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

Policy News

The “Global Gag Rule” is a rule which prohibits international health care organizations from counseling about abortion lest they lose their aid money from the USA. More recently Title X funds are being withheld from groups in the US who perform abortion or mention it as a choice. Many feel this amounts to a domestic gag rule. However, the Trump administration is back peddling, saying it only relieves Title X recipient caregivers of the requirement to mention abortion as an option. These are two very different things. I wonder which is really the case. I wonder too, if this means the Title X grant givers will requests the medical records documenting patients' visits to see what caregivers and patients are discussing. ACOG (American College of Obstetricians and Gynecologists) has called this an “egregious intrusion” in the doctor patient relationship.  Analysts point out that, additionally, these new rules will give those “health clinics" which oppose abortion and birth control easier access to Title X funds.

Medical News 

The Chair of ACOG New York has produced a guide to the Gyn annual exam for the New York Times. In it, she has explained what to expect, including the holistic nature of the visit. Many people think of the annual Gyn exam as just a pap. However, it is wellness and preventive check that addresses the overall health of the patient. Pelvic exams are performed as indicated according to protocol. Patients are also reminded about what should not take place, such as more touching than is necessary. Patients are reassured that they are entitled to an explanation for everything that is done. 

Texas is starting to take the bull by the horns. Maternal mortality and morbidity in Texas has been egregious. Authorities are now honing in on the contributing factors, and devising strategies to address it. The Texas Medical association has drawn up a list of recommendations including statewide legislation to improve health care coverage for pregnancy women, to increase access to long acting reversible contraceptives (LARCS), and to increase the quality of record keeping on maternal complications. 

Tobacco smoke from a pregnant women damages the unborn baby’s lungs (among other things). New research indicates that vitamin C may mitigate this risk. The changes from smoking do not simply harm the baby in that time frame. In utero exposure to those chemicals induce changes in the baby's genes (epigenetic change) which may persist throughout life. 

SIDS (Sudden Infant Death Syndrome) has been a worry for some time. I remember when it was first defined. At that time, we had no clue about its cause. It remains incompletely understood. However we now understand that the odds of it are greatly reduced when the parents do not smoke, and also when the baby sleeps on their back. This knowledge has given rise to the “Back to Sleep” movement which promotes putting babies to sleep on their back. We have also since learn that avoidance of loose bedding and avoidance of co-sleeping is protective. This means newborns must not sleep in the same bed with parents, despite what may seem like convenience. Nonetheless, NPR has recently reported on the disconcerting trend of increasing co-sleeping. AAP the American Academy of Pediatrics has come out again against co-sleeping which iss highly the associated with an increased risk of sleep related deaths in babies under 4 months of age. 

The Institute of Clinical and Relational Science at UCSF (University of California San Francisco) has produced research indicating yoga may help incontinence and anxiety in older women. Findings were presented at the American Urological Association in San Francisco. 

Marijuana in pregnancy is again in the news, with yet more reports coming out about its disruption of fetal brain development. It is also linked to smaller birth weights and irritable behavior in infants. It is also linked to higher likelihood of still birth. And yet, 70% of Colorado dispensaries are recommending marijuana to pregnant women for nausea in pregnancy. Conflict of interest and flagrant irresponsibility, much ? 

Lung cancer in young women has now surpassed that in men. Lung cancer in men and women has decreased over the last two decades, however it is decreasing more rapidly in men. 

There is now good data that air pollution is related to infertility and preterm birth. A new study on the subject shows that the closure of oil and coal plants boosts fertility in nearby communities. 

There’s an app for that. Maybe. There are many apps pertaining to birth control. There may even be one that can help predict the risk of preeclampsia. However, before you go relying on one of these, Please check with your doctor about the validity of such an app. Quality varies, so buyer beware. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Belated Medical Monday

I have just heard the best news about the Republican plans to replace the ACA (Affordable Care Act). Senate Republicans would like to postpone a repeal until……drum roll please …. the year 2020, when, you guessed it… another presidential election will take place ! I think this may be the GOP’s way of saying, “Sorry, never mind. We agree with President Trump who said, “Health care is hard.”." 

Especially now that the piper has started talking about getting paid… i.e. the Congressional Budget Office (CBO) has had it’s say, lawmakers on both sides of the aisle have come to realize that the costs of dropping the ACA provisions may exceed the costs of keeping them. 

There is however a need for action, and Senate Republicans will likely try to take action to stabilize premium costs. They will also to endeavor to continue federal insurance subsidies which help low income American with co-pays and deductibles. 

In other policy news, the Mexico City policy is back in place. This is the policy of withdrawing US aid funds from international organizations which provide reproductive services which include abortion. This is policy is meant to show the current administration's condemnation of abortion, and to curtail the incidence of abortion. However, Kenyan health care researchers have cited clear evidence from the past about what happens when the Mexico City Policy is in place. In fact, if these US funds are withdrawn from these types of health clinics, then many women go without health care and contraception and many more unintended pregnancies occur. Not surprisingly, under these circumstances, MORE abortions are actually performed. It seems impossible that the administration cannot be unaware of this. If this is true then it would seem they are really more interested in political posturing than abortion prevention or the health care of women. I'm going to speculate this this exact sort of thing will happen in that other part of the third world called Texas, where women's health care services have been severely restricted.

