medical care

Medical Monday: Weekly News Update in Obstetrics and Gynecology

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Good Monday !

I am returning from a great five days back at Stanford with our son Forest, who is now also an alumni. We attended “ Classes without Quizzes” and enjoyed ourselves immensely. We learned about numerous things, including a little about the way the brain functions during early language development, the latest in nutrition research, and a MMOG, yes, a massive multiplayer online game called EteRNA which has become a powerful tool in the design of tiny RNA machines which may be used to treat disease. We also took a yoga Piyo Hip Hop Fusion class, went on a pro multi-ethnic eating tour and saw tons of old friends. 

So now we return inspired, excited to move the needle forward in everything we do, including Medical Mondays ! 

Flibanserin went on sale this last Saturday. Flibanserin is of course the pill to treat low libido in women. It goes by the name Addyi. Does anyone know how to pronounced this ? Someone got paid to think of that name, you know. I can’t wait to see the commercials. For some real information about this drug, please see my prior post HERE. 

This week, in a 2000 word opinion piece in the New York Times, a political scientist Courtney Jung, criticized breast feeding activists for putting too much pressure on women to breastfeed. She states broad based research indicates the benefits of breastfeeding are  “ modest”. Could this op ed have anything to do with the fact that she is releasing a sensational new book called “Lactivism” next month ? Imagine running a 2000 word ad for your upcoming book in the New York Times. I wonder if they even paid her for her ad.

Her subtitle includes many of us: 

How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy

I am just going to go out here on a limb and disagree and say that I do not think breastfeeding is bad policy. I guess I’m kind of a rebel that way. 

The American Academy of Pediatricians has come out saying that "no amount of alcohol is safe for unborn babies". The new guideline “identifies prenatal exposure to alcohol as the leading preventable causes birth defects and intellectual disabilities in children.” It was previously thought that "a small amount" of alcohol is okay in pregnancy. According to the CDC (The Centers for Disease Control), about 10% of women self-report that they drink alcohol in pregnancy. So in my simplistic mind this means that if women comply with this recommendation, 10% of the entire next crop of babies could be significantly developmentally better off than the last group. Wouldn’t this have staggeringly good effects on the population ? 

The American Cancer Society has revised its recommendations for mammograms once again stating that they should start at age 45 in a patient of average risk, and go to every other year at the age of 55, provided that the woman is expected to live at least 10 more years. The purpose here is to "eliminate false positives and over treatment’.

Has anyone ever considered asking the question, How bad is the badness of a false positive? And what do they mean by overtreatment? Do they mean biopsies which turn out to be benign or do they mean lumpectomies or mastectomies? Most physicians do not consider a biopsy to be a treatment. Most patients consider a benign result a great relief. I have never heard of a patient saying ”Doctor, my biopsy was benign. It looks like I really didn't need that biopsy after all ”. If biopsies were taken out of the “over treatment “ calculations would there really be any unnecessary “treatments” left to lament ?

The American College of Obstetricians and Gynecologists (ACOG) has maintained their stance on mammograms every one to two years from the age of 40 forward. It also recommends a clinical breast exam annually. The American Cancer Society is dropping their recommendation for an annual clinical breast exam since it has not"been shown to save lives.” They say nothing about whether it extends lives. Is important for readers to know that there are many studies designed to determine whether or not a certain intervention prevents death in the course of the study. Preventing death is the same thing as saving life, no matter if you die at one year or ten years after treatment.  Studies geared to show an interventions ability to save life do not necessarily have the power to show it extends life. ACOG keeps its position on mammograms and clinical breast exams because earlier more frequent mammograms and clinical breast exams are associated with earlier diagnosis and longer life after breast cancer. 

I had better stop writing since there is steam coming out of my keyboard and my ears again. 

Stay tuned for more news from the wacky world of OB/GYN next week on Medical Monday. 

