Care Act exchange which includes comprehensive reproductive coverage. As another example, the "labor, health, and education" bill would eliminate funding for Title 10 family planning clinics which provide a low income women and men with cancer screenings birth control tests for sexy transmitted diseases. The Republican plan for this care is to reroute it to community health centers. However many question the ability of community health centers to meet this increased demand.

MATERNAL MORTALITY BY COUNTRY FROM THE CIA WORLD FACTBOOK VIA indexmundi.com

MATERNAL MORTALITY BY COUNTRY FROM THE CIA WORLD FACTBOOK VIA indexmundi.com

Representative Nita Lowey (Democrat from New York) is the top ranking Democrat on the House Appropriations Committee. She and several colleagues have offered alternative amendments to guarantee that women have access to these health services. They include provisions for birth control without co-pay, Title X family-planning funding, rescinding the Global Gag Rule, and re-instituting funding for the United Nations Population Fund. Without control of Congress these are likely doomed, but at least drafts are in place and the issues are on the table.

Last week, Senate leaders passed some bills that stand to help patients. The first is a bill that will help fund the FDA review of prescription drugs and medical devices.  The second bill, called the”Right to Try” Act, it will help the FDA to “…speed review generic drug applications”.

Even those of us who applauded the Affordable Care Act realize that it needs some more robust Federal funding for the the upcoming years. Republican Senator from Tennessee Lamar Alexander has “...organized bipartisan hearings next month" to help fund ACA a insurance marketplaces next year. Governors from both parties have urged the Trump administration to act continue to making ACA subsidy payments. President Trump has tried to characterize these federal contributions to defray the cost of healthcare as an insurance company "bailout". 

The expanded health care that the Affordable Care Act provided was beneficial in human and longer-term economic terms. However instituted immediately in the then insurance marketplace, it would have been financially unaffordable without federal subsidies. That is the reason why the federal government subsidies were designed in the first place. Consumers would contribute, States would contribute, and the federal government would contribute through the taxpayers, in what amounted to an elaborate cost sharing plan. The implicit and explicit philosophy was that the healthcare of the American people was a shared responsibility and a worthwhile financial investment for the future. 

As has been previously reported, Texas has a maternal mortality crisis. The maternal mortality rate is 35.8 deaths per 100,000 live births as of 2014 where is the rest of the nation sits at 23.8 deaths per 100,000 live births. Texas's rate is characteristic of a third world country Robinson United States of America which has state-of-the-art medical care. This issue has been on the table for several months now in a large study is underway to fully understand the reasons why. Meanwhile editorials in Texas newspapers abound to the effect that the crisis is no mystery. Various pieces of legislation large and small, State and federal, over the last decade have resulted in curtailment of access to women's healthcare, including reproductive health care, general women's healthcare, and prenatal care. Could there be a connection?

In the medical news, we begin with the opioid crisis. According to new research publishing the animals of internal medicine, approximately 2,000,000 Americans self report that they are addicted to opioids. There are likely many more. 11 million admit to misusing opioids. Opioid addiction is surprisingly dangerous and hard to treat as it becomes enmeshed with behavior and Biology. There are specialists who treat opioid addiction but they are few and far between even in sophisticated medical communities. Doctors who will treat pregnant women with opioid addiction correctly are even more scarce.

Do you think cultural factors matter in health? Do you think behavior is ”catchy” ? I just learned that pregnant women in Florida smoke at double the rate of women in the rest of the country. I think such outliers are very interesting and provide potentially informative subjects for study.

I am the sort of person who is very interested in maps and infographics. The idea of regional variations in health behaviors is fascinating to me and can be portrayed in maps. See todays' illustration lifter from indexmundi.com who lifted it from the CIA World Factbook   The case of Florida and smoking, the case of Texas and maternal mortality, and indeed the case of the entire south and rates of obesity should constitute low hanging fruit for any interested researcher. 

The FDA is taking a powerful step in the battle against smoking. We have had warning labels. We have had higher taxes on cigarettes. We have had educational campaigns. However now, the FDA will lower the amount of nicotine in tobacco products. There is good reason to believe that lower nicotine in cigarettes will lead to smokers quitting and enable them to quit more easily.

In the odd and frightening department we see the new research published in the Journal Cancer Epidemiology, which suggests that postmenopausal women with gum infections are more likely to get many common cancers than their peers. Ladies, use those electric toothbrushes, that thick floss, and those peroxide and fluoride mouthwashes. Check in with your dentist. More research is clearly necessary.

Mothers across the world are missing a great opportunity. This is breast-feeding. According to the World Health Organization and UNICEF, only 40% of babies were exclusively breast fed for six months, which is the undisputed recommendation. Rates in the United States are considerably lower with  25% of mothers exclusively breast-feeding for six months. The report included research on the key reason why mother stop breast-feeding. It is the need to return to work. Solving this problem would be a matter of addressing culture, policy pertaining to postpartum leave, paid postpartum leave, and breast-feeding in the workplace.

Breast-feeding has numerous benefits for babies, mothers, families, and society at large. A new study documents that breast feeding may be linked to a lower risk of breast cancer. This study was a meta-analysis of 18 prior studies. 13 of which showed that breast cancer risk dropped 2% for every five months a women breast-fed.

News continues to filter in regarding the use of CRISPR to edit genes in human embryos. At present CRISPR has been used to edit out the single gene mutation that causes hypertrophic cardiomyopathy. The most logical next candidates are other single gene mutations which cause disease. Examples of single gene diseases are cystic fibrosis, sickle cell disease, fragile X syndrome, muscular dystrophy, also known as Huntington's disease. Hope is on the horizon ! 

 

Stay tuned next week for more exciting news from the world of Obstetrics and Gynecology. 

Medical Monday: Delayed Edition

Deep in the backcountry of Montana I was able to almost forget about medical politics. However, now that I am back, the time has come to recap events of last week in both medicine and policy. 

Moderate Republicans had hoped to achieve passage of a rewrite of the Affordable Care Act by making scaling down their proposal, making the changes less extensive. However even this “ skinny ” rewrite failed to pass as three Republican Senators Collins of Maine, Murkowski of Arkansas, and John McCain of Arizona opposed the measure. If you ask me it is no coincidence that two of these maverick Republicans are women and the other, Senator McCain, is a cancer patient. Here are three people who understand what is at stake, i.e. health care for women and the seriously ill. 

Also during the week, 148 Democrats wrote to HHS ( Health and Human Services) Director Tom Price objecting to the decision to cut two years of funding from the TPPP (Teen Pregnancy Prevention Program). Again, if someone could explain to me why decisions of this magnitude can be made single handedly, I would be much obliged. 

Texas has passed a bill which requires women to obtain separate addition insurance coverage for non-emergency abortions. It seems to me that this could be a compromise solution in which everyone would get a chance to support what they espouse. Of all the health care controversies, it seems this one is the biggest, and thus the one to compromise on. 

On the other hand, insurance wold become useless as a tool to support the general health and prosperity of the population if we conceded to every anti-vaccine person who refused to pay for coverage which included vaccines, or a Jehovah’s Witness who refused to pay for insurance covering blood transfusions. You could imagine the list would go on, as there are folks who are anti-antibiotic, and anti-mammogram, and yes, those who are anti-birth control. And just as I would advocate compromising on abortion coverage, I would dig in just as firmly on the critical need for birth control coverage, which is I think essential to our stability and progress as a society, not to speak of essential to the health and well being of women and children. 