The Mexico City rule is also called the “ global gag rule” since all US funds can be withheld even if the clinic staff even speak of abortion.

Did you know that the current administration proposes not only to cut coverage of health care but also to health care research ? In his 2018 budget request titled “ A New Foundation for American Greatness”, cuts are proposed for the FDA ( Food and Drug Administration), the CDC (Centers for Disease Control), and the National Institute of Health (NIH) including the National Cancer Institute. How do you feel about this ? Tell your elected officials. 

Many on the red (Republican) side of the aisle continue to favor covering those with pre-existing conditions. Many of you may know of Jimmy Kimmel, the late night host and comedian. He has entered the health care debate in a most poignant way. His wife recently gave birth to a son with a congenital health defect. This defect required immediate very expensive and live saving surgery, which with insurance under the current Affordable Care Act, will be covered entirely. This baby's care coverage will not be subject to penalties for preexisting conditions, and there are currently no caps on insurance payouts under the ACA. Cases like this do become very costly, and in an environment where there are caps on what an insurance will pay, the Kimmel child might not get all the care he needs to live. So, legislators have spoken of health care plans which “pass the Jimmy Kimmel test". To pass the test, an insurance plan must cover all the care that such a baby would require. Many Republicans are coming out to favor plans which pass the Jimmy Kimmel test. See Jimmy’s moving monologue HERE:

http://ux.azcentral.com/story/life/tv/2017/05/02/emotional-jimmy-kimmel-discusses-baby-sons-heart-surgery/101189324/

In medical news, ACOG is trying to get the word out on normal anatomy. There is a disturbing rise in cosmetic surgery for the female genitalia, even in young women.  ACOG (American College of Gynecologists) is trying to educate patients and clinicians about the considerable variation in normal anatomy. They are also cautioning against so-called vaginal rejuvenation surgeries and other procedures which can have serious complications. One has only to look at the high costs of such surgery and the lack of insurance coverage of it to know that it is simply a moneymaking ploy used by unscrupulous gynecologists. 

In the “ we already knew this” department, a new study has come out reiterating that domestic violence is more common in pregnancy. Everyone needs to be aware of this. 

In the "you have some control” department, new research indicates that even one 10 ounce alcoholic drink may increase your risk of breast cancer- by nearly 10 % in post menopausal women ! The same study also shows that vigorous exercise reduces the risk of breast cancer. Worried ? Stop drinking and start exercising. 

It has now been well established that the HPV vaccine works to prevent genital warts and reduce the incidence of cervical cancer. The new revelation is that for kids under 15, only two rather than three doses are needed. 

Do you snore ? If you do, go get evaluated, regardless of your age. It is clear that sleep apnea increases risk of cardiovascular disease. New research also indicates that it complicates pregnancy, increasing risks of gestational diabetes and preeclampsia. 

Bed sharing with newborns increases risk of SIDS ( Sudden Infant Death Syndrome). A new program which includes face to face education and distribution of baby box kits has been shown to be effective in reducing the incidence of bed sharing. Baby boxes provide a separate space for baby with a flat mattress and a firmly fitted sheet. These boxes, as opposed to a bed or crib with lots of blankets, toys and fluff, are much safer places for baby to sleep. 

Stay tuned for next week’s Medical Monday and thank you for your patience ! 

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

By now the whole world knows that Trumpcare version 1.0, the American Healthcare Act (ACHA) has failed. For now, Obamacare, the Affordable Care Act (ACA), remains the law of the land.

This last Friday, the ACHA bill went to the floor of the House for a vote. However, all day negotiations proved fruitless to bring over Democrats or close the deep divisions between House Republicans. House Republicans broke rank with the President, but did so in two camps. First those on the far right “ The Freedom Caucus”, withdrew support because they felt the bill was still too costly and still too much like Obamacare. Moderate Republicans withdrew support because the ACHA gutted federally funded Medicaid and is widely believed to lead to the loss of insurance for a great many people, putting that burden on the States. Paul Ryan, recognizing the tally, pulled the bill before the vote. 

House Speaker Paul Ryan has indicated the GOP will keep working on heath care. One little publicized option is for the Whitehouse to sue to stop the Fed from paying insurers for work done under the Affordable Care Act. This tact was going on before the ACHA was brought to the House. Their argument is that these contractual payments from the Fed to insurance are invalid and illegal. 

One of Trump’s major campaign promises was to reform healthcare, indeed to provide “universal coverage”. Progressives favoring Universal Coverage may attempt an uneasy alliance in the service of this goal. Senator Bernie Sanders plans to unveil such a proposal entitled “ Medicare for All “. 

