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

Policy News 

The Trump Administration will continue to use a bundled payment model for Medicare recipients. This means that the government will pay a certain lump some to cover all the inpatient and procedure related medical care given to Medicare patient rendered in a 90 day period of time. If the healthcare providers use less than that amount of money they can receive a bonus. This strikes me as a terribly perverse incentive. Hospitals and caregivers have every incentive to skimp on care so they can pocket the bonus. What if the amount of money allocated is not enough for all the care the patient needs within the 90 days? It is interesting to note that this bundled payment strategy was created under Obamacare (The Affordable Care Act or the ACA) and has been reincarnated in almost exactly the same form under the Trump administration.

Several women’s health organizations including the American College of Obstetricians and Gynecologists (ACOG), have instituted a program called"The Care Women Deserve”. Under this program, there will be an effort to educate all women regarding the health services to which, under the ACA which is current law, they are entitled, at little or no cost. Examples of these services include well woman visits, also known as annual exams, Pap smears, contraception, also known as birth control, HIV screening, mammograms and breast-feeding support. Not all women know that they are entitled to all these services.

The Trump administration has long tried to weaken the contraceptive mandate, the part of the Affordable Care Act which requires insurance companies to cover contraception without co-pay. They have received many legal challenges to these attempts. The Trump administration has paid out over 3 million dollars of taxpayer money to to settle these lawsuits.

For the first time in Medicaid's 50 year history certain states will be allowed to interpose work requirements on certain able bodied adult recipients. The National Health Law Center is preparing to challenge this in court.

Washington DC’s only pubic hospital has been closed due to quality concerns. 

The Wall Street Journal is reporting that the GOP is scaling back plans to reform the ACA and social security type programs. They are focusing on basic problems like funding the government. They are even talking about increasing the debt limit and reaching a compromise on immigration. Since when has the GOP been interested in increasing the debt limit ? 

Medical News 

Studies 

• Once again our own immune system is at the heart of a disease process. Evidence from a mice model suggests that the damage caused from Zika virus infection is actually from the mother’s immune response against the virus in the baby. This was published in Science Immunology. 
• A large retrospective study has indicated that pregnant women who take methylphenidate for ADHD have a higher likelihood of having a baby with a heart defect. 
•  A new study published in the Journal Birth looks again at Texas maternal mortality rates. Between 2011 and 2015, there has been an 87% spoke in maternal mortality. The worst has been in mothers over, 40 with that group having a mortality rate 27 times that of women under 40. This is felt to be related to increasing rates on chronic and under treated disease including obesity, lack of insurance and lack of health care. 
• A 172 woman study published in Menopause made the we-already-knew-this-department. They have shown that one year of postmenopausal hormone therapy prevented depressive symptoms more effectively than placebo. Postmenopausal hormone therapy is FDA approved for hot flashes and vaginal dryness, but not for mood disturbance. Maybe it should be. 
• The Journal of Asthma has published a study linking prenatal exposure to PCBs ( polychlorinated biphenyls) to asthma and upper respiratory infections and eczema in children. 
• A new study has indicated that women who work night shifts have a (gasp) 19% higher chance of getting cancer than those who do not work at night. This meta-analysis has shown that the risk is proportional to time worked at night, and that the risks  go up differently for different cancers. The most surprising is skin cancer with a 41% increase in risk. Next is a 32% increase in breast cancer, and an 18% increased risk in digestive cancers. Yikes ! I hope the exact reasons for this get figured out and dealt with ! 

We have a new department ! It is called the stupid and irresponsible department. Our inaugural feature is devoted to the TV show Black Mirror, whose writers decided to depict emergency contraction, aka “ Plan B” or “ the morning after pill” quite incorrectly. In particular, they portrayed a teen who took it as having nausea, which is not typical. A nurse in the show informs her she had taken it “ to terminate a pregnancy”. Basically the show confused the morning after pill with the abortion pill. The morning after pill is progesterone only, thus should not cause nausea. Plan B does not cause abortion of an established pregnancy. It prevents pregnancy. Thanks so much, TV,  thanks. 

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

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

Happy new year ! Hopefully this year we will benefit from the upheaval of 2017. Many of us became more political. The issues about which we care came into distinct focus. Perhaps we clarified our priorities. Hopefully health and quality time are high on your list. 

In that spirit, I am going to try to streamline what I hope has already been a streamlined blogging format, and go to what could perhaps be called “ bullet blogging”. Perhaps you have heard of “ bullet Journalling”  or “dot journalling”? I had been doing it for some time without realizing it. Instead of journaling in full sentences and paragraphs, I journal in bullet lists, small graphics and graphs. It is fun, fast, and lets me indulge my visual nature. 

If you have been into any Michaels, Joannes or any other craft store lately, you may have seen prominent displays showing fancy little bound or three ring journals, sticker sets, small format markers, washi tape, and specialized fill pages - all for such enhanced journaling. There are also many cool online resources for bullet journalling. 

I am an incredibly digital oriented person, and so it may seem a surprise that I would be interested in such analog things. I believe that for every person’s life or work management system, there is a particular optimal balance between digital and analog. Everyone one needs a little paper. In my office, I have suggested that my employees keep “ one notebook to rule them all”. Instead of a proliferation of sticky notes and other scraps to get mangled or lost, the one notebook, complete with dates and legible writing, held everything. I gave them some beautiful starter notebooks, and they took it from there. They seem to enjoy it. One co-worker in particular has made hers into what I would call an art form. That is the idea ! It is to take some joy and satisfaction in even the smallest things, like note taking and scratch calculations at work.

And so it has occurred to me to try “ bullet blogging”. It is my hope it will be faster, simpler and easier on the eyes. I’m going to give it a go. 

Policy News 

Via CMS( Center for Medicaid Services) : 

• 8.7 million signed up for Obamacare, federal health insurance made possible by the Affordable Care Act, likely underestimated 
• 95% of last years level, despite half the signup period and deep cuts to advertising
• Final figures due out in March

CAN YOU BELIEVE THIS ? 

Employees of the CDC ( Centers for Disease Control) and other federally funded health and science organizations were “discouraged" from using seven words in budget reports: 

• Vulnerable

• Entitlement

• Diversity

• Transgender

• Fetus

• Evidence-based

• Science-based

#RESIST 

Two separate letters have been issued from > 300 public health organizations urging the HHS ( Health and Human services) to ignore this. The second letter included signatures from

ACOG ( American College of Obstetricians and Gynecologists)

AAP (American Association of Pediatrics) 

APHA ( American Public Health Association) 

Blocking the blockers 

• Last week  Federal Judge in Northern CA blocked the Trump administration’s loophole which let’s objecting employers out of providing insurance with contraception to employees. 
• The Justice Department is “ evaluating” LOL. 
• Comment: No one ever has, because of Obamacare, made anyone else use contraception. 
• Fact: Contraception reduces teen pregnancy and abortion. ALOT. 

Kick the can

GOP has kicked the real budget and real health care bill into January. Stay tuned. 