Here’s a brand new issue: Menstrual Leave. This is is policy which allows a worker to take a paid day off during her period. Such leaves are in place in several countries including Japan and Taiwan. However, many experts feel that this has the potential to retard women’s progress in the workplace. The notion that work performance suffers during menstruation is a fallacy, and this policy plays into it. If a women’s period is so heavy, painful or otherwise debilitating that she need stay home from work, then she should seek consultation with a Gynecologist. 

In medical news, it turns out that some perinatal exposures may last through several generations. A new study in mice has shown that exposure in pregnancy to environmental pollutants results in offspring with increased asthma risk for up to three generations. 

For your we-already knew-this report of the week, new research has demonstrated that a brief daily run helps protect bone mineral density in women. Indeed brief bursts of any high intensity exercise will do it, increasing bone by about 4 %, which may not sound like much but is considerable. 

In exhilarating and awe-inspiring news, we have CRISPR. If you do not know this acronym, you should. It stands for "clustered regularly interspaced short palindromic repeats”. Basically these are short segments of DNA which read the same way in one direction or the other. In nature, they are used as part of the immune system of various creatures. In technology, they are useful for editing genes. 

The MIT technology review has reported on original research at Oregon Health Sciences University where researchers have edited DNA in the viable human embryos as a way of preventing disease. It is interesting to note that while the federally funded National Institutes of Health does not support studies involving CRISPR in human embryos, the US National Academy of Sciences has “ opened the door to such research providing that the work would address serious inherited diseases.”

 

And with this momentous news we conclude this delayed edition of Medical Monday. See you next week. 

 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

As of Friday, intentions were to hold a vote on the ACA bill in the Senate this next week. This, despite the fact that Senator John McCain (R-AZ) has been diagnosed with brain cancer and will not be back next week for the vote. He would have been a supporter of the bill.

It is clear that there are at least four GOP Senators who have already gone on record saying they will oppose it. Only two opposed are required to kill it. 

For a detailed review of the bill and the consensus on its ramifications, see last week’s blog post which was pretty comprehensive. Really nothing has changed since then. 

Two prominent antiabortion activists who are now on staff with the Trump administration have informed 81 (EIGHTY-ONE !) teen pregnancy centers that their Federal Funding will end in 2018. How can these decisions be made without any due process whatsoever ? 

On to medical news.

 There is not one but two Zika vaccines under development. Zika is the dreaded virus carried by mosquitos in temperate climates which causes central nervous system and eye defects in the unborn. On of the vaccines is in human safety trials, and another is in safety trials for pregnant animals. Vaccine trials may be hampered by reduced funding to the CDC ( Centers for Disease Control) through the Trump administration. 

Another approach to Zika is to introduce genetically modified strains of mosquitoes that die in one to two days. However, some on Texas object to this strategy citing possible unintended consequences. 

Two to three years from now, in 2020, it is predicted that there will be a shortage of nearly 10,000 Obstetricians Gynecologists. This applies not just to rural areas, but to big cities as well. The training is hard, the hours long. The work is risky, from both a medical and a legal point of view.  Costs are high if one is not employed by a large organization. Private practice Ob/Gyn is nearly extinct. Sure it can be rewarding and fascinating. It often is. Lately, though, the lack of regard for women’s health pose new concerns. 

Many rural hospitals are removing maternity services. This should come as no surprise since maternity care is acute care and is potentially intensive or surgical on a reasonably regular basis. Staffing and facility needs for such care is high, and the availability of those who can render it is getting lower all the time. According to recent study, over half of rural counties in the US lack hospital based Obstetrics. In all fairness, this is a big country, unlike Europe for example, and people here sometimes choose to live way out in the boonies. It goes a long way to explaining why the US has the highest maternal mortality rate in the developed world. That, together with the obesity epidemic, its complications of diabetes, hypertension and preeclampsia, and the defunding of women’s health care resources explain it well enough. 

How bad is the obesity epidemic ? Perhaps you have no objections to a full figure. Ok, but do you object to life shortening disease ? Of course. The CDC now reports that over 100 million US citizens have diabetes or pre diabetes. Most with pre diabetes do not even realize they have it. If you are overweight, ask your caregiver to screen you with fasting blood sugar, 2 hour blood sugar after eating, and also screen your cholesterol and triglycerides ! Knowledge is power. 

Fake sweeteners are not helpful. A new meta analysis of 7 studies has shown that people consuming these do not lose weigh compared to those who do not consume them. Moreover, these studies also show that those consuming artificial sweeteners are at increased risk for obesity, diabetes, and cardiovascular issues over time compared to non-users. This probably has more to do with the misbegotten habits of the users rather than something intrinsic to the artificial sweeteners, but we simply do not know. 

We always need some news in the-we-already-knew-this department. This week, we again learned that healthy diet and exercise in pregnancy are associated with lower rates of gestational diabetes and C section. 

Finally, in very interesting and early work, thyroid hormone and metformin (a common diabetic medication) seem to be able to reduce memory and learning problems in rats exposed to alcohol during pregnancy. This groundbreaking work was published in Molecular Cytology and will hopefully spur more research on the subject. 

Stay tuned for more exciting news next week, on Medical Monday. 

 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Finally, this last Thursday, a group of Republican Senators met with representatives from the American College of Obstetrics and Gynecology. This is key since women’s health care is at the center of the debate on health care. As I mentioned last week, at issue is the concept of pooling risk, and pooling money. There are the well who do not want to help subsidize the sick, the non-pregnant who do not want to help subsidize the pregnant, adults who do not want to subsidize children and the young who do not want to help subsidize the old. My religious education reminds me of many scriptural mentions of our obligations toward widows, orphans, and the sick. Do you think that all they meant was to give them the gleanings from the fields ? No. It means paying into a pool of money that will provide for the care of such people. 

Here is a summary of the plans in play : the ACA (The Affordable Care Act which is currently law), the House Bill, and the Senate Plan. This is taken from a particularly clear article from the Washington Post 

(https://www.washingtonpost.com/graphics/2017/politics/obamacare-senate-bill-compare/?utm_term=.a97493829dba)

The ACA requires Americans to have health insurance. The House bill would impose a 30% surcharge on new plans for those with lapsed plans. The Senate plan would impose 6 months wait time before new coverage could be obtained. ( Wait, don’t we want people to be covered ? ) 

Both the House and Senate plans would eliminate the employer mandate to provide insurance imposed by the ACA. 

Under ACA, subsidies from the Fed help reduce insurance premiums for consumers across the board. All plans would sunset this coverage by 2020.  However under the  ACA it would be no sooner than this and it would provide for their continuance. Under the two proposed GOP plans, subsidies could be cut off much earlier than 2020. ( Does Trump really think he will still be President in 2020 ? ) 

Tax credits under the ACA and Senate bills are based on income age and geography, favoring low and moderate income people. In the House Bill, tax credits would be based only on age, and would not increase when premiums increase. 

Under the ACA, one cannot be denied coverage or have premiums increase based on preexisting conditions. Under the House bill, premiums could increase based on preexisting conditions only if a lapse occurred. Under the Senate Bill, insurance companies may not deny coverage or increase premiums. However, they would be permitted to deny coverage for certain preexisting conditions altogether. 

Under the ACA, rates for the old can be as much as three times that for the young. Under both other plans, this factor would increase to 5. 

An HSA is a health savings account that you create in which to save money for health care expenses. You are not taxed on this money. However, there is only so much money that the Fed will let go untaxed. Pretax HSAs maximum amounts under the ACA are $3400 and $6750 for individuals and families respectively. Under both other plans this number would increase.(Remember though, HSA money is YOUR money, just not taxed. If your tax rate is low, this won’t save you much. HSAs are you providing your own health care subsidies rather than the Fed, as is currently the case. This is one of the many ways the GOP plans are trying to get consumers to shoulder more of the burden of healthcare expenses themselves. 

