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

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

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

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

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

On to medical news.

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

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

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

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

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

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

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

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

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

Medical Monday: breaking news from the world of obstetrics and gynecology

Here is some good news on the Zika front. It is been over 45 days without anyone in South Beach Miami contracting Zika virus in from a local mosquito. For this reason Governor Rick Scott has lifted the Zika zone warning in South Beach. Miami's Little River area was cleared earlier this week. Officials are still warning pregnant women to avoid the entire area and to protect against mosquito bites.

Five babies in New York City have been born with Congenital Zika Virus Syndrome. Interestingly, eight other infants have tested positive for Zika virus in New York City but have not shown evidence of the syndrome.

Zika remains a threatening and somewhat mysterious disease. A woman in Columbia has been the subject of study because her Zika virus infection lasted so long. Normally the disease is mild and runs it's course over a few days time. However the pregnant patient in question tested positive for Zika for 107 days after the onset of symptoms. Because of this, researchers speculate that the baby may serve as a reservoir for the virus. When this baby was ultimately born at 37 weeks gestation, it did indeed show microcephaly, indicating that it had been infected by Zika as well. However, interestingly, the baby tested negative for Zika in serum, urine and cerebrospinal fluid. Even though the Zika virus had done it's damage as evidenced by the babies microcephaly, the baby had already developed Zika antibodies prior to birth.

Three experimental Zika vaccines are under development. One of them has finished the first round of human testing then will move to phase 2 trials in the first quarter of 2017. Four or five more Zika vaccines are expected to begin development next year.

Perhaps the most important comments about Zika came from a Dr. Antonio Crespo the Chief Quality Officer at Phillips Hospital at Orlando Health. Writing in the contributors blog for The Hill, Dr. Crespo indicates the northward migration of Zika virus is probably the first of many such diseases. He cautions that the nation's response to Zika and the outcomes that we will see should be studied in preparation for future such threats. 

In other news, youngsters are not the only ones skipping their vaccines. Older people are more vulnerable to influenza, pneumonia and shingles. Vaccines are available for all of these things. 

Young people between the ages of nine and 26 should be vaccinated against the human papilloma virus (HPV). However, vaccination rates in this case fall short of ideal. A new study indicates a counterintuitive result. It turns out that short conversations between Dr. and parents or Dr. and patient are more likely to result in vaccine utilization than are long conversations. Researchers have interpreted this finding by speculating that long conversations raise more doubt than short ones. I would speculate, by contrast, that when a patient shows reluctance or asks questions, the conversation goes longer. Such patients who are disinclined to vaccinate to begin with are less likely to vaccinate even after the conversation takes place. I think the conversations between caregivers and patients need to be as long as they need to be and they certainly very greatly between patients and circumstances. I'm going to file this in the chickens and eggs category.

Also in the chicken and eggs category is the following study. It turns out that researchers have identified a link between pubic hair grooming and sexually transmitted infection (STI) risk. There is a direct relationship between pubic hair grooming and sexually transmitted infection risk. In fact, there is nearly 4 times the likelihood of having an STI among those who are groomed as infrequently as weekly. I ask myself, is this because grooming inherently makes the tissues more vulnerable? Honestly I doubt this. Do those who groom have more partners? Do those who have more partners groom more ? Which comes first?

Officials from the incoming Republican administration have reiterated their plans to repeal the Affordable Care Act (ACA). However reporting on more detailed discussions among leader elect reveals a realistic understanding that this change might take two or three years. They even have a name for their strategy: "repeal and delay".

Meanwhile the American Hospital Association has warned the new administration that "repealing the affordable care act could cost hospitals $165 billion by the middle of the next decade" And "trigger an unprecedented public health crisis". 

Similarly the Urban Institute has reported that 30 million people stand to lose coverage if the Affordable Care Act is repealed without putting anything in place to replace it.

Many women are aware of the likelihood of some form of curtailment of the ACA, particularly of reproductive health care coverage. A Kaiser study indicates that many women are flocking in to obtain contraceptives, including longer acting methods to see them through a longer period of time.

In the good news department, the Senate has passed a landslide vote ratifying the 21st Century Cures Act. This is a $6.3 billion measure to "increased federal support for medical research, mental health care, and controlling the opioid epidemic". The bill had strong bipartisan support and cleared by a vote of 94 to 5.

We will finish with a fantastic study on the relationship between optimism and health.The Nurses Heath Study is a very long running and large study of 70,000 women between 2004 to 2012. It is been mined for all kinds of research. In this most recent study released out of Harvard Public Health, those with the most optimism had 40% lower risk of heart disease and stroke compared to those with the least optimism. Optimism was linked with lower inflammation and healthier biomarker levels including lipid levels. Researchers concluded that the correlation between optimism and longevity was the result of optimistic people having healthier lifestyles such as diet, sleep patterns, and other factors.