Medical News

ACOG President-Elect Lisa Hollier, MD MPH, Houston, Texas, brings a new clear focus: the rising maternal mortality in America. 

• Missouri ranks high is maternal mortality, in the worst ten. 
• Oregon is creating a special commission on rising maternal mortality.
• One in four pregnancies in central Oregon are drug affected. 
• Mississippi has the highest rate of preterm birth, which is high cost in both human and financial terms. The CEO of Magnolia Health in Mississippi is taking aim at this problem. 
• Infant mortality in Kansas is about three times higher for black babies than it is for all babies. 
• Dr. Hollier's own state of Texas takes the cake, with the highest maternal mortality this side of the third world. 

STUDIES: 

Study: Breast pain is not a symptoms of breast cancer. Neither lack of pain nor lack or palpable lumps means lack of breast cancer. Upshot: Get your mammograms ! 

Study: Cervical Pessary may be of use in preventing preterm birth. 

Study: at home STI ( sexually transmitted infection) test kits may increase detection rates. 

Study: Post menopausal Estrogen therapy may protect against some forms of memory loss. 

Study: Income and weight are inversely related for women. This is not true for men. Contemplate. 

FDA (The Food and Drug Administration) plans to increase regulation of homeopathic remedies. Because there are no real studies on these. Contemplate. 

Marijuana update 

• Mj use in pregnancy has increased in CA from 4 to 7%. In pregnant teens it has increased from 10 to 19%. 
• ACOG recommends discontinuation of MJ for those who are or who are contemplating pregnancy. For reasons, see HERE: Marijuana Use During Pregnancy and Lactation 
• It's clear that we as a nation do not value science. Do we value drug induced relaxation over clear thinking or the cognitive development of our children ? Very little contemplation needed. 

Male Contraceptives ? 

NIH ( National Institute of Health) and the Population Council are sponsoring a clinical trial of a hormonal male contraceptive gel. Don’t expect it on the shelves for at least 5 years. I wonder how the GOP will attempt to regulate male methods of contraception. 

It’s best if you follow up on these leads to put together your view of women’s health care in this country. What I have given you should contain enough key words so you can google your way to the source material. Remember to seek out reputable sources like the NIH, the CDC, ACOG, AAP, APHA, or major academic medical centers like Mayo Clinic or Stanford.

2018 is a new year, and a new approach is needed to ensure the best for women’s health care. Get involved. 

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

How stable are the ACA Affordable Care Act, aka Obamacare)  insurance plans? That remains to be seen. At present there is a bipartisan effort to shore up the so called ACA “marketplaces” . This means that certain lawmakers are trying to find a way to create a realistic budget to fund them. The Affordable Care Act was affordable since the Federal government supplied money to insurance companies to subsidize or pay for part of people’s premiums. 

Let’s roll back a second. Let’s make sure all this terminology is clear. 

Bipartisan= involving both Democrats and Republicans 

Marketplace = the system of insurance companies from which consumers buy health insurance 

Premium= the monthly amount consumers have to pay the insurance company to have insurance and to ensure that their insurance is in force 

Subsidies, aka insurance subsidies = payments from the Fed ( your tax dollars) to the insurance companies to defray (reduce) what consumers pay for their premiums. 

Republican concerns at the beginning of the administration change:

1. Obamacare cost the Fed too much and made taxes too high (via the payment of subsidies to insurance companies) 
2. Obamacare funded programs that powerful special interest groups opposed, i.e. birth control (via the Contraceptive Mandate) 
3. Obamacare took away the choice of not having to get health insurance at all. ( Via the Individual Mandate) In other words, Obamacare law via the Individual Mandate required everyone to hold health insurance. 

Democrat concerns at the beginning of the administration change:

1. Obamacare was not adequately funded and could run out of money if not addressed.
2. Obamacare needed to continue to fund birth control as a human right and for the social and fiscal improvements it confers, ie. increased education, job productivity, individual savings, better health, fewer teen and unplanned pregnancies, fewer abortions. 
3. Obamacare needed to continue to fund preventive care and cancer screening since in the long run it prevents serious disease and saves money 
4. Obamacare need to continue to retain the Individual Mandate since

• Each person is obligated to contribute to the insurance fund to make it stronger for everyone. The American Academy of Actuaries has gone on record saying that repeal of the Individual Mandate “... would lead to premium increases” and reduce the "incentive for healthy people to enroll and balance out the costs of the sick.”
• Each person is responsible for covering their own care even if their health takes a downward and expensive turn, and they can only realistically cover it with insurance.
• Persons who do not hold insurance and who end up getting emergency or unanticipated health care get care whether they can pay for it or not, and their bill is absorbed by everyone else. They are cheating the system. 
• The ethic of the greater good should inform the Individual Mandate since health coverage enables health care and health care enables broad social benefits of all kinds. 

The deadline to enroll for Obamacare this year has passed. The site for enrollment, healthcare.gov, was getting crushed right through until the end, and at one point, customers were instructed to simply leave contact information with the expectation of a call back. Many did not know the time frame for enrollment since the Trump administration cut funds for promotion of the program by 50%. Numbers on enrollment are not yet in. 

There is bad news and good news for CHIP, the children’s health insurance program. The bad new is that it will run out of money by the end of January. The good news is that there seems to be broad bipartisan support for refunding it. A bipartisan group of Governors has also come forwards and requested that the government renew finding for CHIP. The question is, what with all that lawmakers have left undone, and still need to do, will they get to it in time ? Remember, the Federal Government only has a budget through December 22nd, which is fast approaching. 

In medical news, we find a convergence of holistic medicine and technology. A new study published in the American Journal of Obstetrics and Gynecology uses app-guided acupressure to relieve menstrual cramps. The results compared this technique with medical therapy of oral contraceptive pills or typical analgesics and the results were significant. 

Sugar and inflammation. I do not know the exact relationship. Let’s talk about excessive sugar. In particular, a new study reveals that pregnant women who consume excess sugar in pregnancy are statistically more likely to bear babies who have asthma later in life. Asthma is an condition of the airways and is believed to be mediated by inflammation. Excess sugar in pregnancy is associated with many more problems, like excess weight gain, and gestational diabetes. 

It is well know that pregnant poorly controlled diabetics have increase risks of serious malformations including spina bifida and congenital heart defects.  In new research, pregnant women with high glucose levels in early pregnancy - even those who are not diabetic, are more likely to have babies with heart defects. The relationship is linear. 

Got your flu virus yet ? I hope so. There are TWICE as many cases of flu this year compared to last. Bottom line: the flu shot is safe and effective in and out of pregnancy. Talk to your doctor. It is particularly risky to skip it in pregnancy since influenza is much more dangerous in pregnant women. 

There is some expected fall out after last weeks publication about a small increase in breast cancer risk with long use of oral birth control pills. Authorities are hastening to point out that while this finding about breast cancer risk was noted, it has also been confirmed that oral birth control pills decrease the risk of uterus, ovary and colon cancer, stabilize bone density and obviously, prevent pregnancy and all of its potential complications. Risks need to be weighed with benefits. 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology on the next episode of Medical Monday. I will have to decide what to do for Christmas week, most likely depending on the news at hand. Let's hope the researchers take a nice break for the holidays. The politicians, well, they can just keep working right on through as far as I am concerned. 