High risk patients are well cared for under the ACA. However both the House and Senate Plans create “ high risk pools” . The House proposes $130 billion and the Senate $182 billion, earmarked for insurers who take big losses. 

Under the ACA, the  States are permitted to expand Medicaid to 138% of the poverty level. The Fed is expected to match funds. Under the House and Senate Bills, States would receive fixed amounts , i.e. “ block grants “ based on how much they are currently spending. In the House Bill, States would not be able to expand Medicaid. IN the Senate Bill, States could expand Medicaid, but the Fed would simply match less of it. 

Under the ACA, "essential health benefits" are covered, such as hospital visits and mental health care. Under the other two bills, the definition of “essential health benefits" could change. 

At the present time, under the ACA, Planned Parenthood may receive Medicaid funds. However, Federal Funds may not be used for abortions. Under the House and Senate plans, there would be a one year freeze in Medicaid funding to Planned Parenthood.

Finally, regarding lifetime caps on insurance benefits, the ACA has none.  This would not change for the House and Senate proposals. However, the Senate Proposal provides for States to lift the ban on lifetime caps on insurance benefits. 

Now that you know what all is being proposed, I will share with you the exact text of ACOG’s (American College of Obstetricians and Gynecologists) response to lawmakers :

https://www.acog.org/About-ACOG/News-Room/Statements/2017/The-BCRA-Cannot-Be-Fixed

 

ACOG: The BCRA Cannot Be Fixed

July 13, 2017

Washington, DC – Haywood Brown, M.D., President of The American Congress of Obstetricians and Gynecologists (ACOG) released the following statement regarding today’s revisions proposed by Senate Majority Leader Mitch McConnell (R-KY) to the U.S. Senate’s Better Care Reconciliation Act:

“This most recent version of the Better Care Reconciliation Act is not “better” for patients. The BCRA is deeply flawed, cannot be fixed and keeps getting worse. Its original version deliberately stripped landmark women’s health gains made by the Affordable Care Act, turning back the clock on women’s health. This new version threatens to leave patients with preexisting conditions without care. Senators drafting these proposals still aren’t listening to America’s doctors. Yesterday, ACOG joined leaders representing 560,000 frontline physicians on Capitol Hill with one unified message to Senators: the BCRA is dangerous for patients and must be rejected.

“ACOG’s bottom line is simple: No legislation should take away coverage that patients have today. There’s only one solution. The Senate should put the BCRA where it belongs, in the circular file, not on the floor for a vote. Republican and Democratic senators should work with ob-gyns and other physicians on a new approach that will preserve women’s access to contraception and maternity care and improve the health care system for everyone. We stand ready to partner with the U.S. House and Senate and the White House on practical solutions to improve our nation’s health and reduce health care costs.”

 

The day the newest proposal was release, several members of Congress stepped forward denouncing it, saying they were unwilling to vote even for putting it up for a vote. 

That’s a comprehensive view of health policy news. 

 

On to the Medicine. 

 

In distressing news, the Journal Cortex has published new research showing that, in mice, alcohol consumed in pregnancy produces adverse brain changes that can be inherited for several generations. Human studies are unlikely to be done due to the nature of the questions. ACOG has already issued a statement indicating that no amount of alcohol is safe in pregnancy. 

In unsurprising news, research out of Texas has recently shown that despite closure of abortion facilities in Texas, abortions in the State actually increased by 3 %. A wealth of data elsewhere has shown that access to basic health care including contraceptives curbs unintended and teen pregnancy, and abortion. In 2011 Texas reduced its family planning budget by 67%. As a direct result, there was a large scale closing of clinics which provided this kind of basic care, all with the goal of decreasing abortion.  

For your consideration: Katy Talento is a White House Domestic Policy Aide to President Trump. She is an avowed anti-abortion advocate. But what defies reason is her campaign against contraception, which has the power to do so many good things including curb abortion. She has, on record stated that birth control is “ breaking your uterus”  and causing miscarriages and abortions. She is probably referring to progesterone only methods which thin the lining of the uterus so that implantation is not possible. However, she is a very well educated woman, and to call this an abortion or miscarriage is disingenuous at best and deceptive at worst. She has alleged that doctors and drug companies conspire to provide birth control which causes cancer. #Alternativefacts have never been so harmful. In fact, combination oral contraceptive pills, while not for everyone, provide a set of strong health benefits from protecting bone density, preventing anemia, preventing endometrial (uterine cancer) and most dramatically, preventing ovary cancer. #stopalternativefacts. 

Recent data support longer time intervals between paps in low risk patients. This is misinterpreted in the press, by patients, and even by certain doctors as meaning that all patients should have paps or even routine checkups less frequently. This is not the case. Add to this the fact the screening for chlamydia and gonorrhea usually occur at the same time as a pap. You have now a recipe for an unintended consequence: increased rates of undetected chlamydia. Findings documenting these increased rates of chlamydia carriage are published in the Annals of Family Medicine. 

Preeclampsia is a disorder of pregnancy involving high blood pressure. In its milder forms, it is one of the commonest complications of pregnancy. However, in its more severe forms, it is one of the most  dangerous. New data published in the American Journal of Obstetrics an Gynecology indicate that preeclampsia continue to be on the rise in America. Obesity, excess weight gain in pregnancy, high blood pressure and sedentary lifestyle are all risk factors for preeclampsia. Is it any wonder the rates are increasing ? It gets worse. Many patients and even some caregivers do not realize or emphasize that having preeclampsia in pregnancy increases the chances of lifelong hypertension and its consequences in perpetuity. 

In the wish-this-were-better-understood department, prolonged breastfeeding appears to confer a protective risk against MS (multiple sclerosis) to the mother. These findings were published recently in the Journal Neurology. 

In the tantalizing department, new research indicates that plain old hydroxychloroquine (plaquinel- a common drug used for both malaria prevention and lupus) prevents the Zika virus from crossing the placenta in mice, there by protecting the fetuses from the virus. This could of course hold promise for humans. 

Also in the very good new and Zika related department, scientists prevented the vertical (mother to baby) transmission of Zika virus with the use of a vaccine in mice. This groundbreaking research was reported this week in the Journal Cell. 

That’s it for this very big week.  Again, it is critical that each and every one of you contact your elected officials and tell them what you think. Find yours here: 

 

https://www.congress.gov

 

See you next week, right here, on Medical Monday. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Policy news this week centered on reaction to the government handling of the proposals for healthcare perform. As before, observers from all sides have noted that proposed changes would result in over 20 million people becoming uninsured, adding to the financial and human burden that we would face. It would also result in premium increases of approximately 20% across the board according to the Congressional Budget Office, and this, well before the next election.

In a stunning turnaround Senate Majority Leader Mitch McConnell (R-Kentucky) warned that if the GOP senators could not get 50 votes required to repay and replace the ACA (Affordable care act), then, (emphasis mine) THEY MAY HAVE TO WORK WITH DEMOCRATS to repair the existing marketplace. The current proposal will, in fact fail since only three Republican votes against it could sink it, and there are many more Republicans than that opposed to the bill.

Delaying action on the GOP plan for healthcare until after July 4 recess week had one interesting unintended consequence. Congressmen returned home for about nine days, not just 4. In that timeframe they had plenty of time to hear from the local officials at home most pointedly, from the Governors of their respective States. Governors are worried about losing billions of dollars in Medicaid funding if the Affordable Care Act repeal bill is passed. Washington will not inherit all the problems that ensue if the ACA is repealed, they will.