Medical Monday: Weekly News Update in Obstetrics and Gynecology 

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Did you know that some insurance companies offer rebate incentives to get indicated mammograms ? A recent editorial in the Journal of the American Medical Association called this “ an ethically disconcerting distraction”. What do you think ? I think advanced breast cancer is far more expensive than early cancer caught and cured. 

A new study from the University of Minnesota School of Public Health has shown that less than half of new mothers returning to work have adequate space and time to pump. Meanwhile, in related news, the Army now requires commanders to allow breastfeeding soldiers to have time and space to pump. To clarify, many soldiers stay stateside or in non-hostile countries with family on bases and serve in technical or support positions. 

One article and two more separate recent studies indicate a higher infant mortality for non- hospital births than hospital births. ACOG estimates risk at two to threefold across the board. Remember there is also evidence demonstrating a 14 fold incidence of first Apgar of ZERO in those delivering their first baby at home. All this seems self evident to me given all my eyes have seen. 

The American College of Physicians has come out against routine pelvic exams in the the asymptomatic woman. The American College of Obstetricians and Gynecologists has made it clear it supports annual pelvic exams. Recall that pelvic exams need not always include a pap, since a pap is the collection of cells from the cervix to be evaluated in the lab. Pelvic exams confer a wealth of information about infection, pelvic relaxation, masses in the uterus, masses in the ovaries, etc. Ask any ob/gyn; They will tell you they find significant things on pelvic exams in asymptomatic women all the time. It looks like this needs to be formally studied. 

Uh oh, more bad news for Essure, those little coils placed in the tubes for sterilization. (Darn it, this seemed so promising. ) A new study in the British Medical Journal evaluated over 52,000 women sterilized with Essure. These women were 10 times more likely to go to surgery in the following year than those that were sterilized with a traditional tubal sterilization procedure. It is interesting to note that the FDA ( Food and Drug Administration) did NOT require documentation of Essure’s performance though a RCT ( randomized controlled trial). 

A study in the Journal of the National Cancer Institute has shown 61% of women obtaining mammograms will have at least one false positive report. They are advocating that physicians do more to educate and reduce anxiety associated with these results. 

In the good news and empowerment department, a Norwegian Study reports that pregnant women who exercise regularly in the three months prior to pregnancy report less pelvic pain in pregnancy that their non exercising counterparts. And this is making me smile: High impact exercise was the most strongly associated with decreased pain. So, did these women go through life feeling less pain to begin with thus tolerate exercise and pregnancy better, or did the performance of the exercise change something about the way they perceive pain ? A study like this cannot answer these questions, but they are interesting to ask. 

Stay tunes for more news form the world of OB/GYN next week on Medical Monday. 

Weekly News Update in Obstetrics and Gynecology 

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Good Monday news readers. 

This week, card carrying Ob/Gyns the world over are going all green on us. The World Health Organization and no less than 6 other international Ob/GYN professional societies have “ come out” calling for “ providers to incorporate environmental health screening as a part of routine practice." They have also asked that clinicians become active on a local, national, and global levels to advocate against exposure to toxic chemicals in the environment. 

In sensational news, a Finnish study reports that discontinuation of hormone therapy may increase the risk of cardiovascular death. This news comes as one of many postscripts to the large Women’s Health Initiative (WHI) study designed to assess the effects of two forms of hormone therapy (HT): combined therapy with conjugated estrogens plus synthetic progesterone, and unopposed estradiol in those with a hysterectomy. Until the WHI, conventional wisdom was that HT prevented heart disease, but fostered breast cancer. Surprisingly the WHI showed women in the combined HT group had small but significant increased risks of both heart disease and breast cancer. Those in the estradiol alone group had neither. 

In Finland, which has a highly regulated and uniform brand of socialized medicine, the use of HT took a steep dive upon the release of the WHI. ( It did in the US too.) Examination of this time period a few years ago in Finland has yielded these new insights. No one knows precisely why this is the case, but the authors speculated that it is because only estradiol, either with or without progesterone, is used in Finland. No conjugated estrogens are used. 