Happy Holidays. 

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

The big policy news this week is that we still have a government. Yes, Congress passed a stopgap measure to avert a government shutdown, but that will not even get us to Christmas. At issue is spending. By now you know that the budget of the nation is greatly influenced by the tax structure and also on major expenditures like health care.  Major expenditures that must be resolved to attain a budget including the funding of ACA subsidies and thus stabilization of the ACA insurance market places. There is also a lot of pressure for CHIP or the children’s health program to be refunded. People across the board are NOT happy about that program being in jeopardy. Now if we can just show people that the health of women and the health of children are deeply intertwined, we will be even better off. 

Did you know that health care spending is not first nor even second on the list of big Federal expenditures? It is third. I am lifting a great infographic from pewresearch.org and giving you the link to encourage you to read the whole article.

http://www.pewresearch.org/fact-tank/2017/04/04/what-does-the-federal-government-spend-your-tax-dollars-on-social-insurance-programs-mostly/

Now that you know the proportions, how about some actual dollar amounts ? 

Health care spending reached it’s new max in the end of 2016 at $3.3 trillion dollars. It increased in 2016, but not as much as it increased the prior year in 2015. The share of the economy devoted to health care went up to 17.9% representing a gradual increase. This grew slightly faster than GDP ( gross domestic product). Expenditure on heath insurance grew to about $2500 per year, while OOP ( out of pockets) grew to about $350 bucks per person per year. 

Is this amount of spending good or bad ? Is it appropriate to spend this percent of income on health? My health means a great deal to me. If you compare countries with health care that is equal to or better than ours, you will find they spend much less personally but generally pay considerably more in taxes. Their taxes are larger,  but the distribution of good health care in their countries is wider. Their higher taxes buys them less income and health disparity as a a country, broader prosperity and better social stability. Do you think that is worth it ? 

You may have noticed from the infographic that number one and two on the list of federal expenditures are Social security at 24% and Medicare at 15%. Do you feel like health care has taken all the budget scrutiny heat ? These other programs may now be in jeopardy too. After the immediate legislative sessions, the GOP is looking at cutting other parts of the social security “ safety net” which old folks have been paying into all this while… Social Security and Medicare. How do you feel about that ? 

The States not the Fed are taking charge of key practical health care issues that need prompt attention. Instead of engaging in the philosophic, sociological or religious debates characteristic of Capitol Hill, they are taking care of business. For example, North Carolina has addressed its high risk pregnancy situation and has created a statewide initiative to identify and give special care to high risk pregnancies. They are doing this through multidisciplinary “ medical homes” where advanced Obstetrical care can be rendered. The District of Columbia has voted unanimously to mandate that insurers offer contraception, breast cancer screening, STI counseling, without raising copays or deductibles. As previously reported, other states such as Massachusetts have protected contraception. 

In medical news, we have a great new data gathering resource, Pregsource. The NIH (National Institute of Health) has partnered with ACOG ( American College of Obstetricians and Gynecologists) to gather a wide variety of data from pregnant women. Research on pregnant women is hard to design and fund, since there are concerns about the fetus. But we need usable information on pregnant women just as much as on other people, and so there needs to be an acceptable way to move forward. The idea of including pregnant women in drug studies is rapidly becoming a hot topic, since to date they have mostly been excluded. But this is often without medical reason, and both caregivers and patients are starting to raise the alarm. 

Here is Pregsource: 

https://pregsource.nih.gov

If you are pregnant, there is no reason not to join. Tell your caregiver so they can make their other patients aware. This is a fantastic example of citizen science in action. It is also a relatively low cost way to assemble a much needed research base of data on pregnant women. 

In the mostly good news department, Sanofi has devoted what appears to be an effective Zika virus vaccine, It has shown good immunogenicity, and a 90% response. However it has been tabled due to “political pressure over pricing”. I think this is promising since it shows that such vaccines are possible. Apparently there are other similar vaccines in the works. I can’t help but connect the dots between the high drug prices we pay and the amazing things that drug companies are able to do with that money. 

Ob/Gyns are becoming a dying breed. I can certainly understand why, what with coverage challenges, political upheaval and malpractice threats. Apparently a new study has shown that 50% of US counties lack an Obstetrician Gynecologist. Just so you know, high risk cases in either Gyn or OB can scarcely be handled by any other types of doctors, except for perhaps general surgeons, and they are generally overburdened to begin with. The number of Ob/Gyns is due to diminish further with a shortage of nearly 8000 by 2020 two years from now. 

A new study on oral contraceptive pills is apt to be misconstrued by the media. It is a large Danish study which has shown a slight increased risk of breast cancer with oral contraceptive pill use of at least a year. They hastened to add the the overall all risk was low, and that it was considered safe. However a twenty percent increased risk on top of a very small number is still a very small number. This is the thing I think the press will miss. I hope the press does not fail to point out the very real DECREASE in risk of ovary, uterus and colon cancer that happens at the same time with oral contraceptive pills. And oh, by the way these prevent pregnancy the vast majority of the time, and pregnancy carries its own risks which are not inconsiderable. 

In sobering news, research out of the CDC (Centers for Disease Control) has shown that black women in dies in childbirth 3-4 times as often as white women. This circumstance of childbirth highlights the worst case of health related racial disparity that we in the US know. We in the US are on a Perinatal Mortality par with Mexico and Uzbekistan.

 If you ask me, now is not the time to be gutting the budget for women’s health. 

Stay tuned for more breaking news from the World of Obstetrics and Gynecology. 

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

Greetings on this Cyber Monday. I am happy to report that we had a great Thanksgiving Break and that I did not even go into town for Black Friday, the official start of the Christmas season. I may however, patronize Cyber Monday. Accordingly, politics has taken a bit of a back seat to commerce and the holiday, and I rather like it. Nonetheless there are a few things to report. 

Massachusetts is bringing good cheer as Governor Charlie Baker, Republican (!) signs a law protecting free birth control without copay. The Baker administration has declared that women of Massachusetts right to contraception will be protected regardless of what goes on in Washington. All the while, the Trump administration is trying any way it can to demand the contraceptive protections set in place through the Affordable Care Act (ACA). 

Contraception again made the news in that a group of states Attorney's General are filing suit against the Federal government over their weakening of the contraceptive mandate for corporations which hold religious or moral objections to it. I still think it is ridiculous to confer beliefs to corporations. 

Meanwhile enrollment in the ACA is up for this stage compared to last year, despite the enrollment time being cut in half. 