Stay tuned for more breaking 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

By a margin of 89 to 7, the Republican dominated Senate voted to move forward and develop a bill to avert a government shutdown and fund the Zika crisis. So, yes, they approved a bill to approve a bill. 

Meanwhile the public ought to be aware that money has been taken from other important sources to fight Zika. The Federal Government has taken money away from funds to fight malaria, tuberculosis, ebola, and more recently, and tragically, cancer, diabetes, heart disease and mental health. Some of this money will be going to continue the development of a zika vaccine. 

The CDC ( Centers for Disease Control) has spent another 2.5 million for Zika lab testing. Getting definitive Zika test results can take 4-6 weeks in the current system. 

The news has prominently publicized the well delineated areas in Miami where the Zika virus is active. However many experts believe Zika is active all around the Gulf Coast. Experts including some within the CDC believe other Gulf cities are experiencing Zika outbreaks without realizing it since the testing is taking so long. 

As of several days ago, Puerto Rico has  20,000 documented cases of Zika, including close to 2000 pregnant women. 

In the not surprising department, those with no out of pocket expense for birth control have fewer unplanned pregnancies. 

Also in the interesting but not surprising department, stress may erase the effects of a healthful diet. It also decreases one’s chances of getting pregnant, especially if it occurs near the time of ovulation. 

About 1 in 5 or 20% of all women will suffer from depression and one point or another in their lifetime. That percent is higher in the 40s and 50s. 

Last week I reported on the appalling maternal mortality rates in Texas. The Institute of Heath Metrics and Evaluation has released data indicating that the United States as a whole has suffered the same trend. We are now considered an outlier among rich nations in this regard. Some of this is attributed to obstetric ( pregnancy) complications arising out of increased background rates of obesity and diabetes, whose rates have skyrocketed in this country. 

In the probably good news department, mammograms received by Medicare beneficiaries increased in the first three years after the enactment of the Affordable Care Act. It is a bit too early to tell if this will result in a reduction in morbidity or mortality from breast cancer, but I am betting that it will have. 

In the definitely good news department, it has now been established that the incidence HPV related anogenital warts is on the decline due to the HPV vaccine. This is true despite the woefully low utilization of this safe and effective vaccine. The HPV vaccine is meant for young people, both boys and girls from ages 9 to 26. 

In the phenomenal and amazingly good news department, Mark Zuckerberg, founder of Facebook, and his wife, Pediatrician Dr. Priscilla Chan, have pledged 3 Billion dollars over the next years to essentially cure or manage all disease by the end of the century. If I had not just attended Stanford Medx this last week and been heartened by all the new technologies and methodologies that people all over the world are bringing to bear for these goals, I would have thought their goal unrealistic. But now I believe it is simply a matter of time.. and money. 

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

Zika again dominates the news in Ob/Gyn. As of Friday, a storm system was approaching the subtropical state of Florida, where 43 are confirmed infected with the Zika Virus. Authorities think the storm may help spread the virus which is transmitted by mosquitos and sex. Meanwhile, the CDC (Centers for Disease Control) does not have enough Zika testing resources. I myself experienced this last week when I was told a specimen we sent to the CDC would take “weeks” to result. We Ob/Gyns are not able to effectively work in time frames like this, and so this week we will have being having some words with the powers that be. 

A new study published in Radiology has shown that Zika can cause many other brain defects besides microcephaly. They have thus far identified 8 major defects. One of the most common was ventriculomegaly, or enlarged ventricles and thinning cortex. 

Thus far the Florida outbreak has been clustered around Miami. However Thursday, an isolated case showed up some 250 miles to the north in Tampa Bay, Pinellas county. It is still unclear how this occurred. On the bright side, modeling done by researchers at the University of Florida has indicated that the total outbreak should limited to under 400 individuals or less, considering all the southern states. They also believe winter will stop the outbreak, which would then recur next summer the same way. It is estimated that 20,000 pregnant women in the Miami area are taking extreme measures such as confinement indoors or moving to avoid Zika infection. 

NewYork officials are noting that travel restrictions to Zika affected area not being properly observed by pregnant or pre conceptual women. How do they expect people to take these restrictions seriously when they gave full sanction to people traveling to the Olympics in Rio? 

Dr. Kristyn Brandi writes that Zika is spreading more rapidly than anticipated in Puerto Rico, and that resources of information and contraception are not adequately available. 

