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

November 14, 2016 in women's health, safety, prevention, prenatal care, Pregnancy, Parenting, medical care, health, Consumer Awareness

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:

severe microcephaly
decreased brain tissue with specific pattern of calcium deposits indicating brain damage
damage to the back of the eyewash a specific pattern of scarring and increased pigment.
joints with limited range of motion
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.

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

October 23, 2016 in women's health, safety, prevention, Parenting, Pregnancy, medical care, health, doctor patient, Consumer Awareness

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.

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

October 17, 2016 in Consumer Awareness, doctor patient, health, medical care, Pregnancy, prenatal care, prevention, safety, women's health

The genome of the Zika virus has been isolated. This is an essential step in learning about the virus and how to stop it.

Meanwhile Zika virus continues its spread in southern Florida with three Zika transmission zones identified. Readers would do well to remember that Florida is still recovering from Hurricane Matthew and all the floodwaters are still receding. Florida has called on the Federal Government to help fund their fight against Zika.

In chilling news, a new study out of Brazil indicates that Zika can affect a baby’s brain even if the mother contracts the infection a week or two before giving birth. This begs the question of whether newborns or even toddlers or beyond can incur damage to the growth of the brain by becoming infected.

Breast and ovary cancer, among the most dreaded female cancers, both have new and promising therapies on the horizon. In the case of ovarian cancer, a whole new class of drugs called PARB inhibitors is showing improvement for all women with recurrent ovarian cancer. For breast cancer, an investigational drug Ribociclib combined with the older Letrozole, is showing significant improvement in PFS (progression free survival) for those with hormone responsive cancers. Such drug “cocktails" are becoming increasingly useful in the fight against many difficult diseases such as those from viruses or cancer.

Researchers at Johns Hopkins Kimmel Cancer Center have created a free web based app to guide clinicians in their treatment of breast cancer. In these days of precision medicine, tumors can be subjected to ever more detailed molecular and genetic analysis to determine the best possible therapy. These are costly, which hopefully will change. For now, this app helps clinicians decide whether or not these more detailed tests are necessary.

Have you ever heard of de-prescribing ? Me neither. Apparently this is when a physician takes a patient off medications. Physicians are increasingly trying to help patients avoid medication interactions or unnecessary medications altogether. I can imagine this being important in an internal medicine practice where patients have medication lists a mile long.

Once again the value of mammograms is being questioned. This time it is in an article in the New England Journal of Medicine. Once again the concern cited is “ ...needless anxiety, treatment and expense.” Let’s be clear here, by “ treatment”they are referring to biopsy. And now that I think of it, use of this language is really irresponsible. Biopsy is not treatment in the case of breast disease. The authors indicated that over half of breast cancers diagnosed on mammogram are a case of mistaken identity…”. First of all, breast cancer is not a radiographic diagnosis. It is a TISSUE diagnosis. So, they could rightfully say, over half of all mammograms which are suspicious for breast cancer, are actually not on biopsy. This, to me is a cause for relief. Understand that if they want to decrease the mammogram frequency, they will increase the number of women with cancer who are picked up late rather than early. How many inconvenienced women are worth one who gets an early and more curable diagnosis of breast cancer rather than a late one ? I’d say many. Very many. How much inconvenience and expense is worth a life ?

We are continuing to expand our understanding of how maternal obesity affects babies in utero, newborns, and even children into adulthood. Four recently published studies are showing these risks, and they include increased risks of stillbirth, diabetes, and blood pressure disorders of pregnancy. More interestingly, risks for children born to obese mothers of these same types of diseases persist into adulthood.

Our national increase in maternal mortality is of paramount concern. Poor maternal health and the conditions which produce poor maternal health are undoubtedly to blame. Accordingly, experts are increasingly beginning to teach that women should attain a healthy weight and attain control of all their medical conditions before attempting pregnancy.

In that spirit, I will report on a relevant and encouraging story coming from the International Olympic Committee. They have found that “ ...strenuous exercise during pregnancy doesn’t appear to increase the risk of most pregnancy complications for mom or baby”. ACOG (The American College of Obstetrics and Gynecology) has recommend institution or continuation of “ moderately strenuous” exercise during pregnancy as well.

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

Wellness Wednesday: Fitness Redux

October 11, 2016 in women's health, prevention, mind body, Mental health, medical care, health, fitness, doctor patient, Consumer Awareness

Wellness Wednesday was originally conceived as a place to post about fitness. While I am glad it has morphed into a space about all kinds of wellness, I’d like to take this moment to focus back on the one thing that is the

best illness prevention,

best mood enhancer,

best fat burner,

best strength builder,

best beauty treatment of all:

exercise, of course.

I don’t think it gets the press time or the limelight it deserves in the the halls of modern medicine, or in our public media space. There are studies are out there to support exercise for both prevention and adjunctive treatment for disorders from A to Z. These studies are not glamorous and not really media worthy, because in many cases they are confirming things which we already strongly suspected. So the results of these exercise studies are not sensational in any way. So the media is partly accountable for not continuing to remind us of the central importance of fitness. Medical caregivers are to blame since their focus is elsewhere and they themselves have insufficient knowledge and experience with fitness. Most importantly, the public is to blame. They would much rather read about a pill to cure obesity than read about how a consistent regimen of 30 minutes of daily exercise can reverse diabetes and heart disease.

I would like to take this opportunity point you back to my website pages on fitness, and encourage you to read through all the links.

Fitness

That way, in about 5-6 minutes you can get the important points in a short period of time. But for those of you who are not link clickers, I will give you the nutshell version here:

Those with medical problems should obtain medical clearance to exercise.
Exercise should be engineered and planned into your day like an important meeting.
Start with brief easy sessions 6 days per week to build a habit.
Determine why you need to exercise.
Resolve to make exercise fun.
To begin, pick at least 3 easy fun routines or an exercise which requires little thinking on your part. Do not go over about 30 minutes per session on your first 3 months of exercise. DVDs or a class are ideal. Chose workouts that include concurrent cardio and resistance. Until you know what you are doing, go with a professionally designed workout which is safe, effective, balanced and includes warm up and cool down. My favorite library of workouts is Beachbody on Demand. I also love Jillian Michaels workouts.
Pick a place of exercise that is time and weather independent. This could be a 24/7 gym, the outdoors, or a DVD in your living room.
Arrange accountability through an app, a log, or a friend.
Arrange self tracking through an app or a log. Include, weight, waistline, type and duration of workout. Do not measure your weight and waistline more than once per week.
Have comfortable and flattering exercise wear.
In the first three months go mellow to let your body begin adjusting. After that ramp up in intensity to your tolerance, provided you are tired but refreshed afterwards, rather than wiped out.
Hydrate well all day long and have water during every workout.
Remember that it takes 3 months to build a habit.
Focus on how good you feel when you are finished.

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

October 10, 2016 in women's health, prevention, prenatal care, Pregnancy, mind body, Mental health, medical care, health, family, doctor patient, Consumer Awareness

It turns out that Dr. Peter Hotez, the Dean of that National School for Tropical Medicine has been thinking about the interplay between Hurricane Matthew and the Aedes mosquito which spreads Zika. His informed speculations were that the Hurricane could provide an initial respite from the mosquitos, being essentially blown away by the tremendous winds. However, the enormous amount of standing water afterwards would provide ideal breeding ground for the virus carrying mosquitos.