 It turns out that the average age of the women in the WHI was 63, a good 12 years older than the average age of natural menopause. These were women who might have accumulated atherosclerotic disease before even starting the HT. Authors of a related recent Finnish study speculated that estrogen may be good for clean vessels, but bad for atherosclerotic ones. This is physiologically plausible since estrogen encourages turnover of the vascular lining, which is where plaques happen. The plot on HT thickens again, but maybe in a good way. Stay tuned. 

Cup half full or half empty ?  The CDC reports that there has been a 44 % increase since last year of hospital policy driven encouragement of breastfeeding within one hour of birth. The trend is good ! However, the respected blog “ Shots”  at NPR ( National Public Radio) decried the findings, pointing out that most hospitals still are not doing a good enough job promoting breastfeeding and most hospitals give formula despite mothers wishes.The cup has some water in it….errr milk. 

Aren’t there some animals who ovulate in response to intercourse ? Kitty cats ? Animal lovers help me here. A new study in the Journal Fertility and Sterility has identified intercourse induced changes the immune system that are pregnancy favorable. Researchers have stated “... sex outside the fertile window is still important for triggering important changes in a woman’s body that may promote a healthy pregnancy.' Meow. 

Stay tuned for more news from the world of Ob/Gyn next week in Medical Monday. 


Medical Monday: Weekly news updates in Ob/Gyn

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Did you know that not all breast cancer is the same? Breast cancer is of course cells from the breast which have become abnormal and behave in an unregulated destructive manner. We can study specific breast cancer cells to determine their particular nature, for example, whether or they have hormone receptors. When we study breast cancer cells for their particular traits what we are really trying to determine is what therapies would be the most effective against that particular breast cancer cell type.

Some tests we do on breast cancer cells are gene tests. A new gene test called Oncotype DX "accurately identifies a group of women whose cancers are so likely to respond to hormone blocking drugs that adding chemo would do little if any good while exposing them to side effects and other health risks”. This test allows certain patients identified by this gene test to skip chemotherapy, and have results which are basically just as good as the corresponding patients who did have to get chemotherapy.

You may have heard that there is increasing support for homebirth in the United Kingdom. The United Kingdom of course has socialized medicine and a completely different medical care and medicolegal  infrastructure than the United States. For example, British homebirth midwives are highly trained graduate-level professionals who have trained with Obstetricians in hospitals. They use modern equipment, can prescribed medications, and are constrained to doing homebirth in very close proximity to hospitals with emergency capabilities. More importantly, they are very careful at patient selection. Finally, medical malpractice liability is handled through the National Health Service. 

None of this can be said for homebirth professionals in the United States where only a high school degree or GED is required along with an online test, care of home birth clinic patients and an observation of a small number of homebirths by a similarly trained person. These “direct entry” or “lay” midwives in the US are not required to carry liability insurance. 

For many reasons including all of this, the American College of Obstetricians and Gynecologists (ACOG) maintains that the safest place to give birth is the hospital or a birthing center. It is interesting to note that because of medical privacy laws and reporting laws of the state, complications of homebirth are vastly under reported and understudied. Those of us who manage complications from unsuccessful home births are very concerned about these things.

Has anybody noticed that the brouhaha over Planned Parenthood has not prevented the government from continuing to function?

A meta-analysis study out of New Zealand  and published in the British medical Journal has once again raised the question of whether or not calcium supplements are useful for strengthening bones. Their study indicates that while supplemental calcium is indeed associated with increases of bone density up to 2%, they conclude this increase was not enough to meaningfully reduce a person's risk of fracture. It is worth noting that in this study they did not actually measure fracture occurrence in the groups over time.

A second study in the the same journal actually showed a slight reduction in people’s fracture risk with calcium supplementation but researchers concluded the change was not enough to make a statement about the effect. Of course the media reported both of these studies as saying that calcium did not strengthen bones. Oversimplify much ? 