Plans under consideration and go all the way from the Sanders bill introduced by Democrat Bernie Sanders which provides for "Healthcare for all", to a buffet style set of plans favored by senate Republicans from Texas and Utah, where one could buy plans in conformance with the Affordable Care Act or less costly, less comprehensive plans geared for healthier people. The problem of course with this is that it short-circuits the whole beauty of broad-based health insurance which pools risk and pools money. Money for low risk people subsidizes the poor and those who are misfortunate enough to sustain expensive and long-lasting illness. It is this exact feature to which many people object, not feeling an obligation to those less fortunate than themselves. I feel people of this opinion exhibit not only a lack of compassion but a lack of fiscal common sense. Money spent on the health of the poor, on early diagnosis, on pregnant women, and money spent keeping up on the care of the chronically ill is money saved and an insurance policy for a better future.

In the Texas and Utah plans there would be a multitiered system of healthcare where some people would not get all benefits. Physicians like me know that one's health cannot always be predicted and that the unexpected does happen. Thus, patients given the option of incomplete plans may find themselves wanting for adequate coverage. Physicians like me also cringe at the notion of a double standard in in health care since it is our training and our philosophy to believe that everyone should get the best of care all the time.

At the present time, under the Affordable Care act, IRS (The Internal Revenue Service) has a role in enforcing the individual mandate. The individual mandate is the portion of the Affordable Care Act which requires that individuals must maintain health insurance at all times or be fined. GOP lawmakers are currently working on a plan to prevent the IRS from enforcing the Affordable Care Act individual mandate. I think you would be hard pressed to find a physician who does not support the individual mandate. 

In our country, one must have auto insurance in order to exercise the privilege of operating an automobile on public roads. Conventional wisdom and existing data teach us that if one does not maintain auto insurance that one poses a significant liability to others. In my opinion, not having individual health insurance is exactly the same thing. Without insurance, one is less likely to obtain contraception, less likely to obtain vaccinations, less likely to obtain mental health and substance abuse treatment, and more likely to blow into the emergency room with some health crisis or accident costing the healthcare system and taxpayers a huge amount of money.

In medical news, the number of total births has declined for two years running. Most notably the teem birthrate has decreased to nearly 10%. Unfortunately rates of preterm birth continue to rise.

In the absurd department, both the UK and United States noted increasing rates of labioplasties not only among women but particularly among teenagers. A labioplasty is the surgical modification of the labia, the flaps covering the vagina, often for cosmetic purposes. Obstetricians and Gynecologists in both British and American Societies of Obstetricians and Gynecologists as well as Pediatricians have sounded the alarm over this trend indicating that it may be a sign of a deeper disorder called body dysmorphic disorder. They have called for clinicians to screen these patients accordingly. I also have to observe that this trend highlights the power of media images in our lives, including those provided by what must be classified as porn.

A recent study of robust design has revealed that women consuming large amounts of sugary foods and drinks in the latter part of pregnancy produces children who are at higher risk for allergies and asthma. The study was published in the European Respiratory Journal. It been hailed as a strong study with a large number of participants. A call has been made for additional research to understand exactly how this works.

In the we-already-knew-this department, a recent study has confirmed that women’s cognitive performance is not affected by her menstrual period. This was documented recently from a study published on July 4 in the journal Frontiers in Behavioral Neuroscience.

In the concerning department, new research has shown that poor sleep may be associated with an increased risk for Alzheimer's disease. It is not at all clear whether the poor sleep leads to the Alzheimer's or whether the impending Alzheimer's leads to the poor sleep.The study involved sampling the spinal fluid of cognitively normal people with an average age of 63. Specific physical findings are present in the spinal fluid which can be followed to determine this relationship. This is clearly an area deserving of more research and this is a step in the right direction. The findings were published online July 5 in the journal Neurology.

In the good news department, a new study has shown that simple aspirin may reduce the risk of complications for those pregnant women who have antiphospholipid antibody syndrome. Yet another study has shown that a simple dose of aspirin at 150 mg per day significantly reduced the incidence of preterm preeclampsia (toxemia) in high-risk women. 

Also in the good news department, clinical trials for Zika virus vaccine are underway. Zika virus can potentially affect all people who contract it,. Most distressingly, it produces serious birth defects in the fetal brain if the Zika virus infection is contracted by pregnant women during her pregnancy. A working group consisting of bioethicists, OB/GYN's, vaccinologists and others have recently released a set of ethical guidelines whereby pregnant women can be included in these clinical trials.

 

 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology, right here, next week, on Medical Monday. And remember... it really matters when you contact your elected officials to tell them what you think. 

Medical Monday: Breaking news from the World of Obstetrics and Gynecology

Health and Political concerns for women have merged into one. Many of you have appreciated this for some time, but now the topic is mainstream. 

Last Wednesday leaders representing over half a million medical students and doctors gathered to lobby Senators against the so-called BCRA (Better Care Reconciliation Act).Among the leaders were the Presidents of The American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists (ACOG). They validated and reiterated widespread concerns that without the ACA (Affordable Care Act) or similar, people will delay or forgo care. For example, under the new proposal, older patients will have cost sharing reductions curtailed in 2 year. The leaders also voiced concern about allowing individual States to determine what constitutes essential benefits. Dr. Munger of the American Academy of Family Physicians indicated this compromising essential benefits would constitute a special threat to people with chronic, rather than acute conditions, since their essential health needs are ongoing. The President of the American Academy of Pediatrics indicated that there will be a calculable “ body count” associated with this proposed law. 

Dr. Haywood Brown, President of ACOG, stated the legislation represented an “ assault on women’s health”. He elaborated, saying BCRA could result in women and men paying differently for health care. It would end the guarantees on preventive care, i.e screening tests like paps and mammograms. Dr. Haywood also noted that fully 50% of pregnancies are unplanned. The BCRA bill would end guaranteed coverage of contraception and maternity services. These changes would worsen the already terrible trends in maternal mortality in the United states. He states he feared going back to the time when having a baby could lead to bankruptcy, and when treatments for cancer were not always within reach. Indeed, the Journal Cancer has published a study containing projections of the numbers of increased cases of late-stage breast cancer that will be diagnosed during to loss of access to screening mammograms. As if to drive home the point ,the Journal Cancer Epidemiology contains new research indicating that breast cancers appear to have been diagnosed earlier after the ACA was implemented. 

California has its own contraceptive requirement, a goal that many States are now have accomplished or are working toward. The California policy, in place since the first of the year, requires that insurers cover contraception. It also requires that they cover 12 months of it at a time. It is estimated that in California, it will reduce the number of unintended pregnancies by 15,000, the number of miscarriages by 2000, and the number of abortions by 7000. Health care costs will be reduced by 43 million dollars annually. 

Low income women are at particular risk if the BRCA goes through, since it would phase out the Medicaid expansion in a more permanent way than the ACA would. Of note, half of all births in the US are covered by Medicaid. One fifth of all American women use Medicaid. 

Many observers have noted that BCRA healthcare bill disproportionately affects women, since it targets maternity, screening, and contraception. Bill Cassidy (R-LA) has come forward to say that the law should include provisions for all insurance plans to include prenatal care and for laws that require employers to grant maternity leave for both parents. Hooray for Republicans standing up for women’s health ! I did a little research and found that Senator Cassidy and his wife are physicians who feel this aligns with their Christian values. Why is this so rare ? 