The funding of the proposed Trump tax cuts is really no mystery. They are to be funded by repealing the individual mandate, the insurance subsidies and the contraceptive mandate,  saving the federal government money that would have been spent on health care. The Fed can then garner support from those people who need deductions, i.e. those who have taxable income. The greater the income, the greater the benefit. So yes, the tax plan is a case of robbing Peter to pay Paul where Peter is health care and Paul is people with substantial income. Again, I have have emphasized this so much: Investment into health care pays itself of many times over, in both human and economic terms. The trump Administrations simply does not seem to know or care about this. They are interested in keeping their campaign promise of cutting taxes. However there is no free lunch, and those that elected him should have realized the money for the tax cut would have to come from somewhere. Perhaps Trump supporters value the short term gain of lower taxes more than they value the long term gain brought by comprehensive, universal and affordable health care. 

Math: The Trump administration quietly cut $200 million from Teen Pregnancy Prevention Programs only to greatly promote a $10 million dollar program of their own that they have recently unveiled. Their philosophy: abstinence only. 

On the medical news. In the Fun and Clever Obstetrics category, there is a new study reporting on work by a Canadian charity to foster early prenatal care in African women. Bridge to Health Medical and Dental is bringing early Ultrasound to women of Africa, but more importantly they are bringing women to Ultrasound. How ? By advertising that “ you will see your baby”. They have shown that women are 9 times more likely to show up for early US if they hear this message. 

More Zika data is filtering in. We know that Zika virus infection in pregnancy is associated with a high rate of fetal malformations. However, we now know it is also associated with a very high rate of miscarriage compared to controls. Among those who survive and are assessed at one year, 94 % appear grossly normal. 

In the news that may impact you department, we have the revision in the definition of normal blood pressure. Formerly normal Bp was defined as anything less than 140/90. Now it is anything less than 130/80. What’s your blood pressure ? The best thing to do to answer this question is to get a BP cuff for home, ideally one that is smartphone connected. Take lots of readings under different circumstances, and see where you really live. Share your data with your doctor. 

We used to recommend having a normal period or two before reattempting pregnancy after a miscarriage. However newer data suggests this may not be necessary. 

New data suggests that Advanced Maternal Age patients 35 or older should be induced by 40 weeks. In the past we waited until 41-42 weeks, but this has proven to be associated with increased rate of complications. 

Kratom. This is the newest herbal supplement to a.) become popular b.) cause serious health problems and even 36 deaths. It is Southeast Asian plant used to treat pain anxiety and depression. It produces euphoria. People in opioid withdrawal use it on the street to treat their symptoms. It is clearly dangerous and the word is not yet out. 

In an interesting twist of research fate, a new study has identified risk associated with the discontinuation of hormone therapy. In particular, women under 60 who discontinue hormone treatment had a higher risk for cardiac death and stroke during the first year of discontinuation. The same was not true in those after 60. Clearly more research is needed to understand the reasons behind this. 

Periodically, research comes out noting the association of lower rates of C sections and episiotomies in those who see midwives. Every time I look at this type of research I find it to be disingenuous to some degree. This means, it does not account for the factor of self selection to midwife care or provider veto of midwife care. I am the principal Obstetric backup for our local midwife practice. We work very closely with one another to see that midwife patients are low risk, and that those who become high risk transfer appropriately to a higher level of care. Additionally, Should point out the patients are generally insightful and understand when low risk care is appropriate, and risk themselves out of midwife care when they feel they are likely to have complications. See how all this would skew these studies ? 

We know that obesity has many adverse health effects. Here is a new one: Breast cancers in obese women are larger at the time of diagnosis. They are harder to feel, and harder to image as a result of obesity. Another reason to attain a healthy weight. 

We have a great entry for the we-already-knew -this-deparment. Americans are not eating enough fruit and vegetables ! Only 12% of Americans ate the recommended amount of fruit while only 9 % at the recommended amount of vegetables. Compliance with recommendations tracked with income but even the highest bracket did a poor job. 

Finally, also in the we-already-knew -this-deparment, 71 % of American women would prefer an annual mammogram rather than every two years. Many groups, including ACOG and the American Cancer Society had to publicly disagree with the US Preventive Services Task Force over a controversial interpretation of data in 2009 saying annual mammograms conferred to benefit. Confusion still reigns in the media. In 2016 the USPTF still reaffirmed hat the harms of screening outweigh benefits. Benefits are early detection of cancer, but that is not addressed by their data. Harms they define include pain of mammograms, fear of mammograms, and indicated breast biopsies whose results return benign. I’d say this last one in particular is actually a blessing. 

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

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

The big policy news is the ACA (Affordable Care Act). It is still in force. Furthermore, As of November 1st, it is enrollment time again, the fifth so far. Apparently 76% of Americans did not know that enrollment started last Wednesday. This is year is different, with uncertainty and confusion abounding. The public needs to be aware that the ACA is still in force, and that those eligible should enroll. A recent poll indicates that 18% of Americans do not think the ACA is still in force. They must be aware they may not see much about it in the media, since the Trump administration slashed funds for advertising by 90%. Moreover, they should be aware that the time for enrollment has been was cut in half, to 6 weeks, with no service for 12 hours on Sundays. The bottom line is that many consumers MISTAKENLY BELIEVE they will not get insurance the next year. 

Those that do sign up will find premiums have risen by 37 % on average. This is because of fears, loss of subsidies, and fewer insurers who are participating. All would do well to realize, though, that while there were 167 insurers in 2017 participating, there are still 132 this year. While the Trump administration has cited rising premiums as evidence that the ACA has failed, 80% of consumers can get a plan for less than $75 per month after tax credits. 

The States have generally recognized the long term and short term value of the ACA. Accordingly Governors, as a rule, have objected to its weakening. There are, however 12 States, who have taken matters in to their own hands, and run their own marketplaces. These plans will advertise normally, and have appropriate infrastructure to help consumers enroll. They realize that more enrollees makes a more stable market, and one that will run at the least possible cost. 

Preeclampsia has made the medical news this week. A new study has focused on the all too common disease process which pregnant women and their babies. An official at the CDC (Centers for Disease Control) has called it the most common severe problem for women in pregnancy. It leads to morbidity for both mother and baby. It has a price tag of over 2 billion dollars annually. And yet it’s exact cause remains unknown. We do know that it is more common in the very young and the very old who are pregnant, as well as the obese, the hypertensive, and those with certain autoimmune disorders. We do not that daily aspirin can help prevent recurrence, but that many patients are not receiving this simple, safe and inexpensive therapy. More research is needed. 

Contraception is again in the news. Columnist Bryce Covert has rightly summarized a large body of scientific literature in his opinion piece about the relationship between the availability of contraception and the strength of the economy. He points out that the Trump administration’s curtailment of access to contraception is likely to be associated with a gradual slowing of the economy. If women are able to easily chose the size of their family, they are more likely to chose a size they can afford. If they can put off childbearing until they are finished with education, their educational and professional attainments will be higher before bearing children, should they chose to do so. The pool of workers will be larger, and it will be more skilled. Families will be more solvent and have bigger savings. All these things contribute to the strength of the economy in very real terms. 

