prevention

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

The health care policy package proposed by the new administration must pass through several committees before actually passing to the House and the Senate. One of these is the Budget Committee. This last week House Republicans brought the American Health Care Act (ACHA)  through this committee by vote of nineteen to seventeen. However three GOP lawmakers voted against it, showing a house divided. Centrist Republicans who approved the bill did so providing the tax credit system change to better benefit the working poor. Nonetheless it is the working poor and older workers who will experience a disproportionate rise in premiums. This is because of the substitution of tax credits for subsidies. Those who have low wages have low taxes and tax credits mean little to nothing to them. As previously reported, tax credits help those with substantial tax burdens, i.e., those with higher incomes.  

Analysts believe premiums will likely rise for a number of reasons. Principally the lack of the individual mandate will keep a lot of money from entering the pool, and this needs to made up somewhere. The premiums from 24 million consumers are likely to come out of the pool,as 24 million are likely to lose insurance with the repeal of the ACA.  This alone is believed to account for what is expected to be a 15-20 % hike in premiums. Those of us who obtain health insurance coverage will make up that staggering shortfall. Moreover, when the uninsured hit the hospital, we will also pay for them in rising medical costs, since the care providers will be left holding the bag. 

Despite all this Health and Human Services Secretary Tom Price still says that the ACHA is “ intended to make health insurance feasible for every single American.” He and others in the new administration insists no one will lose coverage with with transition from the ACA to the AHCA. 

The Department of Health and Human Services budget will be cut by 15 billion, 18 percent. And yet, there will be sizable block grants for the opioid crisis and a “ Federal Emergency Response Fund.” The President’s new budget will cut funding to the NIH by 5.8 billion dollars. 

President Trump wants to give the States ability to alter their own Medicaid. On the table are copays, work requirements an premiums. 

Readers will recall from last week that Representative John Shimkus cited a “War on Men” and decried the mandate that men must purchase insurance which covers prenatal care. He does not believe that men should have to contribute to a general insurance pool if it includes funds for the prenatal care of women who also purchase that insurance. He is the same man who has sponsored anti- abortion bills out of his concern for the well being of fetuses. Connect the dots much ? 

That place where the federal government buck always stops is the Congressional Budget Office or CBO. According to the CBO, defunding Planned Parenthood would increase the number of Medicaid births, decrease overall Medicaid spending, but increase unplanned pregnancies. As unplanned pregnancy rates rise, so do abortions. 

And now for the highlights in medical news. 

Gardisil, the vaccine against Human Papilloma virus, is effective. It turns out that two doses are affected as the currently recommended three, good news for everyone including those kids who failed to get their third dose. 

When I was in training there were no limitations on length of our shifts. We routinely worked 36 hours at a stretch, and in my big training center, most of the time, we have no sleep at all. Shortly after I finished residency in 1994, an 80 hour per week working standard was set. Additionally the limitation of 18 hours per shift was instituted. However now concerns about continuity of care have caused the number to swing back to 24 hour shifts. However, The 80 hour week per limit for residents at all levels remains in place.

Preterm birth remains a serious problem in this country. We've developed various methods to try to predict its likelihood including cervical length ultrasound and fetal fibronectin testing. It does have some utility, together with the clinical judgment. However, it turns out that, according to a recently published study in the Journal of the American Medical Association, they have limited utility in first-time mothers.

Over 400,000 physicians from various disciplines compose the Medical Society Consortium on Climate and Health. Associations who participate include the American College of Physicians, the American Academy of Allergy, Asthma, and Immunology, the American Academy of Family Physicians and American College of Obstetricians and Gynecologists. The group has identified eight threats whose increase is related to climate change which will doubtless have serious effects on human health. They are, extreme heat, extreme weather, air pollution, ticks and mosquitoes, contaminated water, contaminated food, mental-health, and nutrition.

On that sobering note, I would encourage you to get more active in political, social and environmental activities which concern you. Your elected officials are truly easy to reach by phone or email. 

 

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

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

In the most important news of the week, the ACA replacement plan was unveiled this last Monday, March 6th. It’s official name is “The American Health Care Act”. 

The bullet points: 

  • Federal insurance subsidies are replaced by individual tax credits and state grants. 
  • The individual mandate to have insurance will be scrapped, and replaced by a 30% surcharge the next time you try to purchase insurance. 
  • The Medicaid expansion would end. 
  • Protection of those with preexisting conditions will stay.
  • The ban on lifetime coverage caps will stay.
  • The ability to insure children until age 26 will stay. 

Initial reactions were negative to tepid, even among Republicans.  Analysts have noted that the tax credits will range between $2000 and $4000 based on age, rather than income. Tax credits will, of course only materialize for those who pay taxes, and the full credit will be utilized only if the patient pays enough tax to use it. Assuming even that the whole credit is received, it is still not as much as current subsidies. In many cases it will not cover deductibles. In short, the ACA replacement plan lowers prices for the more well off and increases prices for the poor. 

The bill was strongly criticized by very conservative lawmakers based on budgetary concerns. Conservatives and moderates also voiced concerns regarding widespread loss of coverage that will occur. Assuming there are no Democrats who approve the bill, there can be no more than 22 Republicans who disapprove of it for it to fail. 

By the end of the week, two key House Committees, Ways and Means, and Energy and Commerce did approve the bill. Nonetheless, many Republicans are against it as is every doctor group, every health care group, and every consumer rights group. 

Trump is reaching across the aisle on the issue of prescription drugs. He, together with most Democrats, favor allowing Medicaid to negotiate with drug companies on prices. Republicans have long opposed this. Hopefully it will save costs but not detract from research. 

Many continue to worry about the loss of contraceptive benefits by one means or another. One nonprofit called “Child Trends” has come out with an estimate that keeping contraceptive access for all women would SAVE $12 billion yearly. They also estimate this strategy would be accompanied by drops in unintended pregnancies, unintended births and abortions by 63-67%. 

In #alternativemedicalfacts news, many authorities are decrying the Indiana law requiring that the “abortion reversal procedure “ be discussed with patients. Medical authorities including ACOG (American College of Obstetricians and Gynecologists) have been very vocal about the fact that the procedure simply does not work, does not exist, and is not real. Utah has passed a similar bill. 

In Pennsylvania, one bill is seeking to ban the abortion pill. This pill is used to effect very early abortions without surgery. However, it is also used to stop hemorrhages after deliveries or miscarriages. Difficulty getting this medication would be an unmitigated disaster. We use it every day on our Labor and Delivery unit and it literally saves lives there and the world over. 

Kentucky has passed a bill defunding Planned Parenthood even though Kentucky Planned Parenthood does not provide abortion. 

Maryland has devised a bill to fund Planned Parenthood on their own, should it otherwise be defunded. 