Though the Federal government has passed a limited Zika funding measure, the bulk of the costs have fallen on States. The 1.1 billion dollars recently approved requires the development of a spending plan which the Department of Health and Human Services are required to complete by the end of the month. One hundred and fifty two million will go toward vaccine development. The rest will go to local labs to speed up testing, as well as for prevention efforts like mosquito control, and education campaigns.

Much of the press about Zika focuses rightly on its effects on pregnant women, namely microcephaly and other severe effects on the fetal and neonatal brain and nervous system. However, Zika virus effects non- pregnant women and men by increasing their chances of Guillain Barre Syndrome, post viral paralysis. In the recent new wave of such patients, 97% of these patients had symptoms of Zika 4 weeks prior, further cinching the relationship of the virus to the syndrome even further.

At least 808 pregnant American women have Zika. It is likely that there are many more since the infection can be asymptomatic, and testing results are much delayed. Physicians and Institutions are trying to ready themselves for the increase in special needs children which will come as a result of the Zika epidemic.

New Zika recommendations indicate that both men and women wait six months to get pregnant after Zika exposure.

In other virus related news, studies have shown that parents are more likely to ask for HPV ( Human Papilloma Virus) vaccine to be given to their children if their child’s caregiver discusses it with them in a certain way. In particular, if caregivers highlight the parent’s role in preventing HPV infection, parents are more likely to agree to the administration of the vaccine. HPV vaccine is grossly underutilized. Researchers and physicians are trying to increase HPV vaccine utilization rates by funding the vaccine with others and by giving it in school based programs. HPV is a virus which causes serious and sometimes fatal disease processes ( cervical cancer) for which there is an effective vaccine. Yet many will not utilize it. Once we are fortunate enough to have a Zika vaccine, I wonder if some will decline that too.

Speaking of inadequate utilization of vaccine, over half of millennials do NOT plan to get the flu vaccine this year. Half of these people do not believe it is effective and 29% think it will give them the flu. The data do not bear out these concerns.

Here is some bad news that is, at the same time, interesting and useful. First, people in most modern countries gain weight during the holidays. The amount and time frame varies by country. In the US, our weight is at its lowest in October, right after summer, and increases in the ten days preceding the holidays. It appears that holiday related weight gain, regardless of country, takes about FIVE months to lose. That’s right people, gain it in ten days, lose it over five months.

In other bad but fascinating and hopefully helpful news, stress contributes to aging in a very particular and profound way. A large human DNA study has demonstrated that “ adverse events in childhood ...hasten …telomere tear down." I once read telomeres are the protective shoelace tips to our DNA shoelaces. Telomeres keep DNA from fraying as it were, and this prevents premature aging. They were able to determine that each significant stressful event in a person’s life increases the risk of shorter telomeres by 11 percent. DNA codes for what we are… in a very immediate tissue sense of the word. Damaged DNA leads to all kinds of diseases including cancer, and basically the failure to heal and renew properly. We have to start taking the prevention of childhood stress much more seriously.

State Medicaid expansions are most costly than previously anticipated. This is because more qualifying patients have signed up, and they are sicker than had been anticipated. This should be cause for increasing the funding to the expansions, says this fiscal conservative. Why ? It is because preventive care and treatment that is earlier rather than later ALWAYS is cheaper in the long run. Never mind that it is more humane and the ethical thing to do.

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

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

October 02, 2016 in women's health, safety, prevention, prenatal care, Pregnancy, medical care, health, doctor patient, Consumer Awareness

Congress has finally passed legislation allocating $1.1 billion to fund the fight against Zika. This will cover primarily vaccine development, but also mosquito control efforts. This is very good news; however many would argue that this is too little too late. The director of the Centers for Disease Control (CDC), Dr. Anthony Fauci, has indicated that more fundamental research on Zika "will need to be cut back.

There are over 2000 confirmed cases of Zika among American pregnant women. The majority of these are from Puerto Rico. However, the true number is probably under appreciated, due to lack to testing or delays in getting testing results back. Zika Virus may be transmitted through the bite of the Aedes Mosquito, but also via body fluids. By body fluids they mean tears or sweat, not only blood and sex related secretions. Zika virus causes numerous serious abnormalities in the developing fetal and neonatal brain, and can cause post viral paralysis ( Guillane Barre Syndrome) in non pregnant adults.

A scandal is developing in Florida. Officials in Miami Dade County are accusing the Florida Department of Health of keeping the mosquito capture sites secret, a charge which the Health Department denies. This all started when the Miami Herald sued to find out the location of the traps.

Texas, which has not yet experienced a confirmed case of Zika, is still expected to be at risk. This is because such epidemics travel in a delayed fashion. Dr. Peter Hotez, Dean of the National school of Tropical Medicine at Baylor College of Medicine, Has stated that we will not know if we've had local transmission of the Zika virus in Texas until seven or eight months from now, when babies are born with microcephaly. He noted that detecting the virus is difficult because most people who are infected are asymptomatic.

ACOG’s Journal of Obstetrics and Gynecology has published a report indicating that from 2000 to 2014 maternal mortality in the Continental 48 states has increased 27%. A 2015 report from the World Health Organization indicated that the US has a higher maternal mortality rates than Iran, Libya, and Turkey. This is been reported in previous weeks, although these new numbers put it in better global perspective.

In the good news department, the use of antenatal steroids in women at high risk for preterm labor has been expanded. Until recently we used such steroids to accelerate lung maturation in unborn babies through 34 weeks of gestation. For reference, 40 weeks is the due date and 37 to 41 weeks is considered full-term. The period of 34 to 37 weeks was considered preterm, but until recently there was no proof that the use of antenatal corticosteroids helped this group of babies. Now there is. Accordingly the American College of Obstetricians and Gynecologists has published an updated committee opinion on the use of these medications. With this expanded therapy, it would be reasonable to expect fewer breathing complications in this group of premature babies.

In the "proud of my college" category, The American College of Obstetricians and Gynecologists (ACOG) has been solicited by the Federal government to "review and recommend updates to" several preventive health services for women under the Affordable Care Act. ACOG’s draft recommendations states that “ women should be able to get free mammograms as early as age 40 and if any follow-up is required, like a biopsy, it should be considered an integral part of the screening and also covered at no cost.” ACOG has also recommended that male birth control be covered as well.

Also in the good news department, the death rate from ovarian cancer decreased 16% between the years 2002 and 2012.

In the vaccination success department, the World Health Organization (WHO) has declared America free of measles. The WHO Director General Dr. Margaret Chan has indicated that the Americas is the first region in the world to eliminate measles. It has achieved this after a 22 year vaccination campaign. As the measles may be imported from elsewhere, vaccinations for measles should continue as per usual.

Also in the vaccine success department is this: A recent study indicates that the recent introduction of a prenatal TDAP booster vaccination has been effective. This booster can prevent both the development of pertussis ( whooping cough) and decrease the severity of neonatal pertussis infections that do occur.

Our last bit of news this week is also in the good news category. Teen pregnancies have declined over the last 10 years and the most recent data is even better. Data from 2015 indicate indicate that the teenage birth rate in the United States has hit a new record low, according to a report from the Centers for Disease Control and Prevention. The rate had a one year decline of 8% falling to 22.3 births for every 1000 women between the ages of 15 and 19. Experts attribute this to teenagers having less sex, using more reliable contraception, and being more aware of the difficulty of having a child while still a teenager.