Another group is at risk of losing affordable insurance: Those who obtain their health insurance through their work. The Affordable Care Act currently mandates that businesses of a certain size offer their employees health insurance. That requirement is due to go, all or in part, by the wayside. 

Modifications to the BCRA plan are under consideration. GOP senators had considered scrapping the “ wealth tax” on those families making more than $275,000, but now they are considering keeping it to help pay for extra funds to combat the opioid epidemic. Furthermore, GOP senators have conceded, at the urging of insurance officials, that the individual mandate be kept indirectly in that a penalty fee will be levied against all those who do not maintain health insurance at all times. Insurance industry representatives have asked for this to help stabilize the insurance market. Personally, I think it is an important part of any health care plan, since it requires people to prioritize their health, it enables people to comPlanned Parenthoode in for care especially screenings, and it protects patients, caregivers, hospitals and the rest of us paying insurance against direct or indirect financial loss due to health mishaps. 

Two GOP Senators, both women, have criticized the BCRA over its defunding of Planned Parenthood. 

Personally I think it would be just fine if the GOP scraps the ACA then puts it all back together piece by piece, gives it a different name, and takes full credit for it. I just hope that, being Republicans, they find a fiscally responsible and sustainable way to fund it. I favor heavy vice taxes. Why ? Because they discourage vices ( true and documented !) and they make lots of money for the public coffers. Cigarettes are heavily taxed, but they could get taxed even more. Alcohol could be further taxed. Soda taxes could be tried but have not been popular… too bad !  Finally, in my opinion, marijuana should be taxed in those States where it is legal, for all but those with legitimate cards. FaIling these, I favor increased gas taxes and increased sale taxes on luxury items. 

On to the medical news. 

Zika precautions for pregnant and potentially pregnant women are still in place. Travelers heading anywhere south of the Mason Dixon line should inquire on the CDC.gov website about regional risk. 

Opioids. These are the pain pills or IV drugs, the morphine derived compounds that are so addictive. It turns out they are not really that much help with actual pain. It turns out they work less and less well over time, and that eventually, they need to be taken just to feel “ok”.  Patients often begin them for legitimate reasons, but then end up taking them just to cope. They may not even realize they are addicted. Doctors give them for legitimate reasons, but also because they are lazy. It is hard to say no, especially when you think that saying no will cause your patient to leave your practice and medical care altogether. A new study has found that about half of opioids are given for mental health disorders rather than pain. Physicians and patients need to be educated. It is estimated that half a million people will die in the next decade due to opioid abuse, unwitting or otherwise. 

Flu vaccine may be delivered by a painless patch in the future. A new study published in The Lancet reports on this research. I wonder if this will enhance vaccination rates. 

Increased rates of air pollution are associated with shortened life spans. A new study published in the New England Journal of Medicine indicates that “ safe” levels may be lower than previously imagined. Indeed, there may be no “safe” level at all. 

ACOG recently held its annual meeting. New research presented there focused on media representations of female genitalia. Dr. Cheryl Iglesia noted that images of female genitalia are “highly-curated, and extensively retouched” before being presented on the internet, “ leaving men and women little idea of the real range of normal efface genitalia”. She has suggested that this distortion is associated with a sharp rise in labioplasty surgery in the last year. Ten thousand such surgeries were done in the past year, a rise of 23% compared to the previous year. ACOG has issued a Committee Opinion document “...expressing concern about the lack of data and deceptive marketing practices surrounding a number of cosmetic vaginal surgeries”.

So much news ! Stay tuned here next week … for Medical Monday. 

Meanwhile contact your elected officials at Congress.gov !! It's Independence Day ! Exercise your freedom !! 

Medical Monday: Medical Portion

Maternal mortality rates are once again in the headlines, although this time the focus is on Virginia and not Texas. Virginia has 38.2 point two deaths per 100,000 live births. The Virginia Medical Examiner's Office investigated, finding that, "Women who die pregnancy related deaths in Virginia more often die from not having health care than from hemorrhaging, cesarean section complications or other maladies linked to birth." Virginia is not isolated in this regard as the American College of Obstetricians and Gynecologists has reported that there has been a 26% increase in maternal mortality in the United States from the years 2000 to 2014.

In the good news department, we have evidence for a common sense phenomenon. Data reported this month in the Journal Birth has demonstrated that "Physical activity during and after pregnancy improves psychological well-being and may protect against postpartum depression”

A new report in the American Journal of Clinical Nutrition has found that women with gestational diabetes who consume a high proportion of refined grains may give birth to children with a higher risk of obesity by age 7.

A study was performed using a federal nutrition program and an Internet-based program for weight loss. Results on 371 women indicated that this Internet-based weight loss intervention helped women shed their baby weight, i.e.their postpartum pounds. This study was funded by the National Institutes of Health and was published in the Journal of the American Medical Association. 

More data has come in against the practice of water birth. The Arizona Department of Health has identified two cases of Legionnaire's disease which occurred in newborns following water birth.  In both these cases the babies had been born at home in hot tubs. The Department noted that tapwater is not sterile and that legionella bacteria can grow in plumbing systems. While ACOG supports water labor it does not support water birth, citing a lack of definitive evidence showing safety and benefit.

Breast-feeding has numerous benefits for the baby and some obvious ones from mom. However it is somewhat counterintuitive that breast feeding should protect a woman against heart attack and stroke. Nonetheless new study has shown that “ breast-feeding may help mothers lower the risk of heart attack and stroke even decades after giving birth".  Breast-feeding for any amount of time confers a 9% reduction in the risk of coronary artery disease and reduces risk of stroke by 8%.These findings are published in the Journal of the American Heart Association.

A report produced from the Population Reference Bureau calls attention to the difficulties that young women face. The report is called "Losing ground: Young women's well-being across generations in United States". It has quantitatively documented that women in the US are”…poorer than their mothers and grandmothers when they were young, more likely to commit suicide and to be shut out of high tech jobs .” It concludes that ”social and structural barriers continue to obstruct the advancement of female members of generation X and millennials."

In-line with the last report, it's been determined that" opioid related hospitalizations among women in the United States have increased far faster than among men between 2005 and 2014." This has been determined by looking at data from the US agency for healthcare research and quality. Such hospitalizations have risen by 75% during this time interval. 

Breast cancer is in the news. It turns out that a low dose of aspirin i.e. baby aspirin taken daily may reduce the risk of breast cancer in women who have type II diabetes. This is preliminary research published in the Journal of Women's Health.

The National Institutes of Health has recently reported good news regarding breast cancer. Apparently breast cancer rates have been steadily declining since 2005 at a rate of 1.8 % per year.

ACOG has maintained their position that women should be offered mammograms beginning at age 40. Thereafter they should be given every one or two years through a joint determination by the patient and her physician.

 

Stay tuned for more breaking news from the exciting world of Obstetrics and Gynecology next week on Medical Monday. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

On last Thursday afternoon June 22nd the Senate unveiled their draft of the ACHA the American Health Act, which they are calling the “Better Care Reconciliation Act". House Minority Leader Nancy Pelosi put it well: This is a “…tax bill disguised as a health care bill.” As readers begin thinking about it, they should consider that it does one main thing: it shifts the cost of health care away from the Federal Government. 

Most doctors understand that decent health is fundamental to all human happiness and prosperity. Indeed someone once said health is our only real wealth. Additionally, many social scientists and other bean counters have discovered that standards of living go up when the quality of a population's health rises. It has been conclusively demonstrated that particularly when the quality of the health and status of women rise, the entire society benefits, in both social and monetary terms. When there is good access to maternal and child health care, infant and childhood mortality decrease, maternal health increases, and family size shrinks. Earnings, savings, and educational status rise. These are well documented phenomena. 