Nevada democrats are testing the judicial waters by introducing a bill which would require insurers in the state to cover contraception regardless of religious objections. Of course this would be in opposition to the Supreme Court decision prompted by Hobby Lobby which states that businesses “with religious objections”. supplying insurance do not have to cover contraception. Go to Michaels or Joannes instead but stop by Michaels to tell them what you think. #canabusinesshaveareligion ? 

New Mexico has installed state law requiring that all insurers cover contraception at no out of pocket costs. They have gone a step further and added Vasectomy to the list of covered services. 

The US Preventive Services Task Force (USPSTF) has again questioned the utility of the annual pelvic exam. This has happened  before. As before, ACOG has maintained its validity as a screening tool. I personally find all kinds on things on routine screening pelvic exams on asympmotmatic patients. Perhaps the devil is in the details. Perhaps the utility or sensitivity of the exam depends on the examiner. A general surgeon friend of mine one told me with a wry look, “the pelvic exam is not sensitive in my hands”, meaning he really does not know what he is feeling, even though he is an excellent general surgeon. Perhaps if the USPSTF compared the utility of the pelvic exam for ob/gyns to the pelvic exam for other caregivers, they would see a difference. 

Beyond that, I want to know why the routine pelvic exam is being so rigorously studied. Is it costing the taxpayer a disproportionate amount of money ? Is it harmful ? Is it generating false positive results ? Is there a problem ? Aren’t there more pressing problems in health care that deserve our attention ? Why are women’s health care procedures always first on the chopping block ? #waronwomenshealth

We have a new department in Medical Mondays. You’ll love it. It is called “Outrage of the Week”. Let’s hope we do not have one every week, but something tells me we will. You will not believe this, and I mean you all on both sides of the aisle will not believe this. Republican Representative John Shimkus of Illinois has questioned why men should have to pay for insurance covering prenatal care. The Washington Post has reported that, among critics of the ACA, this is not the first time this question has been posed. #waronwomenandchildrenshealth

In the human nature department we report the following: The percent of overweight and obese patients has increased from 53 to 66 % in the last 3 years. However, the percent trying to lose weight has decreased from 59 to 49 %. These patients are invariably very expensive, medically speaking.  Should insurance prices account for weight or other health habits ? Should insurance give breaks for those who do not have issues or those who show documented effort to resolve their issues ? 

In medical good news department, we report on easy cancer prevention. In a two decade study of 60,000 women, published in the International Journal of Cancer, the Mediterranean diet has been found to be of benefit. In particular, it is estimated that about a THIRD of estrogen receptor negative cases of breast cancer would never happen if women were to adhere to this particular diet. 

On that tasty note, we will conclude, and hope that you will have the stomach for next week’s Medical Monday. 

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

Republican efforts to repeal of the ACA (Affordable Care ACT) continues to worry many. In particular, the new administration is starting to hear from cancer patients and cancer survivors. These are people who will forever have a preexisting condition. They have been assured with promises to protect people with problems in any forthcoming health legislation. And, yet, no proposal has yet been put forth to sustain the viability of the insurance companies providing the health care. 

Tackling the ACA has, understandably proven to be more difficult than Republicans estimated. Leaders in the House and the Senate have been meeting with patients, hospitals and insurers. With all these legitimate concerns being brought to the table, divisions are developing among Republicans despite the fact that both the House and the Senate are dominated by Republicans. No one said it would be easy. 

Republican led States are petitioning to reduce Medicaid costs by increasing coverage restrictions. These could take the form new small premiums, work requirements for the non-disabled, and time limitations on coverage. This could lead to different Medicaid benefits in different States. Governance of States' Medicaid programs may come under increasing control of individual States, rather than the Federal government. 

Republicans seek to increase utilization of Health Saving’s Accounts (HSAs). HSA’s are basically registered accounts in which people may place money, tax-free, to spend on health care, usually their out of pocket portion of their insurance. The idea behind this is that when people are spending “ their own money rather than the insurance companies’  money” they will be more careful with it. If a person who has low income and therefore a low tax rate has a high deductible, as many do, for example $5000 to pay their deductible out of an HSA is still $5000. However, if a person in a high tax bracket socks away the amount of his deductible in an HSA and is not taxed on it, they make save as much as 35% of that money as saved taxes. As far as I can see, HSA’s will only help people in high tax brackets. 

Popular support of the ACA increased since the inauguration from 41 to 45%. 

The contraceptive mandate, part of the ACA, requires the birth control be covered with no copay. However, it is believed that the new Secretary of Health and Human Services, Tom Price, will try to repeal it since he did not support it to begin with. Again, it is my opinion, and the opinion of many, that the contraceptive mandate is a money saver, and a abortion preventive. There is solid evidence to both effects. Some was cited in last week's blog post. 

A Federal Judge in Austin Texas has blocked the withdrawal of funds from Planned Parenthood in Texas. He stayed that that State did not provide evidence of any violation warranting such termination. This will protect care for about 11,000 of the State's poor who currently get their Medicaid funded care through Planned Parenthood. 

President Trump has vowed to enforce a “global gag rule” whereby family planning funds from the US will be withdrawn from any international organization who so much as speaks about abortion, let alone performs it. By doing so, $600 million will be withdrawn from these organizations providing broad family planning and health services to women. As a response, the Netherlands has started a fund to replace the shortfall, and has been joined by Norway, Sweden, Denmark, Belgium, Luxembourg, Finland, Canada, and Cape Verde. 

Last week the Indiana House Public Policy Committee passed a law which will require abortion providers to discuss a procedure which does not exist, namely “abortion reversal”.  I have no idea what they can even say about such a thing since it simply does not exist. ACOG (American College of Obstetrics and Gynecology) spoke truth to power about this, but it did no good. 

This week other lawmakers in Arizona are considering a bill to require lifesaving treatment for babies miscarried or aborted at 20 weeks of age which show some signs of life. Babies at this gestational age can briefly have gasping, or a slow heart rate for a very short period of time, but it does not indicate any potential for surviving. This law would require that these babies receive advanced life support measures, similar to an adult with a cardiac arrest. Again, another impossibility. When will lawmakers acknowledge that scientific reality should have a role in laws ? 

Many lawmakers across both sides of the aisle have taken exception to the new president’s anti-vaccine philosophy. They are beginning to speak out in support of their State’s respective vaccine policies. 

Policy news seems to have overshadowed medical news this week. However, there is something from the “ we-already-knew-this” department. New research published in the American Geriatrics Society indicated that, in older women, central body fat is associated with shortened life, more so that being fat overall. They also discovered that being underweight shortens life as well. 

Finally, ACOG has recommended that all pregnant women be offered genetic screening and carrier screening. Formerly, we based carrier screening on ethnicity. However, now it is believed that a large number of Americans are of mixed or unknown ethnicity, and so carrier screening for specific disease causing genes is indicated for all. 

 

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

 

Medical Monday: Breaking News from the World of OB/GYN

Contraception: Get yours while it's hot ! 

Contraception: Get yours while it's hot ! 

