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

Policy News 

People across the political spectrum continue to debate the merits of Brett Kavanaugh for the Supreme Court. Since we now know that the political and judicial systems play such a large role in the health care of women, we’d all best pay close attention to this debate. 

Drug Shortages. We did not used to have them. Now it is common place on routine drugs, even IV fluids. No slight to third world countries, but sometimes it feels like we are in a third world country. The FDA is forming a new task for to more critically and quickly investigate and solve this problem. 

Companies that make formula are multinational. The Trump administration is avowedly pro business and this is particularly evident in the international sphere where of late, this had unsavory consequences. In its zeal to unfetter corporate interests, The Trump administration has taken an anti breastfeeding stance. At present advertisements of formula is limited regionally in areas where it could be misused or hazardous. The Trump administration has desired to “ reopen” these markets, under the auspices of free trade, seemingly oblivious to the perils of selling formula  in places where literacy (ability to mix correctly) and clean water is unavailable . The entire medical and public health establishment has reacted, concerned that breastfeeding continue to be encouraged as the safe and superior method that it is. Many are pointing out that formula manufacturers have no place at the health policy table. This baby feeding battle resurfaced last year when Ecuador proposed a resolution to the WHO (World health organization)  to support breastfeeding. The Trump administration through the US delegation at the World Health Assembly, tried to water down the resolution. When this did not work they threatened Ecuador with a trade war. Can you say “evil empire” ? ACOG (American College of Obstetricians and Gynecologists) and AAP (American Academy of Pediatricians) have responded formally. 

Did you know as little as two months of breastfeeding reduces risk of SIDS ? 

Did you know breastfeeding reduces mom’s risk of breast and ovary cancer, heat disease, and endometriosis ? 

Did you know the US ranks 26th among industrialized countries in breastfeeding ? 

The Trump administration seems to want people off the ACA. They have reduced the “navigators” fund from 36 to 10 million per year. Navigators are those who help people enroll in the ACA. The Trump administration says private health insurance agent and brokers do a better job. Do private brokers and agents get a fee for this ? 

Medical News 

Abortion facts were highlighted by NBC this last week: 

Death by childbirth is 14 times greater than death by abortion. 

Banning abortion does not reduce its incidence. 

Free birth control reduces abortion rates. 

Before legal abortion, 5000 women per died through complications of illegal abortion. 

Depression is not the only feature of postpartum depression. A new review has highlighted the fact that anger is often a big component of post partum depression. 

Your microbiome is the population of microorganisms that you have on your body and in your gut. This is affected greatly by what you eat. In pregnant women this microbiome is passed to the baby. Thus, what pregnant women eat can influence the microbiome of their child, for better or for worse. Newer research in multiple fields are beginning to describe the role of a healthy microbiome to overall health. 

The US birth rate is at an all time low for the second year running. Some site child care expense, wanting to spend time with existing children and concerns about the economy as chief reasons to wait. Germany and Japan have addressed their falling birth rates by putting better child care policies in place. Falling birth rates are not necessarily a bad thing, as they are associated with greater savings and higher levels of educational attainment. It is certainly an oversimplified falsehood to think that a larger population means a better economy. 

Stay tuned for more interesting news from the world of Obstetrics and Gynecology this time next week on Medical Monday. 

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

These Summer days are very busy for me and my family. So I am going to keep to an abbreviated or bullet version this summer. A little later, I’ll let you in on a fun little secret about why I am so busy. 

The biggest policy new has to do with the need to fill the vacancy in the Supreme Court created by the resignation of Justice Kennedy. The most contentious issue thus far has been abortion, Thus, all conceivable candidates are being scrutinized for their views the subject. Justice Kennedy had been a more liberal justice, and Trump has promised to install an anti abortion justice who would then contribute to the making of law for the rest of their tenure. At present, under Roe V. Wade, abortion is legal. Prior to that it was not, yet many many women and caregivers defied the law, often at great peril. My late father in law, an Obstetrician Gynecologist minted in the early 1960s remembered the days before legal abortion, and while no friend of abortion, told us cautionary tales about the complications that illegal abortions could produce. 

The ACA (Affordable Care Act) has more users now than it did last year. As of this last February, 3% more people paid for ACA plans than the prior year. This is especially noteworthy since the Fed decreased funding for outreach about the plan by 90% and halved the enrollment period. 

Starting in 2019 the Joint Commission ( a chief governing body for hospitals) will require accredited hospitals to have a newborn identification protocol. Details to follow, though we know it will require “ two factor authentication”. 

The Senate has approved 50 million dollars in funding to reduce maternal mortality. Most of this will go to the Federal Maternal and child Health Bureau to expand life saving evidence based programs. Some will also go to the CDC and some will go to Healthy Start programs for mothers and babies. 

The Senate also has approved three new bills pertaining to maternal and child well being. In particular the money will be used to reopen closed programs which aim to prevent preterm birth. 

One major piece of the maternal mortality puzzle is the lack of Obstetricians and Gynecologists. It is tough job with tough call and its pay lags behind that of similar surgical specialists. It is estimated that there will be a shortage of nearly 8800 Ob/Gyn in just TWO YEARs, in 2020. The shortage is very likely to keep growing. 

Medical News

Non-European women with ovary cancer seek genetic testing less than their peers. Genetic testing after ovary cancer may help identify risk factors for other members of the family dn may define the patient’s tumor type in such a way as to tailer its treatment and make it more effective. 

Flight attendants have been found to have a higher incidence of many various types of cancers. The findings were published in the Journal Environmental Health. It is unclear why this is the case. Theories include increased exposure to ionizing radiation, circadian rhythm disruption , or to other carcinogens. More study is needed. 

Many older women or their caregivers begin to lessen the frequency of their bone density screenings after about 65 years of age. I have never liked this approach as it smacks of marginalizing older women. Many older women begin their final decline with a hip fracture that could’ve been prevented. Now, new recommendations from the USPTF, US Preventive Services Task Force has produced evidence saying it could be worthwhile. This is true because there are many meaningful potential treatments, which when instituted, could help prevent bone fractures and the debility that those entail. 

Probiotics. They are for gut health, right ? Turns out a new study has shown that probiotics given to women protect against the loss of bone density. See the Journal of Internal Medicine. 

There are nine vaccine which pregnant women may receive. ACOg has recently released a single page list of these and his encouraging all pregnant women to speak with their physician about these. 

Smoking. It’s bad. How bad ? Well its bad enough to increase your risk of miscarriage…. even if it is just your partner who smokes ! Yes, second hand smoke from a partner is associated with an increased risk of miscarriage. 

In separate research, smoking also appears to double your child’s chances of having hearing loss. 

In clinic, most people report being active. And yet, the CDC report s that fewer than 23 % of US adults are meeting federal standards for time spent exercising. 

In rather disturbing news, over 1 in 4 girls have harmed herself in the past year, often by cutting or burning, compared to 1 in 10 boys. 

There is more good news about vitamin D. It turns about high levels of vitamin D may help prevent breast cancer. Vitamin D levels in our lab should sit between 30 and 80 to be considered normal. However, there is more and more evidence that sitting on the higher end of that spectrum may have benefits. New research has indicated that having a level near 60 confers 80% lower risk of breast cancer compared to a level near 20. Associated risk factors were depression, suicidal thoughts, buying and substance abuse were risk factors. See the recent edition os American Journal of Public Health. 

Oh… my fun little secret ? I am starting a traditional French Bakery and Bistro. No, I will not be baking. Yes, I will continue full time Obstetrics and Gynecology. It has always been a dream, and, along with a great team of people, I am getting to realize it. Stay tuned. We will open in late August. Visit me at 

bonjourbakeryandbistro.com 

to learn more. And...stay tuned for more news from the fascinating world of Obstetrics and Gynecology, here, next week on Medical Monday. 

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

It is no secret by now that the Trump administration is systematically enacting policies to ban abortion and limit access to contraception. Medical experts have indicated their concern all along, saying these policies are likely to backfire, increasing unplanned pregnancies and abortions overall. 

Legal challenges to Trump administration policies are now coming from many quarters. Mississippi and Louisiana have pending legislation to ban abortion after 15 weeks. Both laws will now go to Federal court to be tested. Meanwhile, New Jersey is suing the Federal government against the exemption which permits corporations to purchase insurance without contraception coverage if they object to it on “moral” grounds. Since when can a corporation have morality ? People, owners, and board members can have morality or the lack of it.

The Federal Courts are going to have a big role in determining how much of this Trump era law stands. For example, a federal judge in Washington struck down the decision by the HHS (Department of Health and Human Services) to withhold funds for the teen pregnancy prevention program. The judge called the cancellation of funds “capricious”.  HHS actions have been struck down by federal courts four times to date. 