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

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

September 26, 2016 in women's health, safety, prevention, Pregnancy, prenatal care, medical care, health, Consumer Awareness

By a margin of 89 to 7, the Republican dominated Senate voted to move forward and develop a bill to avert a government shutdown and fund the Zika crisis. So, yes, they approved a bill to approve a bill.

Meanwhile the public ought to be aware that money has been taken from other important sources to fight Zika. The Federal Government has taken money away from funds to fight malaria, tuberculosis, ebola, and more recently, and tragically, cancer, diabetes, heart disease and mental health. Some of this money will be going to continue the development of a zika vaccine.

The CDC ( Centers for Disease Control) has spent another 2.5 million for Zika lab testing. Getting definitive Zika test results can take 4-6 weeks in the current system.

The news has prominently publicized the well delineated areas in Miami where the Zika virus is active. However many experts believe Zika is active all around the Gulf Coast. Experts including some within the CDC believe other Gulf cities are experiencing Zika outbreaks without realizing it since the testing is taking so long.

As of several days ago, Puerto Rico has 20,000 documented cases of Zika, including close to 2000 pregnant women.

In the not surprising department, those with no out of pocket expense for birth control have fewer unplanned pregnancies.

Also in the interesting but not surprising department, stress may erase the effects of a healthful diet. It also decreases one’s chances of getting pregnant, especially if it occurs near the time of ovulation.

About 1 in 5 or 20% of all women will suffer from depression and one point or another in their lifetime. That percent is higher in the 40s and 50s.

Last week I reported on the appalling maternal mortality rates in Texas. The Institute of Heath Metrics and Evaluation has released data indicating that the United States as a whole has suffered the same trend. We are now considered an outlier among rich nations in this regard. Some of this is attributed to obstetric ( pregnancy) complications arising out of increased background rates of obesity and diabetes, whose rates have skyrocketed in this country.

In the probably good news department, mammograms received by Medicare beneficiaries increased in the first three years after the enactment of the Affordable Care Act. It is a bit too early to tell if this will result in a reduction in morbidity or mortality from breast cancer, but I am betting that it will have.

In the definitely good news department, it has now been established that the incidence HPV related anogenital warts is on the decline due to the HPV vaccine. This is true despite the woefully low utilization of this safe and effective vaccine. The HPV vaccine is meant for young people, both boys and girls from ages 9 to 26.

In the phenomenal and amazingly good news department, Mark Zuckerberg, founder of Facebook, and his wife, Pediatrician Dr. Priscilla Chan, have pledged 3 Billion dollars over the next years to essentially cure or manage all disease by the end of the century. If I had not just attended Stanford Medx this last week and been heartened by all the new technologies and methodologies that people all over the world are bringing to bear for these goals, I would have thought their goal unrealistic. But now I believe it is simply a matter of time.. and money.

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

Wellness Wednesday: Stanford Medx

September 21, 2016 in women's health, prevention, Mental health, mind body, medical care, health, doctor patient, digital arts, Consumer Awareness, connectivity, communication

I just knocked something off my bucket list.

Stanford Medx is a multi-day conference on innovation in health care. The conference is akin to it’s older and more popular cousins TEDx and TED, programs which are available online to everyone and which deal with topics in technology, entertainment and design, really all the big issues.

Medx brings together people interested in moving medicine to a new and better place. It’s themes are people, technology and design. I would like to share with you some of the material that I encountered and the people that I met, together with a few images.

On Wednesday my first day, I travelled. It is always an entertaining shock to change biomes so quickly, going from the alpine to the sonoran in little more than a couple hours. From cool pine I went to warm eucalyptus. After getting settled, I attended presentations and a workshop at the D school - The Design School on the Stanford Campus. There I met designers, architects and medical people all coming together to make buildings, objects, and even procedures which would make getting medical care more effective and pleasant for patients and caregivers. I met a women who is involved in renovating the Women’s and Children’s hospital at Stanford, just as I am at my hospital. I also met the grandson of Charles and Ray Eames who reviewed principles of design though a survey of his grandparents’ work. I also met the mother of an unexpectedly premature baby who had struggled with expressing colostrum. She had, as a result, developed a clever and inexpensive device to modify existing pumps to make them more effective. We expect its use to become widespread.

Day two was a workshop on shared decision making. This was meant to be decision making between anyone and anyone else: doctor-patient, doctor-nurse, and family member to family member. Shared decision making was a key theme which dovetailed into one of the main themes of the conference, EVERYONE INCLUDED.

Decisions from the top down can be problematic, and partake of hierarchy. Hierarchy for its own sake is to be banished from medicine. Effective communication, and therefore better results, satisfaction and even safety grow out of shared decision making. This was amply explained an demonstrated across all the varied content of the conference.

Communication needs more than clarity. To be optimal, it is two way, and involves empathy. EMPATHY was another key theme echoed over and over again. As physicians, engineers and designers, we must employ empathy in all our thinking. We need to ask the patients and the users for input at all stages of development. Such a process creates more user satisfaction and better results.

On day two, we partnered up. Our group was composed of the professionals I mentioned, but also of special “ e-patient scholars”. These were medically sophisticated patients with serious chronic medical conditions who could speak to us about their long experience in the medical system. They were there to help us see through their eyes. I was paired with an older woman in a wheelchair with end stage MS and lupus. Since I have lupus we exchanged notes about that. But it was her MS that was making the critical problems. She spoke about her end of life plan. Even so, she was as pleasant and sparkling as a person could be.

On days three four and five we had presentations from morning until evening, often rapid fire. That is when the conference really took on a life of its own. The conference designers were smart. They had substantial breaks every hour or two, and provided food, and tables, and encouraged everyone to live tweet the conference. The session to break ratio was optimally dialed for stimulation and interaction. All the speakers made themselves accessible, so not only did you hear these phenomenal stories, you met the phenomenal people. Bread was broken and contact information was exchanged.

Key themes were as follows:

open medical data, especially genetic data
open research data
the quantified self
gamification of healthy lifestyle goals
getting patients, doctors and researchers together, often through the internet
patient education, often self education, through apps and the internet
collaborative and integrative medicine
collaborative end of life planning

A lot of this came together under the topic of PRECISION MEDICINE. This means care tailored to one's precise condition, down to the genes if possible. It also means giving exactly the right amount of medical care, not too much, and not too little. It also means care tailored precisely to the patient’s wishes. Finally it means oversight so that care dollars are used optimally.

By far the most stunning presentation was that of Dr. Lucy Kalanithi, the widow of Dr. Paul Kalanithi, Stanford neurosurgeon who wrote “ When Breath Becomes Air”. Her presentation detailed the reality of love and connection despite suffering and death in a way that I have never imagined. Her presentation had more power than any I have ever heard. I recommend the book.

Besides being stunned, I was also charmed. I got to meet so many delightful people who were also talented beyond measure. The same people were uniformly willing to share their insight and experience. Noteworthy among these was Dr. Wendy Sue Swanson, Seattle Mama Doc. She is a Pediatrician, mom, and writer extraordinaire. Check out her website, blog, and book " Mama Doc Medicine".

It was also great to meet Dr. Kyra Bobinet, who shares my interest in helping patients realize their goals in fitness, nutrition and health in general. She told me that everything she knows is in her book, " Well Designed Life". I didn't believe her but I can't wait to read it.