Policy news is moving at light speed and I recommend everyone start reading it from various reliable sources. I also recommend people familiarize themselves with their elected representatives and give them and their staff regular meaningful input. 

On to actual medicine. 

A new study from the Journal of the Academy of Nutrition and Dietetics indicates that most American women do not eat a healthy diet when they are pregnant. This is something we see in clinic on a regular basis. It is worth noting however the many women believe that they are eating healthy diet, even though they are not. These are well-intentioned people who have been taken in by advertising or who are victims of their busy schedules. Unless the physician or nurse midwife takes a detailed dietary history they will not know how their patient is really eating. Merely asking the person whether or not they eat healthy is not enough. People generally say they eat healthy and people generally say they are active or fit. That is because they believe it to be the case. Until people have objective definitions in front of them they cannot reliably answer these questions. Doctors take important shortcuts if they do not delve into a reasonable amount of history taking detail. When patients get specific explanations of exactly what we mean when we say "eat healthy", they're much more likely to do so. One of the problems of course, is that many doctors do not know precisely what it means to "eat healthy”. 

Four prior commissioners of the Food and Drug Administration (FDA) have produced a joint letter warning Congress about the legalization of importing drugs from other countries. Certain members of Congress have indicated that they would support this in an effort to reduce drug costs. In particular, the commissioners emeriti have warned against counterfeit, substandard and contaminated medications, since standards from other countries may not be adequate.

Pregnant women with HIV have a better chance than ever of avoiding transmission of their virus to their children. Preventive treatment including retroviral drugs given in pregnancy account for this progress.

In other viral news, a new gel treatment for genital and perianal warts is under study. These are caused by the human papilloma virus. The treatment is based on nitric oxide. Stay tuned for more on this nascent therapy.

Also regarding human papilloma virus, the American Society of Clinical Oncology has issued global statement regarding the primary prevention of cervical cancer. They recommend that all girls ages 9 to 14 receive two doses of the human papilloma virus vaccine also known as Gardisil. In the last few years there has been definitive evidence that Pap smears combined with this vaccination reduced the incidence of cervical cancer. The vaccine is also available for boys of the same age group.

Yet another study has demonstrated that exercise during pregnancy is safe and beneficial. This most recent study published in the Journal of the American Medical Association is meta-analysis of studies with more than twenty five hundred pregnant women. This is in line with ACOG (American College of Obstetricians and Gynecologists) recommendations which indicate "women without major medical or obstetric complication should get at least 20 to 30 minutes of moderate intensity aerobic exercise… on most days of the week."

In the concerning department, the FDA (Food and Drug Administration) has now linked anaplastic large cell lymphoma (ALCL)  to breast implants. This disease is a rare malignancy in the immune system which is statistically linked to breast implants, particularly those which have a rough versus smooth surfaces. The FDA has issued a statement indicating that women with breast implants have a very low but increased risk of developing ALCL compared to those who do not have breast implants. It is worth remembering that a statistical link does not prove causality. Concerned patients should speak to their plastic surgeon about this matter.

In other cancer news,  new research indicates that breast cancer gene testing is underutilized in America. A simple history in the caregiver’s office can identify whether or not a patient is at high risk of having abnormal genes, i.e. breast cancer gene mutation, or BRCA. Women with two first degree relatives such as a mother or sister are at high risk for having an abnormal gene and should explore the possibility of testing. Those patients with close relatives with any cancer should make sure their caregiver is aware of it. 

New research coming out of the Cancer Genome Atlas Project and the Cancer Research UK Database have indicated that only about a third of cancers are due to a special inherited genetic mutation. This means that two thirds of cancer-causing mutations arise spontaneously and are not able to be inherited by one's children.

We conclude with the good news department. A new device called the Alexis retractor is being tested across the world. Preliminary indications in Europe show reduced infection rates and reduced post operative pain after Cesarean section. 

Finally, many States are following another European lead and introducing baby boxes. Currently Americans put their newborn babies to bed in a wide variety of ways. However, clear research shows that the incidence of SIDS (sudden infant death syndrome) can be significantly reduced if babies are placed on a flat surface on their backs, head uncovered, in a special sleep sac or a one piece sleeper, and WITHOUT any blankets, swaddling, bumpers, padding or or toys. The sheet on the firm mattress should be fitted. The baby box programs are designed to provide all this teaching as well as an actual  baby box and mattress. For those who are not aware, the baby sacs are like insulated zip overalls with a closed bottom, which allow babies to move. They are not to be confused with swaddle wraps, which are also associated with SIDS. Babies typically wear a shirt and a diaper with it. Very cute inexpensive ones can be obtained at Ikea, Target and online. 

Here is an authoritative link from the NIH for those who want to learn more: 

https://www.nichd.nih.gov/sts/about/environment/Pages/look.aspx

Our photo for today's post was brazenly lifted from the pages of the National Institute of Health linked above. 

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