So called Obamacare, aka the Affordable Care Act (ACA), made the health of women and children a priority. For example, the ACA included mandated insurance coverage of maternity care. Yes, this meant that the cost of giving maternity care to some was shouldered by all, since everyone contributed to a “pot” that paid out for maternity care expenses.  Implied is the notion that society as a whole has a vested interest in the welfare of pregnant women and the children that they bear. The idea is that it is our collective responsibility to ensure the well being and betterment of the next generation. 

Indeed the whole notion of insurance used to be that people could rest easy knowing that they had a way to deal with life’s unexpected or costly events. They could contribute to a pool for emergencies and other medical needs, and it would be there for them when the need arose. This was by mutual agreement between all the contributors and governed by certain pre-agree upon stipulations. Everyone knew that more people meant better benefits and more stability of the fund. 

Health insurance was viewed as a social and financial responsibility. Nonetheless, if you did not have heath insurance, you would still get emergency care, since the moral values of society and the medical profession would kick in. At the same time, people who could get health insurance but didn’t were viewed as irresponsible since they would simply take their chances or let others foot the bill if they did land up in the hospital. 

People in the US disagree about what constitutes the responsibility of government. They disagree about the role of government in health care. However, progressive and prosperous countries across the globe have examined the question from a data- based rather than political point of view. They have determined that the social and financial benefits of universal health care coverage are well worth the price. In developed countries, the government sees to the national security, and it sees to our infrastructure. These are examples of enormous and costly tasks that no one person, family, or even state could accomplish. But, a nation can. Health care is like that. A healthy prosperous nation requires massive collective input, both from a planning standpoint, and a financial standpoint. I can think of no better use for the collective monies obtained through our taxes. In this light we consider the new health bill draft. 

The new health plan draft basically proposes massive cuts in what the Fed spends on health care. Not only does the Fed currently spend on Medicaid and Medicare, under Obamacare it spends by paying private insurance companies "subsidies” so that the the insurance companies can charge more reasonable premiums to consumers. 

This great reduction in Federal expenditures toward health care would be accomplished in several ways. First it will reduce the number of enrollees.The mandate to have insurance would be eliminated. Fewer people will therefore obtain insurance. They will also curtail the number Medicaid enrollees by making requirements more stringent and by rolling back the Medicaid expansions. The assumption is that these uninsured folks will simply not cost the Fed money. However they will cost someone money over time as they end up in the Emergency Room with their unmet health care needs and emergencies. The health care system and the insured patients who pay into it will cover their bills, and health care costs will have to rise to compensate. 

Secondly, the Fed will save money by asking consumers to shoulder a higher percentage of their health insurance costs by paying higher premiums and having higher deductibles. In return the Fed plans to offer “ tax credits”. Tax credits are not money. They are a lower tax bill at the end of the year. But who can use tax credits ? Only people with appreciable taxes. Tax credits will do low income or even middle income people little to no good. These are the people who need the most help. 

Thirdly the Fed will save money by requiring States to pay more for health care. They have proposed cutting Medicaid money dispensed to states giving instead “ block grants” of lesser value. 

Fourth the Fed plans to make huge cuts to key health organizations such as the National Institute of Health and the Centers for Disease Control. 

Fifth and perhaps most importantly, the Fed will save money by cutting services. First on the chopping block is the contraceptive mandate. And if some of you say the Fed will only pay through the nose for increased unintended pregnancies, fear not, there is talking of cutting maternity services as well. Emergency services and mental health services will be cut, and Planned Parenthood is to be defunded. 

The anticipation is that millions would lose health insurance altogether. The related expectation is that costs for those that remain in the market will skyrocket. Millions of tax dollars will be saved, and this will be trumpeted as a great benefit. In fact it will be a benefit only to those with a significant tax burden. Those with bigger incomes will obviously benefit the most, since they pay the most taxes. So, in the final analysis, money for the general welfare of the nation, the care of pregnant women and children, and the care of the poor will be taken out of the public coffers and placed back in the hands of the well to do who currently pay large taxes. Make no mistake, these wealthy people will still pay high taxes. They will just be slightly less high. The degree of good done by the tax cut for the wealthy will not match the harm done to the poor by the loss of their insurance. 

This plan would most likely result in millions of uninsured. There will be less health screening. Thus there will be fewer pre-cancers and early cancers caught and treated. There will be more unintended pregnancies. There will be more abortions, and more STIs. There will be more unreimbursed emergency visits at hospitals. There will be more missed work, unemployment and disability. There will be more resentment. 

The betterment of society is a collective responsibility. There are some older senators who have complained that they do not want to foot the bill for birth control or maternity care since they themselves will never need any. How would they feel if I said I did not want my insurance premiums to encompass the burden of paying for those who smoke, drink, or do not stay fit ? Perhaps I should start an insurance pool for the young, fit and beautiful. That would be great except they would not let me in. 

A firestorm of objection has been lit. Among the incensed are Senate Democrats. Also objecting for different reasons are certain Republicans: Rand Paul (KY), Ted Cruse (TX), Ron Johnson WI) and Mike Lee (UT, and others, members of the so called “ Freedom Caucus".  Also expressing reluctance were other Republicans Toomey (PA) and Collins (ME). 

Top medical groups have criticized the bill, most notably and loudly, the American College of Obstetricians and Gynecologists (ACOG). It is worth repeating the College’s statement on the legislation: “ Despite numerous efforts to collaborate and provide input throughout this process, women’s health expertise was rejected. It is reckless for legislation that will have such an immense impact on American lives and the economy to proceed without the opportunity for public hearings or any external commentary.”. 

On Capitol Hill there were angry protesters demonstrated, many of whom were in wheelchairs. 43 were arrested. Elsewhere across the country, demonstrations have been taking place. It seems the whole country is worried and upset. 

What’s next ? The draft goes to the Congressional Budget Office. There they will attempt to assess the direct and indirect, short term and long terms costs of the proposal. From there it may make it to the Senate floor for debate. If even as few as two Republican Senators disapprove of the bill, it will not pass. 

My father in law was a conservative gentleman who practiced Obstetrics and Gynecology for over 40 years. He was a Republican and very active in medical politics, advocating for  better health care for pregnant women across the state. He passed on a couple of years ago. I am glad he has not witnessed the degeneration of the Republican party and the disregard with which health care, women, and children are being treated. 

Medical Monday, medical portion, will have to come in a subsequent post, since this is already a very long dispatch. 

Again, please accept this reminder to call your Senator and let them know what you think. 

And for something upbeat, take a look at a book I just finished. It is called The Year of Living Danishly. You will get some smiles, but also some understanding of how another very successful country runs the relationship between taxes, health care, and happiness. 

 

 

Medical Monday: Delayed Edition

After I got my diagnostics squared away, I discovered ACOG’s ( American College of Obstetrics and Gynecology) news site was down. Members like me have access to their news and research paper aggregator. I use it as my starting point for creating your news digest blog post page Medical Monday. Finally, all is well and we have some catching up to do. 

GOP leaders have once again announced a deadline for a vote on their health care plan, the American Health Care Act (ACHA). The deadline is to be the end of June. However, as of this writing, there are still significant disagreements over the particulars. Moreover, the drafting of the bill has now gone behind closed doors. This has met with consternation not only from Democrats but from Republicans too, since such interested stake holders cannot have a say or even see what is going on. 