A survey of various health care groups has shown the 95% have strongly criticized the Trump administrations efforts to weaken the ACA (Affordable Care Act). The American College of Physicians has published a paper calling for recognition and addressing of the discrimination against women in health care. Health care disparities include those pertaining to reproduction, family and medical leave, domestic and sexual abuse and inclusion in clinical trials. 

Elsewhere in the world, Ireland has voted to repeal the countries ban on abortion. The popular vote passed by a margin of 2 to 1. To put things in perspective in this historically Catholic country, divorce was only legalized in 1995. Gay marriage has also been ratified in Ireland, and an openly gay man has served as Prime Minister. 

Medical News

We all know that genes influence our physical health. But they also influence our mental health. They are a number of genes which are associated with the development of Schizophrenia. However, even if they are present, the odds of actually developing schizophrenia are low. New research has indicated that pregnancy complications such as gestational diabetes and preeclampsia increase the risk of schizophrenia in susceptible individuals, as can smoking. This is all thought to take place via epigenetics and the placenta. More research is needed. 

A new study indicates what we have often observed; that those women who introduce a bottle in the hospital are much more likely to give up breastfeeding. Breastfeeding is recommended as the sole food source for babies for six months. 

The Nurses Health Study has produced data about nutrition and healing loss. Turns out those who had a diet most closely resembling a Mediterranean or DASH (Dietary Approaches to Stop Hypertension) diet were 30% less likely to experience moderate or severe hearing loss later in life. 

You will hear all kinds of unscientific reasons from patients about why they will not get a certain vaccine. We all know vaccines stimulate the immune systems and we all know they can make you feel a bit flu like in the process- no fun. New research has now proven that HPV ( human papilloma virus) vaccine does not cause increased autoimmune activity in girls. This confirms two prior large cohort studies. Despite all this, there is still a lot of push back against vaccines. It is hard for a caregiver to persist when a patient or a parent declines a needed vaccine. However new research indicates that physician persistent leads to 94% of children being vaccinated against HPV. 

Many times I hear talk to the affect that obesity alone is not a problem. There must be other factors such as diabetes or hypertension for obesity to be a threat to health. FALSE.. Newer date now tells us that having obesity ALONE makes you 39% more likely to have heart disease. 

We have been finding a lot of vitamin deficiency up here in the North Country. This has been true in pregnancy. We have undertaken supplementation regimens with the input of Endocrinology and are tailoring better maintenance regimens for both diet and supplements. New research has now show some good news : that those who take vitamin D in pregnancy are 28 % less likely to have low birth weight babies or stillbirth. 

In other vitamin D related news, new research also indicated that women with sufficient levels of vitamin D are 10% more like to get pregnant after a miscarriage, and 15% more likely to have a live birth after a miscarriage. 

Folic acid is also important in pregnancy and is known to prevent birth defects such as spina bifida. New research indicates that poorer women rarely takeout before it during pregnancy. This is something that should have a really easy fix. 

Stay tuned for more news from the fascinating world of Obstetrics and Gynecology, here, next week on Medical Monday. 

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

We will start off with novel and beneficial new research. A think tank called “Center for American Progress” has released an analysis of the current state of "sex ed” in America. They found the states to be, as a whole, deficient in teaching about issues of healthy relationships, consent and sexual assault. Only a handful (10) of states programs even mentioned these things at all. 

Backlash continues across states and the nation. Last week, Iowa passed a law which bans abortion once a heartbeat is detected. This contradicts the law on the books at this time, Roe VS. Wade. Iowa is being sued by the ACLU and various abortion providers. 

The Trump administration intends to cut all Title X funding to any clinic which even counsels about or refers for abortion. Eighty-five separate groups have signed a letter to HHS Secretary (Health and Human Services) Alex Azar to restore Reagan era regulations. 

The Trump administration has shown political and financial preference toward family planning clinics who promote only abstinence for birth control, even though it is neither effective nor evidence-based. Since family planning clinics have been organized and staffed by those who endorse evidence-based effective contraception not including abstinence only, this effectively defunds all family planning clinics. The States have a serious interest in this since they realize the health and prosperity of their populace depends on such services. In that light, the States Attorneys General have come together to back family planning clinics nationwide to sue the Department of Health and Human Services over its policy. They argue that the current policy violates the terms of Title X enacted in 1970 with bipartisan support. 

Should Medicaid recipients have a lifetime limit on benefits? Certain states, in cost-cutting bids, have been lobbying for this. However, the Fed, via the Center for Medicaid Services (CMS) has rejected these requests. In doing so, the Fed has broken rank with party conservatives. 

Care for women, pregnant women and postpartum women is not just germane to women. The health of women extends to others in the way that the health of men simply does not. Pre-pregnancy health, we are learning, is more germane to a child’s health than we previously realized. During pregnancy our opportunities to intervene to prevent morbidity and mortality are obvious. Less obvious are the manifold opportunities in the postpartum period. New recommendations from ACOG (American College of Obstetricians and Gynecologists) the Society for Maternal Fetal Medicine, and the Academy of Breastfeeding Medicine reflect a growing understanding that support in the extended postpartum period reaps many benefits. They now recommend that postpartum care should extend to 12 weeks and become a sustained period of support for the new mother and infant. It has come to light that for every 10 weeks pf paid job protected leave, infant mortality decreases about 5 percentage points. 

With the legalization of marijuana all around the country, more and more pregnant and breastfeeding women are using. Until recently, we had only vague warnings for these women. However, now new data indicate that using during pregnancy leads to a 50% increased chance of low birth weight. Use during breastfeeding is associated with decreased motor development in babies. 

The nation is indeed split on the issue of women and children. Part of the country is set on shifting away from collective responsibility toward women and children as they actually live. The current administration is intent on solidifying its base through supporting the explicit ideology of its voters, which gives women certain constraints in society:  abstaining from sex before marriage, using abstinence only for birth control, and rejecting abortion. The administration has combined these emblematic stipulations with their advertisement to cut taxes, and the result is that healthcare budgets for women have been slashed. And as if to add insult to injury, it is not at all clear if the money lost to the health care system will actually end up back in the hands of the taxpayer. 

The other part of the country is looking at the real problems of maternal morbidity and mortality. They are trying to solve problems with the best available science, rather than with ideology. States are beginning to realize that the lack of good routine health care, prenatal care, and postpartum care is expensive. It is expensive in the emergency room and in the workplace. Professional, scientific and legal groups are starting to fight back. 

ABC has just done what amounts to an exposé on the poor quality of pregnant and postpartum care in the US. This column has dealt extensively with the percentage statistics and trends on maternal morbidity and mortality. However, I have rarely included raw numbers. Here they are. In the US seven hundred women die each year in childbirth. Sixty five thousand more almost die. In a response to this program, ACOG has publicized its coordinated initiative to reduce maternal morbidity and mortality state by state. It is called AIM, Alliance for Innovation in Maternal Health. It has already been implemented in 18 states. 

Science marches on. 

New research indicates low levels of free t4 in pregnancy are associated with lower non-verbal IQ in children ages 5-8. Most caregivers are now including thyroid labs in their prenatal panels. Ask your doctor to be checked. 

BRCA genes are not the only genes pertaining to breast cancer. Newer multi-gene testing panels are now available for selected patients. Ask your doctor to speak with a geneticist if you are uncertain. 

Common sexually transmitted diseases are on the rise in California.  New data indicate that chlamydia is most increased in women in their 30s, while men account for the majority of new syphilis and gonorrhea cases. 

Fertility rates in the US have fallen to record lows for the second straight year. The same is true for several other developed countries. What are we to think? We know that at present, 50% of births are unplanned. As women become more educated and have more autonomy, birth rates naturally decline. You hear environmentalists’ concern about overpopulation, and politicians bemoan declining birth rates. The devil is, as always in the details. Certain subgroups in our population are decreasing and others are increasing. All of this will add up to social and economic change. I have one main concern: that growth be sustainable. Since my life’s work is mainly done one woman at a time, I am concerned that my patient's health habits and healthcare are sustainable. I am concerned that she have the means to grow her family or finish her family's growth in a sustainable way. I am concerned that my town and my countryside have sustainable growth. However, for me, growth is not the right word. I’d rather my community mature, or flourish. We shouldn’t always need more people, more buildings or a larger economy. What we need is for the family size to be ideal as determined by the parents. We need our towns to function optimally and to improve the space we have until it is optimized. The same is true for our nation. But our financial institutions are geared toward growth: more consumers, more goods, more profit. But this comes a human, societal, economic and ecologic cost. When we think about family size, birth control, population statistics, and even prosperity in general, we have to think about what we want our future to look like. When women lack access to health care, we cannot craft our futures. 

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

Belated Medical Monday

I have just heard the best news about the Republican plans to replace the ACA (Affordable Care Act). Senate Republicans would like to postpone a repeal until……drum roll please …. the year 2020, when, you guessed it… another presidential election will take place ! I think this may be the GOP’s way of saying, “Sorry, never mind. We agree with President Trump who said, “Health care is hard.”." 