In the conventional wisdom department, new research suggests that women who"begin hormone therapy toward the beginning of menopause may have a lower risk of developing heart disease”. Apparently women who start hormone replacement therapy within five years at menopause stayed free heart disease for a longer time than non-users.".

This is exactly what we thought would take place before we studied the matter in the large very important Women's Health Initiative study, which released in 2002. The Women's Health Initiative study or WHI, demonstrated that those on combined estrogen and progesterone hormone replacement therapy actually had slightly increasing cumulative risk of adverse cardiovascular events after menopause. This was not what researchers expected. Conventional wisdom had always been the hormones like estrogen protected against cardiovascular disease, accounting for the commonly observed phenomenon of that premenopausal women rarely had heart attacks, compared to men or postmenopausal women. Unfortunately the Women's Health Initiative was a bit of a lumper, (as opposed to a splitter) in that it evaluated postmenopausal women of all ages all at once. Moreover, the average age of the test subjects was 63. Thus these women for far more than five years after the average age of menopause which is 51. These women would be likely to have already developed pre-existing cardiovascular disease, in the years after the onset of menopause but before the onset of their research protocol hormone replacement therapy.

Many researchers have speculated that there is something disadvantageous about starting hormone replacement therapy once the patient is long into menopause. Conversely clinicians everywhere have noticed positive effects on health and well-being in those who are able to take hormone replacement from the beginning of menopause and into old age. It will be interesting to see if evidence based quantitative science catches up with or remotely matches the conventional wisdom on the streets.

The Federation Internationale of Gynecology and Obstetrics (FIGO) is stepping up its research on the relationship between toxic environmental chemicals like BPA and problems like miscarriage and cancer.

Finally, in the good news department,  the American College of Obstetrics and Gynecology (ACOG) “recommends pregnant women without obstetrical or medical complications exercise at least 30 minutes a day most if not all days a week, just like the rest of the population.” 

Stay tuned for more fascinating news from the world of obstetrics and gynecology next week on Medical Monday. 

 

 

 

Medical Monday: Weekly News Update in Obstetrics and Gynecology 

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The Republican dominated House voted to defund Planned Parenthood last Friday the 19th. About a week later, the Senate rejected the same bill by a vote of 52 to 47. It turns out defunding Planned Parenthood would have allowed lawmakers to come in on budget and avoid a government shutdown on October1st. Both sides of the aisle are woking on plans to keep the government going after October 1st. I will say this: that meeting budget and funding Planned Parenthood are really two separate issues and should be treated as such. It is not as though Planned Parenthood is the ONLY straw that could have broken this camel’s back. 

The Food and Drug Administration (FDA) held a public hearing this week about the relatively new method of sterilization called Essure. This procedure involves the insertion of small coils into the inner aspect of the the Fallopian tubes as they open into the uterine cavity. Is is an office procedure without incisions, which is its appeal. However there are now 5k plus reports of complications associated with the device and more pregnancies than were intially advertised. A panel of experts criticized both the maker, Bayer Health Care Pharmaceuticals, and the FDA, in the handling of device’s testing.  A long running social media campaign has influenced the convening of this hearing. 

Long acting reversible contraceptives (LARCs) like IUDs ( intrauterine devices) have been found to be 20 times more effective at preventing pregnancy that all other contraceptive methods. In more good news, almost everyone, even childless women and women with medical conditions, are eligible to use them. Their use is up in the last few years from 1.3% to 7.2 %. The American Academy of Pediatrics recommends that they be first-line contraceptives for sexually active teens.

Most women know there is a vaccine available to prevent cervical dysplasia and cancer. But now a clinical trial from Johns Hopkins University School of Medicine has shown effectiveness in a new genetically engineered vaccine to ERADICATE existing high grade precancerous cervical lesions in half of the test subjects. Wow, fantastic ! 

Stay tuned for more news from the wild world of Ob/Gyn in next’s week Medical Monday. 