The Department of Health and Human Services, (HHS) has a nonpartisan economic unit called The Office of the Actuary. According to a recent analysis done by this office, adoption of the ACHA would cause out of pocket expenses to rise about 61%. This means premiums and deductibles would rise 61% for the consumer. While the real cost of the premiums would be somewhat lower, the government subsidies to defray them would diminish, leaving the consumer to pay the difference. The current administration wants to pay less, and wants we consumers to pay more. Remember that the government’s money is really our money, collected in the form of our tax dollars. While about 29% of the American public supports the ACHA, it is not formally supported by a single State government. This is because the Fed is trying to do to States what it is doing to us. It is trying to shift more of the financial cost of health care off of itself and onto the States. If the current administration succeeds in shifting health care costs to the consumer and the States, it will claim it is saving taxpayer money.

Many of you are already aware that Texas is facing a crisis in maternal morbidity and mortality. Concern is mounting that the crisis will only get worse if the ACHA is passed, since it will reduce already limited funds for the care of women and pregnant women. 

Business leaders are starting to register concern about the looming changes in health care. In particular, the cancellation of the contraceptive benefit is projected to have huge economic and social repercussions for American families, such as spikes in unplanned pregnancies, and ripple effects though the workplace. A statement by Allan Peace of Trillium Asset Management notes that “ institutional investors… see compelling evidence that widespread access to sexual and reproductive health care benefits” promotes  the “interrelated outcomes” of women having greater control over their lives and the facilitation of economic growth. I would add that this has been demonstrated not only domestically, but around the world. Yes, prosperity and the status of women are directly related. 

In the good news department, Maine is the next in a line of States taking matters into their own hands. They have passed legislation requiring insurers to pay for up to 12 months of birth control at a time, and have prohibited insurers from charging copays for birth control. They cited data from California indicating that the unintended pregnancy rate fell by 30% when they enacted similar measures. Twenty eight states now have some sort of contraceptive equity law, aiming to make contraception very affordable or free. Let’s hope we get 50. 

The Royal College of General Practitioners has presented research again confirming that oral contraceptive use does not confer increased long term cancer risk. 

In further good news, the City of San Francisco has spelled out clearer rights for breastfeeding women in the workplace. This includes the stipulation that employers provide a clean private space with electricity, a surface and a chair. 

In medical news, Zika is back. Zika is a virus carried by the Aedes Aegyptae mosquito found from the southern US southward. When contracted by pregnant women, it causes serious malformations in the nervous systems of developing babies. 1900 women in the US have had confirmed Zika infections. The proposed White House budget proposes an emergency fund for Zika but would also cut billions from budgets of the National Institute of Allergy and Infectious Disease and the CDC (Centers for Disease Control) where work is underway on a vaccine. The first cases of the 2017 Zika season have come in from … Texas. 

A new study confirms from JAMA Pediatrics indicates that even small amounts of alcohol in pregnancy may result in babies with slight facial abnormalities. 

Obesity (BMI of 30 or more) is a huge problem. However being overweight (BMI 25-29) takes its toll as well. New research published in the New England Journal of Medicine indicates that, worldwide,10% of people are overweight. Altogether 30 % of the world are affected by weight problems. The US leads the world in obesity in children and young adults. The US also has the greatest number of obese adults. Excess weight accounts for 4 million deaths worldwide, seventy percent of which are from cardiovascular disease. 

A new and large study from Sweden indicates that the risk of major birth defects increases proportional to the severity of a mother’s obesity. These patients are also at greatly increased risk of hypertension ( high blood pressure ) and diabetes. 

That gets us up to date with the news from the world of Obstetrics and Gynecology. 

Medical Monday Postponed

 Gentle  readers,

I must once again ask your forbearance for a small delay in the publication of Medical Monday. I began preparing for a weekend without my family as they departed on white water trip. I have had big plans for all the things that I could get done without them here, including some exhaustive computer maintenance that is been overdue.

 I'm the sort of person who makes somewhat optimistic lists. Nonetheless, I was determined to get my computer maintenance done, as I was covetous of the increased speed it would hopefully confer.  So I did the first thing that one should do when performing computer maintenance. I backed up. Yes, I back up to the cloud; I use iCloud since everything I do is part of the Apple universe. However I thought it prudent to back up the entire hard drive to another physical hard drive as well. 

I have a habit  of filling up rather large hard drives and so I should not have been surprised when my physical back up took all night Friday and half of the day on Saturday. From there I could go on to diagnostics.

Since I gotten a new larger terabyte hard drive I realized I to had re-create what is called an Edrive as a bootable entity on the main hard drive itself.  This is because the computer cannot properly do diagnostics on itself unless it is booted off something else. So after creating the Edrive using my diagnostic software Tech Tool Pro I rebooted to the Edrive and set about doing diagnostics.  I chose the whole suite of tests, thinking it would perhaps take four hours. I began the diagnostics Saturday afternoon and now I see very late on Sunday night that they are still working away. 

 And while right now I am OK with dictating you this quick note on my iPad, I will wait to do Medical Monday since, trust me, I personally have to have three big screens open to do the homework to write Medical Monday, checking sources and whatnot. 

So let this be a lesson to all of you. Keep up on your computer maintenance. It's really not very hard, it really is not. Basically you obtain appropriate software for your operating system and version, and you follow the instructions. If you use the Macintosh operating system I can unreservedly recommend the TechTool pro software which you can buy at microtek.com.  Since I don't use Windows I'm not familiar with the best choices but I know there are several easily obtained pieces of software and many choices out there even some of which are good and free available on the Internet. However, always read their documentation and read the reviews from independent sites before buying or installing. And by all means, back up your machine before doing anything. In fact, back up two different ways,  once physically and once to the cloud. 

Let's hope my diagnostics are done by tomorrow. 

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Medical Monday: Part Two

Medical Monday: Medical News Section 

Pregnancy related death continues to rise in at a fairly steady rate in the US. As of 2013, we sit at 17.3 women per 100,000 live births with a rage of about 12 per 100,000 for whites and 40 per 100,000 for blacks. Cardiovascular diseases of various kinds accounts for about 40% if these deaths. About 9% are due to pulmonary embolism, and 7% are related to high blood pressure and preeclampsia. The rest pertain to infection, hemorrhage and rare disorders like amniotic fluid embolism. 

Teen births are statistically high risk. It turns out that high teen birth rates cluster in certain cities. Analysis of the data shows these clusterings are not random and are not related to poverty to education. Most generally, the clusters are in the southern states, but they also exist in Denver, Fresno, and Yakima. San Antonio has the distinction of being the number one urban center with a teen pregnancy cluster. These findings my begin to help shed light on what is no doubt at least partly a cultural phenomenon. 

Breastfeeding has been touted has having numerous benefits, including health benefits to the mother. It turns out that prevention of uterus (endometrial) cancer is one of those benefits. Breastfeeding EVER confers an 11% reduction of risk. The longer the breastfeeding the more the risk was reduced, until risk reduction peaked at somewhere around 6-9 months of breastfeeding. 

Polycystic Ovary Syndrome (See PCO section HERE) is a complex of problems which include problems with ovulation (producing an egg), as well as obesity, excess male hormone, and difficulty metabolizing carbohydrate. A given patient may have one, all, or just a selection of the features of this varied disease. Generally, doctors have assumed that obesity and carbohydrate intolerance goes together. However new research has shown that even normal weight patients with PCO have have significant insulin resistance. This points for the need to counsel normal weight patients to eat a very high quality diet rich in protein, vegetables and fruit, and healthy fats. 

The overall incidence of depression in teens in higher than once previously believed, coming in at about 14% for those between 12-17. Of note, by 17, girls had a three fold higher incidence than boys. 

