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Medical Monday : Ob/Gyn News Weekly

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News about Ob/Gyn topics has GOT to be important to all women. I like to read this stuff since it makes a difference in people's lives. So with a more recognizable title, I will continue to report on it. 

A paper in The Journal of the American Society of Nephrology has properly substantiated what Obs have always observed: that women who suffer from hypertensive disorders of pregnancy like preeclampsia are prone to high blood pressure later in life. Newsflash: so are their siblings, including brothers. 

Apparently prevalence studies of the breast cancer genes BRCA1 and BRCA2 in breast cancer patients were done predominantly in white populations. Taking a preliminary look at 400 black breast cancer patients, a Florida study shows 12 % of them carry one of these genes. In a similar population of white breast cancer patients, the rate is only 5 %. This has implications for screening and prevention. 

New help for older women with osteoporosis (bone thinning) may come from Human Growth Hormone. It's helpful effects seem to be particularly long lasting. 

The CDC reports we have achieved a 90% vaccination rate on polio, measles, mumps, rubella, hepatitis B and varicella (chicken pox virus). I realize this is better than it was, but, this doesn't sound too great where herd immunity is concerned. 

The CDC ( Center for Disease Control) reports that since 2012, school lunches are measurably healthier, with metrics being more fruits, vegetables, whole grains and salads. Thanks to all those lunch ladies and gentlemen as well as FLOTUS Michelle Obama. 

And in other good news, the great State of Texas has passed a strong "right to breastfeed" law. Public employers must give breastfeeding mothers time and space to pump during workdays. The law also prevents discrimination or firing related to breastfeeding at work. 

Stay tuned for more news from the world of OB/Gyn next week on Medical Mondays. 

Medical Monday: ACOG weekly news

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Headlines proclaim “ Aggressive Treatment for DCIS May Not Save Lives”.This sounds rather dismal. Reading further, what they should have said is “ Aggressive Treatment for DCIS May Not Be Necessary to Save Lives”, which is good news. DCIS is very early microscopic breast cancer, and as such its concerns everyone. Such an alarming headline got my attention. But once I found out the news was actually good, I was a little dismayed.  There must be a chapter in the Journalism textbook where it says bad news gets more attention than good. I don’t know. Read carefully out there ! 

Just to refresh your memory, ACOG stands for the American College of Obstetricians and Gynecologists. They send its Fellows, myself included, news updates throughout week. These are articles of pertinence to women’s health. Each Monday, I pick a small sample and present them to you for your consideration. More such articles can be found at www.acog.org. 

There is such a thing as “ distracted snacking”. The Journal of Health Psychology reported the results of a small study which indicate that distracted snacking results in greater intake even afterwards. I speculate that it has to do with the fact that distracted snacking results in greater intake that say “ mindful snacking “ ( my term)  causing insulin levels to spike more than they would have, and more hunger to be stimulated later. So be mindful about your snacking and remember to always include some protein. 

The venerable diaphragm has gotten an upgrade. A Seattle based nonprofit has developed a new more contoured model. It’s name is Caya. Go to Caya.eu to learn more. It is not yet available. 

Finally, ACOG has released new guidelines regarding the treatment of morning sickness. First line therapy should be in the form of the class A combination of doxylamine and vitamin B6, commercially available over the counter without a prescription in the US as Diclegis. ( Class A is the safest pregnancy category for a drug. ) This is not to say that we are not still going to need Zofran for certain patients. It will still be considered after Diclegis is deemed insufficient. 

When you read medical related articles in the mainstream press, read very carefully. It is tricky to report accurately if you do not have medical background. For more on that please see our section “ Your internet learning toolbox”. 

Stay tuned for more medical news next week on Medical Monday. 

 

 

 

 

Medical Monday: ACOG weekly news

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What's an Ob/Gyn site without a little OB/Gyn news ? I like reading the Ob/Gyn News and I like translating science information into clear non medical language. So I'm going to give Medical Monday's another go. 

A large Finnish study has show that those who have depression and who are treated for it in pregnancy have lower rates of preterm labor than those who have it and are not treated for it. 