The chair of ACOG (American College of Obstetricians and Gynecologists) has written a strongly worded piece which has criticized how politics has prevented the funding of an adequate Zika response. He and co author, Dr. Didi Saint Louis of Morehouse School of Medicine have called for the full funding of comprehensive reproductive health care to allow women to avoid or delay pregnancy. They have called on Congress to reconvene to deal with this. 

In the non-Zika news, HPV virus is in the spotlight. This virus is responsible for abnormal paps, and cervical cancer, among other things. It has an effective vaccine which is meant for young people between the ages of 9 and 26. However parents remain wary to give it to their children. Research is being done regarding the prospect of putting it on the list of already mandatory vaccines which must be done before school entry. Surveys show that parents would accept this as long as there was an opt out provision. As of 2014, only 40% of girls and 20% of boys were vaccinated. It will be interesting to see if there will be those who decline the Zika vaccine once it gets developed. 

Breastfeeding is practiced by about 80% of all American women when they leave the hospital. However less than a third keep it up for the recommended time. The American Academy of Pediatrics has recommended that infants should get nothing but breast milk for six months, and that breastfeeding should continue one year. 

Co-sleeping beyond six  months has been shown to produce significant stress on women. Researchers at Penn State note this may be related to fragmented sleep and less time with partner. Perhaps this is related to the falloff in breastfeeding. 

In the everyone-already-knows-this department, researchers at UCLA have discovered that menopause accelerates aging. In all fairness, what they have determined is that methylation increases in menopause, accelerating cellular aging about 6 %.

And in the we-should-have-known department, the “ baby simulator” program in high schools designed to deter teen pregnancy may actually be encouraging it. Graduates of the program with over third more like to have a teen pregnancy. 

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

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

We continue to learn more about the way Zika virus affects babies.  It turns out Zika can affect babies late in pregnancy. In fact, Zika related brain changes may not become apparent until months after they are born. The reason for this is that the baby continues to grow all except the brain, which does not. 

Zika also appears to produce joint deformities. This may take the form of curved or crooked legs or arms. 

We are also learning more about the sexual spread of Zika. Men may be able to spread Zika for longer than six months, longer than previously reported. The Obama administration has shifted another $81 million dollars from the Department of Health and Human Services to continue development of a Zika vaccine.

Florida officials continue to deal with more local spread of Zika in the Miami area. Aggressive spraying programs are underway to reduce mosquito populations. Additionally there are plans to release genetically modified mosquitos which will mate with the natural Aedes Aegypti and render their offspring sterile. This has reportedly reduced the Aedes populations in Brazil, Panama and the Cayman islands by 90%. 

Various commentators are now starting to focus on how abortion politics played a role in the Congressional failure to develop a funding plan for Zika. It continues to play a role. Since Zika produces grave birth defects in babies which usually live, it is a condition for which some women might chose abortion. Marc Rubio (Republican from Florida)  has come out this week saying that he “doesn’t believe a pregnant woman infected with the Zika virus should have the right to an abortion-even if she had reason to believe the child would be born with severe microcephaly. “ A recent STAT Harvard poll indicates that 59% of Americans believe that a women should have a right to end a pregnancy after 24 weeks of testing showed a serious possibility that the fetus had microcephaly caused by the mother’s Zika infection. The same poll also showed most Americans are unaware that Congress left for vacation without securing Zika funding. Meanwhile women and health care workers in Puerto Rico are trying to overcome historical cultural barriers to contraception in a territory at very high risk for Zika. 

The Obama administration has shifted another $81 million dollars from the Department of Health and Human Services to continue development of a Zika vaccine in Phase 2 trials. Stage 1 is preclinical development, in labs and on animals. Stage 2 is when the vaccine is first tested on humans. This second stage proceeds first to study safety and then, if it passes, to effectiveness. 

In other news, ACOG (The American College of Obstetricians and Gynecologists) has updated its opinion on home births. New data has prompted the revision. The new Committee Opinion Document states that babies are twice as likely to die and more than three times as likely to have seizures soon after birth, compared to hospitals. I would point out that this is case even when most home birth attendants chose low risk patients to deliver at home. I would also point out that the literature on which this is based only reported on two of the worst outcomes, death and seizures. The many lesser but still significant complications like subsequent learning disability remain unquantified. 

In other sobering news, the US maternal death rate has increased. Between 2000 and 2014, the death rate increased from 19 per 100,000 to 24 per 100,000. It is unclear as to why though more thorough reporting methods are believed to account for much of the increase. However some of the increase is real, and authorities speculate that it is because women having babies are older and more likely to be obese than in the past. This gives rise to more complications such as maternal hypertension and diabetes. 