Medical Monday: Weekly News Update in  Obstetrics and Gynecology

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It's a mixed week in OB/GYN news, as always.

A Swedish study indicates that women who are overweight or obese at the time of the first pregnancy are more likely to develop diabetes in the next decade or two of their life. The risk of increase is six times baseline.

The eighth circuit court of appeal in St. Louis Missouri has taken the position that forcing employers to cover the cost of contraception through their insurance “ violates the groups religious freedoms".

In other news in the war on contraception, the Congressional Budget Office has estimated that cutting off funds from Planned Parenthood for one year could "reduce healthcare access for about 390,000 people" and at least through the Planned Parenthood budget with sales tax payers about $235 million. They hasten to indicate that defunding the organization could result in"several thousand unplanned births that would drive up government costs elsewhere such as in the Medicaid budget which pays for 45% of all births in this country.

The Census Bureau reports that the percentage of people without health insurance dropped in 2014 to 10.4 % down from 13.3 % the year before.

In the department of general women's health the following finding is rather striking. When comparing the cost of institutional care for male Alzheimer's patients versus women's Alzheimer's patients the following is noted. The cost of caring for women with Alzheimer's is six times greater then for a man with the same diagnosis. This is because when man has Alzheimer’s, female family members put much more time and energy into their care, saving them from expensive institutionalization. The reverse is not true when male family members take care of women with Alzheimer’s.

In other gender gap news, the Journal of the American medical Association reports that the gender gap in academic medicine is alive and well. Despite the fact that half of all medical school graduates are and have been women for sometime, Men are 15 percent more likely to have the rank of full professor. It also shows that women generally do produce less reach her research than men, But that this may be due to lack of mentorship, institutional support, and most importantly research funding through research grants. According to the same study, men received over twice as much research funding from their employers for equipment and labs. Women researchers are also less likely to receive NIH grants than there male colleagues.

For some good news this week we will have to turn to the field of vaccines. The CDC or Centers for Disease Control found that about 90% of children under the age of three were vaccinated against the common disease entities in the years between 1994 and 2013. What did this do for us? The CDC estimates that this will have prevented 732,000 early deaths in United States alone.

Finally, also in the good news department, the flu vaccine may be more effective this year according to the CDC or Centers for Disease Control. It is estimated that it will be nearly 3 times as effective as last year’s preparation. Remember that even if the vaccine doesn't prevent flu entirely, it will decrease the severity of flu which is very important in children and other vulnerable populations.

Stay tuned for more news from the world of OB/GYN next week in Medical Monday.

 

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. 

Structure Sunday: The Structure of Friendship

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Tonight I had dinner with a friend I have known since early high school, about 40 years ago. I love the the idea that we have been friends that long. I actually don’t like the idea of ever losing any of my friends, regardless of time or distance. And there has been a great deal of time and distance between me and most of my friends. Nonetheless, I think old friendships hold the world together. 

This friend took the initiative to keep in touch. We went to the same small high school and left there in 1977 and 1979 respectively.  Our high school was an intense, supportive and inspiring place, and as a group, we departed there meaning to do good in the world. He and I went off to separate colleges a continent away, and went about marrying, having kids, going to school, school, and more school. I became a physician and he became a researcher for the World Health Organization, among other things. 

After Facebook reunited many people, he decided it would be nice to visit. And so he did, especially since I live in eminently visit worthy place. Of course, truth is stranger than fiction, so during his visit, he naturally he fell right in love with my wonderful neighbor and returned later to stay many months with her. Eventually they parted ways as friends and he still visits to this day. 

So tonight I had my good neighbor and my old friend over for dinner since he is visiting. It was such a treat since I also invited my niece and nephew over as well so they could meet my old friend. For you see, my friend did go out and do good in the world, and I wanted to share it with these kids. 