GOP leaders again met to discuss repeal of the ACA (Affordable Care Act). The same measures were discussed this week as last: health savings accounts, tax credits, and state high risk pools for the chronically sick. A bill is anticipated next week. 

A measure passed in the House which enables States to pull funding from any facilities who perform abortions. This funding is not specific to paying for abortions. It pulls funding from the facility altogether for all the care it provides, whether it is flu testing, mammograms, or pap smears. This will directly defund Planned Parenthood. In the short term, i.e. one year, it will save money, but in the long term, researchers estimate it will cost much more than current expenditures because of diseases untreated, disease caught later, and and of course, due to unplanned pregnancies and the costs they incur. 

Indiana is voting on a so called “ abortion reversal” procedure which has no basis whatsoever in scientific fact. The American College of Obstetricians and Gynecologists have weighed in, saying that it has “ not been scientifically proven to work”. There is no reason to believe that it would. 

Many states are working on measures to reduce abortion at a time when abortion rates are at a modern low. Today's rate is the lowest since Roe versus Wade was made law in 1973. According to the a broad base of research data from around the world, restrictive abortion laws do not prevent abortion. They simply prevent legal abortion, and lead to illegal abortion and it's consequences. Moreover, research has shown that access to contraception DOES prevent abortion. However, distressingly, these same states who are moving to pass restrictive abortion laws are also moving to restrict access to contraception. Teens have the highest rates of unintended pregnancies. Teens are also the most likely subgroup with unintended pregnancies to get abortions. Data from the Contraceptive Choice Project have shown that when teens have access to the free birth control of their choice, abortion rates plummet. In this study of 9000 subjects, the abortion rate went from 41.5 abortions per 1000 teens to 9.7 per 1000. 

In the fake out department, The current administration is introducing rules to help keep insurers in the ACA (Affordable Care Act) . This is ostensibly being done to stabilize the market. This sounds good, right ? However, it is being done in such as way as to make criteria for inclusion in the ACA stricter. Additionally the enrollment period will be reduced from 3 months to 45 days. Tightening the criteria and shortening the enrollment will shift costs onto patients and off insurers. 

The ACA will lose its teeth. Why ? The Trump administration no longer plans to withhold tax refunds from those who ignore the requirement to have health insurance. Instead these uninsured people can show up on the doorsteps of hospitals everywhere with God only knows what needs, get them promptly and properly taken care of.  As uninsured people, they then either pay their medical bills regular price out of pocket (fat chance, especially with something costly like heart disease, diabetes, cancer, trauma or worse) or leave hospitals, caregivers, and ultimately taxpayers and those of us that pay for insurance in the lurch. Meanwhile data has come in for 2016 that the uninsured rates dropped to record lows in 2016, to 8.8% to be particular. This is felt to be due to the ACA. 

In medical news, two new studies show that scalp cooling cuts chemo related hair loss in half. This study was done on women with early stage breast cancer. Hopefully it will reduce some of the insult that comes with this all too common injury of breast cancer. 

There is a widespread shortage of ObGyns in rural America, with only 6% of us working in the rural setting. People decry this and classify this as an “ access to care” issue. However, it makes sense that Ob/Gyns do not want to work in isolation, far from hospital and community resources. Truthfully, birth should take place within a community, however small, which has access to surgical services and support people of various kinds. I believe people who live remote even from these small scale services should plan according and make arrangements to “stay in town” when they have complications or get near term. I have many such patients who have rudimentary services near their homes on the plains or in the woods, but prefer to come an hour and a half  "to town” for their care. They are clear about valuing the beauty of their countryside or wilderness homes, but also clear about realizing that a modern medical facility just cannot be there. I appreciate their insight on the situation. 

In the good news department, our extreme preemies are surviving not only longer, but better, that they have in previous years. Specifically, they are doing measurably better in their neurodevelopment parameters. Kudos to our friends in Neonatology and the newborn ICUs around the US. Kudos too to all the ObGyns working to treat moms at risk for preterm delivery, and to those researchers who developed antenatal steroids. 

Also in the good news departments, LARCS (Long acting reversible contraceptive such as IUDs) are proving acceptable for the vast majority of users. No surprise there on these elegant and effective methods. 

And finally, in the we-already-knew-this department, exercise is proving effective at improving hot flashes and QOL (quality of life) in postmenopausal women ! 

 

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

 

Medical Monday: Breaking News from the World OB/GYN

Policy news is once again front and center this week. For starters the Senate approved the controversial nomination of Representative Tom Price to be Secretary of Health and Human Services. The legislator is an outspoken proponent of repealing the Affordable Care Act (ACA). He has suggested replacing it with tax credits, health savings accounts, and high risk pools for sick costly consumers. 

Meanwhile more than 12.2 million people have enrolled in the ACA despite its uncertain fate. At the same time, insurers are warning that insecurity in the sector by itself could drive up premiums in the near future. 

The current CEO of the American College of Obstetricians and Gynecologists (ACOG) Hal Lawrence III has stated that there have been clear benefits to women's healthcare contained in the ACA. Accordingly, ACOG  is combating GOP efforts to completely repeal the ACA, urging lawmakers to confirm preserve a provision which prevents insurers from charging women higher premiums than men. Key physician groups including ACOG who provide care to women and children went to Washington last week to lobby for retention or expansion of features of the ACA which provide benefits for women and children. They along with increasing numbers of GOP lawmakers are advocating a repair not repeal approach. Nonetheless, House Speaker Paul Ryan has insisted that repeal and replace will be passed this year though acknowledges it may take several years for it to be implemented. Speaker Ryan has given the GOP semantic permission to repair the ACA by stating that repeal and repair  “essentially amounted to the same thing.” 

The federal government has been looking at Medicaid block grants as a way to save money. This means each state would receive a grant of a fixed amount of money and it would be up to them to allocate it as per their state specific needs. Those favoring this approach cite the amount of money that would be saved. Those against this approach, divided, not surprisingly bye party lines, argue that it would result in slashed benefits and increased costs to states.

On medical news, obesity is back in the spotlight. Obesity is epidemic, and it is costly. It also happens to affect fertility. New research from the National Institute of Child Health and Human Development found that among couples where the woman is obese the time taken to become pregnant is longer. When both members of the couple are obese, i.ewith the body mass index of 35 or higher, it takes 60% longer to become pregnant.

Polycystic ovarian syndrome or PCOS is a cluster of signs and symptoms that relate both to fertility, menstrual functioning, carbohydrate metabolism, and cardiovascular health. It is often accompanied by high body fat percentages, if not obesity. New research indicates that disordered eating behaviors are four times greater among those with this syndrome compared with controls. Is already well-known that when PCOS patients lose weight, their menstrual functioning infertility improves.

Obesity is a risk factor for many forms of cancer. New research published in the Journal of Clinical Oncology has indicated the converse. Intentional weight loss may reduce postmenopausal women's risk of uterine cancer.