Many including me are cheering the relaxation of rules surrounding marijuana research. It is currently being used legally in several states without evidence of its effectiveness. New studies should be able to “ weed” out the legitimate from the bogus uses of which I suspect there are many. 

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

Florida has an ongoing Zika outbreak in a Miami neighborhood of Wynwood. The CDC (Centers for Disease Control) has confirmed local transmission there for several days. In response, Florida Governor Scott has pledged that Zika tests will be free for all pregnant women. Apparently there is a Zika test kit shortage and physicians' offices have waiting lists for their use. Pregnant residents in Florida are beginning to curtain their activities and travel in their home towns. Other women are delaying pregnancies, freezing eggs for later, or leaving the area when pregnant.

California has the seen the first births of Zika infected babies. These cases have been from mothers who travelled to Zika affected areas. 

Texas Medicaid has decided to cover the cost of mosquito repellant to women of reproductive age. 

President Obama has asked Congress to reconvene early to work on Zika. Meanwhile the CDC has itself provided an additional  $16,000,000 to 40 states to combat Zika. They had already given $25,000,000 in July. This comes out to and additional $400,000 per state on average and does not sound like much in the scheme of things. The money is meant for developing programs to collect and track data on both the mothers and the babies affected by Zika. I have to say that when money is short, as it is, that making the choice to fight the virus with information seems like the wisest first step. When more money comes in, which hopefully it will, it can go to bigger ticket items like better mosquito control and vaccines. Current mosquito control techniques are poor against the mosquito since it can live indoors or outdoors, can hatch in a tiny amount of water, can bite multiple people, and has eggs which can last for months. 

The CDC has clarified that all pregnant women need to be assessed for risk of Zika. They do not necessarily need to be tested, but their travel history and the travel history of their partner or partners should be assessed. 

The CDC has reviewed data which show that the use of Long Acting Reversible Contraceptives (LARCS) is low in Zika affected States. LARCS are among the most effective means of contraception and considered safe for most all women. 

Finally in encouraging Zika news, The Journal Science has reported that three different Zika vaccines have worked “to perfection” in rhesus monkeys. Each of these vaccines works by a different mechanism to stimulate the immune system to combat the virus. One vaccine uses dead virus, but the other two use two different viral DNA subunits to stimulate an effective immune response. 

In other news, the CDC has reported that adults across the board are about 15 pounds heavier than they were 20 years ago. Boys and girls weigh more as well, though boys' heights have gone up. Girls' hights have stayed the same. The average 5’4 woman weighs 168.5 pounds, which qualifies as a BMI (Body Mass Index)  of 29, nearly going from overweight to obese at a BMI of 30. Normal BMI is somewhere between 19 and 25. See the NIH (National Institute of Health) BMI calculator HERE: 

http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Vitamin D is in the news again. Apparently Vitamin D levels decrease by 20 % after cessation of oral contraceptives (OCs). This has potential consequences not only for women but for any pregnancies that ensue. Because of his new finding, it might be appropriate to check Vitamin D levels after OCs are stopped or before pregnancy is considered. 

In the close-to-science-fiction department, we turn our attention to telomeres. What is a telomere ? Tasciences.com quotes Blackburn and Epel from the Journal Nature, saying that

“ Telomeres are the end caps at the end of each DNA strand that protect our chromosomes, like the plastic tips at the end of shoelaces. Without the coating, shoelaces become frayed until they can no longer do their job, just as without telomeres, DNA strands become damages, and our cells can’t do their job.”.

Telomere length is therefore a marker of cell aging. Cell lifespan shortens as telomeres shorten. We are born with a certain telomere length. The majority of telomere shortening occurs in the first 4 years of life. Little is known about why telomeres shorten. It turns out that early exclusive breastfeeding for just 4-6 weeks is associated with longer telomere length at age 4-5 years. This may have consequences for long term health and overall longevity. The CDC has reported that just about half of all postpartum women are breastfeeding at 6 months. Less than a third were still breastfeeding at a year. The American Academy of Pediatrics has recommended that women breastfeed for at least 6-12 months. 

The Journal Pediatrics reports that “ Breast milk give a boost to premature babies mental and physical development.” Those who received breast milk during the first 28 days of life had measurably better IQ, math, memory and motor skills at age 7 compared to those who received less breast milk. I will comment that to pump breast milk for 28 days while your premature baby is in the NICU (newborn ICU) requires a high level of dedication. Perhaps it is difficult to factor out this maternal dedication as a factor in the better outcomes of the breastfed babies in their study.  These breastfeeding mom’s of preemies either are or become some of the most dedicated and resourceful moms out there, due, at least in part, to what they have to deal with. Maybe the better outcomes are born of the mother’s overall dedication. Hat’s off to you…. dedicated NICU moms. 

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