Medicine is moving forward folks, and you will want to come with it. Medicine needs your input to be what it needs to be. Monitor yourself. Get your health data. Try to connect with your caregivers. Tell your story. Listen and see an alternative point of view. Have a discussion. This is the basis of the future of medicine, medicine 2.0.

Not nearly everything from the conference is uploaded, but a Stanford MEdx youtube channel exists. Check out the link below and I know you will be inspired.

https://www.youtube.com/channel/UCK1chhgXNHf7iB5mlqzXODA

Well Designed Life: 10 Lessons in Brain Science & Design Thinking for a Mindful, Healthy, & Purposeful Life

$12.00

By Kyra Bobinet MD MPH

Buy on Amazon

Mama Doc Medicine: Finding Calm and Confidence in Parenting, Child Health, and Work-Life Balance

$13.12

By Wendy Sue Swanson

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

September 19, 2016 in Consumer Awareness, safety, health, medical care, breastfeeding, women's health, prenatal care, prevention, doctor patient

Greetings from the heart of Silicon Valley. Please excuse the blog silence over the last few days as, believe it or not, I have suffered from sporadic Internet connection. I have been attending a very busy conference, Stanford MedX, on which I will fully brief you later. I could not blog at the conference but I took a lot of notes and pictures and they will serve as the basis for my reports to you sometime late on Wednesday. Where I stayed was a beautiful residence deep in a grove of old-growth trees so dense that it interfered with us cellular and local Wi-Fi coverage. So I right now without pictures, I will make this dispatch to you because I think medical Monday is so important. Text will go, but pictures will have to wait.

Some continue to doubt the association of the Zika virus infection with the development of microcephaly. However this latest study should put this to rest. The Journal Lancet Infectious Disease reported work that studied newborn Zika babies both with microcephaly and without. It turns out that babies with microcephaly we're 55 times more likely to have been infected with the Zika virus in utero. However, none of the 62 newborns in the comparison group who appeared normal showed any sign of infection.

Of chilling significance is another story published the Journal of Emerging Infectious Diseases. Those authors note that "for infants about four months and up to eight months of age" babies were "born on average on measures of weight length and head circumference" but "fell even further below average as time passed".

The CDC (Centers for Disease Control and Prevention) has now indicated that Zika virus can spread through "contact with bodily fluids such as tears, discharge from infected eyes, saliva, vomit, urine or stool." This has obvious implications for those living with and caring for those affected by the Zika virus.

Florida may offer free Zika virus testing, but that does not mean women are getting results. Apparently results that take a private lab a few days to report are taking weeks for the state run service. Time is of the essence when inquiring about Zika virus infection in pregnancy, since many women consider the option of abortion if there is evidence that their baby could be or is infected. Access to abortion is more restricted in what now could be called the Zika belt of our country. Women consider this drastic measure because central nervous system manifestations of Zika virus in pregnancy are often devastatingly severe. We now know they're also potentially progressive even after the baby is born.

A recent poll suggests that the risks of Zika virus to pregnant women have caused some Americans to soften their view on abortion. 62% of voters living in the 10 battleground states in the south and along the Gulf Coast have said that they "support abortions after 24 weeks if a doctor believes there is a serious possibility that a woman's fetus could have severe birth defects from the Zika virus."

As of this writing the funding to combat the Zika virus is virtually spent. The Obama administration as well as the CDC, the American College of Obstetricians and Gynecologists and others have appealed to Congress to put aside partisan politics and fund the fight against the crisis

It is worth reiterating news from last week coming to us from the Zika belt state of Texas. Texas maternal mortality spiked from 18.6 maternal deaths per 100,000 live births in 2010 two more than 30 per 100,000 into thousand and 11 and remains at that level through 2014. This statistic may not seem huge but it has increased dramatically and is a higher rate than anywhere else in the country. It is also higher maternal mortality rate than in most other industrial countries. Numerous writers, ACOG and the State Heath Services of Texas maternal mortality task force all recommend an increase in health care services to women as the solution.

Global maternal mortality rates are not where they should be. The United Nations sustainable development goals (SDG) indicate the rate would have to fall by nearly 70% to meet the target globally of 70 maternal deaths per 100,000 live births. It is felt that this should be accomplished by adding an estimated 18 million Women's Health workers including midwives and obstetricians.

A new study by the Urban Institute has indicated that only 31% of women know about the most effective forms of birth control, the LARCs, the long acting reversible contraceptives. ACOG has said that such IUDs and implants are the most effective reversible contraceptives available and are safe to use by almost all women of reproductive age. Of note, weeks ago it was reported that Puerto Rico, which is greatly affected by the Zika virus, had been given a large supply of IUDs but was unable to fully utilize them due to the lack of providers trained to insert them. LARC use in Texas is on the rise.

The rest of the news in brief:

US preventive services task force recommend screening all nonpregnant adults and adolescents at risk for syphilis, which is on the rise.

The British medical Journal reports that pregnant women with higher ambient glucose levels who are not meeting the criteria for gestational diabetes still have an increased risk of complications. These complications would include preeclampsia and overly large infants (macrosomia). Additionally, related complications are noted, such as shoulder dystocia, which is the condition where babies are dangerously difficult to deliver due to a larger girth at the shoulders.

The national Cancer institute is once again encouraging all children adolescents and young adults 26 years of age or younger to obtain the vaccine against the human papilloma virus, HPV. Only 40% of eligible girls and 21% of eligible boys have received the vaccine. Vaccination rates in Australia and the United Kingdom are in the range of 75 to 92%

In the good news and we already knew this department, an article in the Annals of Oncology has reminded us that use of oral contraceptives decreases ovarian cancer risk by 50%. For the record, having children and breast-feeding them also decreases this risk.

In the good news department, The number of Americans without health insurance has fallen to a recent level of less than 10%. This is attributed to people buying insurance on the Affordable Care Act (ACA) exchange.

Stay tuned for more exciting news from the world of Obstetrics , Gynecology, and Women's Health, next week on Medical Monday.

Travelling !

September 14, 2016 in women's health, productivity, prevention, mind body, Mental health, health, medical care, doctor patient, digital arts, Consumer Awareness, connectivity, communication

I'm on my way to Stanford MedX conference and I'm very excited. My usual blogging format will give way to posting as I go, so you can experience some of the amazing things that this trip will bring. Our journey starts in just a few hours ; )

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

September 12, 2016 in women's health, safety, prevention, prenatal care, Pregnancy, medical care, health, doctor patient, Consumer Awareness

Vice President Biden has called for the Congress to separate the issue of funding Planned Parenthood from the issue of funding the war against Zika. He has addressed the Republic led Congress in the strongest possible terms. He went so far as to point out the irony of the the fact that the people ostensibly most concerned about the unborn, anti-abortion Republicans, being the least willing to take measure to protect the unborn. Earlier this week, the Senate rejected a 1.1 billion dollar funding bill. Sixty two percent of Americans feel that Congress should approve additional funds to fight Zika, rather than pull them from other programs.

The CDC (Centers for Disease Control) has reported that Brazil has already noted a doubling of their rate of nervous system defects, including but not limited to, microcephaly. The rate of Guillane-Barre or post viral paralysis has tripled.

In the mice model, there is some evidence that Zika resides in the eyes. There is speculation, therefore, that it can be spread by tears.