Is strange and concerning report, it has been discovered that large amounts of maternal licorice consumption during pregnancy may be associated with lower IQ, ADHD like behavior and early puberty in children. This was reported in February 3 online edition of the American Journal of Epidemiology. The study was a community based cohort study of 1049 people in Helsinki Finland. The compound in licorice thought to be the culprit is glycyrrhizin. This substance apparently blocks an enzyme we have which shields the developing baby from maternal steroid fluctuations. More research is necessary. 

It has also been shown that the prevalence of certain types of bacteria in the cervix may affect a woman's risk of preterm birth. Bacteria which we have considered normal, such as Lactobacillus, are protective against preterm birth, while other bacteria, specifically several anaerobic bacteria greatly increase the risk. These findings were presented at the Society of Maternal Fetal Medicine’s annual meeting.

There are new recommendations for HPV vaccine. Children less than 15 would obtain it need only get two doses. Older children still need the three shot regimen. TapHOPV vaccine protects against cervical cancer and genital warts and may be given between the ages of 9 and 26.  

Stay tune for more exciting news from the World of Obstetrics and Gynecology, next week, on medical Monday.

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

We start this Monday with the piece of grossly under reported news. few seem to be aware of the fact that prenatal cannabis use is linked with cognitive impairment academic under achievement in children. Both the American Academy Pediatrics and the American College of Obstetricians and Gynecologists advise against its use because best. Many patients assume that because it is legal it is safe. Marijuana’s main psychoactive ingredient THC or tetrahydrocannabinol crosses the placenta to reach the fetus. It not only affects brain development and cognition but also birth weight as well. Have you seen anything about this lately? 

Planned home birth is again in the news. A new study shows that planned home birth  is associated with increased risk of complications, especially in women who are having their first baby or in those 41 weeks or more. This particular study looks at the rate of neonatal death, the most severe complication.  Researchers found that those who delivered with midwives at home had a neonatal death rate of 24.4 per 10,000 birth compared to 5.09 per 10,000 births delivering with a midwife in the hospital. 

300,000 babies are born in United States every month. Typically 273,000 women take time off of work to care for newborn whereas 22,000 men do the same. A recent study in the American Journal of Public Health as shown that maternity and paternity leave rates in the United States have been constant over the last 20 years. This may be related to the fact that only 12% of workers in the private sector have access to pay family leave. This lags far behind other developed nations of similar socioeconomic status.

Recent work from the Pew Research Center revealed the new president's views on vaccines are not shared with the majority of Americans who overwhelmingly support requiring children to be vaccinated before attending school. 82% of Americans support children receiving the MMR vaccine before attending school. 

Representatives from numerous physicians organizations have descended upon the halls of the Senate offices to lobby their respective representatives about the need to retain certain characteristics of the Affordable Care Act (ACA). These organizations include the American Academy of Pediatrics, the American Academy of Family Physicians, The American College of Obstetricians and Gynecologists, and the American College of Physicians, and the American Osteopathic Association. They have placed particular focus on the provisions for the care of women and children as these provide the foundation for lifelong medical care and wellness. They have placed particular emphasis on the need to have a replacement in place before the current plan is repealed. The same groups, representing over half a million United States physicians, sent a letter to the White House and Congressional leaders leaders asking them to ensure that women's health, including preventive prenatal and neonatal care, be protected. 

A subcommittee within the House is beginning to work on replacing the ACA. They are looking at the issue of preexisting conditions, and at age ratings which determine the charges paid for insurance by age. They're also considering a shorter grace period for those who fail to pay premiums on time. The process is contentious between Democrats and Republicans,  but it is also reportedly contentious between different Republican legislators as well. Republican lawmakers nowassert that they intend to “repair not repeal” the ACA. 

Last week, a meeting between State Insurance Commissioner's and brokers met with the Senate Health Education Labor and Pension Committee. They warned the Committee that more healthcare plans are likely to”defect from the Affordable Care Act marketplaces unless Congress and the Trump administration provide concrete assurances within the next two months”. They also warned that those insurers that remain are likely to increase their rates by as much as 20% if this occurs. Specifically, the insurance industry wants GOP lawmakers to ensure that they will fund ACA subsidies in 2018. They need this information so that they can make their budgets for the next year. ACA subsidies are currently the subject of court battle between Republican Representatives and the White House. Amidst all this, the Department of Health and Human Services introduced a rule, the "Patient Protection and Affordable Care Act; Market Stabilization”, which is meant to stabilize the health insurance market for individuals. The GOP appears to understand that it is in everyone’s best interest to stabilize the insurance markets. 

Threat of repeal of the ACA continues to spur women women into seeking long acting reversible contraceptives (LARCs) such as MIrena (IUD) and Nexplanon (subderrmal insert). Month-to-month adoption of these methods is at record highs and continues to rise. Women are also stockpiling prescriptions of contraceptive and the prescriptions Some states such as New York are addressing the problem by requiring State governed insurance agencies to cover contraception with no or minimal copays. Massachusetts has developed a bill to provide free contraceptives to all of its residents. 

The is busy time for women’s health  and health care in general. Find out the names and contact information for your elected officials. Make your views known. 

 

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

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

On last Monday , President Trump signed an executive order “ granting relief” from the stipulations of the ACA (Affordable Care Act). Among other things, this means the Department of Health and Human Services (DHHS) may reduce what insurers are obligated to cover for patient’s care. 

Planned Parenthood reports that the number of women trying to get IUDs in their clinics has gone up 900% since early November, i.e. the election. IUDs are a very reliable long acting contraceptive.  They are obtaining these IUDs under the contraceptive benefit under the ACA, which they fear will be repealed under the current administration. 

The Democratic Governor’s Association has urged Congress not to overturn the Medicaid Expansion or to convert to block grants. They stand to lose a great deal of coverage and funding for their constituents. 

Two moderate Republicans, Senator Susan Collins of Massachusetts, and Senator Bill Cassidy of Louisiana, a physician, have indicated a partial replacement for the ACA, which would allow states to continue to operate under it if they chose. Under this proposal, states who opted out of the ACA could get a block payment to administer on their own. The authors have emphasized that the bill is a work in progress. 

At the recent GOP policy repeat, a plan was made to have a replacement for the ACA  to the House floor by the end of March. The House Speaker, Paul Ryan indicated that they intend to get these replacement laws made in 2017. 

The US has frozen funding to health care providers in poor countries who discuss abortion as an option. This policy is called “ The Mexico City Policy” and it is been enforced and revoked back and forth through the administrations of Clinton, Bush, Obama, and now Trump. 

The CDC (Centers for Disease Control) reports that consumption of sugar drinks is still “ well above” the recommended limit. Consumption of these drinks has decreased steadily for the last ten years but now seems to have plateaued. 

The South has higher cancer mortality rates that the rest of the country. These are areas of the country where poverty, smoking and obesity are more prevalent, and these factors are believed to be the reasons. Overall, the US health rate from cancer has decreased 20% in the last ten years. 