He recently finished his residency in Anesthesia, as he decided later in life to become a doctor. At the end of his residency, the Ebola outbreak began, so he departed for Sierra Leone, one of the hardest hit areas, to help. He spent six weeks there, and at tonight’s table, he told us about all we wanted to know and more, from the percentages that lived, to the special suits he wore, to his American co-worker who contracted the disease and lived. I was so pleased that he could share all this, especially with the kids present. It not only tied us together, it tied us together with all the Ebola fighters, and even put us degrees closer to the Ebola patients themselves, and helped us understand their humanity in a near first hand way. Best of all, he told us about the preliminary announcement from about three weeks ago, that an effective Ebola vaccine is on the horizon. 

So as the night wore on, and the topic of Ebola played itself out, we realized that my nephew plans to travel to just the area of Italy where my old friends and my neighbor have visited: Venice. So I was the happy recipient of colorful descriptions of Venice. My nephew was given numerous recommendations about places to visit, things to do, and travel strategies to use. I got to listen to exuberant descriptions and enthralled questions about this place, which at this point, to me, is nearly mythical, yet now more real. 

So because of this long friendship, tonight, at my own table, I traveled from darkest Africa to brightest Venice. We were able to appreciate each far flung place as the real place that it is, and understand that hope blooms in both. We renewed bonds, and shared all this with the younger generation. 

Are your friendships in good shape ? They are so important to our collective well being, that I suggest having a look. 

 

 

 

 

 

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. 

 

 

 

 

Wellness Wednesday: Physical Methods

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Not uncommonly I have patients with pain issues, mood issues or both. Now, I suppose I write as many prescriptions for these conditions as the average doctor, but such a thing is hard to know. And yet, I am an advocate of what I like to call "physical methods" to control these problems.  

Since I practice evidence based medicine, I am committed to sticking to methods that have evidence supporting them. Believe it or not, the following methods are all evidence based. 

Let’s tackle pain first.

It’s pretty simple. If you have pain when stationery, you need to move. If you have pain when moving, you need to reduce movement or get help to find a better way to move. Physical therapy can provide this. 

Use heat and cold. Heat is to increase circulation which helps tight muscles or cramps. Cold is best for anything inflammatory or injury related in the first 24 hours. 

Massage is helpful in many cases of muscle pain. 

Abdominal binders, support hose, and wrist braces can be helpful in certain circumstances like pregnancy related pain. 

For the open-minded, I advise yoga for all sorts of pain: migraines, rheumatologic conditions like lupus, and for back pain pending approval of the back doctor.

Meditation takes a little more commitment, but it too, is evidence based and has been shown to favorably impact pain. 

Of course actual exercise is well known to improve resilience and to make people more resistant to pain. 

I consider music a physical method. Post operative patients have lower pain medication requirements when exposed to music they consider pleasant. The applications go way beyond that. 

Physical Methods for Mood 

All of the above also improve and stabilize mood. But did you know that the smell of natural citrus elevates the mood ? That’s why we have atomizers for natural essential citrus oils in our office. 

Simple adequate sleep is a proven method to improve the mood and increase the pain threshold. 

And if you haven’t heard this term before, you need to: Hangry. It is the combination of angry and hungry, which pretty much makes the connection between mood and blood sugar. Yes, something as simple as three meals and three snacks rich in protein can improve the mood immensely. 

All of these interventions and their effects are quite measurable and act via the nervous system and the circulatory system. Take the time to incorporate them into your life. They work. They’re cheap, and they’re fun. Because we all need to feel better sometime. 

 

 

To learn more see our pages: 

 

Meditation 

Yoga

Music and Health

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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I have noticed that this is not the most popular column. I thought hard about reducing to three posts per week, eliminating this one. For now I have decided to keep it since it helps me keep up to the minute on news pertinent to the field of Obstetrics and Gynecology. Please let me know what you think.

The state of Delaware has banned the dispensation of formula from the hospital to new moms in an effort to promote breastfeeding. Some mothers have weighed in with opposition saying that many workplaces stigmatize breastfeeding making formula feeding necessary. Two comments: those little sample from the hospital aren't enough to make or break your formula supply. Buy your own formula if you want to. And, wouldn't it be better to help the whole situation by introducing some sort of " Freedom to Breastfeed" program in the workplace ?