More good news for breastfeeding. Breastfeeding has numerous benefits to mother and baby. For mother, it helps slow post partum bleeding. It helps loss of pregnancy weight gain. It fosters bonding. It is convenient and hygienic. For babies, it enhances dental health, immunity, and growth of the newborn brain. It fosters bonding. New research also indicates that just two months of breastfeeding lowers the risk of SIDS, sudden infant death syndrome. The American Academy of Pediatrics recommends a minimum of one year of breastfeeding. 

Preterm birth rates are creeping up in the US, disproportionately affecting minority women. Complicating matters, is that the one proven preventive, 17- hydroxy progesterone, brand name Makena, is expensive, and is greatly underutilized nationwide, especially in underserved area. And here, I’d like to speak to insurance companies: Think Makena is expensive ? Try comparing that with a long stay in the Newborn ICU ! 

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

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

In policy news, President Trump has publicly declared the Opioid Crisis a “Public Health Emergency”. In concrete terms, this means that Medicaid money can be used to combat the problem. Trump also explained it also meant there would be money spent in an effort to develop non-addictive painkillers. Thirdly he indicated that there would be an advertising campaign to address the problem. 

The idea about non-addictive pain killers is interesting to me. I do not view the opioid crisis as an issue of pain control. I view it as an issue of coping with life. Opioid use may start with need for pain control, but then abuse and addiction develop later from different factors. The FDA( Food and Drug Administration) Commissioner Scott Gottlieb as recommended MAT, or Medication assisted therapy, which combines medication treatment of addiction with counseling. 

An undocumented 17 year old at 16 weeks of gestation has succeeded in her appeal to obtain an abortion. Since September, this undocumented immigrant has been detained in a federally funded shelter and has been requesting an abortion. Her case has highlighted the fact that the Trump administration has quietly changed policy on the matter, and now denies abortions to minors in custody. The particular memo is in an email from E. Scott Lloyd, director of HHS (Health and Human Services) Office of Refugee Resettlement. It states “…government funded shelters… should not be supporting abortion services pre or post release; only pregnancy services and life affirming options counseling. “ The position of the Justice Department on the matter was that it did not dispute the Constitutional Right to abortion. However, it asserted that it was not obligated to facilitate abortion by releasing her from federal custody. In order to obtain an abortion, she could either leave the country or find a custodial sponsor. Some accused HHS "anti-abortion zealots" of “holding her hostage” to prevent her from obtaining an abortion. E. Scott Lloyd was an avowed and zealous anti-abortion activist before he was appointed by the Trump administration to the Department of Health and Human Services. 

The lawsuit against the Trump administration over the plan to end insurance subsidies was denied by a US District Judge Vince Chhabria. At issue was whether the cessation of subsidies would cause immediate harm to consumer. Somewhat ironically, the Judge argued that since many States had, on an emergency basis, anticipated and provided for shortfalls, that no immediate harm would come to pass. This decision, of course, simply sanctions the transfer of insurance expenses from the Fed to the States, who are variably able to afford them. The Judge also wrote that it was a “close case” and that it was in an “early stage”. 

In medical news, it is once again confirmed that the teen birth rate and the US abortion rate fell during the years of the ACA (Affordable Care Act). The US teen birth rate has fallen to its lowest rate since the 1940s. The abortion rate fell the fastest among American teens. Evidence points to contraceptive availability as the cause of the decreases. 

At the same time, use of fertility treatments has doubled in the past decade. Twelve percent of reproductive aged women use these services. 

Yet another case has been added to a list of cases of babies who have developed a life threatening infection after water birth. While ACOG ( American College of Obstetricians and Gynecologists) supports water labor, it does not support water birth where there is  potential for babies to inhale not only water, but particulate matter such as non-sterile blood clot and fecal material, not to speak of whatever else in is the pool. Readers should remember that human lungs are not made to accommodate water, even sterile water or saline. Amniotic fluid may look like water, but its chemical composition and properties are far different. 

In the troubling and should-be-easy-to-fix department, we consider US Maternal Morbidity and Mortality. The CDC (Centers for Disease Control) identifies maternal deaths through death certificates. Death certificates are very short documents and do not allow for elaboration. This limited source of information does not allow us to calculate the true rates of maternal mortality or late complications, much less to determine which deaths were preventable. Being simple and brief, these forms foster a gross under-reporting. Surely a more informative digital cloud based solution could be devised. 

Texas continues to struggles with a crisis in maternal morbidity and mortality. In particular, African American women are dying or pregnancy and birth related complications at an alarming rate. These women account for 11.8% of Texas births, but 29% percent of Texas pregnancy and birth related deaths.  Experts believe potential causes relate to obesity, poverty, diabetes, delayed prenatal care, higher C section rates which result form these other factors, drugs, hypertension and related cardiovascular problems. 

In major scientific news, result of the OncoArray Consortium have been published. This is a global project wherein 550 researchers shared genetic data from 300 institutions and 275,000 women, 146,000 of whom have had breast cancer. The work, published in Nature and Nature Genetics, has identified many more previously unknown genetic mutations associated with breast cancer. We have long suspected and counseled patients that BRCA1 and BRCA 2 are probably not the only cancer mutations. Now we have specific confirmation on this. While these results may initially seem daunting, they are the kind of data that can lead to better “precision" methods of diagnosis, prevention and treatment in the not so distant future. 

Reader should take note of the multilaterally of this OncoArray Project. The non-academic person understands that research studies take money, time and test subjects. They also understand that more money, subjects and time mean higher quality results. One might ask then why has it taken this long for researchers the world round to combine resources to get truly powerful results ? Indeed perverse incentives have, until recently, been in place to silo, hoard or hide data, one researcher from the next, or one institution to the next, in a climate of competition for research dollars and accolades. Even at present, the open date movement is not mainstream among researchers, nor is the idea of sharing medical record information including genetic information popular among patients. There are costs to sharing data, but the benefits may well prove to be greater. 

Did you know that there are various sizes and types of IUDs ? There is most likely one that is suitable for everyone, including teens, women who have not had children, and women near menopause. Many misconceptions about IUDS arise among patients and caregivers. For example, we used to believe that IUDs prevent implantation of a fertilized egg. However, ACOG now recognizes that IUDs prevent fertilization. Many who oppose a method which fosters non-implantation of the fertilized egg will be comfortable using this method knowing its mechanism of action. 

“Vaginal seeding” is the deliberate transfer of a mother’s vaginal flora to the infant’s nose mouth or skin. This procedure is under research investigation and should not be attempted at home. Women who undergo C section may have an interest in this as their newborns have not been exposed to vaginal flora like an infant born vaginally would have been. There are very real risks to vaginal seeding, because, as with many things, the devil is in the details. It turns out that vaginally born and cesarean born babies microbiota are slightly different, but that they equalize after about 6 months. It also turns out that breastfeeding provides the best and safest transfer of flora.

Stay tuned next week for more fascinating news from the world of Obstetrics an Gynecology.   