Most everyone has heard of BRCA1 and BRCA2, the genes conferring increased of breast cancer. Unfortunately there are many more gene mutations which are associated with the development of breast cancer. Fortunately, testing for 20 more of these genes may soon become available for select patients with strong family histories of breast cancer. 

Fully one quarter of American women 65 and older have osteoporosis. Thank our marginal diet, heredity, Big Soda, Big Tobacco, alcohol and our sedentary lifestyle. 

One third of ovary cancer patients are living in excess of 10 years. This is a substantial improvement over the last several decades. 

Finally, stats are in through 2013 and infant mortality in the US has dropped to a record low. Wow, finally ! I'm going to try to end on a good note, so with that, stay tuned until next week. 


Medical Monday: ACOG weekly news

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This is the second in a series of reports on current events and research reports in Obstetrics and Gynecology. We hope you like the new format for Medical Mondays and invite you to comment. 

A recent study showed that about 50% of women gain more weight than they should in pregnancy. This has serious effects on the health of the newborn as well as the mother. Institute of Medicine guidelines indicate weight should be about 30 pounds if pre-pregnancy weight is average, less if the patient is obese, and more if the patient is underweight. 

Maternal mortality in the US is on the rise, sitting at 18.5 per 100,00 births. This is against the trend of most developing countries. The conditions most likely to cause maternal death are hemorrhage, severe hypertension and preeclampsia, and venous thromboembolism ( abnormal clotting). 

There is an effort to make birth control pills available over the counter, without a prescription. This is already the case in Oregon and California. The interesting thing is that this is a bipartisan effort. These efforts come in the wake of the accomplishment making birth control "no- cost" under the Affordable Care Act. 

Speaking of the Affordable Care Act, it is currently not true that patients can see whoever they want. A recent analysis indicates patients insured through the ACA chose from one third fewer doctors and hospitals than patients insured otherwise. 

Plans were confirmed by the House last week to approve the creation of a commemorative gold coin and to donate the proceeds to The Breast Cancer Research Foundation. The Susan G. Komen foundation was originally to have also been a beneficiary, but GOP members required they be removed to due their "funding" of Planned Parenthood. It turns out Komen does not fund Planned Parenthood. 

Ob/gyns the world over disapprove of douching since it disrupts normal vaginal flora. However now it appears that common commercially available douches contain a chemical known to be an endocrine disruptor, diethyl phthalate. 

For this and more medical news from the world of Ob/Gyn, tune in every monday for Medical Mondays. 

 



Medical Monday: ACOG weekly news

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Today I'm going to do Medical Monday like a good old fashioned news cast. I am going to take the weekly news items of most importance to the American College of Obstetricians and Gynecologists and summarize them for you. What's  important to ACOG is important to us. Let me know if you like this format. 

 

( newscaster voice here... ) 

Medicare, which is for those over 65 or who are officially disabled, "will now pay for women to get a joint Pap smear and Human papilloma virus test every 5 years to screen for cervical cancer. " Never mind that ACOG and The American Society for Colposcopy and Cervical Pathology (ASCCP) state they should be done this way every 3 years. 

A Yale study found that the cost of a delivery varies from $1200 to $12,000 depending on the hospital. Unpacking this revealed that birth was costlier at poorer facilites that served higher percentages of Medicaid moms. They also found higher complication rates in those same higher cost hospitals. CBS news reported on this, and opined that this contradicts the notion that more spending leads to better outcomes. Never mind that poorer patients have been less well served in their lives, are unhealthier and have higher risk pregnancies on average. Maybe the complications come before the high cost but what do I know. 

The European Journal of Preventive Cardiology published the obvious in saying that women who smoked and had preterm deliveries went on to have higher risk of heart disease. Had they not yet heard that smoking is associated independently with both preterm birth and with heart disease ? 

Of importance, the FDA nows states that use of NSAIDS like ibuprofen and Aleve are associated with increased risks of heart attack and stroke. Discuss this with your doctor and buy stock in Tylenol's parent company. 

The Salt Lake Tribune, right in the heart of the conservative Mormon heartland, featured an editorial, which among other things, advised that the best way to reduce abortions was to provide contraceptive choice ! Well done Salt Lake. 