 

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

 

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

This Monday the world has become a different place. A new Administration has taken office in the United States. But more importantly, women across the country and across the world have become galvanized. Many marches of hundreds of thousands each took place on Saturday. These were largely demonstrations by and for women to make a statement against sexism, misogyny and against the loss of health benefits in the US. I’m not sure the world has ever seen political activism for one goal on such a large scale. 

Democratic lawmakers made a last ditch appeal on Friday, urging that the GOP halt the repeal. They cited the many clauses of the ACA which prohibit practices which are discriminatory to women, such as denying coverage of contraception and coverage for women-only health screenings such as mammograms. They cautioned that this, along with defunding Planned Parenthood, would harm women in every state. 

It is becoming clearer and clearer that many Republican governors do not favor a wholesale repeal of the ACA. They know that repeal would cause chaos in health care, as well as increasing costs for their state programs. 

In the shocking numbers department, it has been determined that HALF of all men have genital infections caused by HPV. One in four of those have viral strains which can cause cervical cancer. 

Meanwhile, New York State is reporting a 50% decline in cervical cancer deaths since 1976. This is attributed to women obtaining regular paps to detect precancerous conditions and the introduction of the HPV (human papilloma virus) vaccine Gardisil. 

It is interesting to note that abortions are at a new low since the institution of Roe versus Wade case law in 1973. Researchers attribute this new low to the increased availability of affordable and longer lasting contraceptives. 

If the ACA is repealed, both these important gains might likely be lost since the ACA has covered contraception and health screening for women. 

As if to add insult to injury, repeal of the ACA would also strip breastfeeding protections from the workplace. These protections are in place through the ACA. 

The ACA deals with more than women’s health issues. The ACA contained provisions to authorize a fund to combat the costliest of our chronic diseases: diabetes and heart disease. Repeal of the ACA could eliminate this fund, which is for state public health programs.

Americans may be divided, but 40% across both sides of the aisle agree that health care should be a top priority for the new administration. Meanwhile, the popularity of the ACA is steadily climbing in the polls. Forty eight percent of Americans strongly approve of the ACA. Of those 22% of respondents who want it repealed, half want to do so only when a replacement is in place. The Congressional Budget Office itself has calculated that if the ACA is repealed, 18 million people will lose their insurance in the first year. Over a decade, 32 million would lose insurance. They also estimate that individual premiums would double. 

In Zika news, officials have been debriefing from the season. They feel the greatest failure has been of prevention in the areas most affected by Zika. They have emphasized that the toll taken has scarcely been counted. 

Fetal alcohol syndrome (FAS)  is still a scourge. Over a hundred thousand babies are born yearly with this condition. Britain has one of the highest rates of FAS in the world, with 40% of British pregnant women drinking during pregnancy. 

The American College of Obstetricians and Gynecologists has continued to take issue with the FDA on their overly conservative and out of context warnings on anesthetics in pregnancy. Their concern is that caregivers and patients will be reluctant to have critical procedures such as appendectomies and gall bladder removals in pregnancy should they become necessary. Surgical illnesses such are these are very much threats to both mother and babies in pregnancy and should be dealt with in the standard fashion. To put theoretical concerns from animal studies ahead of clear and present dangers is missing the forest for the trees. 

Contact your elected officials with your concerns. It is not enough to march. 

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

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

More than one organization is working hard on vaccines against the Zika Virus. Currently trials are with inactivated vaccine. These take longer to develop than vaccines, with live virus. However live virus vaccine trials are more risky, and it might be difficult to find volunteers for such a trial. And that is all the Zika news for this week. 
Leading the news is the ACA, the Affordable Care act and it’s fate. 
More information is coming in about how the ACA affected us. For one, it’s institution seems to have been associated with increased mammography utilization among older women. Unfortunately the same increase in utilization was not seen with colonoscopy screening for colon cancer. In practice, this is indeed a harder sell, but the truth is, it saves lives, and is not that bothersome of a procedure. 
Senate Majority leader Mitch McConnell has stated that the ACA will be “ replaced rapidly after repealing it”, though he provided no details. He did admit that “ There ought not to be a great gap between the first step and the second.” Many GOP leaders estimate that it will take 2-3 years to devise a replacement. 
Hospitals are continuing to voice their concerns that repealing the ACA could cause a major crisis in health care. Increasing numbers of GOP lawmakers are voicing concerns about a lack of replacement for the ACA. They fear the financial consequences to their states and their constituents, as well as allegations of being reckless and the political consequences that that entails. At the same time President elect Trump has demanded an immediate repeal and replacement. . On January 12th, GOP Senators voted 51-48 on a non-binding measure approving a budget blueprint to repeal the ACA.  Personally, I think it is still worthwhile to contact your elected representatives and tell them how you feel about this. 
Enrollment in the ACA continues to outpace that of last year. As of December 24th, more than 11.5 million people have enrolled. Twenty million Americans altogether have their health care through the ACA. 
Oddly, Mr. Trump made certain campaign promises regarding 6 weeks of paid maternity leave and reductions in child care costs. Last week he held meetings about these issues while urging his party to gut health care. 
Speaking of women’s health care, contraception is currently covered by the ACA. it’s repeal would of course threaten this benefit. However, states have the ability to require insurance companies to cover it entirely. Not surprisingly, many states are moving to establish laws that will resemble the ACA in their coverage of contraception. 
In medical news, the flu is clinically worse this year than in other years. But, good news ! The vaccine this year is a good match, and is very helpful. There is still time to get one. 
In other vaccine news, there is a herpes vaccine under development. It is showing promise to decrease frequency and severity of outbreaks. 
Breastfeeding moms need to take prenatal vitamins, Calcium and Vitamin D. Many people including pregnant women and nursing mothers are low in Vitamin D. All breastfeeding moms should be supplementing their breastfed babies with vitamin D drops. This message is not getting out as well as it should. Consult your Pediatrician. 
 

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

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

The Society for Maternal Fetal Medicine (SMFM)  recently convened a special session to summarize our current knowledge about the Zika virus. Maternal Fetal Medicine Specialists are also known as Perinatologists. They are essentially Ob Gyns who drop Gyn and take a couple additional years of training in Ultrasound and high risk pregnancy management. They also tend to comprise the research side of Obstetrics. They may or may not continue to deliver babies. They, together with general Obstetricians have been the group of health care providers most affected by the Zika epidemic. As such, the group as convened a special session to review CDC (Centers for Disease Control) recommendations pertaining to the Zika virus. Together with the CDC director, they have emphasized the the concern over Zika is ongoing. Pregnant or potentially pregnant women are encouraged to stay away from places where Zika is spreading. They have cautioned that the worst is not over. 

Meanwhile, insights are being gained into the pathogenesis of the Zika related disease process. (Pathogenesis means the particular way something causes disease.) In looking at the Zika virus genome and several important proteins produced by the virus, researchers from the University of Maryland have obtained what they classify as “ really valuable clues for future research”. 