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

Now here is something we haven't seen in a long time. Four days ago on Thursday Congress practiced bipartisanship. With the news the abrupt cessation of insurance subsidy payments by the federal government, those all over the healthcare sector were scrambling. Lawmakers had to cooperate against Trump’s decision or risk chaos. Senators Lamar Alexander, Republican from Tennessee and Patty Murray, a Democrat from Washington state have announced that they have a viable bill. This bill to reinstate subsidy payments has 12 sponsors divided evenly between Republicans and Democrats. These Congressmen are promoting a bill to resume federal subsidies to insurers that Trump has blocked. The Senate Majority Leader Chuck Schumer has confirmed that all 48 Senators would vote for the bill. They number 48 which, when combined with 12 sponsoring Senators who are already known to support the bill, would give 60 votes at least, enough to defeat a filibuster.

Good thing lawmakers have decided to try to cobble together a solution to this problem. It turns out that several powerful states have banded together to sue the Trump administration over the decision to end ACA subsidy payments. Lead by the attorneys general of both California and New York the states include California, Connecticut, Delaware, Kentucky, Illinois, Iowa, Maryland, Massachusetts, Minnesota, New Mexico, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia and Washington state. Additionally, the healthcare industry and the insurance industry have roundly condemned the interruption of subsidy payments, stating that this move will cost US economic and health harm.

 A group of medical associations, the so-called"Group of six”, the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, the American Congress of Obstetricians and Gynecologists, the American Osteopathic Association, and the American Psychiatric Association, has made a joint statement “ Our organizations strongly reject a marketplace that allows insurers to discriminate against any individual based on their health status age or gender allowing insurers to sell narrow, low cost health plans likely will cause significant economic harm to women and older sicker Americans who stand to face higher cost and fewer insurance options."

Concerns have already been raised that restoring subsidies paid from the federal government to insurance companies would benefit it insurers more than consumers. The authors of the bipartisan bill, Alexander and Laurie, and explicitly addressed concerns that"Restoring the payments to insurers could be viewed as… a bailout”. They indicated that the agreement would contain"The strongest possible language" to insure that the money provided for the subsidies would go to the benefit of consumers, not insurers. It is unclear at this time whether or not this bill, once enacted, would prevent some or all of the large rate hike that all of us can expect in our premiums this next year.

The fine details of women's reproductive health care are very much on the table in this political climate. As you are no doubt aware Trump has weakened the Affordable Care Act’s contraceptive mandate. Last week he created a loophole which will allow employers to stop providing birth control coverage in their corporate insurance plans if they have religious objections. This week the bill has been introduced to reverse this exception. The bill is called"Protect Access to Birth Control Act”. Unfortunately it does not yet have the bipartisan support that it needs. 

A Denver school teacher, Jessica Campbell, has filed a federal lawsuit against the Trump administration for it's modification of the contraceptive mandate in the Affordable Care Act. The suit names the President and his Secretaries of Health and Human Services, Labor and the Treasury.The suit states that the exceptions “jeopardize women's health and economic success in order to promote certain religious and moral views by attempting to nullify the right equal access to preventive medical care, particularly contraceptive care and services, protected by the US Constitution set forth by Congress in the Women's Health Amendment to the affordable care act.” The suit seeks to prohibit enforcement enforcement of the changes. 

The Omaha World Herald, has surveyed several large Nebraska and Iowa employers. They presented their informal findings in a recent article which explains that according to their survey, most Nebraska and Iowa employers will continue to offer insurance plans with contraceptive coverage.

IUDs (Intrauterine devices)are one of the best and one of the most expensive contraceptive methods. This is because they're extremely effective with very low failure and complication rates. It is also because they are able to be used by women who cannot tolerate hormones. Although the most popular IUDs contain hormones they contain only enough to treat the lining of the uterus and they do not produce systemic effects outside of the uterus. The their side effect rate is low. Some experts worry that because this method is particularly costly i.e. somewhere upwards of $1000, Women may lose effective access to it. 

Dr. Haywood Brown, President of the American Congress of Obstetricians and Gynecologists has written an opinion piece indicating that he is opposed to the Trump administration’s ”…regulation that will threaten contraceptive access for women everywhere, particularly in underserved rural communities”. He argued that access to contraception” amounts to more than just dollars and cents. It can be life saving for women who already faced serious medical conditions such as heart disease, diabetes and high blood pressure."

Access to all forms of reproductive health care have been compromised in various ways under the Trump administration. An important methodology utilized by the Trump administration has been the political appointment of many antiabortion and anti-contraception activists to government positions despite lack of qualifications. It is ironic and disturbing that the restrictions placed on contraception, a benign medical treatment, will lead to a certain increased rate of abortion.

On to the medical news. 

In the good news department, vaginal estrogen is safe for all postmenopausal women. This includes women who have had a hysterectomy, women who still have an intact uterus, women with history of cancer, those with cardiovascular disease, only those with thromboembolic history such as a deep vein thrombosis for a pulmonary embolism. The results of this study presented recently at the annual meeting of the North American Menopause Society also fall under the category of the we-already-knew-this department. This is because we have always known that estrogens given vaginally do not get into the systemic circulation, this research finding is worth reiterating because indicates that no post menopausal woman need suffer with a painful atrophic vagina.

Also in postmenopausal news, and in the we-already-new-this department, a new study confirms that oral estradiol and progesterone may improve menopause related quality of life. While this type of therapy reduces hot flashes and mood instability related to menopause, but it's use is constrained particularly in those who still have a uterus. This is because the administration of the combination of both estrogen and progesterone may only be given for about five years or the shortest amount of time at the lowest effective dose. After five years or so concerns begins to mount for increasing risk of breast cancer and cardiovascular disease.

There is an increasing number of women in South Carolina who are giving birth without any prenatal care whatsoever. It has been long established that lack of prenatal care is a contributor to for birth outcomes.

Tanning addiction is real, and it increases risk of skin cancer. A new study published online any October 11 edition of Cancer, Epidemiology, Biomarkers and Prevention, Young white women with a history of depression were found become prone to tanning addiction. Indeed, over 20% of young white women who have frequented at tanning salon do become addicted to tanning. The study noted that these young women "depend on tending to feel attractive often show symptoms of depression.”

Oral HPV and the disease that it produces are increasing. HPV stands for human papilloma virus and it is the virus responsible for general warts, cervical cancer and cancer of the mouth and throat. Girls and boys between the ages of 926 should be completely vaccinated against the virus. The vaccine remains underutilized and many do not realize it must be given to males as well as females. I'm going data on the vaccine continue to confirm its safety.

At the present 7% of women with breast cancer are younger than 40 years of age. It Is noteworthy that this percent has been increasing since the mid-1990s. With all the debate about mammogram testing frequency and age at first mammogram, I wonder how we can be expected to screen for these cases among young women. At present, the debate is between whether to start mammograms at age 40 or age 50. With increasing cases in women under 40 this provides a good argument for the breast self exam and also to tailor mammogram screening to risk factors.

In related news, the percentage of women who opt for breast reconstruction surgery right after mastectomy for cancer is increasing rapidly. Over the past five years the proportion of breast cancer patients opting for reconstruction grew by about two thirds. In 2009 only about a quarter of women opted for reconstruction whereas more recently in 2014 and 14 the number rose to 40%.