The WHO ( World Health Organization) has modified their advice for those in or returning from a Zika affected area. Men were to practice safe or no sex for 8 weeks. Now, that recommendation has extended to the same time frame for women: 6 months. This recommendation stands whether or not the couple is trying to conceive. Only 58% of people in the United States know Zika can be spread by sex.

Not all South American Countries show cases of microcephaly after Zika infection in pregnancy. Not all mosquitos can transmit Zika. For example, Columbia, has had fewer than three dozen cases of microcephaly whereas Brazil has had 2000. Culex mosquitos, which are 20 times more common than Aedes mosquitos, cannot transmit Zika. The sooner basic research is done to find out the reasons behind these observations, the sooner we may get some control over Zika.

There is other big news. The FDA, Food and Drug Administration, has banned 19 chemicals commonly found in antibacterial soaps, saying not only do they not do any good, but that they actually may do harm. There is concern especially over triclosan and triclocarbon in that they are now felt to promote antibiotic resistance. There is also concern that they may be endocrine disruptors, meaning they may interfere with sex hormones like estrogen and testosterone. Soap and water are the best ways to get clean. While I advise the frequent soaping of hands at work, and routinely upon arriving at home, I prefer my patients avoid soap on the face or any delicate tissues.

In the good news department, we have several items. First, MRI without contrast appears to be safe in pregnancy. MRI is useful for taking care of pregnant women with many important conditions.

HPV vaccine provided in the middle school setting met with an 86% adoption rate. This is much better than “ in the wild”. Research of this kind may provide insights into improving vaccine utilization. Maybe some of it boils down to convenience.

Recent research indicates that use of hormones, in both oral contraceptive and postmenopausal hormone replacement forms, may be responsible for decreasingly mortality rates from ovarian cancer. Hormone use is known to suppress the ovaries which also seems to suppress the development of this type of cancer. Ovarian cancer is one of the most dreaded Gyn cancers. This is for two reasons: It usually presents at an advanced stage, and the screening tests for it are not very good.

Help for ovary cancer treatment is coming from an unusual source. IBM’s supercomputer Watson is utilized in a program called Watson for Genomics wherein the genes of known cancer patients are sequenced and uploaded to a database. Personalized treatment plans can be developed for each patient. In the future, this data might be used for better early risk assessment and detection as well.

Stay tuned next for more breaking news from the world of Obstetrics and Gynecology. Next week should prove very exciting since I will be at Stanford MedX - an amazing conference on innovation in health care. Check it out here :

http://medicinex.stanford.edu

Wellness Wednesday: How to Visit Someone in the Hospital

August 30, 2016 in doctor patient, Consumer Awareness, connectivity, family, health, medical care, Mental health, mind body, social life, women's health

On first glance this seems self-explanatory. However, a few tips may make things easier.

If you are uneasy about visiting the hospital, figure out why. Are you afraid of embarrassing the patient ? Do you not like hospitals ? Do you fear illness yourself ? Figure out your reasons and decide if they are reasonable. Remember that the visit is for the benefit of the patient, and that it is an act of care. People in hospitals can very easily feel isolated, as though everyone else is out there living life to the fullest…but them.

Call beforehand. Based on circumstances, call the patient, her significant other, or perhaps the nursing station of the ward that she is on. Find out the visiting hours, if there are any, and whether or not a visit is appropriate. When you call, ask if the patient needs anything from home or from the store. Sometimes little things can make a big difference, i.e. gum, or their iPad.

Consider bringing a small gift of your own. However, when considering gifts of or drink, make sure you know the patient’s dietary limitations. In the hospital, dietary restrictions are common, such as during the time before and after surgery, or stroke. When considering flowers, make sure they are permitted. Some units cannot have them because of infection risk. If the patient can do things to pass the time, consider bringing activities that he or she will like, such as card games.

When you arrive, check in at the nursing station and with the patient’s nurse. Wash your hands. Once in the patient’s room, it is important to suss things out. It may be a time for visiting and joking, but it also may be a time to just be present in silence. Either way, it is a comfort. Even without a lot of conversation, just being there is very beneficial. On the other hand, patient’s still like to hear about what is going on in their friend’s lives as they would normally. If the patient is too tired to read, they might like having the paper read to them. Do remember that hospitalized patients are almost always tired. Watch carefully so that you do not stay too long, to that there are so many guests that the patient feels overwhelmed.

Do not ask prying or personal questions about the patient or the illness. If the patient wants to talk about them, be a good listener. Even then, do not pry. Do not ask the nurses, doctors or other staff about the patient’s condition. They are not permitted to discuss the case without the patient’s permission, and asking right then might be uncomfortable.

When you are there, consider offering material help to the patient or to her helpers. She may need kids shuttled, dogs walked, or lawns mowed. You could even offer to set up a google doc or some equivalent to coordinate the helpers if the need is extensive.

Consider helping your friend after they transition back to home. Getting around will not be the same even if they are stable enough for discharge. Plus, hospitalized patients get a lot of attention to help them through. To have that come to a screeching halt upon discharge would not be all that fun. Connection, not isolation, is essential to healing.

Most major religions, certainly Judaism and Christianity, include visiting the sick as a formalized duty. It represents the best of society, and embodies compassion. The secret is, it blesses the visitor as much as the visited.

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

August 28, 2016 in women's health, safety, prevention, prenatal care, Pregnancy, Parenting, Menopause, medical care, health, family, Consumer Awareness

Zika again dominates the news in Ob/Gyn. As of Friday, a storm system was approaching the subtropical state of Florida, where 43 are confirmed infected with the Zika Virus. Authorities think the storm may help spread the virus which is transmitted by mosquitos and sex. Meanwhile, the CDC (Centers for Disease Control) does not have enough Zika testing resources. I myself experienced this last week when I was told a specimen we sent to the CDC would take “weeks” to result. We Ob/Gyns are not able to effectively work in time frames like this, and so this week we will have being having some words with the powers that be.

A new study published in Radiology has shown that Zika can cause many other brain defects besides microcephaly. They have thus far identified 8 major defects. One of the most common was ventriculomegaly, or enlarged ventricles and thinning cortex.

Thus far the Florida outbreak has been clustered around Miami. However Thursday, an isolated case showed up some 250 miles to the north in Tampa Bay, Pinellas county. It is still unclear how this occurred. On the bright side, modeling done by researchers at the University of Florida has indicated that the total outbreak should limited to under 400 individuals or less, considering all the southern states. They also believe winter will stop the outbreak, which would then recur next summer the same way. It is estimated that 20,000 pregnant women in the Miami area are taking extreme measures such as confinement indoors or moving to avoid Zika infection.

NewYork officials are noting that travel restrictions to Zika affected area not being properly observed by pregnant or pre conceptual women. How do they expect people to take these restrictions seriously when they gave full sanction to people traveling to the Olympics in Rio?

Dr. Kristyn Brandi writes that Zika is spreading more rapidly than anticipated in Puerto Rico, and that resources of information and contraception are not adequately available.

The chair of ACOG (American College of Obstetricians and Gynecologists) has written a strongly worded piece which has criticized how politics has prevented the funding of an adequate Zika response. He and co author, Dr. Didi Saint Louis of Morehouse School of Medicine have called for the full funding of comprehensive reproductive health care to allow women to avoid or delay pregnancy. They have called on Congress to reconvene to deal with this.