President Obama meets with Congressional Democrats this week to devise a strategy to save the ACA (Affordable Care Act). Meanwhile some commentators have noted that even repealing the ACA will not make it possible to roll back all of the changes the ACA has wrought. Americans have become accustomed to a new standard in the expansion of health care coverage. Meanwhile, the incoming Republican administration has seemingly settled on a repeal and replace strategy. The health coverage of 20 million Americans is at stake. This December, 8.8 million people enrolled in the Federal Exchange. This is more than the 8.6 million of last year. The American College of Obstetricians and Gynecologists (ACOG) and others have come forward with a recommendation that there should be a replacement plan in place before repeal. Yet ate last week, Republican leaders including the House Speaker Paul Ryan as well as Senate Majority Leader Mitch McConnell have asserted that a quick repeal and replacement "within this year" is needed. Senator McConnell classifies the ACA as a “ failed, partisan experiment”. 

A new analysis presented by CNN Money indicates that repeal of the ACA will cost the Federal Government $350 billion dollars over the next ten years. In comparison, the ACA was crafted to be budget neutral. 

ACOG and the AMA (American Medical Association) concur that oral contraceptives are appropriate for over the counter use. The FDA (Food and Drug Administration) is in the beginning steps of this regulatory process. 

There are many patients who have trouble attaining a healthy weight, even some who exercise regularly and eat appropriately. A new study has focused on this group and found some good news. These “non responders” benefit from rotating their exercise routines. Truthfully, I have heard this from many trainers. 

Also in the good news department: a 25 percent decline in cancer death rates since 1991. This is a fresh statistic from the American Cancer Society. They attribute this decline to reductions in smoking, as well as early detection, and better treatment. 

Finally, in the easy and lifesaving department, peanuts are now recommended for the very young. The National Institute of Allergy and Infections Disease has issued new guidelines recommending that parents introduce peanuts into their child’s diet early (before 6 months !) and often. This is to prevent the development of peanut allergy in the future. This recombination is a “ significant departure from the past”. These new guidelines could dramatically reduce the prevalence of this deadly allergy. 

 

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

Wellness Wednesday: A Thousand Small Cures

Not a day goes by that I am not asked about one “cure all” or another. Wellness Wednesday has been a column devoted to just the opposite- the many, sometimes small things, which done repeatedly, amount to the “cure”. The “cure” offered by longstanding attention to wellness is none other than prevention. 

Even when unpreventable illness or injury happens, wellness behaviors can make the difference between a good outcome and a bad one. We have so much power over our health but people scarcely realize it. Some realize it but are not up to taking that responsibility. It feels better to ascribe their poor health to genes, “toxins” in the environment, or something else. Strangely, empathy rather than blame is in order here. Why ? Because empathy is empowering and empowerment works. Once people get the message (though empathy) that they are not alone, they have the courage to begin improving their health related behaviors. 

Taking charge of your health is easy and empowering from day one. That is the secret that popular media and medical professionals alike keep obscuring. It is not so much a matter of discipline as it is of planning. It need not take place all at once. Once people get the message that wellness behaviors are easy, and need not be hard to be helpful, they are more apt to do them. 

How do people get these messages ? There is of course the popular media. To find this material about health maintenance you must be seeking it. These people are already on the right track. But what about others ? Here is where I believe the responsibility falls on all doctors to talk to patients about their health maintenance. Even before that, I believe it behooves all physicians to set a good example in this regard, and keep themselves as healthy and fit as possible. Nobody is perfect, and nobody should be held to an unrealistic or extreme standard. Yet, doctors should practice what they preach and lead by example. 

Physicians offices should be set up to refer liberally to nutritionists, physical therapists, counselors and others who can specifically teach and monitor health maintenance behaviors. Physicians themselves should learn how to discuss sensitive matters like weight. They should ask about life at home and work to screen for interpersonal issues or abuse. 

It is my hope that popular culture will increasingly embrace legitimate ideas about nutrition, fitness, mental health, and health care.  By now, most people know how ideas travel though communities and social media. Good ideas are sticky, and should be circulated. For example, food and workout posts which we love to hate actually bring these ideas to the fore. 

My website is a repository for health information related to Obstetrics, Gynecology and Health Maintenance. However, it has a limited readership. My plan to curtail blogging to Medical Mondays only is an attempt to get "more bang for the buck” and try another format for distributing this information. There are a couple decent books out there in this subject area, but mainly the field is lacking. I will be looking at the possibility of an ebook versus apps to serve as resources for women looking to improve their health. I hope you stay with me along the way. 

 

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

For the first time in many months, there is nothing new to report about the Zika virus. I am going to take this is as a good thing and report on the rest of the news. 

With the end of 2016 approaching, ACA (Affordable Care Act) signups have reached a new high. At the same time many fear loss of their contraceptive method if the ACA is repealed. The ACA as it currently stands, pays 100% for contraceptives. 

The ACA seems to have enabled more people to keep up on preventive care. Also according to a new study, the number of adults who skipped recommended medical care fell about 20 % between 2013 and 2015. Similarly, a new Vanderbilt study showed that patients accessed emergency department care more quickly since cost was not a consideration in choice of hospital.  

Texas has noticed all Planned Parenthood Clinics that it is removing them from the Medicaid Program. This means that no Medicaid recipients may be seen at Planned Parenthood, which normally serves predominantly the Medicaid population. I’m wondering if this will have unintended consequences. For example, perhaps Planned Parenthood will have to start filing their clinics with well insured women, while the private and hospital owned clinics uptown will start to fill with medicaid patients ? It will be interesting to see how this will play out. It almost certainly will mean less access to care and a shift in who sees whom. Planned Parenthood is appealing the Texas Health and Human Services Division. 

ACOG (American College of Obstetricians and Gynecologist) has officially endorsed 30-60 seconds of delayed cord clamping. This procedure allow baby to get more blood from the umbilical cord. This is especially beneficial for smaller, early babies, but can be good for term babies as well. It results in higher blood hemoglobin counts, but also, understandably more jaundice, since jaundice comes from the breakdown products of blood cells. As an obstetrician, I can tell you that this works out most of the time. However, if baby is not breathing well, I get them to the nursery staff right away. Also, if there is excess maternal bleeding, we cut this procedure short, and move to get the placenta delivered. 

On a personal note to readers, I have appreciated all the attention to my posts. However, I plan to curtail my blogging to once a week come January 1st, 2017. I will continue Medical Monday since I believe this information to be very important to you. Additionally, I do plan to put out an occasional digest of existing website pages and posts on selected topics, which I think will be high value. However, based on my numbers of readers and subscribers, it seems clear to me that I need to get my information out in more accessible forms, such as in books or apps. There is so much material on the site now, that most topics are really well fleshed out, though the material is deep in the pages. I will need some time to pull this content out and organize it. At the same time, you are of course welcome and encouraged to access the website anytime via the menu, the search page, or the blog tags on the right of the home page on your own and free of charge. My website will be there free for all as an up to date medical resource.  