Stay tuned until next week. 


Structure Sunday: The Structure of Our Practice

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Some say medical care in America is deeply flawed. Some say it is the best in the world. On some level, I think both are true. But one thing is sure: Medicine is evolving. We are evolving with it. On July 1st, we will be joining Kalispell Regional Medical Center. 

This is a decision that has been some time in coming. My staff, hospital administration and I have put a lot of time and care into crafting us into a new thing: a medical practice that embodies the best of solo private practice, while benefitting from the support of a larger medical center. 

We want to be on the cutting edge. We want to be a part of the future, where care becomes more rational. Rational care means that duplication of services in the community is avoided. It also means that gaps in care are filled. It means that everyone can get the care they need when they need it.

To this end, our hospital is embarking on an expansion that will bring much enhanced services to women and children here and in our surrounding region. It is a very exciting time to be here and I and my staff are excited to be on board. 

I'm lucky because I work at a hospital with a philosophy of service, teamwork and congeniality. My solo office has worked this way for 21 years and will continue to do so for at least another 15. Our patient care has been based on evidence based medicine, but it has, just as much, been based on quality relationships. My patients can rest assured that none of this will change. 

Our billing will change and our overhead will go down. Eventually, I will have some call coverage, which will be more inline with current practice recommendations and with my health. The office, the staff, and our style of medicine and management will stay the same. There will still be music playing in the rooms and essential oils wafting through the halls. 

I am proud to say that in the course of merging with the hospital, we have received numerous compliments about the way we have been doing things. For that, I have to give credit to our brilliant managers, Tara and Dorothy. I have been truly blessed with these and my other staff members past and present. My only worry is that that administration will find out how truly valuable these women are. 

We look forward to seeing you in clinic and online as per usual. 

Medical Monday: Are there really any low risk pregnancies ?

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In today's post I report on some recently presented work which questions the validity of classifying pregnant women into either low risk or high risk groups. 

These categories have been important to women and their caregivers since they have used the information to determine the most appropriate site for delivery, from freestanding birth center, to community hospital to university medical center. 

But while Obstetricians have gone along with the use of the category " low risk", we know from anecdotal experience that ANY patient can unexpectedly have complications with out any warning or risk factors. A cross sectional investigation published in the American Journal of Obstetrics and Gynecology, February 7th, 2015, has shown us in precise numerical terms just how often this happens. 

Please note that in this study, those with no prenatal risk factors were classified as low risk. Those with one or more risk factors were classified as high risk. 

Here are their results: 

Of 10,458,616 pregnancies analyzed, 38% were identified as low risk, and 62 % as high risk. 

It turns out that 29% of those classified as low risk had unexpected complications. 

It is not surprising that high risk pregnancies had complications. It turns out that 57% percent of them did. However, 29%, almost a third of the low risk patients had complications. For certain outcomes, like use of vacuum, forceps, meconium and infection, so called low risk pregnancies had a higher incidence than those in the high risk group. 

If you look at all pregnancies and add the 62% who are high risk to begin with and the 29 % of the remaining low risk 38% group who ended up having complications despite their low risk designation, it adds up to 73% of the total group. 

So, according to this large study, 73% of all pregnant women can either be classified as high risk from the get go, or are low risk and going to have a complication. This 73% of all pregnant women are those that belong in the care of Obstetricians or Certified Nurse Midwives working in the hospital under the care of Obstetricians.

Here's the problem. While we can select out those in the high risk group for higher level hospital care, it is not so easy with those classified as low risk. When we consider the low risk group, who are over the third of the whole group, we know about a third of them will have complications. WE JUST DONT KNOW WHICH WOMEN THEY WILL BE. That is the problem. That is why, in my mind, all women deserve access to a high level of care in a congenial but fully equipped setting...the hospital. 

It is imperative that birth be congenial but even more critical that it be safe... 100% of the time. To achieve both does not require taking birth out of the hospital realm, instead it means transforming the hospital birth environment to be all that it needs to be.. comfortable, accommodating, beautiful, as well as fully equipped for any medical or surgical contingency. 