In the non-Zika news, HPV virus is in the spotlight. This virus is responsible for abnormal paps, and cervical cancer, among other things. It has an effective vaccine which is meant for young people between the ages of 9 and 26. However parents remain wary to give it to their children. Research is being done regarding the prospect of putting it on the list of already mandatory vaccines which must be done before school entry. Surveys show that parents would accept this as long as there was an opt out provision. As of 2014, only 40% of girls and 20% of boys were vaccinated. It will be interesting to see if there will be those who decline the Zika vaccine once it gets developed.

Breastfeeding is practiced by about 80% of all American women when they leave the hospital. However less than a third keep it up for the recommended time. The American Academy of Pediatrics has recommended that infants should get nothing but breast milk for six months, and that breastfeeding should continue one year.

Co-sleeping beyond six months has been shown to produce significant stress on women. Researchers at Penn State note this may be related to fragmented sleep and less time with partner. Perhaps this is related to the falloff in breastfeeding.

In the everyone-already-knows-this department, researchers at UCLA have discovered that menopause accelerates aging. In all fairness, what they have determined is that methylation increases in menopause, accelerating cellular aging about 6 %.

And in the we-should-have-known department, the “ baby simulator” program in high schools designed to deter teen pregnancy may actually be encouraging it. Graduates of the program with over third more like to have a teen pregnancy.

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

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

August 07, 2016 in women's health, safety, prevention, prenatal care, Pregnancy, medical care, health, family, doctor patient, Consumer Awareness

Florida has an ongoing Zika outbreak in a Miami neighborhood of Wynwood. The CDC (Centers for Disease Control) has confirmed local transmission there for several days. In response, Florida Governor Scott has pledged that Zika tests will be free for all pregnant women. Apparently there is a Zika test kit shortage and physicians' offices have waiting lists for their use. Pregnant residents in Florida are beginning to curtain their activities and travel in their home towns. Other women are delaying pregnancies, freezing eggs for later, or leaving the area when pregnant.

California has the seen the first births of Zika infected babies. These cases have been from mothers who travelled to Zika affected areas.

Texas Medicaid has decided to cover the cost of mosquito repellant to women of reproductive age.

President Obama has asked Congress to reconvene early to work on Zika. Meanwhile the CDC has itself provided an additional $16,000,000 to 40 states to combat Zika. They had already given $25,000,000 in July. This comes out to and additional $400,000 per state on average and does not sound like much in the scheme of things. The money is meant for developing programs to collect and track data on both the mothers and the babies affected by Zika. I have to say that when money is short, as it is, that making the choice to fight the virus with information seems like the wisest first step. When more money comes in, which hopefully it will, it can go to bigger ticket items like better mosquito control and vaccines. Current mosquito control techniques are poor against the mosquito since it can live indoors or outdoors, can hatch in a tiny amount of water, can bite multiple people, and has eggs which can last for months.

The CDC has clarified that all pregnant women need to be assessed for risk of Zika. They do not necessarily need to be tested, but their travel history and the travel history of their partner or partners should be assessed.

The CDC has reviewed data which show that the use of Long Acting Reversible Contraceptives (LARCS) is low in Zika affected States. LARCS are among the most effective means of contraception and considered safe for most all women.

Finally in encouraging Zika news, The Journal Science has reported that three different Zika vaccines have worked “to perfection” in rhesus monkeys. Each of these vaccines works by a different mechanism to stimulate the immune system to combat the virus. One vaccine uses dead virus, but the other two use two different viral DNA subunits to stimulate an effective immune response.

In other news, the CDC has reported that adults across the board are about 15 pounds heavier than they were 20 years ago. Boys and girls weigh more as well, though boys' heights have gone up. Girls' hights have stayed the same. The average 5’4 woman weighs 168.5 pounds, which qualifies as a BMI (Body Mass Index) of 29, nearly going from overweight to obese at a BMI of 30. Normal BMI is somewhere between 19 and 25. See the NIH (National Institute of Health) BMI calculator HERE:

http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Vitamin D is in the news again. Apparently Vitamin D levels decrease by 20 % after cessation of oral contraceptives (OCs). This has potential consequences not only for women but for any pregnancies that ensue. Because of his new finding, it might be appropriate to check Vitamin D levels after OCs are stopped or before pregnancy is considered.

In the close-to-science-fiction department, we turn our attention to telomeres. What is a telomere ? Tasciences.com quotes Blackburn and Epel from the Journal Nature, saying that

“ Telomeres are the end caps at the end of each DNA strand that protect our chromosomes, like the plastic tips at the end of shoelaces. Without the coating, shoelaces become frayed until they can no longer do their job, just as without telomeres, DNA strands become damages, and our cells can’t do their job.”.

Telomere length is therefore a marker of cell aging. Cell lifespan shortens as telomeres shorten. We are born with a certain telomere length. The majority of telomere shortening occurs in the first 4 years of life. Little is known about why telomeres shorten. It turns out that early exclusive breastfeeding for just 4-6 weeks is associated with longer telomere length at age 4-5 years. This may have consequences for long term health and overall longevity. The CDC has reported that just about half of all postpartum women are breastfeeding at 6 months. Less than a third were still breastfeeding at a year. The American Academy of Pediatrics has recommended that women breastfeed for at least 6-12 months.

The Journal Pediatrics reports that “ Breast milk give a boost to premature babies mental and physical development.” Those who received breast milk during the first 28 days of life had measurably better IQ, math, memory and motor skills at age 7 compared to those who received less breast milk. I will comment that to pump breast milk for 28 days while your premature baby is in the NICU (newborn ICU) requires a high level of dedication. Perhaps it is difficult to factor out this maternal dedication as a factor in the better outcomes of the breastfed babies in their study. These breastfeeding mom’s of preemies either are or become some of the most dedicated and resourceful moms out there, due, at least in part, to what they have to deal with. Maybe the better outcomes are born of the mother’s overall dedication. Hat’s off to you…. dedicated NICU moms.

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

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

August 01, 2016 in women's health, sleep, prevention, mind body, Mental health, medical care, health, fitness, doctor patient, Consumer Awareness

About 1.6 million pregnant women are at risk for Zika virus infection in South and Central America. Now, health officials are concerned that local transmission of Zika virus has begun in southern Florida. This means the virus was acquired in Florida, instead of being acquired elsewhere while a person was traveling. This means that some of the mosquitos in Florida carry the virus.

In related news, the blood supply in South Florida is now considered to be potentially contaminated with Zika virus. The FDA ( Food and Drug Administration) has asked that all blood donations from South Florida halt until all donations can be screened for Zika virus.

In even more striking news, the CDC ( Centers for Disease Control) is recommending that all pregnant women be screening for the Zika virus.

As most of you know, Congress left for its seven week vacation without coming to an agreement on Zika funding. The President of the American College of Obstetricians and Gynecologists has written a strongly worded letter to Congress on this matter.

http://www.acog.org/About-ACOG/News-Room/Statements/2016/ACOG-Statement-on-Congress-Failure-to-Take-Action-on-Zika

Proceedings from the National Academy of Sciences include research that indicates that women who enter menopause early age faster than other women. They were able to quantify this, saying that menopause speeds up cellular again about 6 %. They also indicated that poor sleep can trigger similar aging type changes.

In related news, women who start menstruation late and who have menopause late compared to average are more likely to achieve 90 years of age. Information like this is useful in that it helps identify factors tied to longevity.