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

A total of 4575 Zika cases have been documented in the United States including 1172 pregnant women. We are now beginning to collect data on these pregnancies and the resultant births. It turns out that about 6% of Zika infected pregnant women in the US had a baby with at least one birth defect. This new research was published in the Journal of the American Medical Association. The data was gleaned from a total of 442 Zika infected women who completed their pregnancies this last year in 2016. In stratifying this group it was discovered that those who were infected in the first trimester had an 11% chance of delivering a child was birth defects, higher than the average of 6% indicating that Zika poses the greatest risk earlier in the pregnancy. Moreover, these rates are on a par with what is being seen in Brazil at this time indicating that the virus is working in a similar way in both populations. 

Personally I see these numbers evolving as the duration and post natal effects of Zika virus have yet to be fully described. CDC (Centers for Disease Control & Prevention) researchers have indicated that Zika can replicate in the fetal brain for up to seven months after the mother has become infected with the virus. They have noted that babies born to Zika are very likely to have brain damage even in the absence of obvious abnormalities like microcephaly and that the virus may keep replicating long after birth.

The CDC  has added Brownsville Texas to its list of Zika travel advisories. This is because five locally transmitted Zika infections were recently reported. Texas has had a total of 274 Zika cases.

Also in Texas news, it has been discovered that a booklet titled “A Woman's Right to Know" was revised earlier this year to contain misinformation about the relationship between abortion and breast cancer risk. This booklet must, by law, be given to any woman seeking an abortion. 

New research published in the journal Science Translational Medicine as reported that researchers have described two antibodies that appear to be important in the fight against Zika. Apparently these two antibodies were able to eliminate Zika virus in animal subjects in the lab. Hopefully we will hear more about this in the future.

In other news, fears about the repeal of the Affordable Care Act continue. Republican lawmakers are gaining appreciation for the ramifications of a fast repeal including the loss of insurance by over 50 million people and a huge loss of revenue for hospitals across the country, on the order of $165 billion dollars. Even with fear of a repeal looming, sign-ups for the ACA are occurring at a higher rate compared to this time last year. Moreover the Fed is extending the healthcare.gov deadline until Monday, December 19th. 

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

Wellness Wednesday: Help for the Elves

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

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

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

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

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

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

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

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

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

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

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

Enjoy these last few days before Christmas ! 

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

Zika has crossed the Atlantic to the United Kingdom. There are 265 known cases there already, including one whose transmission is believed to have been sexual. People traveling from moderate or high risk areas are asked to abstain, or contracept and use reliable barrier methods. HA ! That’s an oxymoron: reliable barriers. 

It is winter in North America, and that includes the US territory most affected by Zika: Puerto Rico. While Zika transmission continues, it is decreased at this time of year, due to reduced mosquito activity. Attention turns now to the pregnant Zika infected women. There have been 2600 confirmed cases of Zika in pregnancy in Puerto Rico. Many have miscarried, but many are yet undelivered. 

Texas now joins Florida as the only continental US state to document a local transmission of Zika. Local transmission means a Texas mosquito bit a person in Texas and transmitted the Zika virus. What this says about the number of mosquitos in Texas which have Zika is unclear, but it says something. Until now, all other Texas cases of Zika have been linked to travel. 

In other news, the ACA (The Affordable Care Act) has top billing. As mentioned last week, the ACA is now integral to our healthcare system and cannot be easily dismantled. Twenty million Americans now depend on the ACA for their health care. It is becoming more widely acknowledge that for the time being, it will have to stay as it is, notwithstanding the change in administration. Enrollment for 2017 is beginning, and it seems, continuing apace, 2.1 million so far, despite GOP’s vows to dismantle it. 

GOP lawmakers have started discussions with insurers to try to prevent a collapse of the insurance market if they pass a repeal of the ACA. GOP lawmakers are now indicating that it may take them “ years” to repeal the ACA, hopefully more than four. 

As a physician, completely unrelated to politics, I am for some form of the ACA. I have seen women whose only health care was during their pregnancy, who can now come in with pride just for their annual. They are able to get the recommended screening tests, and can begin to think about health maintenance and limiting family size if they chose. I know, as a physician, that prevention saves money. I also know that disease caught early and treated is far cheaper than disease caught late. GOP lawmakers MUST factor this in if they are to modify the ACA or create their own plan in such a way as to make it affordable and sustainable in the long run. 

The GOP is mixed on the Medicaid expansion. Many Republican Governors are glad to get so many more or their poorest patients insured. 

New research published in the Journal of Women’s Health indicates that women with chronic conditions do worse without access to the internet. This may have to do with access to information and social connections with others, especially others who share the same conditions. 

Many women and many providers believe that there is an age cutoff after which mammograms are no longer beneficial. I am unaware of such data. New research using data from 6 million mammograms between 2008 and 2014 confirms there is no clear cutoff point. Mammogram decisions should be made between a patient and her caregiver, and factor in the best available data and the patient’s overall health. 

Tom Price, the Health and Human Services Secretary elect is said to be both anti-abortion and anti-birth control. It is beyond me when someone who is anti-abortion is also anti-birth control. The theoretical planned repeal of the ACA will not ban these things per se, but a report out of Kaiser indicates  that the costs of contraception will rise during this time period. Drug costs across the board will likely rise whether or not the ACA is repealed. 

In the good news department, the House, in a landslide vote, passed the 21st Century Cures Act. This provides an increase in finding to the FDA ( Food and Drug Administration) by $500 million, for drug development and testing,  and would also provide $1 billion to address opioid addiction. There’s a billion dollars we theoretically should not have to spend but, we do. This is why we cannot have nice things. 

Planned Parenthood, ACLU, and the Center for Reproductive Law and Policy are filing lawsuits which challenge several laws which limit women’s rights to various reproductive services. The lawsuits are arising as quickly as the limitations these days. 

The House Energy and Commerce’s Subcommittee on Health has taken what I consider to be a monumentally positive step in reigning in the US Preventive Services Task Force. They have recommended that the small, non-clinical committee receive more input on formulating their recommendations, from (surprise!) medical authorities before they make recommendations which influence patient care and insurance coverage of various screening procedures. The bill comes from Republican Marsha Blackburn from Tennessee who has pointed out that USPTF recommendations on many issues pertinent to women’s health including mammograms differ from those of, for example, ACOG, the American College of Obstetricians and Gynecologists. The bill provides for input from both primary care medicine and specialist authorities. Bravo Representative Blackburn, and bravo to you for reading all this. 

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

 

Medical Monday: Breaking News from the World of Obstetrics andGynecology

Upset  pregnant woman crying.jpg

Regular readers of this column know that for many months we have started with news pertaining to the Zika virus epidemic. This is of special interest to those in the field of Obstetrics and Gynecology, since it is both perinatally and sexually transmitted. This means that once a person acquires Zika virus from a mosquito, she may pass it to her unborn child, and anyone may pass it to a sexual partner. Zika has been widespread in South and Central America and has come as far north as the southern part of the United States. During the warm spring and  summer months, officials were frantic to control it, employing measures of all kinds, but without anything truly effective. Many thousands were infected, and many of those were pregnant. This column has not only served to educate readers about Zika; it has also documented in realtime the painstaking progress of work that has been done, bit by bit, to understand and control the disease. 