In the vice department, the news is sobering. New research from the Journal of Drug and Alcohol Dependence has shown that children born to women who smoke as few as 10 cigarettes per day have problems later in life. In particular, they have increased problems “learning and thinking”. 

The British Medical Journal has published research showing that even small amounts of alcohol produces changes in brain function which play out as poorer performance on language related tests. This data comes from research on 550 men and women over a 30 year period of time. 

Hard data is in from last year’s mosquito season in America (including Puerto Rico). Zika virus, which is transmitted by mosquito, produced birth defects in about 5% of babies who’s mothers became infected in pregnancy. This number was higher for those infected early, and lower for those infected late. We should learn even more this  year, and hopefully get one season closer to a vaccine for this dreaded disease. 

For those in Zika- vulnerable states: Remember, DEET is safe in pregnancy. Zika is not. 

 

Stay tuned next week for more breaking news from the world of Obstetrics and Gynecology. 

Medical Monday: Breaking News from the World of Obstetrircs and Gynecology

We start with encouraging policy news. Republican Kevin Brady of Texas, Chairman of the House Ways and Means Committee, has asked that Congress “ immediately provide funding for subsidies to insurance companies to keep insurance premiums affordable for subscribers in 2018. This is a provision of the current law of the land, the Affordable Care Act (ACA) . It basically means that, under the Affordable Care Act, the Federal Government pays a good chunk of the originally high insurance premiums to keep them affordable for consumers. I can appreciate Texas Representative Brady’s concerns. Health care is a huge focus in his ethnically diverse state, which is part of the so called "fat-belt", and also has the highest maternal mortality rates in the Union. Keeping his poorer constituents in health insurance costs federal tax dollars to be sure. Yet these subsidies will go to provide low priced preventive measures which will in turn prevent high priced diseases. Chairman Brady knows that beyond Texas, America, the economy and the budget cannot afford for these people to lose their health care. 

In other encouraging policy news, the board of pharmacy in New Mexico has ruled to allow pharmacists to write for oral contraceptive pills. This way, most of the time, a woman will not have to visit a physician to obtain a prescription. Physicians, especially Obstetricians and Gynecologists applaud the measure since it removes barriers to contraception, and because the safety profile of oral contraceptive pills is so good. 

Delaware has had its share of abortion restrictions, including waiting periods, parental consents, provisions that there need be maternal risk, fetal abnormalities or rape, etc, etc. However Roe vs. Wade established in the 1970s that abortion is permissible until viability, and that remains the Federal Law. Delaware recently rescinded all of of these and simply reinstated the consistency of its State Law with existing Federal law. 

Connecticut failed to pass a bill to insure, on a statewide basis, the coverage of women’s health care services through insurers operating in their state. The bill tried to ensure 21 essential benefits for women, including breast cancer screenings. The bill passed the Connecticut Senate unanimously, but died on the floor when attempts were made to amend it pursuant to abortion. Hopefully it will be edited and brought forward again, in a way that will get results. 

New York is working to safeguard coverage in their state. They have drawn up their own plan to ensure the 10 basic benefits as identical to those in the ACA, which include prescriptions, hospitalizations and maternity care. 

States handle health care for their low income populations through either the ACA or Medicaid. This was possible in part due to the Medicaid expansions that took place under the ACA. A new Kaiser Family Foundation report has shown that fully 71% of Republicans, 93% of Democrats, and 83% of Independents feel that this Medicaid expansion funding should continue. Countrywide, Medicaid covers 70 million low income children, pregnant women, disabled and elderly. I do not think, especially after seeing this data, that the American people are grudging about this expenditure of their tax dollars. They do want to know, however, that that those dollars are buying them something. There is a burden on government and the medical profession alike to demonstrate with data how Medicaid dollars spent on routine care save huge monetary and societal costs later. In the field of Obstetrics and Gynecology, this sort of research has been done. For example, it has been shown that birth control is the best value on the dollar anywhere. 

Medical Monday will conclude there for tonight, at the end of our policy section. Tomorrow I will tackle the medical news, as tonight has gotten rather short. 

Medical Monday: Breaking News from the Wrold of Obstetrics and Gynecology

In this week’s policy news, focus is on The Contraceptive Mandate. This is the part of the Affordable Care Act (ACA) which requires all insurance companies to cover birth control at no cost to the insured. The New York Times has reported that the Trump administration is working on broadening the criteria through which employers and insurers may refuse to provide contraception as a benefit within their health insurance.

Initially, one company, Hobby Lobby, went all the way to the Supreme Court to argue that based on their religious principles, they had a right to decline to provide insurance which covered contraception for their employees . They argued that contraception is against their religious principles. The Trump administration would like to expand the criteria for which companies can claim a moral or religious objection to the provision of contraception.

The President of the American College of Obstetricians and Gynecologists has spoken out in multiple ways against this trend and has added his objection to discussions pertaining to the elimination of the necessity to cover maternity care. Can you believe it? Attorneys at the American Civil Liberties Union have begun to elucidate a very powerful argument that these policy trends violates the separation of church and state. Moreover they constitute discrimination based on sex.

At the present time approximately 55,000,000 women receive contraception through this no cost benefit. The scientific data supports the Democratic assertion that there is a clear and evidence-based correlation between The Contraceptive Mandate of the Affordable Care Act and the historically low unintended pregnancy rates, teen pregnancy rates, and abortion rates.

Women are not the only target in the latest round of discussions on healthcare policy. A certain group of GOP senators I'm working on a revision of the Affordable Care Act which will no longer classify employer purchased health insurance as a tax deductible expense. This appalling antibusiness and anti-healthcare piece of legislation threatens the 177 million Americans who have their health care coverage through their employers. Additionally anybody who has a pre-existing condition or who has to watch their health care expenses is at risk if any of these GOP draft revisions to the health care bill are enacted. 

On to the medical news. Did you know that there is no safe level of alcohol consumption pregnancy? People widely assumes that the rule of moderation applies to alcohol and pregnancy but this is not at all the case according to the CDC, (the Centers for Disease Control and Prevention), the National Institute of health, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. No alcohol should be consumed in pregnancy. Not a popular message. 

An increasing number of states have legalized the use of marijuana. Accordingly pregnant women have gotten the skewed message that this sends and have been using marijuana in record numbers. No one seems to be listening to the repeated messages coming out of scientific circles such as the American College of Obstetrics and Gynecology indicating that marijuana use in pregnancy is associated with brain development problems in the fetus. A whopping 14% of pregnant teenagers ages 12-17 use marijuana. Dumb and Dumber. That is my fear. Also not a popular message. 

It is Zika virus season again in North America. To date 64 babies have been born in the US with Zika related birth defects. Diagnosing infections and tracking the spread of the virus is of paramount importance, together with enacting virus prevention measures such as spraying and education. All this costs money, and funding is tighter than ever this year, pursuant to the policies of the current administration. Zika virus, when contracted by pregnant women, produces a high risk of severe brain damage in the baby. Zika virus is spread by certain species of mosquitoes which live in the southern portion of the United States and points further south, most notably Central and South America. Florida already has 43 documented cases of Zika virus infection in pregnant women. 

Finally, in the good news department, women who breast feed their children for at least six months reduce their risk of endometrial cancer by over 10%. Of course they do their babies an infinite number of goods from improving their teeth to improving their brain development, but who knew there could be such tangible and profound effects on the health of the mother. 

Stay tuned next week for more sensational news from the world Obstetrics and Gynecology, right here on Medical Mondays.