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

Good Monday.

First the Zika news. Dr. Anne Schuchat, the principal deputy director of the CDC (Centers for Disease Control) has stated that "everything we look at with this virus seems to be a bit scarier than we initially thought”, noting that "the virus has been linked to a broader array of birth defects throughout a longer period of pregnancy, including premature birth and blindness in addition to the smaller brain size caused by microcephaly”. Additionally, she announced that "the mosquito that carries the Zika virus is present in 30 states, more than twice what officials originally thought. The maps at right indicated the territory of these mosquitos. Click on the image to take you to the CDC site on the subject. 

The White House has shifted nearly $589 million or over half a billion dollars in leftover Ebola funds in order to fight the Zika virus. This comes well short of the $1.9 billion that has been requested by the National Institute on Allergy and Infectious Diseases. Dr. Anthony Fauci, the Director of this organization has announced that he will also be diverting funds from other areas in order to close the gap on funding what he views as critical efforts.

Florida leads the nation in number of Zika cases which last week totaled 84. Zika cases in Florida account for 23% of all cases in the states. Mosquito activity is of course greater in warm climates. It is expected that when the rest of the southern part of the country achieves these temperatures that Zika transmission will increase. The CDC has reiterated that insect repellent containing DEET are safe to use at any stage of pregnancy.

Zika is now associated a third clearcut disease entity. We already know a fair amount about microcephaly which is incurred by the fetus when a pregnant woman acquires a Zika infection during pregnancy. We also know about Guillain-Barré syndrome, post viral paralysis, which can effect of minority of people after a Zika infection. Researchers in Brazil are now reporting that the virus may be linked to "an autoimmune disorder known as acute disseminated encephalomyelitis or ADEM. In this syndrome neurological symptoms could start right away or as long as two weeks later. 

New research from the CDC indicates that white women between the ages of 30s and 50s are dying at increasing rates. This is been attributed to poor access to healthcare in rural America. In related news, a new study from Delaware has indicated that women enrollees in their state Medicaid program outnumber men to 2 to 1. State officials are interpreting this as an indication of increased poverty among women.

California has expanded the care that pharmacists are able to give. Perhaps most significantly, they are now able to prescribe contraceptives without the patient having to visit to another caregiver. While three quarters of physicians in one poll do not support the dispensing of birth control by a pharmacist, the American Congress of Obstetricians and Gynecologists support this legislation wholeheartedly.

Delaware has modified its Medicaid policy to require that contraceptive costs be bundled with the hospital’s charge for obstetric care. The Governor of the state, Jack Markell, recently wrote an op-ed for the New York Times describing this change and indicating his belief that it would allow for better family planning. He also went on to argue that contraception is vital to prosperity. 

The Guttmacher Institute recently released a study showing that teen abortion and pregnancy rates have dropped to historic lows. Teen pregnancy rates in particular have been cut in half between the years 1990 and 2011. The teen pregnancy rate in 2011 was 52.4 per thousand and, also of interest, is nearly 25% lower than the rate in 2008.

That seems like plenty to think about this week. Stay tuned next week for more news from the amazing world of Ob/Gyn. 

Medical Monday: Weekly News Update in Obstetrics and Gynecology

It's a mixed week in OB/GYN news, as always.

A Swedish study indicates that women who are overweight or obese at the time of the first pregnancy are more likely to develop diabetes in the next decade or two of their life. The risk of increase is six times baseline.

The eighth circuit court of appeal in St. Louis Missouri has taken the position that forcing employers to cover the cost of contraception through their insurance “ violates the groups religious freedoms".

In other news in the war on contraception, the Congressional Budget Office has estimated that cutting off funds from Planned Parenthood for one year could "reduce healthcare access for about 390,000 people" and at least through the Planned Parenthood budget with sales tax payers about $235 million. They hasten to indicate that defunding the organization could result in"several thousand unplanned births that would drive up government costs elsewhere such as in the Medicaid budget which pays for 45% of all births in this country.

The Census Bureau reports that the percentage of people without health insurance dropped in 2014 to 10.4 % down from 13.3 % the year before.

In the department of general women's health the following finding is rather striking. When comparing the cost of institutional care for male Alzheimer's patients versus women's Alzheimer's patients the following is noted. The cost of caring for women with Alzheimer's is six times greater then for a man with the same diagnosis. This is because when man has Alzheimer’s, female family members put much more time and energy into their care, saving them from expensive institutionalization. The reverse is not true when male family members take care of women with Alzheimer’s.

In other gender gap news, the Journal of the American medical Association reports that the gender gap in academic medicine is alive and well. Despite the fact that half of all medical school graduates are and have been women for sometime, Men are 15 percent more likely to have the rank of full professor. It also shows that women generally do produce less reach her research than men, But that this may be due to lack of mentorship, institutional support, and most importantly research funding through research grants. According to the same study, men received over twice as much research funding from their employers for equipment and labs. Women researchers are also less likely to receive NIH grants than there male colleagues.

For some good news this week we will have to turn to the field of vaccines. The CDC or Centers for Disease Control found that about 90% of children under the age of three were vaccinated against the common disease entities in the years between 1994 and 2013. What did this do for us? The CDC estimates that this will have prevented 732,000 early deaths in United States alone.

Finally, also in the good news department, the flu vaccine may be more effective this year according to the CDC or Centers for Disease Control. It is estimated that it will be nearly 3 times as effective as last year’s preparation. Remember that even if the vaccine doesn't prevent flu entirely, it will decrease the severity of flu which is very important in children and other vulnerable populations.

Stay tuned for more news from the world of OB/GYN next week in Medical Monday.