An entirely useless article came out about a number of mortalities among those who experienced complications during Robot surgery. Non medical media didn't bother to compare these numbers with the numbers of mortalities in those with complications from non Robot surgeries. Also, it is unclear whether or not attention was restricted to new resident doctors, of whom a greater percent use the robot, seasoned surgeons, or both. It would obviously make a difference. 

Recent studies indicate breast cancer survival is aided by aromatase inhibitors, as well as good old fashioned bisphosphonates like fosamax. Cheap help ! 

Republicans want to defund Planned Parenthood in the wake of the recent videos discussion the disposition of the products of conception after abortion. Some say the videos are controversial, some say they aren't. The republican House speaker, John Boehner, has stated he wants the " facts first". FYI Planned Parenthood also does routine check-ups, cancer screening and provides birth control at low cost. 

Breast cancer death rates have declined 33.5 %  from 1988 to 2010 !  Good news. I bet it has decreased more since then. 

Finally, 60% of women over 60 are sexually active. Stereotypes be gone ! 

Stay tuned for next week's Medical Monday ! 

 


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. 

 



Wellness Wednesday: Beyond Relaxation to Renewal 

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Most of us are familiar with the recommendation to relax on a regular basis. We are all familiar with the ravages of stress and the problems associated with insufficient sleep. We generally think of relaxation as the antidote. To most people this means to physically rest or sleep , and to be quiet and still. There is no doubt that some of this kind of time is good on a daily basis, especially if it is done in a mindful fashion such as in meditation.

But sometimes we need more than relaxation. We need renewal. Renewal goes beyond relaxation. It is similar to relaxation in that it is a break from the usual work routine. However, after that, the similarities end. Renewal is more planned. It may involve physical activity, such as exercise, or an outdoor adventure. It may even involve a challenge. It often involves other people, especially people who are new to you. It involves unfamiliarity, learning and even getting outside of one’s comfort zone. 

Productivity experts are extolling such “ strategic renewal” as the newest productivity tool in the success toolbox. This concept can be utilized on different time schedules: daily, weekly , monthly, quarterly. 

Daily Renewals 

  • exercise 
  • meditation 
  • reading 
  • connect with close family and friends 

Weekend Renewals: 

  • connect with farther flung family and friends, socialize and entertain
  • patronizing the arts 
  • sports 
  • spiritual observance
  • volunteer
  • outdoors 
  • reading 
  • exercise 
  • creative pursuits outside of work 

Monthly or Quarterly renewal: 

  • adventures 
  • conferences 
  • different kinds of work projects 
  • travel

See to the basics first: adequate sleep, regular exercise, and good nutrition. Ensure some relaxation on a daily basis. But go beyond all this and try to start thinking about renewal as well. 

To learn more :

See our sections on Sleep Yoga and Meditation 

LIfehacker

Huffington Post 

New York Times 

Stanford University Cafe Science

What Most Successful People Do On the Weekend, by Lauren Vanderkam 


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. 


Food Friday: Drink !

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I am absolutely compelled to write again about hydration in this, our week of three digit temperatures. I had one reasonable and well intentioned patient who came in with symptoms and was FIVE LITERS short on her hydration ! 

Let us review. Normally, a non pregnant woman needs 2 liters of fluid per day. A pregnant woman needs three. Add another liter for temperatures over 85 degrees, and yet another liter for activity such as hiking. So if you are pregnant and hiking on a hot day, your fluid requirement is easily 5 liters, and that is assuming you are coming to the day adequately hydrated in the first place. 

The human body is about 60 % water. Let's say you weigh 154#. That means you weigh 70 kg. That means you contain 42 kg of liquid or 4.2 liters. Getting short on fluid percentage wise is easier than you think. 

