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

I spent this week at Stanford MedX Conference. This conference covers some of my fondest professional interests. In particular, we covered various themes of technology in medicine, such as the use of devices and apps for patients to use to follow chronic disease conditions like diabetes. We covered the increasingly important role of apps in research. 

We explored the phenomenon of peer to peer connections among patients and discussed how it is especially helpful with rare or undiagnosed conditions. 

Another prominent theme at the conference was design in health care. We heard lectures and  participated in workshops in human centered design, or more particularly patient centered design. We used design thinking to create maps of the patient experience, then took that information forward to inform features as disparate as language used in phone notifications, seating in exam rooms, and interior decor. 

One theme of the conference was “everyone included”. I already knew this meant the voices of all genders. I also learned it meant all those in health care, not just patients and caregivers. Namely, it also included family members, medical researchers, device makers and all those who design and evaluate the health care experience. 

The genius of the conference in my mind was that it brought together those who were traditionally separate. In my two years of attending the conference it became readily apparent that fantastic synergies were possible by bringing together people from these varied  backgrounds. Patients, physicians, scientists, designers and computer scientists, sat around around common tables to learn methods to solve vexing problems in health care. And yes, we were given large sheets of paper, colored markers and sticky notes. 

But... the people ! This was the best part of all. I am here to report that there are plenty of good and brilliant people in the world with the ability to conceive of solutions to serious problems. At this conference, they came in all shape, sizes, ages, nationalities and genders. You could not pick them out at a grocery store. But if they had a conversation at your dinner table, you would quickly learn how special they were.  

On to policy. The Congressional Budget Office (CBO) continues to predict a 15 percent rise in premiums for policies under the Affordable Care Act (ACA). They have reported that this will likely be the case due to uncertainty over the Federal government’s willingness to pay subsidies to defray the cost of health care. Also likely contributing might be reduced  number of enrollees now that the individual mandate is not being enforced. 

GOP Senators have pared their efforts down to a one point bill. This final attempt to repeal and replace Obamacare basically takes Medicaid expansion money and shifts it to block grants administered by States. 

At the same time, Senator Bernie Sanders has proposed a near opposite. He has proposed retooling Medicare in the image of Obamacare and providing it to everyone. This is the so called “Medicare for all” proposal. While this has no likelihood of passing this Congress, it is espoused by most of the potential upcoming Democratic candidates for President. The rationale here is that such a plan would save money in the long run. The reasons for this being conceivable have been discussed before and elsewhere. In a nutshell, it has to do with people’s willingness to keep up on their prevention, screening, contraception and prenatal care, thus avoiding costlier more severe phenomena. 

The Senate Finance Committee has obtained an easy bipartisan agreement to refund CHIP, the children's health insurance program,

In another strikingly bipartisan move, Congress has rejected deep cuts to the National Institute of Health. Indeed lawmakers on both sides of the aisle have defied the Commander in Chief and increased spending on biomedical research. 

In medical news, HPV vaccination rates continue to be sub par. However new data shows that vaccinations that have been given may be conferring a herd immunity as HPV infections have decreased 32% between 2009 and 2014. 

Vaping is viewed as a safe alternative to smoking in pregnancy. There is NO data to support this. In fact, newer data show an association between maternal vaping and asthma in the offspring.

Marijuana is viewed as safe in pregnancy. However, it is associated with learning difficulties in grade school  offspring. The State of Nevada is beginning a program to educate about this. 

In concerning but unsurprising News, pregnant women’s exposure to pesticides appears to be associated with premature delivery and low birth weight. 

 A recent study shows a faint correlation between two flu shots in row and miscarriage. Ever hear of signal to noise ratio ? This is probably noise. ACOG continues to reiterate the real demonstrated need for flu vaccine in pregnancy. 

Belly fat; it’s always the last weight to come off. However, it is well worth the effort. We’ve known for some time that belly fat was associated with increased rates of cardiovascular disease. However, new research indicates that central obesity is associated with increased rates of several cancers. Moreover, in the case of breast cancer, it is more closely associated with higher risk forms of hormone receptor negative cancer. 

As data science improves, so do our results. New research published in JAMA, the Journal of the American Medical  Association, constitutes the largest longest and best designed trials on the safety of postmenopausl a hormone replacement therapy. Happily, it does not increase the risk of premature death. This is medicine’s way of saying that the therapy is safe. 

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