Medical Monday : Two Week Catch Up

Happy Easter and Happy Passover. We have two weeks to cover. Thanks for reading ! 

Policy News

Much of the National Health Policy News this week deals with contraception and reproductive health. Can anyone remember any time in this or any other country when these private matters were ever so much on the national stage ? The politically conservative aspects of my nature questions why this degree of government intervention in private lives is necessary. My medical qualifications and medico-legal experience cause me to classify some of this meddling as practicing medicine without a license. 

Title X is a federal grant program whose purpose it is to promote positive birth outcomes and healthy families. It provides grants for family planning and health services. So here’s my first question: Why is it not run by health care professionals ? Trump administration officials are now contemplating new wording which would add additional criteria for clinics to receive Title X funding, namely the provision of primary preventive services. Sounds good right ? Well many clinics offer only reproductive health services. These clinics would have to expand or close. This measure seems like just another way of closing family planning clinics.  Now whether pap smears would qualify as preventive health is unclear, or whether paps would be classified as reproductive health, I don’t know. 

Texas is challenging the federal government’s withholding of funds for its family planning programs. They were withheld several years ago based on the fact that these providers, many of them through Planned Parenthood, also provided abortions.

Planned Parenthood itself is challenging the Federal Government on its withdraws of funds from the teen pregnancy program. Between this and two other plaintiffs, the Department of Health and Human Services has partially and temporarily restored some of the funding until litigation can be completed. 

Idaho has failed to solve the problem of insurance for those whose income falls between Medicaid and the Affordable Care Act coverage criteria. A proposal called Plan First Idaho would have funded family planing services for women in the gap. My question is, what rocket scientist designed the State’s the two programs such that their income qualifying criteria do not meet seamlessly ? This is a problem of their own making and it needs solving. Republicans in the Idaho House stalled this measure. 

Idaho Governor “ Butch” Otter has approved a measure by which prospective abortion patients must a told about “ abortion reversal” a procedure that does not exist. Additionally, he has signed legislation which will require abortion providers to collect personal and demographic information which, in de-identified form they intend to make public. I don't know what they think this will accomplish, but I have a feeling it may backfire, since they will be able to see how many and how diverse a group of women utilize the procedure.

The Supreme Court is hearing a case between the State of California and a group of "crisis pregnancy centers”, an actual chain of 130 outlets run by “ The National Institute of Family and Life Advocates”. These centers are anti-abortion counseling facilities, however they are licensed as family planning providers. California has a law requiring that all licensed family planning facilities to post notices of the availability of free or low cost birth control and abortion services and they are challenging it. They are arguing that this posting requirement violates their free speech.  So far the Court has expressed concern that these clinics not be singled out from other clinics. California has argued that their staff, many of whom are not medically qualified, present medical misinformation as truth, all to the end of dissuading patients from abortion. Apparently theses non-credentialed counselors actually wear white coats. 

Along with the opioid epidemic has come a hepatitis C epidemic. Kentucky, having seen a surge of the disease, has passed a law now requiring all pregnant women to be tested for it. Hepatitis C used to be very hard to treat. However, patients have much more hope nowadays due to the availability of effective therapy. 

Missouri has expanded Medicaid for pregnant women in drug abuse treatment. Their continued coverage will be contingent upon them staying in treatment, and could under those conditions, be continued up to 12 months.  

And now for more of a purple to blue state review:

Florida is considering a bill requiring HPV (human papilloma virus) vaccination to be required as part of the vaccinations required of children attending public school. Human papilloma virus causes multiple illnesses most notably cervical cancer and genital warts, and the vaccine has not demonstrated any conclusive evidence of harm.

It is interesting to note that physicians are not prescribing HPV vaccine equally for female and male children. Doctors recommend the vaccine twice as often for girls as they do for boys. This puts the boys at increased risk for HPV disease, and puts all their future partners at increased risk too. 

Mississippi passed a law banning abortion after 15 weeks Of course this is unconstitutional based on Roe V. Wade which is still on the books. A Federal Judge over turned Idaho's ban. 

New Hampshire has passed a bill which will allow pharmacist to prescribe birth control. No doctors visit will be necessary. The medical establishment has concluded that vast majority of the birth control methods are safe for the vast majority of women. They certainly are when compared to pregnancy for those same women. Authorities believe this will eliminate yet one more barrier to contraception. Utah signed a similar law into place earlier in the week. 

On the other coastline, the state of Washington now has a bill that will require insurance to cover contraception, abortion and maternity care. Additionally, after the first of the year, all contraception has to be co-pay and deductible free. This includes voluntary sterilization. 

The new budget has failed to shore up the ACA ( Affordable care Act) marketplaces. States will have to tighten their belts and work on their budgets one by one. 