How can you lose so much fluid ? Well there are the obvious ways, but then there is also respiration, sweat, and something short of sweat which is still fluid loss through your skin called insensible loss. It all adds up. Heat and activity increase insensible losses like crazy. 

Here is the interesting stuff: 

" ...fluid loss of 1% impairs thermoregulation (the ability to regulate your temperature), and thirst occurs at this level of dehydration......Vague discomfort and lack of appetite appear at 2 % . Dry mouth appears at 3%. At 4% work capacity is decreased. Difficulty concentrating, headache, and sleepiness are observed at 5%. Tingling and numbness of extremities can be seen at 6%, and collapse can occur at 7% dehydration. " ( reference from the World Health organization) 

Here is the fun stuff: 

Summer is a great time for cold drinks. Try to take the traditional summer cooler and put a healthy spin on it. Here are some examples that will provide you with much needed electrolytes as well as fluid and taste. 

  • Club soda with a splash of 100% fruit juice. 
  • Mocktails like Virgin Mary, Virgin Daquiris
  • Herbal iced tea or sun tea on ice with lemon and mint leaves, sweetened with a little fruit juice 
  • Healthy fruit frappes made with fresh fruit, ice, and plain yogurt or kefir. 
  • Decaf mocha frappes made with ice, one pump of chocolate, and your milk of choice. 
  • Stay hydrated and enjoy ! 

For more information see : 

Drinks in Nutrition 

Weathering the Heat 




Wellness Wednesday: Music and Health

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Yesterday Apple debuted its all encompassing music service. With a subscription, one can listen to the entire contents of the iTunes music store 24/7/365. There are infinite permutations and possibilities for creating playlists and stations. It is the music service to end all music services. 

The association of Apple Computer with music has been long and fundamental. Much of their product inventory has been about consuming and even creating music, and other forms of art such as as film. There is a belief within Apple and indeed, within many decades of California Bay area culture that music is essential to the good life. I believe modern science is beginning to substantiate that belief. 

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Since I have been totally immersing myself in music since the services inception 18 hours ago, I decided to learn more about what is happening to me when I listen to music. What follows is a characteristically nerdy report on the relationship between music and health. It's amazing and stirs hope. 

A rather casual Google search promptly unearthed a plethora of research and commercial articles on the subject. I will give you the "digest" form and, of course, the references. The oldest work I evaluated was from 2009. Study designs varied, but many were randomized and controlled. Many of the studies were done in the setting of assessing benefit to peri-operative or hospitalized patients. 

 

 

 

In short, exposure to "pleasant" music, self chosen or otherwise, was associated with the following: 

  • decreased preop anxiety,
  • decreased post op cortisol levels, blood pressure, heart rate, pain level, thus decreased requirements for post op sedation and pain medications 
  • decreased pain and depression in fibromyalgia patients 
  • decreased heart rate and pain in hospitalized pediatric patients 
  • improvements in both branches of the immune system, cellular and humoral, in the elderly 
  • improvements in athletic performance 
  • improved sleep 
  • improved cognitive function 

 

 

How does our body and mind produce all these responses through music? The precise science is not entirely worked out. However, studies using measurements of hormones and neurotransmitters by blood tests and targeted neuroimaging reveal the involvement of the dopamine, serotonin, and adrenal pituitary axis systems, among others. 

The cardinal work on this matter seems to be an article produced by one of my old college housemates, Dan Levitan, and his colleague Mona Lisa Chanda. (See reference below.) They evaluate and ultimately support the claims that music produces its effects through the bodies systems for reward, motivation, pleasure stress, arousal, immunity and social affiliation. And these responses, of course, work through various brain centers which produce the aforementioned hormones and neurotransmitters. 

So how you feel on music is very very real. So I suggest you indulge yourself. Find your music and bring it into your life. Better yet, make your music. And if you have small children, do everything you can to get them into music education as early as possible. It helps develop the brain and enhances the power of all the good things music can do for us.