Research from the Journal Circulation has indicate that only 2.5 hours of moderate exercise per week has measurable effects on heart disease risk in women. Let’s see, taking one day off per week leave six days for exercise. Divide that into 2.5 hours to get the time per day needed for exercise. Only 25 minutes per day needed to reduce cardiac risk !

Stay tuned next week for more breaking news from the world of Ob/Gyn and women’s health.

Wellness Wednesday: Healthy Bowels

July 27, 2016 in women's health, prevention, Pregnancy, Nutrition, Menopause, medical care, health, doctor patient

What affects our health, how we feel, and how we look, but is rarely discussed ? You guessed it: Bowel movements, or lack or them, or problems with them. Today we will give some attention to the humble colon, indeed the whole female pelvis, as we contemplate the well being of this part of the body.

Those of us that operate on the female pelvic organs the uterus tubes and ovaries can tell you that they are in close proximity to the bladder and the colon. In fact, they are sandwiched between the bladder in the front and the colon (large bowel) in the back. Constipation can affect the way the uterus and bladder feel and function, and visa versa.

Definition

A common definition of constipation is bowel movements less than every three days. The American College of Gastroenterology defines constipation more completely, factoring in all sorts of problems with bowel movements, such as straining, small or hard stools, a sense of not being able to empty the bowels, or difficulty passing stool. Bloating, abdominal pain and excessive gas are also related issues.

Risk factors

Risk factors for constipation include being a woman, being pregnant, being older, dehydration, low fiber diet, being sedentary.

Causes

The basic cause of constipation is an unduly slow passage of stool through the bowel such that the stool becomes hard and relatively dry. This slow passage may be caused by a blockage in or near the colon such as a tumor, or a narrowing of the bowel from a stricture or a scarring of an anal fissure.

Since the colon moves stool forward using muscular contractions, poor muscle function can cause constipation. This can be from problems with the nerves that innervate the colon, such as in diseases like MS, stroke, and spinal cord injury. The colon muscles also function poorly if they do not contract and relax normally, or if the surrounding pelvic muscles are weak. Weak pelvic muscles can be caused by injury at childbirth, overweight, poor conditioning, poor posture, or all of the above. Hypothyroidism and diabetes can cause constipation.

Constipation can also be caused by medications, most famously narcotic pain medications and sedatives. Certain high blood pressure, antidepressant antacid and allergy medications can do it as well. Diuretics like caffeine and alcohol can cause constipation.

Poor bowel habits can start a vicious cycle of constipation. Ignoring the urge to go for reasons of convenience or modesty leads to more time for water to be extracted from stool, a harder stool, and a more difficult passage. The urge to go may even go away, compounding the problem.

Poor dietary habits are probably one of the most common causes of constipation. A diet high in saturated fat and sugar can predispose to constipation. A diet low in fruits, vegetables and fiber will surely cause constipation.

Complications

Untreated constipation may damage the area around the anus, either by producing sore dilated veins (hemorrhoids) or by causing small tears (anal fissures). The pressure and straining associated with constipation will worsen the condition of the pelvic muscles. It may do this to such an extent that the bladder may also start to have problems emptying, holding urine in, or both ! Constipation may even predispose a person to frequent urinary tract infections.

Evaluation

Persons suffering from constipation should not suffer in silence. Constipation is one of the most common reasons people go to the doctor. The workup of constipation consists of a history, physical exam, and possibly some imaging procedures.

Treatment

Treatment is determined after the workup is complete. Taking care of serious pathology is critical. But this is less common than lifestyle factors. Dietary and activity changes are front and center in the treatments for most people. Fiber, both soluble and insoluble, are key, along with ample hydration all through the day. Supplements of fiber are widely available if patients just cannot seem to get the right foods into their diet. Finally enemas and medications can be utilized.

Enemas and suppositories can be used for serious cases. Other classes of medications can be useful, but one must be aware of how they work.

Stool softeners like Colace do just that.
Bulking agents like Citracel or Metamucil hold additional water.
Osmotic agents like Milk of Magnesium chemically hold water in the colon.
Stimulant laxatives like senna or bisacodyl stimulate the colon muscles to contract more.

The first two are generally safe for everyone, but the last two should be used with the supervision of a doctor, since there can be medical consequences. Laxatives should be used with great caution, since they can even be addictive like narcotics, with more and more being required to get the desired effect.

Those with pelvic floor dysfunction can be treated with pelvic floor physical therapy. More and more medical communities are incorporating this treatment modality into their centers. This is key since these issue disproportionately affect women. These women have often curtailed their work, social lives, or exercise because of problems with bowel and bladder, and this is a significant loss, especially when treatment is available.

Stay tuned for this week’s Food Friday, when we will explore the dietary remedies for constipation in more detail.

References:

http://www.mayoclinic.org/diseases-conditions/constipation/basics/definition/con-20032773

http://www.emedicinehealth.com/constipation_in_adults/article_em.htm

https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/constipation/Pages/overview.aspx

http://patients.gi.org/topics/constipation-and-defection-problems/

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

July 25, 2016 in doctor patient, Consumer Awareness, health, medical care, Nutrition, Pregnancy, prevention, safety, women's health

The news this week is dominated by virus science.

The first United States baby with Zika related microcephaly has been born in New York City. While this is not surprising, the fact that many women are ignoring Zika related travel warnings is. This summer, over 2000 pregnant women traveled to Zika affected areas and have com back requesting testing. In many cases, they are traveling to the Dominican Republic. AS f the present, cases from the Dominican Republic account for more than a fifth of all US cases. The CDC(Centers fro Disesase Control) and the American Academy of Pediatrics are grappling with how to develop protocols to care for infants who will be born with microcephaly. These infants have serious mental and physical disabilities since the higher portions of the brain are underdeveloped.

Florida is one of the most vulnerable states in the Union to the Zika virus. Authorities estimates over a quarter of a million women are at risk in Florida. Various research indicates that a Medicaid expansion there would help reduce the risk of pregnancy women to Zika. There is also a push to require employers to take measures to limit their pregnant employees exposure to mosquitos.

As of mid July the CDC is tracking around 1300 cases of pregnant women with Zika. Fourteen were sexually transmitted, and the rest acquired through travel.

There is also a Utah case on record this week of a man who acquired Zika through close family contact. He was taking care of an elderly man who had acquired Zika due to travel.

Hepatitis C is on the rise, both in women of reproductive age, and not surprisingly, in their children under 2. There is no vaccine yet for Hepatitis C, but very recently, a very good treatment has been released.

In other viral news, work has been done showing that certain vaginal flora (Prevotella BIVIA) make it easier to transmit HIV. However, a silicone ring imbued with antiviral drug may help reduce the risk of transmission. Pregnant women with HIV have now been shown to do better if their therapy is continued postpartum.

Finally, in some other good news pertaining to viruses, the American Cancer Society has endorse the vaccination of all preteens, boys and girls against HPV (Human papilloma virus.).

Say tuned for more riveting news from the word of Ob/Gyn next week on Medical Monday.

Wellness Wednesday: Sleep Hygiene with Sketches

July 20, 2016 in digital arts, women's health, sleep, safety, productivity, prevention, Parenting, mind body, Mental health, health, medical care, family

It is summer in the far north and the days are long...so long they stretch into the night. Farmers work until 11 pm and dinner is at about 9pm in broad daylight. Then the evening comes, and by 11 pm you feel the evening is just getting started. A movie is chosen and whoops, you are up way too late, especially since the sun comes blazing in shortly after 5:30am.