Obstetric history stays important long after your last baby is born. Preeclampsia may indicate a tendency towards high blood pressure later in life. Similarly, pregnancy associated or gestational diabetes can signal a risk for diabetes and even heart disease later in life. Recent study published online in JAMA internal medicine has shown that patients with a history of gestational diabetes can mitigate their risk for cardiovascular disease by healthy lifestyle. In particular, gestational diabetes was not significantly associated with cardiovascular disease risk elevation among women he maintained a healthy diet, were physically active, never smoked, and maintained normal weight. 

A rather fascinating new bit of research indicates that lack of sleep could raise a pregnant woman's risk for gestational diabetes. In particular, women he slept less than 6.25 hours and I were almost 3 times likely this study tells us nothing about which where the causes and which were the effects. Still it is an interesting relationship and one which deserves more scrutiny perhaps even outside of pregnancy.

The CDC(Centers for Disease Control) has released a new data indicating that obesity rates among US adults is steadily increasing with the current rate of about 40%. This is not near overweight where the body mass index is between 25 and 30. This is obesity, with body mass indices in excess of 30. Approximately 30% of people where obis in the year 2000 15+ years later that is increased by 10% to 40% of all people. Of course there's significant state-by-state variation but the numbers are formidable across the board. For every state where the percentage is lower than that there is a state whose percentage is higher. Obesity sits with mental health and addiction as the three topmost priorities the Department of Health Services.

These days, when a patient asks to have her tubes tied, we may suggest that she have her tubes altogether removed. This is because of the relatively new Revelation that many if not most of all ovarian cancers actually come from the tubes. Thus we can get some theoretical and hopefully real cancer reduction by removing the temps instead of merely tying them for cutting them. This interesting conclusion about the origins of "ovarian" cancer have come from the nascent field of molecular genomics.

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

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

Policy News this week is monumental. President Trump signed an “ executive order” which allows small businesses and individuals to buy cheaper less comprehensive policies which do not met the minimum ACA (Affordable Care Act) requirements. Critics have several issues with this legislation. First, it decreases money in the collective pot used to cover anyone with a catastrophic illness for which a large payout is required. Second, it will drive prices up disproportionately, hurting mostly older Americans. 

Perhaps more impactful is the Administration’s decision to stop making federal subsidy payments to insurers. It is effective immediately. The President has further said that it may continue subsidy payments if a bipartisan agreement is made on health care. This last bit may illuminate the whole issue. When I first heard this announcement about cutting of subsidies, I ascribed it to wholesale lunacy. However now I view it more as blackmail. Without subsidies, the insurers will either bail or fail. Then the economy will follow, according to many analysts. No administration wants this. A bipartisan agreement has been impossible to craft, thus far. However, opposition to this move, and even opposition to the President himself may cause a high degree of motivation to compromise. Leading Republicans have called for continuing payments to insurers. As you read this on Monday, I wager you will be hearing fierce objection from both sides of the aisle. 

Hot off the press is an announcement that the current Administration will allow health insurance sales across State lines. Many of us did not realize that health insurance is sold within a given state. Insurers and their plans must be approved within that State and must answer to that State's Insurance Commissioner. Trump and many other Republicans have endorsed this before. They have asserted that, through increased competition,  premium prices will drop across the board. However, the National Association of Insurance Commissioners has called this a "myth". They have warned that this will start a " race to the bottom" wherein Insurance Companies will choose more lenient State regulators. Such regulators would require less and less coverage to consumers in order to maximize profits. This would result in healthier people getting cheap policies that cover little, and everyone else needing standard coverage getting steep rate hikes to compensate for the insurance company's loss in revenue. 

Unbeknown to most of us, the insurance industry was the Wild West before the ACA came along. Most of us only knew about insurance in their own State. But, it turns out there were different levels of what was covered, different caps on out of pocket, and different limits to premium prices. That all got more standardized with the ACA. That standardization is now being deconstructed bit by bit by changes like this plan of selling across State lines. 

The Department of Health and Human Services has put forth a couple of deeply controversial issuances. They have issued new rules on contraception. Without data or authority they have stated that “ Imposing a coverage mandate on objecting entities whose plans cover many enrollee families who may share objections to contraception, among some populations, affect risky sexual behavior in a negative way.” Importantly, this sentence uses confusing syntax. The subject of the sentence is “ a coverage mandate”. The verb phrase is “would…affect” the object is “risky sexual behaviors”. Thus the gist of the sentence it, a coverage mandate would affect risky sexual behaviors. Perhaps they meant to say the following: contraception WHICH could, among some populations, affect risky sexual behavior in a negative way. I suggest this because they have taken this position before: that contraception promotes sexual activity, particularly teen sex activity. A mass of available up to date and well derived data indicate otherwise.  For example, no-cost contraception is associated with a decrease in the number of partners. Additionally, contraception is NOT associated in a rise in sexually transmitted infections. Available research data clearly show too that rates of abortion and pregnancy fell among teens, when no-cost birth control was provided. ACOG (American College and Obstetricians and Gynecologists) has voiced it’s objections to the weakening of the contraceptive mandate. They have shed light on the patently false claims of the Administration about contraception. Many States have sued the Administration over the weakening of the contraceptive mandate. 

The second controversial issuance by the Department of HHS, Health and Human Services, has been to define life as “beginning at conception”. It has done so through a strategic plan document. This draft reads “HHS accomplishes its mission through programs and initiative that cover a wide spectrum of activities serving and protecting Americans at every stage of life, beginning at conception.”. Defining life at conception is not arguable in scientific terms. That is because it is a belief. In fact, it is a religious belief. As such, one might ask whether including this language in the strategic plan document of the HHS violates the separation of church and state. Clearly this language was advanced by those whose religious beliefs preclude abortion. 

I do not believe there has ever been a time in history when government has been so intimately involved in matters pertaining to Obstetrics and Gynecology. 

Pap smear frequency is again becoming controversial. As usual, the minimalist and government funded USPTF ( US Preventive Services Task Force) has interpreted the available data to mean the need for less frequent screening. They seem to consistently overemphasize the harms of screening (extra false positives, extra office biopsies) and consistently underweight the harms, i.e. more cancer cases. ACOG, various other cancer organizations, and patient advocacy organizations, give less weight to extra false positives and biopsies, with more concern focus on catching cancer early. ACOG still states that paps and HPV testing should go together from 30 to at least 65 years of age, and that for an average risk patient. Smokers, for example, would be screened, even more often. 

In the we-already-knew-this department, a new study shows that epidurals do NOT prolong second stage (the pushing part) of labor. The study, published in Obstetrics and Gynecology, also show no adverse effects of epidural on mother or fetus. 

Also in the we-already-knew-this department, a new study shows that women who have their fibroids embolized may need additional procedures. In particular, they have a fair chance of still needing a hysterectomy later. These women who go from embolization to subsequent hysterectomy were still better off in terms of complications than those getting myomectomies (removal of the fibroids from the uterus) to begin with. 