Especially now that the piper has started talking about getting paid… i.e. the Congressional Budget Office (CBO) has had it’s say, lawmakers on both sides of the aisle have come to realize that the costs of dropping the ACA provisions may exceed the costs of keeping them. 

There is however a need for action, and Senate Republicans will likely try to take action to stabilize premium costs. They will also to endeavor to continue federal insurance subsidies which help low income American with co-pays and deductibles. 

In other policy news, the Mexico City policy is back in place. This is the policy of withdrawing US aid funds from international organizations which provide reproductive services which include abortion. This is policy is meant to show the current administration's condemnation of abortion, and to curtail the incidence of abortion. However, Kenyan health care researchers have cited clear evidence from the past about what happens when the Mexico City Policy is in place. In fact, if these US funds are withdrawn from these types of health clinics, then many women go without health care and contraception and many more unintended pregnancies occur. Not surprisingly, under these circumstances, MORE abortions are actually performed. It seems impossible that the administration cannot be unaware of this. If this is true then it would seem they are really more interested in political posturing than abortion prevention or the health care of women. I'm going to speculate this this exact sort of thing will happen in that other part of the third world called Texas, where women's health care services have been severely restricted.

The Mexico City rule is also called the “ global gag rule” since all US funds can be withheld even if the clinic staff even speak of abortion.

Did you know that the current administration proposes not only to cut coverage of health care but also to health care research ? In his 2018 budget request titled “ A New Foundation for American Greatness”, cuts are proposed for the FDA ( Food and Drug Administration), the CDC (Centers for Disease Control), and the National Institute of Health (NIH) including the National Cancer Institute. How do you feel about this ? Tell your elected officials. 

Many on the red (Republican) side of the aisle continue to favor covering those with pre-existing conditions. Many of you may know of Jimmy Kimmel, the late night host and comedian. He has entered the health care debate in a most poignant way. His wife recently gave birth to a son with a congenital health defect. This defect required immediate very expensive and live saving surgery, which with insurance under the current Affordable Care Act, will be covered entirely. This baby's care coverage will not be subject to penalties for preexisting conditions, and there are currently no caps on insurance payouts under the ACA. Cases like this do become very costly, and in an environment where there are caps on what an insurance will pay, the Kimmel child might not get all the care he needs to live. So, legislators have spoken of health care plans which “pass the Jimmy Kimmel test". To pass the test, an insurance plan must cover all the care that such a baby would require. Many Republicans are coming out to favor plans which pass the Jimmy Kimmel test. See Jimmy’s moving monologue HERE:

http://ux.azcentral.com/story/life/tv/2017/05/02/emotional-jimmy-kimmel-discusses-baby-sons-heart-surgery/101189324/

In medical news, ACOG is trying to get the word out on normal anatomy. There is a disturbing rise in cosmetic surgery for the female genitalia, even in young women.  ACOG (American College of Gynecologists) is trying to educate patients and clinicians about the considerable variation in normal anatomy. They are also cautioning against so-called vaginal rejuvenation surgeries and other procedures which can have serious complications. One has only to look at the high costs of such surgery and the lack of insurance coverage of it to know that it is simply a moneymaking ploy used by unscrupulous gynecologists. 

In the “ we already knew this” department, a new study has come out reiterating that domestic violence is more common in pregnancy. Everyone needs to be aware of this. 

In the "you have some control” department, new research indicates that even one 10 ounce alcoholic drink may increase your risk of breast cancer- by nearly 10 % in post menopausal women ! The same study also shows that vigorous exercise reduces the risk of breast cancer. Worried ? Stop drinking and start exercising. 

It has now been well established that the HPV vaccine works to prevent genital warts and reduce the incidence of cervical cancer. The new revelation is that for kids under 15, only two rather than three doses are needed. 

Do you snore ? If you do, go get evaluated, regardless of your age. It is clear that sleep apnea increases risk of cardiovascular disease. New research also indicates that it complicates pregnancy, increasing risks of gestational diabetes and preeclampsia. 

Bed sharing with newborns increases risk of SIDS ( Sudden Infant Death Syndrome). A new program which includes face to face education and distribution of baby box kits has been shown to be effective in reducing the incidence of bed sharing. Baby boxes provide a separate space for baby with a flat mattress and a firmly fitted sheet. These boxes, as opposed to a bed or crib with lots of blankets, toys and fluff, are much safer places for baby to sleep. 

Stay tuned for next week’s Medical Monday and thank you for your patience ! 

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

Forty prominent groups concerned with women’s health have written a letter of complaint to the new administration. The recipients include President Trump, the Secretary of the Department of Health and Human Services Tom Price, White House aide Ivanka Trump. The letter has criticized each of the major changes that the present administration has either enacted or proposed, for example replacing Obamacare, cutting funds to Medicaid, reducing access to women's healthcare by shutting down Planned Parenthood as well as the "global gag rule”, also known as the “ Mexico City policy”  which prevents international organizations who offer abortion as part of their services from receiving any US funds. The letter further alleges that women's healthcare needs have been traded for political benefit. The letter went out during Women's Health Week to call attention to the issues. In order to begin addressing these concerns, Ivanka Trump has begun meeting with various groups concerned with women’s health, including female Democratic leaders. 

Imposition of the global gag rule may cut off millions in funding to combat other conditions like HIV/AIDS and malaria, leading to a global health crisis. 

In a move long opposed by Republicans, the Trump administration’s budget proposal will include 6 weeks of paid family leave for both mothers and fathers. 

Texas is still trying deal with having shot itself in the foot. Texas took a stand against abortion and removed Planned Parenthood from their Federal Funding recipients. By doing so under the Obama administration, they lost their Federal funding for the Texas Medicaid Women’s Health Program. Texas has the highest maternal mortality rate of all the States, and a very high percentage of uninsured people. They want their Federal funds back. 

Health insurance is not just about a single subscriber, or even a single family. It is a funding pool that we agree to make together, that lets us all have predictable manageable health expenses, even if something really bad and expensive should happen. It also is a way for everyone in society to help safeguard the future, by contributing to the care of the next generation. This is done by contributing to a pool that pays for the care of women and children. This elementary and beneficial concept behind health insurance seems to have escaped Republican Rod Blum from Iowa who believes men do not need to contribute to an insurance pool which covers pregnancy. He was jeered off the stage in a town hall meeting. 

And now for a piece of news that cinches the connection between policy and health care. Research presented at the annual meeting of ACOG (The American College of Obstetricians and Gynecologists) has shown that the Affordable Care Act (ACA) under Obama led many pregnant women to get prenatal care earlier and that led to better perinatal outcomes. Of course this is in jeopardy now. 

Researchers with the American Cancer Society have presenting new findings indicating that increased access to care under the ACA led to early detection of some cancers. These included breast, colon and lung cancers. Early diagnosis leads to more cures and longer survival. The biggest changes occurred in states with significant Medicaid expansions. These gains too are in jeopardy. 

A recent study has shown that women under fifty doubled their survival time in recent years. I suspect mammograms played a role in this. There is controversy on when mammograms should start: 40 versus 50. ACOG recommends 40. So do breast cancer survivors under 50. Cancer patients over 50 also saw increased survivals, but not quite so dramatic. 

The World Heath Organization has presented the shocking news that pregnancy complications are the leading cause of death for teenage girls worldwide. The biggest causes were hemorrhage, complications  from abortion, and obstructed labor. 

Lancet, one of the world’s premier medical journals produced research on “ Amenable Mortality”. “Amenable Mortality means deaths that could’ve been avoided through timely or effective medical care. American scores 80 on the heal care quality index (HAQ) and that is at the bottom on the second decile, on a par with Estonia and Montenegro. 

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

House Speaker Paul Ryan has confirmed that this administration is bound to continue funding the benefits to those under the ACA (Affordable Care Act) and is likely to do so through 2018. Tom Price, Secretary of HHS ( Health and Human Services) echoed this sentiment saying he would uphold it as long as it was the law of the land. However, at the same time the GOP will continue it’s lawsuit against the ACA on the grounds that they believe the ACA is unconstitutional since it was not approved by Congress. 

Meanwhile States are acting of their accord to tailor heath care to their particular needs. California is considering a single payor system. Kansas’ Governor just vetoed a bill to expand Medicaid that had bipartisan support in its House and Senate. 

Did you now the NIH, the National Institute of Health, is facing a 20 % budget cut ? The National Institute of Health is the nation’s premier research institution. And yet, Representative Tom Cole ( R- OK) chair of the subcommittee that oversees HHS says the CDC (Centers for Disease Control) and the NIH are just s important as national defense. What do you think ? Tell your members of Congress. 