Here is the link to this current research: 

http://www.ajog.org/article/S0002-9378(15)00268-9/fulltext

 

 

Wellness Wednesday: Quantify Yourself

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I have always said that knowledge is power. This is especially true in this digital age since we have access to so much searchable knowledge. I have also always said that one of our primary goals in our medical practice is to empower women to take charge of their own health.  It is therefore natural that I am very interested in helping women to empower themselves through the use of technology.

It turns out that one of the most powerful things we can do to take control of and change our own behaviors is to observe, record and track them. This habit is called quantification. People who do this regularly as a part of their self improvement are participating in the "quantified self’ movement. Livescience.com defines the quantified self movement as a “movement which aims to measure all aspects of our daily lives with the help with technology.” 

Quantifying ones habits such as hours of sleep, minutes of exercise, or calories eaten, does not necessarily need to be done with a high tech device. It can be done with paper and pencil. However, since smart phones are nearly ubiquitous, these records are most often kept on these small powerful personal devices.  Of course there is a proliferation of different apps for this, one for every topic and several for many parameters. Not only is there a proliferation of different software apps to help with quantification, there is a proliferation of different hardware such the Apple watch and the FitBit. 

If the patient and I decide to follow some detail of her health such as her blood sugar, we begin some sort of record keeping. The patient makes the measurements, records them and naturally evaluates them herself as she goes through the week. This alone often results in substantial improvement in her numbers, since she can begin to discern patterns and the reasons behind them. Taking measures to push the data toward better performance is gratifying day by day. It becomes like a game that the patient is determined to win. This is called ”gamification" and it too, it is powerful in behavior change.

When the patient comes in to review her data, she can get even more benefit when we analyze her data together. If we add another layer such as her diet, and superimpose it graphically on the blood sugars in her records, we can see a cause and effect relationship between what she eats and her blood sugars over time. Sometimes a third layer of data such as activity can be added into her records and we can use this variable to improve her blood sugar control even more. 

This kind of record keeping puts the facts and the control in the hands of the patient. It is much more effective than a doctor simply telling her to eat better and exercise more. It has been my consistent observation that all sorts of patients have success with this type of approach. Moreover, in reading about this "quantified self movement" it seems apparent that this technique can be used for many types of conditions, like weight, exercise, autoimmune activity, sleep problems and even mood disorders. It can also be used for broader issues of life performance, in relationships and on the job. 

I hope this introduction into the quantified self movement has inspired you to learn more. Here are some fun references which makes for very interesting reading.

The Quantified Self, a TED talk by Gary Wolf

The Quantified Self at Livescience.com

The Beginners Guide to Quantified Self, at Technori

Why You Should be tracking Your Habits ( and how to do it well) at Lifehacker.com

The Quantified Self: How Cold Hard Data Improves Lives, at Bloomberg.com

The Data Driven Life, at the New York Times 

How Self-Tracking Apps Exclude Women, at The Atlantic

Structure Sunday: The Structure of Time

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For life to be good, we need a rhythm in the day, the week, the month, the season and the year. These circles within circles allow us to feel accomplishment, and to look forward to celebration. These finite periods allow what is overwhelming to become manageable. Structuring time helps us take the one lifetime that is ours, and fill it mindfully. 

I need to feel I am making progress on my long term goals every year. I use the annual holidays like Thanksgiving and New Years for self assessment. I can look back at the same time one year back and see the changes. 

The seasons hold a different joy. Each time I am sad to see the leaves fall, I am, shortly thereafter, shocked by the beauty of frost and snow. I am reminded that all seasons hold beautiful surprises, and that I am foolish to imagine that nothing exciting is around the corner. 

My business cycle is the month. This is how bills are paid, and accounts are balanced. Accountability is examined month by month. Actual money is one representation of work and effort, and as such it is a useful tool to use in gauging how we are meeting our responsibilities. 

My work cycle is the week. I want a chance to get stuff done, and I want to be creative in that work. I try to pace myself all week long, with a lighter day midweek, then forge on to the weekend, when I would hope to be creative. 