Finally for a trifecta in we-already-knew-this department, we feature a new study which indicates that “intensive exercise may attenuate excessive gestational weight gain for obese pregnancy women”. Excessive weight gain in pregnancy increases the odds of gestational diabetes, large for gestational age babies, and need for C sections. Research elsewhere also indicates that exercise in pregnancy also produces many other good effects, such as increased likelihood of vaginal delivery. 

Somewhere between politics and medicine we find people and society, and society has a lot to do with health. This week those in the entertainment industry have been reeling from all the revelations of sexual abuse and misogynistic workplace bullying by Harvey Weinstein. It has been sickening and yet illuminating to read the accounts of the women involved. The victims were abused in various ways. Those that escaped unscathed, had career setbacks by failing to acquiesce. They all suffered the shame and anger associated with such encounters, and even now are having to answer for why they did not disclose sooner, why they acquiesced, why they did not have more sense to begin with, etc. etc. 

see: 

http://www.vulture.com/2017/10/the-harvey-weinstein-sexual-harassment-assault-accusations.html

It is widely believed that Harvey Weinstein is not the only such perpetrator in Hollywood. It is also well known that Hollywood is not the only industry where this occurs. Although Weinstein's victims were generally celebrities, most victims are not. Yet even these celebrity women were caught off guard and were made to feel powerless and vulnerable. How much more so must the average woman feel, working a standard paying job on which they depend. 

Harvey Weinstein’s methods were outrageous. The vaster number of abuses in the workplace today are far more subtle. They are microaggressions. They are just enough to make you uncomfortable, but not enough make you realize it is abuse, much less move forward to report it. All of this adds up over time, and it takes a toll professionally and personally, and on stress levels, which eventually impacts health. I had one patient who developed certain medical problems. In taking care of her and getting to know her better, it turned out she had an extremely hostile workplace environment. We encouraged her to speak to people at the local department of labor. After a lot of effort and gumption on her part, the case went to the courts, where she prevailed. She emerged empowered and eventually healthy. But it had been years that she had suffered before she understood what she had actually been dealing with and where it fit on the spectrum of normal social interactions. 

Sometimes we do not realize that what we live with may not be normative. Our standard for what is acceptable behavior may be skewed due to a rough upbringing, or a innate tendency to think that we ourselves are the problem. If you think you may be living or working in some kind of an abusive environment, reach out to a trusted physician, attorney, local social services agency, community health center or mental health professional. Life is too short to let your quality of life or health suffer. 

Stay tuned for more news from the work of Obstetrics and Gynecology her, next week, on Medical Monday. 

Please remember to contact your elected officials to tell them what you think about all of this. 

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

The Graham-Cassidy Bill leads the policy news this week. This is the GOP's last ditch attempt to repeal the ACA (Affordable Care Act). It has been simplified down to one key point : redistributing Federal funds for Medicaid expansion and insurance subsidies as State block grants. The bill was introduced by two GOP Senators, Lindsey Graham of South Carolina, and Bill Cassidy of Louisiana, and with support from others. 

During the week that the Graham Cassidy bill has been around, it has been scrutinized. The Kaiser Foundation has determined that the redistribution of funds in those plan would be quite unequal between States. Consider that different States expanded Medicaid more than others, and some did not expand it at all. What States would stand to have taken away would therefore vary. Overall Federal spending on health care would drop by more than 100 billion dollars between 2020-2026 under this plan. Many physician groups have also criticized the plan. Most notably, ACOG (the American College of Obstetricians and Gynecologists). Eleven Governors including some from the GOP have come out against the bill as well. 

It is unclear if there will be enough votes to pass this bill. More than 50 are needed. Toward the end of the week Senator John McCain has stated he will not support it, and that alone may doom it. Remember that Senator McCain was recently diagnosed with brain cancer this last year, and is therefore deeply involved in the health care world. 

The deadline to pass this bill is September 30th. But it will only be brought to the floor if it is determined beforehand that it will pass. This deadline is needed in part because insurance companies and insurance commissioners need to settle on rates which the commissioners will approve and that will keep the insurers solvent. 

The Iowa legislature voted to forego Federal Funding just so they could deny funding to Planned Parenthood. Now the Iowa Department of Health and Human Services is beginning a collection of data about the effects that this is having. They are trying to determine if defunding Planned Parenthood has reduced access to reproductive health services for Iowans. Seems bass ackward to me. 

In a interesting and positive turn, State Senator Ray Ward, a Republican out of Bountiful, Utah  has proposed a bill that would allow Utah Medicaid recipients to have a postpartum IUD placed while they are still at the hospital. This would bring the red state in line with all but 6 other states which lack this law. 

On to the medical news. 

How bad is the opioid crisis ? It is so bad that death from opioid overdoses is skewing our life expectancy gains statistics. 

Women and opioids are a special case. It turns out opioid addiction and sexual violence are closely linked. In these cases, police are seldom called due to the presence of the drugs and fear or retaliation. 

Speaking of drugs, ACOG has come out with a new Committee Opinion. In this latest document, they have stated clearly that pregnant and breastfeeding women should not use marijuana. 

In the this-makes-perfect-sense department, a new study out of Harvard has shown that adequate sleep and adequate support protect against postpartum depression. That said, even those with high levels of support can get postpartum depression. For example, Ivanka Trump has recently shared her story of postpartum depression. 

An insulin pump may give better control to pregnant diabetics than conventional prick and inject methods.We currently use insulin pumps in non-pregnant diabetics, but have not until now, seen evidence about their use in pregnancy. 

There was a recent Apple event with new product announcements. In it, mention was made of the Apple watch, and the app called Health Kit, and their potential for ultimately helping patients like diabetics. Fast forward only a few days later when I attended Stanford MedX conference. We heard from a young diabetic woman who solved her own problem. Using small cheap components and a little home built computer set up called raspberry pi, she combined a blood glucose sensor with some dosing software and an insulin pump to create her own “ artificial pancreas”. We heard her presentation as an example of what an empowered patient could do. Empowerment plays a huge role in healing. 

The opposite of empowerment is psychological trauma, with resultant PTSD. It turns out that this sort of thing significantly increases one’s risk of being diagnosed with lupus. Lupus is a serious autoimmune disorder characterized by inflammation of the joints and many other tissues. According to a study published in the Journal Arthritis and Rheumatology, trauma even without PTSD are than doubles the risk of getting the disease. Those with PTSD are three times more likely than their peers to get lupus. Nearly 55,000 women’s questionnaires were examined over a 24 year period. This news reinforces the already widespread advice that stress management is important. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

On to the medical news. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Medical Monday: Delayed Edition

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

On to medical news.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ACOG: The BCRA Cannot Be Fixed

July 13, 2017

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

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

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

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

That’s a comprehensive view of health policy news. 

On to the Medicine. 

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

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

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

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

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

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

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

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

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

https://www.congress.gov

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

On to the medical news. 

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

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

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

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

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

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

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