Tanning beds. They cause cancer. Many children under 16 use them. Guess who brings them there ? Their mothers. A new study was published in JAMA (Journal of the American Medical Association) Dermatology. The researchers were surprised at this appalling finding. 

Older people are more sensitive to alcohol than others. Women are more sensitive to alcohol than men. These are some of the reasons why it is so alarming that older women are drinking more than ever. Binge drinking is increasing at a rate of 4% per year for women. 

Are you flossing ? Gum disease in women 55 and older is associated with a 12% increased risk of dying from any cause. Stay up to date with your dental care. It will make you smile. 

In the not surprising department, smokers who undergo radiation treatment for breast cancer have more complications than nonsmokers. Was do they mean by complications ? They mean lung cancer and heart disease. Ask your doctor how you can quit. You can, you know. 

In the good news department, yet another study has shown that oral contraceptive pills are protective against three major cancers: ovarian, colorectal, and endometrial ( cancer of the uterine lining).That protection lasts at least 30 years. 

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

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

By now the whole world knows that Trumpcare version 1.0, the American Healthcare Act (ACHA) has failed. For now, Obamacare, the Affordable Care Act (ACA), remains the law of the land.

This last Friday, the ACHA bill went to the floor of the House for a vote. However, all day negotiations proved fruitless to bring over Democrats or close the deep divisions between House Republicans. House Republicans broke rank with the President, but did so in two camps. First those on the far right “ The Freedom Caucus”, withdrew support because they felt the bill was still too costly and still too much like Obamacare. Moderate Republicans withdrew support because the ACHA gutted federally funded Medicaid and is widely believed to lead to the loss of insurance for a great many people, putting that burden on the States. Paul Ryan, recognizing the tally, pulled the bill before the vote. 

House Speaker Paul Ryan has indicated the GOP will keep working on heath care. One little publicized option is for the Whitehouse to sue to stop the Fed from paying insurers for work done under the Affordable Care Act. This tact was going on before the ACHA was brought to the House. Their argument is that these contractual payments from the Fed to insurance are invalid and illegal. 

One of Trump’s major campaign promises was to reform healthcare, indeed to provide “universal coverage”. Progressives favoring Universal Coverage may attempt an uneasy alliance in the service of this goal. Senator Bernie Sanders plans to unveil such a proposal entitled “ Medicare for All “. 

Policy news is moving at light speed and I recommend everyone start reading it from various reliable sources. I also recommend people familiarize themselves with their elected representatives and give them and their staff regular meaningful input. 

On to actual medicine. 

A new study from the Journal of the Academy of Nutrition and Dietetics indicates that most American women do not eat a healthy diet when they are pregnant. This is something we see in clinic on a regular basis. It is worth noting however the many women believe that they are eating healthy diet, even though they are not. These are well-intentioned people who have been taken in by advertising or who are victims of their busy schedules. Unless the physician or nurse midwife takes a detailed dietary history they will not know how their patient is really eating. Merely asking the person whether or not they eat healthy is not enough. People generally say they eat healthy and people generally say they are active or fit. That is because they believe it to be the case. Until people have objective definitions in front of them they cannot reliably answer these questions. Doctors take important shortcuts if they do not delve into a reasonable amount of history taking detail. When patients get specific explanations of exactly what we mean when we say "eat healthy", they're much more likely to do so. One of the problems of course, is that many doctors do not know precisely what it means to "eat healthy”. 

Four prior commissioners of the Food and Drug Administration (FDA) have produced a joint letter warning Congress about the legalization of importing drugs from other countries. Certain members of Congress have indicated that they would support this in an effort to reduce drug costs. In particular, the commissioners emeriti have warned against counterfeit, substandard and contaminated medications, since standards from other countries may not be adequate.

Pregnant women with HIV have a better chance than ever of avoiding transmission of their virus to their children. Preventive treatment including retroviral drugs given in pregnancy account for this progress.

In other viral news, a new gel treatment for genital and perianal warts is under study. These are caused by the human papilloma virus. The treatment is based on nitric oxide. Stay tuned for more on this nascent therapy.

Also regarding human papilloma virus, the American Society of Clinical Oncology has issued global statement regarding the primary prevention of cervical cancer. They recommend that all girls ages 9 to 14 receive two doses of the human papilloma virus vaccine also known as Gardisil. In the last few years there has been definitive evidence that Pap smears combined with this vaccination reduced the incidence of cervical cancer. The vaccine is also available for boys of the same age group.

Yet another study has demonstrated that exercise during pregnancy is safe and beneficial. This most recent study published in the Journal of the American Medical Association is meta-analysis of studies with more than twenty five hundred pregnant women. This is in line with ACOG (American College of Obstetricians and Gynecologists) recommendations which indicate "women without major medical or obstetric complication should get at least 20 to 30 minutes of moderate intensity aerobic exercise… on most days of the week."

In the concerning department, the FDA (Food and Drug Administration) has now linked anaplastic large cell lymphoma (ALCL)  to breast implants. This disease is a rare malignancy in the immune system which is statistically linked to breast implants, particularly those which have a rough versus smooth surfaces. The FDA has issued a statement indicating that women with breast implants have a very low but increased risk of developing ALCL compared to those who do not have breast implants. It is worth remembering that a statistical link does not prove causality. Concerned patients should speak to their plastic surgeon about this matter.

In other cancer news,  new research indicates that breast cancer gene testing is underutilized in America. A simple history in the caregiver’s office can identify whether or not a patient is at high risk of having abnormal genes, i.e. breast cancer gene mutation, or BRCA. Women with two first degree relatives such as a mother or sister are at high risk for having an abnormal gene and should explore the possibility of testing. Those patients with close relatives with any cancer should make sure their caregiver is aware of it. 

New research coming out of the Cancer Genome Atlas Project and the Cancer Research UK Database have indicated that only about a third of cancers are due to a special inherited genetic mutation. This means that two thirds of cancer-causing mutations arise spontaneously and are not able to be inherited by one's children.

We conclude with the good news department. A new device called the Alexis retractor is being tested across the world. Preliminary indications in Europe show reduced infection rates and reduced post operative pain after Cesarean section. 

Finally, many States are following another European lead and introducing baby boxes. Currently Americans put their newborn babies to bed in a wide variety of ways. However, clear research shows that the incidence of SIDS (sudden infant death syndrome) can be significantly reduced if babies are placed on a flat surface on their backs, head uncovered, in a special sleep sac or a one piece sleeper, and WITHOUT any blankets, swaddling, bumpers, padding or or toys. The sheet on the firm mattress should be fitted. The baby box programs are designed to provide all this teaching as well as an actual  baby box and mattress. For those who are not aware, the baby sacs are like insulated zip overalls with a closed bottom, which allow babies to move. They are not to be confused with swaddle wraps, which are also associated with SIDS. Babies typically wear a shirt and a diaper with it. Very cute inexpensive ones can be obtained at Ikea, Target and online. 

Here is an authoritative link from the NIH for those who want to learn more: 

https://www.nichd.nih.gov/sts/about/environment/Pages/look.aspx

Our photo for today's post was brazenly lifted from the pages of the National Institute of Health linked above. 

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

Food Friday: Food Traditions and People

Winter is here and Christmas is upon us. Our family and friends are assembled. The serious cooking has begun. 

Christmas and Hannukah coincide this year, which is nice for our family. My husband has Lutheran roots, and I am Jewish. We have learned to be inclusive, and both holidays hold real meaning for us. Plus, we get all the good foods ! 

While we partake of many traditional holiday dishes, some treats have taken hold in our tribe. Each dish has a champion and ... a relationship to go with it.  Here is how it is playing out. 

One friend presides over the mass creation of decorated gingerbread houses every year. Another friend is the undisputed pie expert and can always tell what you are doing wrong. My son in law is the grilling king. My sister in law reliably arrives with snickerdoodles. My brother in law is a master of soups and chilis. Two nieces could go pro with cake decorating, and like to do their work here, in my kitchen. Great Grandmother roasts lamb. 

My husband is all about a fancy breakfast. He is one of those Nords who gets up early with a smile on his face. He makes waffles with fruit. Even at dinner we " give him a job he likes" which is making fruit salad. 

The youngest is starting to correspond with me from college about main dish recipes, usually with deer or elk, our red meat of choice. I owe him a custom cookbook, but have been slacking. Last week it was pot roast, and I got pictures. I think our culinary relationship is still forming. 

Our middle child cooks all the time. We have several dishes that bind us, but the most fantastical is our Buche de Noel. We also make fancy non-traditional Latkes. No mere white potatoes for us. We use sweet potatoes, yams, carrots, scallions and the like. I think this year we will fry in coconut oil. 

Our oldest is a skilled self taught chocolatier. This is what she and I do for the holidays. It is epic. We make moulded chocolates filled with ganache. I make the ganache, she makes the molds. Facebook and Instagram light up. So I though I'd share this little slice of our holiday with you. Have a Merry Christmas and a Happy Hannukah. 