ProPublica has reported that the “US is the most dangerous country in which to give birth”. States all over the US are creating programs to quantify and address the problem of maternal morbidity and mortality, even as the Federal government under Trump is dismantling reproductive and maternal health care piece by piece. 

Do you ever get the feeling that the various States in America are becoming like the countries of the European Union with different values, cultures budgets and laws ? 

Medical News: 

Obstetrics: 

Striking research findings presented at Lancet Global Health conference have shown that the death risk is double among pregnant women who are anemic compared with those who are not. The lead study author also found the correcting anemia is not a sufficiently high enough priority among physicians. 

Research presented at Diabetes UK conference has shown that excess weight gain incurred during pregnancy by  gestational diabetics is associated with greater risk of cesarean section.

Women who exercise in pregnancy have shorter labors. This interesting news was published in the May issue of European Journal of Obstetrics and Gynecology and Reproductive Biology. The study group attended a professionally led session of moderate exercise three days per week. Labor was shortened about one hour, mostly in the first stage, or dilating phase. ACTIONABLE ! 

Children who were breastfed exclusively for at least 6 mores were less likely to become overweight to obese than their counterparts. The conclusions were drawn by analyzing over 38,000 records from children South Korea. The finding were presented at the Endocrine Society Annual Meeting. 

Gynecology/General Medical News: 

There may be a male birth control pill on the horizon. Research at the Endocrine Society's annual conference has presented information on a new male birth control pill called DMAU. It contains androgen and progestin,  which is analogous to the contents of the female birth control pill, estrogen and progestin. Once daily tablets appear to be safe and effective. No period required. 

Menopause and aging in general is characterized by a loss of muscle mass and bone density as well as the deposition of fat. As suspected, the Mediterranean diet may have a positive impact on bone mineral density and muscle mass in postmenopausal women. The Mediterranean diet emphasizes the eating of high quality protein, large volumes of fruit and vegetables, healthy fats such as olive oil and a modest amount of complex carbohydrates such as whole grains. As a whole, the diet is lower in simple carbohydrates than the typical American diet and is also higher in protein and antioxidants.

There are now over 400 cases of a rare lymphoma which are linked, epidemiologically, to breast implants. Breast implants are not new. Lymphoma is not new. However our ability to collect and parse data is better than it has ever been. The FDA it's taken this ability and created a meaningful database for this type of information. While an association between breast implants and this rare lymphoma is being established through data collection, a causality between the two is not necessary implied. That said, nothing is more likely to lead us to understand the causes of this problem than amassing quality data about it. 

Federal funding support for cancers is disproportionately low for gynecologic cancers if you rank them by lethality. Cancer of the ovary and the uterus ranked near the bottom of the funding list. Contact your elected officials ! 

A new modification of the current device used for pap smears can identify cells from endometrial (uterine lining) and ovarian cancer. The investigational PapSEEK uses an analysis of 18 genes and analysis similar to that used in prenatal screening for Down’s syndrome to identical the genetically abnormal cancer cells. THIS IS SO COOL ! 

A new study on postmenopausal hormone therapy has shown that it does help maintain thinking and memory skills. This is the case IF it is initiated shortly after the onset of natural menopause. This study was presented in the Journal Neurology and was a high quality randomized controlled trial of 75 women between the ages of  42 and 56. 

In my mountain state, there is not a great deal of sunlight or seafood. As a result we have a high prevalence of vitamin D deficiency. New research indicates that vitamin D deficiency increases a post menopausal women’s risk of metabolic syndrome. Metabolic syndrome includes the unholy triad of diabetes, high blood pressure, and abnormal serum lipids ( cholesterol and triglycerides) which together increase cardiovascular risk. Vitamin D levels are checked by a simple blood test. Ask your doctor about this ! 

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

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

POLICY NEWS 

Good Monday. The media continues to focus on the Trump administration’s Department of Health and Human Services (DHHS) Policy of promoting “ abstinence only” to reduce teen pregnancy rates. Physicians like me deplore this scientifically disproven strategy. My governing body, ACOG, the American College of Obstetrics and Gynecology espouses and promotes access to evidence based contraception as fundamental to women’s health care. 

However there is more to the story. There is nothing wrong with the choice of abstinence. There is no problem if a patient choses abstinence as her birth control method. But to offer abstinence “only” in the context of a health care or teen pregnancy prevention setting, is folly. Similarly, there is no problem with discussing the “ benefits of avoiding sex” as the administration proposes. Furthermore, health care providers in particular would be happy to support the DHHS in avoiding the normalization of “ sexual risk behaviors”. I am assuming that they mean high risk sexual behaviors. All of this would be fine if it were not for the deal breaker clause “ abstinence only”, and, oh yes, defunding those who do not march in step with it. The NY Times has published an editorial exposing the shift to Title X funding priorities to abstinence only programs under the direction of Valerie Huber, a longtime advocate of abstinence only birth control. 