My personal cycle is the day. I believe we all thrive with a good day's work. However, in my opinion, this includes some important health and productivity features. Consider the basics:  sleep , nutrition and exercise. Most people need at least 7 hours of sleep. With this, you will have more concentration, stamina and productivity. You might even have a better mood. Life is just more fun and you will be more successful with a modicum of sleep. 

Food is so important! It is your fuel. You should frontload your day with a healthy breakfast of protein, fruits, vegetables, and whole grains. That will turn on your metabolism and your brain. Later in the day, food can give you several healthful recharges: your midmorning snack, your lunch, and your afternoon snack. This way you will not tank your metabolism, feel sluggish, or hardly be able to think. Eating three meals and three snacks per day is a foundational principle of nutrition, and will help you feel better and perform better. 

Somewhere in the course of the day you must carve out at least a half an hour for exercise. It is best to schedule this formally, just like a meeting or an appointment, and to take it just as seriously. The magic of routines will reward you if you persevere. The more you do it, the easier it will be. 

 Everyone from a teen mom to the CEO of a large corporation needs a schedule. To achieve mastery over your time, you must invest in either a paper or electronic system. Smartphones generally come with everything you need in this regard, but the old school day runners can do just as well. But these alone won't do the trick. You must develop a routine of sitting down with the schedule to look it over and fill it in mindfully. I recommend looking at your schedule every Sunday to assess the coming week, and also looking every evening to prep for the next day. Make your schedule check a routine. The habit will stick better if you do it at the same time and place every day. 

Routine lowers stress. Breaking up goals and plotting them over time encourages success. These are among some of the most important things I want for my patients. The particulars I teach them about disease conditions and health maintenance will not help them unless they can follow through on the recommended treatment or prevention steps. Fostering patient success will continue to be a big thrust of this blog and the website in general. 

For more information, please see the hyperlinks in the text. Have a great week ! 

Medical Monday: Participatory Medicine

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Are you an empowered patient? Do you participate in Medicine 2.0 and Health 2.0? Learn more about these terms and the interesting and beneficial changes that they describe.

Click HERE to learn more. 

P.S.  We would be very pleased if you would consider subscribing. I have placed a Subscribe and Comment page in the navigation menu for your convenience. When you subscribe, you will receive a White Paper (see definition HERE) entitled "How to Become an Empowered Patient " with our compliments. 

Medical Monday: C Section Delivery

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Do you know about VBAC, TOLAC and RCS? Obstetricians love acronyms. The website section about C sections has been updated and expanded to include a comprehensive section on VBAC (vaginal birth after C section), TOLAC (trial of labor after C section) and RCS (repeat C section). Go to the general C section page, then scroll down to the part on Repeat C sections and VBAC.  

Click HERE to learn more about this hot alphabet soup. 

Medical Monday: being a patient

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Yes folks that's my arm. There's nothing better for a doctor than to be a patient sometimes. Your regularly scheduled blog post is thus interrupted with this post about my small experience of being a little too sick. 

You may wonder how I came to be such a health nut. Well it's because I have lupus. I have to be extra careful and on top of things to stay healthy. The majority of the time I do very well, but once in a while a simple upper respiratory infection gets the better of me. I had to come in briefly for some extra medication and  I am feeling much better. I will probably not be in clinic for the next couple days. 

I was reminded of how vulnerable and wretched you feel when you are truly sick. I was reminded how much it means when people help you out. I had a good friend or two cover for me on labor and delivery, my husband who brought me in, and all the hot shots in the emergency room to tune me up. 

There are two messages as far as I can see. Number one, if you are not doing well reach out and get some help. Number two, if you see someone else not doing well check in with them. It means so much.

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Medical Monday: Hysterectomy

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Hysterectomy is a topic that is highly politicized in our media and in our culture. It is the most common operation that women have except for Cesarean section. The reasons or indications for hysterectomy are fairly well defined. And yet there is debate about when to do them and how to do them. The good news is that the quality of our research and the quality of our surgery is improving by the day. Our decision making processes regarding treatments, our ways of discussing options with patients, and our methods of surgery are far better than they used to be. 

Click HERE to learn more.