Wellness Wednesday: Good Relations with Family

Holidays bring family together and that is good. However, family issues that were never resolved may come to light. To help your family time during the holidays be peaceful and bright, I have collected a few insights and recommendations for your consideration. 

Accept that family relations are complex. Accept that high stress during holidays is real. It relates to the practical demands of decorations, gifts, entertaining, finances and family relations. It also has to do with the inevitable taking stock of the year in conversations in one’s own mind and over the holiday table. People inevitably present their year in holiday card humble-brag style, and it is difficult not to make comparisons between one family and the next. 

Establish a realistic idea about who you are going to see and how they are likely to interact with you. Behavior patterns (also called dynamics) between people are very durable. That is, they are challenging to change. If you have a dysfunctional or uncomfortable dynamic with someone you are likely to see, prepare for it. Consider developing responses in advance should difficult topics come up. Remember to make “ I statements ”, i.e., "I feel", "I think". 

Set your own boundaries and stay within them. Begin by going to a family gathering focusing on the positive about yourself. Hold to those positive beliefs. Likewise, be tolerant of others and their idiosyncrasies. Focus on the positive in others. 

When you are reconnecting with people, greet them directly and warmly. Ask simple open ended questions but don’t pry. There is often no need to evaluate what they say or respond, just to listen with empathy and understanding. 

Do not go outside of your boundaries. Do not defend yourself if challenged. Just agree to disagree. Do not try to control or persuade others about old or new issues. Do not get drawn into an argument in a family gathering even if you have stake in the issue. It is not the time or the place. 

Remember the reason you celebrate holidays. They should be a time to celebrate the wondrous healing power of hope for the future. Holidays should be about celebrating the value of relationships. If your family relationships have not been well cared for, holiday time is a good time to start your part in this. Medical science has shown that we are happiest and healthiest if our relationships are healthy. Attaining optimal nutrition, fitness, and physical health are not easy. These take considerable learning, patience, and routine. Relationship health is no different. 

Wellness Wednesday: Help for the Elves

Are you that truly time strapped gift giver with the finite budget ? Have you been reading all that advice about scaling back this holiday ? Are you tired of the materialistic holidays, the stress, and the excessive spending ? Here is some SMART advice to help you through. SMART means specific, measurable, attainable, relevant and time bound. Instead of saying, I’m going to do better this year, have a SMART plan for getting your tougher gifts done. 

They say the best things in life aren’t things. Here are some: 

Home made paper or gift certificates for activities with YOU ! Examples: 

• a movie
• lunch out or lunch in 
• a hike in the outdoors 
• spa day 
• craft day 
• joint workouts 

Here’s athoughtful gift for that person who has enough “stuff” : A donation to their favorite charity, cause or advocacy group, (usually able to be made online). You can send a card or a decorated email to announce the gift. 

For those who would like to give, but are perhaps late on mailing things to faraway relatives, ebooks and audiobooks come to the rescue. You can send an inexpensive but special ebook instantly even on Christmas eve and be right on time. Amazon.com is my go-to for the instant gifts. Your recipient can read them on any device, not just a Kindle. Kindle apps are available on virtually all platforms including the desktops PCs and Macs, as well as Android and IOS. Your gift can combine an ebook and an experience if you gift the book and buy one for yourself, then propose that you and even a faraway friend can read it “ together”. 

Audible.com is my source for ebooks since I am a member. This service is certainly worth looking into, especially if you ever have long commutes, flights, or road trips. 

For an even more economical gift, you can send music, even just one song, or an app, as a gift. These too are electronic, and thus accomplished at your desk in the wink of an eye. 

It’ s the small things that count. So send valuable information ! Most of us have a recipe or two that is special to others. Write it up with nice paper or digitally with graphics, and send the recipe or a collection of them as a gift. 

Other small things include thumb drives - perhaps one filled with your best photos of activities you and your recipient have shared. Tie it with a ribbon or some twine and you have a very easy, very economical and very special gift. 

Making celebrations and gift giving is fun but can be overwhelming. Get inspired, and stretch a little, but do not stress or worry yourself. That would be missing the forest for the Christmas trees ! 

Enjoy these last few days before Christmas ! 

Wellness Wednesday: Making and Giving

There is a good book called “ The Five Love Languages” which I recommend. My husband and I read it together long ago. It turns out that our love languages are very different and this understanding helped us. One of my primary love languages is gift giving. As such, it is hard for me to understand people who say they cannot figure out what to give. My problem is editing my gift giving plans. 

This post is approximately 25 days until Christmas. That, in my mind, is enough time to come up with several clever, inexpensive gifts… Homemade gifts… before Christmas. I am taking a stand here and recommending that you consider home made gifts this year. You could save money, and really touch the heart of the recipient all at the same time. 

You may assert, and I have heard people say, that they have no artistic talent. This just hurts me to hear, as I believe it to be uniformly false, and one of the worst forms of self talk. I think with the resources that we have these days, Pinterest, magazines, and the internet at large, there are instructions for everything. Pro tip: Search " best DIY gifts". The key is to keep it simple and heartfelt. The other key is to stretch just a little each time, and you will learn more and more. Pretty soon you will be making stained glass windows. 

Here are some other keys to making and giving: 

• Be kinds to yourself and keep your sense of humor. 
• Prepare your time, your workspace, and your supplies before beginning. 
• Establish a budget and stick to it. 
• Read through all the instructions first !
• Be prepared to goof up and fix things. 
• Enjoy the process. 
• Consider the pros and cons of doing it yourself, versus together with a supportive friend. 

Here are a few ideas for categories of home made or home assembled gifts. You know your own skill set and will be prepared to build on it. You also know your recipient. Trust yourself and move forward.

Made Things: 

Wearable Gifts:

• e.g. infinity scarf of some special fabric
• colorful rice filled heat packs with essential oil 
• felted wool hats and mittens from shrunken thrift store sweaters

Edible Gifts: 

• e.g. flavored salts and sugars 
• holiday foods in nice containers, including baked goods in festive ceramics, or treats in exotic jars
• jerky, jam, dried herbs

Assembled Things:

Themed gift baskets and “kits"

• movie night basket with gift cards and popcorn
• bath basket - with oil or fizzy bombs
• garden baskets- with new gloves and seeds
• art basket - with supplies 
• cooking themes; Try going by country, i.e. Italian, French, Mexican, Cajun, Japanese, etc. 
• knitting or crochet kit
• crafting kit 
• fishing kit
• hunting kit
• sports related kits 
• workout kit 

Don’t worry if your gift is not perfect. Just take care that it reflects the connection between you and the recipient. 

Making and giving is a soul growing exercise. Give it a go this year. 

Wellness Wednesday: DNA testing

Your DNA is the code to your programming. It is literally your genetic code. It determines your physical makeup, from appearance, to reproductive potential, to disease states. It may also determine certain hardwired aspects of temperament and cognition. Wouldn’t such information be useful for maintaining health and curing disease ? The answer is of course yes. However, the science of the use of DNA for medical purposes is still in its adolescence if not its childhood. 

DNA (deoxyribonucleic acid) is made like a set of modular children’s toys, K’nex for example. The subunit is a pair of tiny molecules called bases which bind to one another to make a base pair. These are held in a long structure like rungs on a ladder, and this ladder itself bunches and curls depending on the particular molecular sequence of base pairs. A certain series of base pairs codes is a gene for the manufacture of a certain animo acid, and strings of amnio acids are the proteins of which we are made. One famous gene mutation is BRCA, which allows breast and ovary cancers to form much more easily. Another is the gene for ALS ( Amyotrophic Lateral Sclerosis) or Lou Gehrig’s disease, which afflicts Stephen Hawking. 

DNA contains the keys not just to disease, but to health as well. Understanding DNA can help us understand any inborn vulnerabilities to disease in time to take action against them. Understanding which genes go with which diseases may help us come to understand how diseases are caused, and thus, how to cure or mitigate them. The vast majority of human genetic material, also called the human genome, is not understood. However we all have DNA, and we all have a health history, even if all that it says is that we are healthy.  Just think: If we had lots of people record their health history, and the same large number of people sequence their genome, we could use modern computing power to look for patterns between the clinical histories and the DNA. 

DNA tests are now sold direct to consumer (DTC). People are using them to search for their ethnic heritage. This is an imperfect science, and it can only narrow it down to a continent level. Some people use DNA tests to find long lost relatives, but results depend on your long lost relatives having been tested as well. 

I have been thinking about giving my family members the gift of DNA testing. My initial thought was simply to throw our data into the big pool, and add to the collective accumulating accuracy of DNA and disease correlation. It was also my hope that in the process, it would be useful in the future, when hopefully, health enhancing measures could be taken based on a person’s specific DNA profile. 