There’s more. The latest healthcare budget proposal not only seeks to redirect Title X funds, it also seeks to defund Planned Parenthood and other family planning programs altogether, as well as scrap, not just reduce, the budget for the Teen Pregnancy Prevention Program. Democrats plan to block this budget proposal. ACOG has stated that half of all pregnancies are unintended and this is a major public health problem.  41% of teens have had sex in high school. 

Scrutiny of drug prices is increasing in this administration. FDA administrator Scott Gottlieb as criticized drug pricing constructs used by the big drug companies which result in large OOP ( out of pocket expenditures) for patients. He was quoted as saying “ sick people aren’t supposed to be subsidizing the healthy”. Of course this sounds very pro-patient, but the bottom line is that the government current insures a great many people through Medicare, Medicaid and the Affordable Care Act, and it wants to pay less for drugs. 

Many of you know that I believe data should be free. Accordingly, I believe patients should have access to all their medical information and it should be complete, digital and portable to other providers. The Trump administration has indicated an interest is facilitating this trend. While access to complete digital medical records has many patient and caregiver advantages, it also makes it easier for insurers and regulators to determine eligibility and reimbursement, or lack thereof. For the time being, I think I’d trust Amazon, Google or Apple with my data more than I would trust a government medical database. Although theoretically, de-identified data would make it possible to do a lot of helpful population based research like they do in the Scandinavian Countries which have Universal Health Care. 

Work requirements for Medicaid recipients sounds like a good idea. However, Medicaid recipients are often pregnant single mothers. Arkansas has approved such regulations. Alabama is examining the idea. Children’s advocates are concerned that work requirements will take these parents away from children, while providing no daycare to supplant them. Single unemployed people on Medicaid rarely can afford daycare or even transportation to and from a job. Why is this not obvious ? My idea: Given these people a computer with internet access and require them to take an online class toward a certification. Make passing required and grades count. This could be done from home and the need for a car or daycare would go away. Maybe I will write my elected officials. 

The Trump administration wants to test work requirements to see if they improve patient care or reduce costs. ( Who decided those endpoints ? ) However the GAO (General Accounting Office) has asserted that such analyses in the past have not been rigorously conducted, and their results have-not been published, limiting their utility.

I thought Republicans wanted less government intrusion into our lives. Senate Bill 1394 in Arizona would require hospitals or clinics to report if a woman had an abortion and to report the REASON she had it. Seriously ? As if these reasons weren’t personal and complicated and no business of our elected officials ? It would also require that hospitals require reporting to the State in the event of any abortion complications, though this is not the case for complications of any other procedures. Arizona ACOG has come out in force against this. 

MEDICAL NEWS

Preterm birth has been an unmitigated scourge in the US. It is twice as much so for women soldiers recently returned from duty. Preterm birth is poorly understood, but its many associations point to various forms of stress, such as socioeconomic deprivation, racism and abuse. I interpret this to mean anything that makes the women’s body a hostile environment for the fetus. It makes sense that a military environment would meet this criteria. 

On the other hand, exercise is an entirely different kind of stress, a good stress. Recent research has confirmed not only that pregnancy women may exercise, but that they may safely exercise in warm weather. They may also take hot baths and short saunas. That said, it is critical that patients considering these activities check with their doctor first as there may be caveats. 

Nurx. My new company crush. Go to Nurx.com. This is a San Francisco startup offering doctor prescribed brith control online, with or without insurance. It currently operates in 18 States and they are looking to hire more docs in more states. Teens are welcome. 

In the “ olden days”,  male medical students generally entered surgical specialties and female medical students entered non-surgical specialties. The crossover came with Ob/Gyn which is surgical. Women had a natural affinity for the field, and patients almost always prefer them. When I entered the field, it had already become half and half. However, now, 25 some years later, only 17% of Ob/Gyns are men. Male doctors are worried about getting into the field, and women in the field are worried about the demonstrated historical monetary devaluation of a field once it is predominantly filled by women. The big picture is this: Ob/Gyns are in short supply and the supply is growing smaller by the year. We should welcome and properly reimburse any docs of any gender willing to take on the vicissitudes of the profession. New data suggests bolstering the ranks of Certified Nurse Midwives could also help to address the shortage of skilled Obstetrics care providers, and together improve our deplorable maternal morbidity and mortality statistics.  

Good news ! A new study has indicated that probiotics and fish oil in pregnancy are associated with reduced allergies and eczema children. The study is of very high quality since it is a meta-analysis, a compilation of 19 other high quality studies onto same subject. That may warrant a policy change in the office. 

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