As a physician of 27 years, I have read about many disease processes. I have never, however, witnessed the observation, diagnosis and gradual clarification of a new disease quite like this. I was in college when HIV/AIDs came to the fore (1979-1983), but by the time my third year of medical school (1987) had come along, we had wards of patients with HIV/AIDS related complications like Kaposi’s sarcoma, pneumocystis  pneumonia, and disseminated herpes. We understood only a bit at that point, and we felt rather helpless. I am by no means a caregiver on the front lines of the Zika Virus battle. However, I can imagine how they must feel, based on my limited experience with HIV. 

Zika is different in that in can affect the next generation. HIV can also be passed perinatally and also by sex. However, when it affects a baby, it leaves that baby neurologically and developmentally alone. Not so with Zika. For some reason, Zika targets the baby’s brain and sets some process into motion which disturbs and potentially stops the brain's growth, while the rest of the baby continues to grow. As with other perinatal viral infections, contracting Zika early in pregnancy makes matters worse, and interferes with development at an earlier stage. This makes sense. However, the latest revelations about Zika are even more troubling. A new study by the CDC (Centers for Disease Control) indicates that a Zika affected mother may produce a term baby who appears entirely normal at birth. However, that baby may well go on to develop microcephaly, the hallmark of the Zika's affect on the central nervous system. This seems to indicate that we do not know how long the effects of Zika virus infection can last. It raises questions about newborns, toddlers, or growing children getting their own Zika infections. This has far reaching implications for how all families in Zika affected areas live their lives. It clearly has implications for the medical community and society at large. 

Meanwhile, the WHO (World Health Organization) has declared that Zika is no longer a public health emergency. Well, of course it is. However this designation simply means that the crisis should no longer tap emergency funds, but rather should have it’s own proper ongoing budget. Nonetheless, some authorities feel this is premature, and have urged the WHO to reevaluate the decision come warmer weather. The CDC, by contrast, will retain Zika at the highest emergency level. Brazil, the epicenter of the outbreak, will continue to consider it an emergency. The hope is that these deliberations and administrative designations will not get in the way of efforts at infection control, basic research and of course, the much hoped for VACCINE. 

In other news, a new study has emphasized the importance of thyroid function in pregnancy. The immune system changes in pregnancy and so does thyroid function. Not uncommonly pregnancy is the time when low thyroid is diagnosed. This new study has highlighted the very important fact that optimizing thyroid function in pregnancy improves birth outcomes in measurable ways. We know that seriously low thyroid functioning pregnancy is associated with mental deficits in children, a condition called Cretinism. However, optimizing thyroid replacement also prevents still birth, and low birth weight infants. 

 A majority of the news otherwise on this short week had to do with the new administration’s plans to dismantle or alter the ACA (affordable Care Act). As time goes by, we hear different things about this. I get the feeling that reality will set in and that pragmatism will have it’s way with lawmakers and their promises. Perhaps the new administration will be satisfied if they can shuffle and rename a few things, then take credit for the good ideas. 

Wellness Wednesday: DNA testing

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

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

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

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

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

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

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

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

 

http://isogg.org/wiki/Autosomal_DNA_testing_comparison_chart

 

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

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

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

Happy Thanksgiving 

 

More reading: 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Two weeks worth of news will be covered this week !

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Food Friday: Comfort Food

I think we could all use a little comfort food after this week. 

We turn to comfort foods when we are stressed, sad or lonely. I know lots of people felt this way after this week’s presidential election, especially women. So I am here with some ideas for healthy comfort food. 

Comfort foods are traditionally loaded with simple or refined carbohydrates. Classics include baked goods like muffins and pie, heavy savory food like french fries, mashed potatoes and spaghetti and meatballs. They are filling, warm and associated with good memories. How can you make some of your own without going into a carbohydrate coma and feeling worse after you’re done ? 

I suggest starting with some hot tea, dressed nicely with lemon and and a little agave. This might be all you need. A savory alternative is a hot chicken broth, made easily from jarred organic broth mix which is readily available in standard grocery stores these days. 

If you need more, and you need it quickly, consider homemade popcorn with olive oil, salt, herbs, lemon pepper, or nutritional yeast. (The nutritional yeast is something you’ll have to get at your local organic foods store.)

If you can take the time to prepare something, be strategic. We will go with the traditional items, just tweaked for the cause of health. 

 

Muffins:

Try my fruit muffins 2.0 HERE  and use gluten free flour or whole wheat flour, depending on your tolerances. Try cutting the sugar. 

 

Pie: 

Try a Paleo nut crust with a fruit that doesn't need much sweetening. Plums come to mind. When I thaw frozen pie fruit out of season, I do so in a large nonstick frying pan, and pretty much get the water poured or boiled off, and the filling made. How about Paleo pumpkin pie made with coconut cream ? 

Here’s some recipes: 

https://elanaspantry.com/paleo-pumpkin-pie/

http://blog.paleohacks.com/pumpkin-pie-recipe/#

These recipes are for YOU. Don’t expect to serve a huge room of extended family these healthy alternative recipes and not get some comments about how they are different. They are different in that the crust is not the same and the fillings are less sweet. But they are treats you can feel good about. A brief search on Pinterest will yield dozens of Paleo pumpkin pie recipes. 

 

French Fries: 

This is easy: Crispy baked or broiled sweet potato fries made with coconut or olive oil. The key is in the cut. Sharpen your knife. Make them uniform. If you are brushing them with olive oil, make them thin, so high heat is not required. I recommend a large cookie pan lined with parchment. Lay the fries in a single layer brushed with oil and salted with kosher salt. The add pepper or herbs as desired. Bake at 375 in the upper half of oven until they are beginning to crisp. Dip in paleo or home made olive oil mayonnaise instead of sugary ketchup. Aioli sauce would also be nice. You may cook them in a hotter oven if you use coconut oil, but watch them carefully. 

 

Mashed "potatoes": 

 

Here you can try the now famous FAUX potatoes which are made with cauliflower. Wash and cut a whole head of cauliflower, cook until fork tender. You may steam, boil, or roast it. Then blend with a tablespoon of healthy fat like olive oil or a little butter, add salt or pepper to taste. Some people add a little garlic puree, but that is optional. Garnish with turkey bacon bits, and maybe chives. 

 

"Spaghetti" and meatballs: 

 

This gives you the chance to try Zoodles, or zucchini noodles. Use a peeler, or a special tool widely available in the kitchen gadget section of major stores. They cook quickly, so beware and do them last. Make the marinara sauce and meatballs of your dreams, the simply have them over the well drained Zoodles. 

 

I hope you have a nice comforting weekend.