There is another kind of DNA testing which I should mention for completeness. It is testing for specific genes, and not just testing to view the whole genetic code. Physicians and researchers test for specific genes when a person’s family history is strong for a certain disease process, say colon cancer. If the unaffected relative tests positive for the risky gene, preventive measures may be able to be implement to help them avoid the disease. Genetic tests can also be done on tumor cells themselves to determine what treatment is the absolute most targeted for the specific tumor cell type. This is becoming the norm when treating breast cancer. This helps both improvement in outcomes and decreases side effects of treatments not likely to be helpful. 

In doing the research for this post, I have discovered some good advice. First, it is important to think about why you want this information. Do you really want to know about long lost relatives ? Do you really want to know your ethnicity ? What if it is not as you expected ? What if you discover a gene for a bad disease that you do not already have ? 

There are several companies that do DTC DNA testing. I found a good chart which details some of the differences. 

http://isogg.org/wiki/Autosomal_DNA_testing_comparison_chart

Some systems of testing, analyzing and reporting are better for genealogy, and some are better for medical care, and still others are best for research. Some tests go deeper, and research paternal or maternal family lines, but this requires analysis of the X and Y sex chromosomes, rather that just the autosomal chromosomes. 

All of the tests are expensive, ranging from $79 to over three hundred. My research has raised more questions that it has answers. I plan to speak to our genetics counselors at our hospital to see what they think and I will get back to you about what they say. 

Meanwhile, it is Thanksgiving week. It is a good time to think about being grateful for what you are and what you have in the present. You may be coded by genes, but that is not the whole story. Our genes are not a static set of molecules. Instead, they switch on and off like the holiday lights that people are putting up this season. Additionally, a lot of this gene regulation depends on lifestyle choices. This is where we can leverage our health habits to make the most of the genetic cards we have been dealt. 

Happy Thanksgiving 

More reading: 

http://www.legalgenealogist.com/2015/02/02/2015-most-bang-for-the-dna-buck/

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

The World Health Organization will have convened on Friday to evaluate whether Zika is still to be classified as a “ public health emergency of international concern.” I am not sure of the criteria for such a classification, but it does not seem to me that we have yet seen most of the consequences of Zika in those yet to be born. Furthermore, it is not clear how Zika will fare though the turn of the seasons. 

The effects of Zika are generally serious to devastating. It is fascinating and confounding that these effects vary by geography. This means Zika has different effects depending on where the infection is contracted. The American Society for Tropical Medicine recently convened and examined this question which needs much more formal study. 

Women are more likely to get Zika from men than men are to get it from women. This is because the virus is now believed to suppress the vaginal immune response (Vaginal immune response ! Who knew ? ) and thus go undetected so it can establish infection in both mother and baby. 

Blood banks in affected states have been screening for Zika. Only 40 out of 800,000 positives have been found. This is not meant to represent an assessment of Zika prevalence in these states since the people who come to donate are screened and kept from donating if they have risk factors for the infection. 

In other news, there is another option for women with vaginal atrophy. Many older women and those who have had cancer have vaginal atrophy, which manifests as dry, thin, inelastic tissue. It also manifests as pain during intercourse. Fourteen percent of all women have low equal desire and sex related personal distress. Part of this in older women may related to vaginal atrophy. Unfortunately, this is not always addressed at the doctor’s office. Many such patients are not able or wiling to use vaginal estrogen. They may now use DHEA, dehydroepiandrosterone, an adrenal androgen, as a daily vaginal capsule, to help with this. The trade name will be Prasterone and it has recently been approved by the FDA ( Food and Drug Administration) for this use. 

The idea of using vaginal estrogen in breast cancer survivors has, until recently, not been considered due to concerns that the hormone enters the systemic circulation and might cause increased risk of recurrence. However a recent study published in JAMA Oncology has shown that estradiol secreting vaginal rings and intravaginal testosterone cream are both safe and effective therapies in those breast cancer patients who are receiving aromatase inhibitor (AI) therapy. 

In insurance news, President elect Trump has indicated that he favors preserving the prohibition against insurers denying coverage due to preexisting conditions. He also favors allowing parents to keep children on policies until the age of 26. An article in the Wall Street Journal recently opined that keeping these provisions without keeping the universal mandate (requirement for everyone to have insurance or be fined) and the funds it would bring in, would strain the coffers of health insurance companies bound to keep the first two provisions. 

At this point, hearsay reigns in matters of the new administration’s policies. Before the election, Republican politicians spoke of eliminating the individual mandate on health insurance. Now, there is talk of revamping it. Similarly, and more realistically, it is said that Medicaid under the new administration is more like to be altered than it is to be shrunk, as Republican candidates suggested. 

This column has covered the falling teen birth rate. Recent analysis of this data has shown that this is the case much more in urban compared to rural areas. Between 2007 and 2015, the teen birth rate fell 50% in cities, but only 37% in rural areas. Teen birth rates fell most among white and hispanic girls. 

In related news, a recent study in the American Journal of Public Health showed some interesting relationships between childbearing and longevity. Over 20,000 women were followed for over 16 years. Researchers discovered that a larger number of children is associated with less longevity in black women, but more longevity in white women. They also found that women who delay their first birth until at least 25 are more likely that their counterparts to live until age 90. 

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

Food Friday: Paleo Thanksgiving

I have an ongoing debate in my mind about using recipes. Sometimes I’d rather just use good ingredients and good cooking principles. 

But this is an artifact of having cooked for family and friends for some time. It is also related to the fact that I am in possession of a rather large cookbook collection. It is from using good recipes that we learn to use good ingredients and good cooking principles. These days, it is only for certain novel or complicated dishes that I actually use a recipe. But it is not uncommon for me to crack open one or several cookbooks at once, spread across our table to get inspiration for any one dish that I want to prepare. I pick and choose elements from various recipes and combine them into something I will really like.

This Thanksgiving I'm going back to the books, albeit books like Pinterest and websites,  as well as my trusty cookbooks. This because I plan a Paleo Thanksgiving dinner. Numerous foods of the season lend themselves to the Paleo approach to eating. For instance, squash, as featured recently in another Food Friday post HERE. This is because squash is a complex carbohydrate which is nutrient rich. Along with sweet potatoes, it is the healthy eater’s white potato.

What makes a Paleo approach is tailoring foods to fit optimal human nutrition and metabolism. Not only does Paleo avoid foods such as simple processed carbohydrates like sugar and flour, it also avoids foods with harmful components, be they artificial colorings, flavorings, preservatives, trans fats, high fructose corn syrup and anti nutrients like alcohol and caffeine. 

Enough about the don’ts. What’s on the menu ? Turkey, venison, elk, and oftentimes salmon. Squash will be paired with cooked fruits, dried fruits, toasted nutrient rich nuts, and healthy fats like coconut oil and olive oil. Vegetables will come in grand combinations, such as brussels sprouts, with bacon, nuts, and pomegranate arils. (Scrabble word there…arils) And of course, faux potatoes made from cauliflower. Cranberry sauce will make it onto the menu, but this year paired not only with orange, but with applesauce for sweetness. I include wild rice stuffing, which I have featured before HERE. 

Pies must be made. This year I am intent on learning the nut crust. We always have pumpkin, and two flavors of fruit, one of which is cherry. There will be a little sweetener involved, perhaps agave with a lower glycemic index, and coconut cream to top. 

Beverages will be Pellegrino, and new this year, Kombucha, which to me is as delightful as Champagne, but with health benefits. Afterwards, we will make looseleaf organic Earl Grey Decaf, and french press water process decaf from freshly ground coffees. Coffees can be served with chocolate and coconut cream, and teas with lemon wedges and cream. 

That is my vision. Check out my Paleo album on Pinterest HERE if you like.  I thank you for letting me incorporate my planning here in your blog post, but this is the way a great meal starts. Happy Thanksgiving Week.  

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

Two weeks worth of news will be covered this week !

Nearly two third of infected Zika patients are women. This has been determined recently in Puerto Rico, but also widely across South and Central America. Experts are not sure about the origins of this number, stating this might be because women are more likely to seek care and be diagnosed. 

In the good news department, an experimental vaccine has been shown to protect mice against Zika. This is a promising step, but still many steps from a human vaccine. And in the reminds-me-of-science-fiction department, antibodies from the blood of recently recovered Zika infected mice can be injected into other Zika infected pregnant mice. This causes the levels of Zika virus to drop in the unrecovered mice.  This novel treatment is to be tested next on non-human primates. 

A Zika “ syndrome” is coming into definition. It has five cardinal features: 

1. severe microcephaly
2. decreased brain tissue with  specific pattern of calcium deposits indicating brain damage
3. damage to the back of the eyewash a specific pattern of scarring and increased pigment. 
4. joints with limited range of motion
5. too much muscle tone. 