So I though I would take this opportunity to share with you some sketches I did for my wellness reminder cards that pertained to the importance of good sleep hygiene. Each card will hopefully remind the user of a key principle, with the image on one side, and the reminder on the other.

1. Adequate Restorative Sleep

With few exceptions, adults need 7-8 hours of sleep. You should wake, almost spontaneously, and feel rested. That is the meaning of restorative sleep.

2. Consistent Wake Time

Having a consistent wake time actually helps you fall asleep properly at bedtime.

3. Consistent Sleep Time

Once you get in a routine, you will start to get sleepy at the right time.

4. Correct Sleep Environment

The room should be dark, quiet and cool, without electronics or snoring people.

5. Medical Evaluation of Necessary

Most major hospitals have a Sleep Center or Department of Sleep Medicine. There is now the recognition that sleep health underscores all health. Rigorous studies can be done to assess sleep problems, and treatments are available.

To learn more see our webpage on sleep HERE.

Next week on wellness Wednesday we will continue with more wellness reminders.

Nighty Night !

Wellness Wednesday: Healthy Habit Formation

July 13, 2016 in women's health, sleep, safety, productivity, prevention, Parenting, mind body, Mental health, medical care, health, Consumer Awareness

Healthy habits are the basis of peak wellness. Heathy habits are something we can develop. Whether the healthy habit is taking vitamins, being grateful, exercising, or eating fiber, the practice only works if it is done over and over for extended periods of time. This repetition is achieved through habit formation.

What does science say about how habits are developed ?

The brain is designed to form habits. New behaviors or tasks can be challenging. Over time, the brain “chunks” small possibly difficult behaviors into automatic routines which becomes easy or even effortless. This is a habit. Habits are adaptive and have helped us survive. Habit formation is our brain’s way of automating certain key behaviors, so more conscious attention can be paid to novel situations. If we understand how this works we can form new habits at will.

What do we need to form new habits ?

In simple terms there are three steps:

Cue
Routine
Reward

This is called a habit loop. These are well explained in Charle’s Duhigg’s book "The Power of Habit”. The cue triggers the routine, and the routine triggers anticipation of the reward. For example, my exercise routine is cued by changing into exercise clothes. From there, I go downstairs to workout, and the reward is the endorphins and the satisfaction. There is no doubt that at first, it is hard to link the steps. But it becomes easier with each cycle. To be realistic, it takes somewhere between 6 weeks and 3 months to form a new habit.

What about bad habits ? They too have cues, routines and rewards. Basically, they have to be understood in terms of their rewards, namely, what you get out of it. In many cases, smokers smoke to get a moment of peace in a busy day. This is obviously legitimate. However, the cigarette is unhealthy and chemically addictive in addition to being behaviorally addictive. It turns out we should not exactly delete bad habits since this leaves a void. Instead we are better off to overwrite them with good ones. To illustrate, a smoker could use patches to wean down on the addictive nicotine, while overwriting her smoking habit with a healthful tea drinking habit. Perhaps to make it more engaging, she would brew the tea from loose leaves. Her reward would be the moment of peace, the taste, smell, and mental clarity that followed.

My subject in this post are the cues. In simple terms, they are reminders of health habits. I decided to expand my set of reminder cards to include not only the subject of nutrition, but also the subjects of sleep, exercise, communication, and creativity. I believe these are some of the elements in total peak wellness. Here are my cue phrases so far.

Sleep

The Power of Habit: Why We Do What We Do in Life and Business

$9.18

By Charles Duhigg

Buy on Amazon

Adequate restorative sleep
Consistent wake time
Consistent sleep time
Correct sleep environment
Medical evaluation if necessary

Exercise

Start easy and short
Warm up
Cool down
Value initiation over endurance
Good gear
Eat for exercise
Hydrate for exercise
Tunes for exercise
Podcasts for exercise
Exercise daily
One break day per week
Stretch after exercise
Buddy exercise
Track your exercise
Explore HIT
Include yoga
Mix it up
Use good form
Consult professionals

Creativity

Get inspired through people travel and media
Find your styles
Express creativity in your personal space
Make a space for your creativity
Take time for hobbies
Take time for Travel
Take time for recreational reading
Pick a hobby and learn it well
Share your creative work

Work

Always work
Honor work in and out of the home
Chose meaningful work
Become expert at your work
Give work boundaries in time, space, and thought
Do you best at work
Communicate effectively at work
Reach out often at work
Play as a team
Ask for appropriate compensation

Communication

Breathe and think before speaking
Use Honesty
Use courtesy
I statements
Precision of speech
Closed loop communication
Listen more than speak
Listen actively
Repeat back clarification
Acknowledge others’ point of view
Build common ground

You can find nutrition reminders HERE discussed in a prior post. I plan to devote a few wellness Wednesday’s to the development of these reminders or cues.

For more reading :

http://jamesclear.com/three-steps-habit-change

https://www.psychologytoday.com/basics/habit-formation

https://www.sciencedaily.com/releases/2014/08/140808111931.htm

http://www.scientificamerican.com/article/power-of-habit-excerpt/

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

July 11, 2016 in women's health, safety, prevention, prenatal care, Pregnancy, medical care, health, doctor patient, Consumer Awareness

Women in Latin American are more likely to get Zika than men. We presume they are exposed equally to Zika carrying mosquitos. This difference appears once girls become sexually active. How do you put it together ? Here is what doctors and researchers think. They believe sex may spread Zika more than was previously believed. Furthermore, getting Zika though sex is easier for a woman than for a man. Other sexually transmitted infections follow this pattern and in their case, it is because sex in women causes undetected micro abrasions which allow greater access to the bloodstream.

President Obama has come out and said that Congress should not recess for summer until Zika funding is secured. With this funding, a vaccine will be produced sooner. Some speculate that the issue of Zika calls to mind issues of contraception and abortion, and that is why Congress is unable to deal effectively with it. Zika is bringing reproductive rights into focus. ACOG ( American College of Obstetricians and Gynecologists) representatives have noted that the southern states likely to have the most Zika are the same ones which have high unintended pregnancy rates and poor access to family planning resources. But Texas is taking a different angle anyway. They are trying to scratch up enough funds on its own to provide mosquito repellant to it’s poor women, budgeting 2 bottles per month per women.

In other news, US maternal mortality rates have doubled in the last 25 years. Black women fare the worst, with mortality rates quadruple that of white women.

The president of ACOG has come out stating that we should have a much more critical attitude toward chemicals in the environment which may cause birth defects. Project TENDR has been created from a variety of expert disciplines to advocate for greater government oversight on the chemicals. TENDR stands for Targeting Environmental Neurodevelopmental Risks.

Newborns get about two months of flu protections from a shot given to mom during pregnancy.

Despite the demonstrates efficacy of the HPV vaccine, it is still woefully underutilized. Moreover, HPV related cancers are on the rise. Between 2008 and 2012, they have increased about 17 %. HPV cancers are not just cervical cancer in women. They also include head and neck cancers in both men and women.

Finally, in the good news department, an eight study meta-analysis out of Europe has shown that obese infertile women who have trouble ovulating do better with lifestyle intervention than fertility drugs. Six months of interventions resulting in weight loss were four times more likely to conceive than their counterparts who used fertility drugs alone.