The very first baby born in Puerto Rico remains hospitalized. This baby and all other Zika affected babies will be followed until age 3 in a registry called the "Zika Active Pregnancy Surveillance System”. 

In non-Zika news, a recent study indicated those who give birth in winter may need extra vitamin D supplementation. Our recent experience substantiates this. We have yet to quantify this, but in our obstetric population, it is not uncommon for us to uncover vitamin D deficiency. Good news: prescription supplementation is easy and works well. 

Did you know that long acting reversible contraceptives such as IUDs can be placed immediately post partum ? This is a breastfeeding compatible way of providing women with reliable contraception especially if they are unlikely to follow up at later visits. 

Preliminary reports on a herpes vaccine in humans are encouraging. This new vaccines reduces lesions and viral shedding for several months. It consists of three shots three weeks apart. 

Rates of preterm birth are increasing in the US. This is especially true among black and native women. 

Antenatal steroids for lung maturity were, until recently used only until 34 weeks. Now, they have found to have been useful for late preterm births between 34 and 36 weeks, and even for women undergoing planned C section 37 weeks and later. Steroids reduce the rate of neonatal distress syndrome these babies. 

In the we-already-knew-this-department, researcher have now shown that low carb meals reduce insulin resistance. Insulin resistance is bad; it means your cells don’t respond normally to insulin and do not transport sugar from the bloodstream into the cells well a they should. Eating low carb restores the cells responsiveness to insulin. 

The World Health Organization (WHO) has issued revised recommendations for antenatal care. This includes double the number of recommended prenatal visits compared to before. (Surprise ! Prenatal visits help ! )

There is yet more good news. When Kenyan women are provided with HIV self test kits, partner and couple testing increases to more than 90%. As they say, knowledge is power. 

Stay tuned for next week, when we will cover more news from the world of Obstetrics and Gynecology, and doubtless, reactions to the election from those in health care. 

Food Friday: Preparing for a Halloween Party

Halloween food can be goofy or elegant. But one thing's for sure: It should be good and not overly sweet. That's because is needs to buffer the sugar from the treats. Tomorrow we are having a Halloween birthday party, since our youngest was born on Halloween. 

Decor is dark botanical, with raven feathers, black roses and peacock feathers. Candles will be plentiful and a large illuminated spider web graces the large window. Black cheesecloth is draped over a dark green tablecloth, and mismatched silver completes the look. I always feature some little treasure on the table, and this time it is organic chocolate peanut better cups.

For the menu, the main dish will be traditional. he side dishes will be more exotic. Accordingly, I will do roasted chickens with multicolored potatoes. Side dishes may include an exotic vegetable mix with mushrooms, asparagus, eggplant and anything else interesting and provocative. I will try to get some heirloom black tomatoes for a salad of dark greens. 

Dessert will be cherry pie and a six layer chocolate cake. Drinks will be Pellegrino and a " cauldron" of fruit punch with dry ice. 

So at this point I will share the prep work and the decorations, and tomorrow some actual food shots. 

Wellness Wednesday: Halloween

This is our last Wellness Wednesday post before Halloween, one of my favorite Holidays. It has been our family tradition to have a grand Halloween party and this year is no exception. In preparation, I would like to share with you how my view of Halloween does indeed bear on wellness, especially for children. Before I share my philosophy on Halloween and how that translates into our gatherings, I would like to go over some basic Halloween safety tips. 

1. Go out with your children if possible. Cloak yourself and hang back near the street while they practice their confidence and their manners. If they are older and you feel it is safe, let them to go in groups or pairs. Older kids should take their cell phone and turn on tracking. On iPhone that is through an app called “ find friends.” Pushback ? Who pays for that anyway ? 

2. For kids going without an adult, review a map in advance and agree on a route. 

3. Set time limits beforehand. 

4. Feed kids a healthy festive and favorite meal before nightfall, so they are not tempted to feast on Halloween candy as they walk. 

5. Ask kids to refrain from eating candy until it can be inspected under good light. Discard anything opened or tampered with. 

6. Discard anything that is not commercially prepared, unless you know the source. 

7. Ensure that costumes are safe for the weather, and the dark. Use reflective tape if need be. 

8. Make sure that decorations are safe. Be especially wary of open flames or electrical installations. 

9. Give kids flashlights and or glow sticks for visibility. 

10. Forbid children from entering the homes or cars of strangers. 

11. Remind them to observe traffic laws as there will be lots of cars as well as pedestrians. 

12. Remind them that some people drink and drive on Halloween. 

13. Remember sometimes kids get creeped out by creepy costumes. Make it comfortable for kids to come home if they do not like it. 

Here is an except from my Halloween post last year which I would like to share again.

My different perspective comes from the historical roots of Halloween which is a witches' brew of an ancient Celtic festival Samhain (pronounced Sow-in), the later Roman holidays of Feralia and Pomona, and finally the Catholic Feast of All Martyrs/All Saints/All Hallows day. The name " All Hallow's"  literally says, " all that is holy”. These are beautiful holidays are full of respect for the harvest, the circle of life, ancestors, saints, and the turn of the seasons. They all included feasts, and outdoors activities late in the night complete with festive fires. Accordingly, " Halloween" is of course a contraction of the words " Hallowed" and " Evening".

I have a soft spot in my heart for All Hallow's Eve as I like to call it, since our youngest child was born on that day. As a result, it has always been a big family celebration for us, and so we have always had a party. Accordingly I have never gone in for the typical commercial Halloween decoration and imagery. True, I like a very dark and mysterious Halloween. Particularly after I had children, though, I haver saw fit to incorporate images of violence into the holiday. For example, I am totally not into the blood gore and mutilation thing. Instead, Halloween is to me about the beauty and magic of the night and the natural world. For example, I have incorporated themes of stars, the moon, planets and comets. People consider these magical motifs but to me they evoke magical math and science which can describe their movements. I also incorporate anything botanical. At this time of the year the leaves are getting crinkled and brown, and the branches are bare. Some are dried all but the berries, but there is beauty even in this. You can make them even more evocative with paint, glitter, or interesting low lighting.

I incorporate the creatures of the night in my All Hallows' decorating. From mice, rats, bats, spiders, beetles, wolves, and owls to moths chasing a flame, these are all interesting and beautiful creatures who are worthy of our attention. Instead of vilifying them or presenting them in caricature, I try to present them as they are, almost like museum specimens. If I could have live ravens with their glossy black feathers, I would. For children I might do a faux insect display, with a little parchment note about the creature, and how they fit into the ecosystem. 

And fire, of course fire, since fire harkens to the primordial processes in the heart of our sun which make life on this earth possible. Did you ever think about the fact that when you watch the flame you are watching matter being turned into energy? To bring fire to the home and patio in first must be safe. I like metal tea lights since they turned safely sat inside a beautiful container. These are easy to clean up as well. I use lots of candles and keep the regular lights down low. For fire outside, make a traditional bonfire. Check your local fire regulations and use common sense of this, especially with children.

So use branches, bugs, bats in mobiles, candles, and faux spiderwebs is done carefully, with dark elegant colors, or moonlit white. But whatever you do, make your party beautiful enough to transport your guests to different holiday "Hallowed" frame of mind.

Reference: 

http://drginanelson.com/drginablogs/2015/10/15/food-friday-food-for-halloween-party?rq=halloween

Halloween can involve a healthy dose of fantasy. People of all ages love costumes and stories. There are so many fantastical costumes to try, there's no need to resort to the grotesque or sinister. Here's my Pinterest album of costumes and cosplay for your inspiration.

https://www.pinterest.com/drginanelson/costume-and-cosplay/ 

You might also like my collection of steam punk fashion which celebrates the popularization of science and engineering in Victorian age.

https://www.pinterest.com/drginanelson/steampunk-fashion/

Halloween should not be about fear and horror. Quite the contrary. It should inspire. Its historical roots lay in the efforts common people trying to encounter the wondrous. It recalls village life and the collective joy of the good harvest. It celebrates the interplay of chaos and order, day and night, summer and winter. This is the wellness of the holiday: that we gather together to express respect for the harvest, community, ancestors, Saints, the cycles of life, science, nature and hints of the divine.

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

As the northern hemisphere encounters fall and winter weather, mosquito activity and the risk of Zika infection by mosquito falls but does not go to zero. Of course, sexually and birth related (perinatal) transmission are not affected and can continue unabated. 

Researchers at the University of California, San Diego, have honed in on the mechanism of action of the Zika Virus on human cells. It appears that Zika virus alters our RNA directly. 

We now know that Zika can persist in vaginal secretions for two weeks after onset of infection. During this time, a woman can pass infection on to a partner. Additionally, it has been determined that Zika is detectable in serum ( the liquid portion of blood) for a week. However it is present in whole blood for at least 80 days. These insights have been made possible through the contribution of one particular patient infected with Zika since the beginning of the epidemic. Through frequent and repeated testing on her, we have been able to ascertain these findings. We use a debt of gratitude to this female Zika patient who has allowed herself to be the subject of invasive scientific study since the beginning of the crisis. 

Everyone has heard of menstrual migraines. Some happen right before the period and some happen during the period. Those preceding the period are believed to arise from sharply falling estrogen levels. It turns out that the late-cycle migraines may be related to low ferritin levels from the blood loss of the period. This could lend insight into prevention, which of course might involve ongoing iron supplementation. 

In the things-we-already-knew-but-had-not-yet-been-conclusively-documented department, research published on the Arthritis Care and Research site indicated that systemic lupus wanes during pregnancy and flares in the postpartum period. Nonetheless, the research is quite welcome in that it sheds concrete insight into the baseline mechanisms of lupus and autoimmunity in women. Autoimmune disease as a whole is prevalent and predominantly affects women. Most patients are on current treatment strategies which decades old and are rife with significant side effects. This lupus patient applauds any sound research into autoimmunity in general and lupus in particular. 

Also in this same journalistic department we are now assured that smoking and alcohol are linked to 11 of 15 of the worst cancers. By worst, we mean those cancers most "responsible for premature death and loss of healthy life years”. Any second year med student can assure you conclusively of this. 

Pediatricians are being encouraged to change their counseling of parents about the HPV (Human Papilloma Virus) vaccine. Instead of highlighting the prevention of sexually transmitted HPV infection which can lead to warts, they are being encourage to highlight the cancer prevention aspects of the vaccine. It would be nice if we could simply explain that the HPV virus causes genital warts, precancerous changes on the cervix, which can then develop into cervical, vaginal, penile and even oropharyngeal (mouth and throat) cancer. I am tempted to think that we oversimplify subjects too much for people. People are capable of understanding a great deal if someone takes the time to explain it to them. 

In related news, new data has demonstrated that those children who obtain the HPV vaccine before 15 years of age only need two shots rather than three. Even more incentive to gets your kids done ! 

New research from the Agency for Healthcare Research and Quality have show that the C section rate for low risk patients is about 16%, whereas the C section rate for high risk patients is about 76%. Intellectually, I am a splitter rather than a lumper. Consequently, thinking about C section rates in this way is much more useful that saying, the C section rate in the United States is about 32%. I think information presented in this way will help patients understand their own risk factors, and how to prospectively stack the deck in their favor in the future. 

Here is some sobering but critically important news that I suspect will be woefully underreported. Maternal body mass index (BMI) is inversely correlated with newborns’ telomere length. Whoa, what does that mean ? Basically, the heavier a mother is, the less robust her newborn’s DNA strands will be. DNA is protected at it’s ends by segments known as telomeres, and when they are short, DNA is more apt to be damaged. Shorter telomeres means shorter DNA lifespan, which most likely means shorter lifespan overall. 

We have all heard by now of the micro biome, which means the healthy or not so healthy populations of bacteria and other organisms that populate our body. Women mostly focus on the micro biome of the vagina, knowing that if it becomes disturbed, yeast or bacterial vaginosis can result. However, the vagina is not the only concern. It turns out that the breast has a micro biome. Moreover, it turns out that breasts sampled and found to have benign disease versus those with cancer have very different micro biomes. This could be a clue to something, I’m not sure what. But is is a new and interesting concept. 

In disappointing news, the CDC (Centers for Disease Control) reports that rates of common sexually transmitted diseases have reached all times highs. This include syphilis, gonorrhea, and chlamydia. I’m going to give a shout out to bad parenting and network TV here. Thanks so much, guys. Oddly, syphilis was at an all time low in 2001, and gonorrhea was as recently as 2009. 

In surprising news, 43% of those with no type of health insurance could qualify for either Medicaid or coverage through the Affordable Care Act exchange. The reasons for this are unclear. I will say that some people seem to have quite a bit of trouble filling out the forms online. I have joked to my office staff that the government  should outsource both health care and the elections to reliable companies like Amazon or Google who can design a nice reliable website. 

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

Wellness Wednesday: Being Proactive

I found myself a little out of my comfort zone this week. I was working on a little app for the App Store, and I am new to developing. I had done my due diligence, reading, and going through the tutorials. And yet, things were just not working out how they were supposed to. I got a little down about it. I got a little mad about it. Tech support sent me a lame email back not really addressing the questions I had clearly asked. I put the project aside for a couple days. I thought, maybe this is just not my thing. Then Monday morning rolled around, and thought, I am going to wend my way through the phone networks of Apple Computer and find someone who can help me. Three layers deep, I did. The person I reached was amazing. She agreed that I had done all that I should have; She took on my cause and bumped it up the chain of command. Ultimately the advice she gave me worked. I looked back on the incident and realized how silly I was to have gotten discouraged. Only when I got proactive and reached out, did things get better. 

Proactive is the opposite of reactive. To be proactive is to be psychologically healthy. It means being the one who takes the steps to make your life what it is. It means to be responsible for one’s self, one’s thoughts, actions and circumstances. It means to be self-determined. 

To be reactive, on the other hand, is to be a victim of life. You life is determined by other people and other factors. What you do is a reaction to other factors which have happened “to” you. You may feel out of control or like a victim. 

Wouldn’t anyone want to be proactive ? You may want to become a proactive person. And yet, until you adopt the mindset and behaviors of being proactive, it would be very difficult. 

How do you become a proactive person ?

Responsibility

The first step is to realize that you are responsible your own well being and success.  Life hands people circumstances which range from good, to bad to ugly, and yet, mindset is the main determinant of how people feel and how they do in life. Remind yourself you are empowered in your life. Pin a pin, put up a poster, or do what you need to do to train yourself to remember this. 

Honesty

Also central to the process of being proactive is to understand your starting point. This requires honesty with one’s self about one’s present state. It is like talking a good hard look at the balance sheet of your life. What are the assets, and what are the liabilities ? Only then can you realistically plan for going forward. Train yourself to honesty. 

Accountability

To be responsible is to be accountable for yourself. In literal terms, you are the accountant of your life. You have the ability to set a budget, or a goal, and work backward to meet it. You are more than dreams and talk. You have real steps to realize your plans. You may even use the so-called SMART goals. (Click HERE to learn more.)You are reliable to others and to yourself. Train yourself to take regular inventory or your life. Train yourself to use SMART goals. 

Action

When you use SMART goals, you will get used to the idea that big goals are achieved with small steps. Furthermore, you will get used to taking small steps. Many people who haven’t realized their goals are simply not used to taking steps outside their normal routine. Being proactive means training yourself to get used to taking new and different steps as part of a larger, realistic plan. It also means training yourself to get used to the fact that meeting goals proactively takes time.  

Resilience 

When you become proactive in your life and start to take steps toward realizing your life goals, you usually encounter obstacles. These may derail or discourage you temporarily. This is natural. However, the proactive person must have resilience. This is the trait which embodies the best response to adversity. With resilience, the problem is acknowledged, analyzed and the steps of the plan are reworked. They are iterated, and reiterated.  With resilience, one has to train oneself to keep a flexible positive attitude, along with the idea that continual reiteration is part of the process. 

Communication 

In everyday life, being proactive is easier said than done. Everyone feels pressured, angry or frustrated at times. These are small everyday examples of being reactive. Sometimes even bigger situations like peoples' jobs or relationships are the result of being reactive rather than proactive.  Learning the emotional and communication skills associated with being proactive is no easy task. 

During challenging encounters, the natural reaction is fight or flight. Proactive communication requires acknowledgement of these reactive feelings, but not acting on them. Simply pausing, and breathing is an essential first start. In that moment, the feelings of anger, frustration or sadness are acknowledged and set on the back burner. Then a constructive response can be proactively made in accordance with the speakers highest and best ideas.

A proactive person also knows she has the right to defer. She can take time to think about things, calm down, or gather more information. She knows how to say these things the right way. She uses responsible closed loop communication. Responsible communication uses "I statements”, i.e.“ I think”, ,”I feel”, or “I need” or “ I want”.  In this way, you speak for yourself. You may not be listened to, but at least you have spoken up for your self, and your statement has the weight of authenticity which may well continue to sink in after the conversation. 

Closed loop communication has to do with listening well. When you speak, you are obliged to listen. Listen with full attention until the speaker is finished. Then use another “ I statement” , which is “ I heard….” then repeat back a nutshell version of what you thought you heard the speaker say. This is especially useful for challenging or complex conversations. It honors both the speaker and the listener and greatly reduces the chances of misunderstanding. 

Train yourself to breathe, pause, use "I statements", and closed loop communication. 

So you see that being proactive is a training process. Nobody has a charmed life. But everyone can use the methods of responsibility, honesty, accountability, action, resilience and communication to be more proactive and move toward the life they want.