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 this week is monumental. President Trump signed an “ executive order” which allows small businesses and individuals to buy cheaper less comprehensive policies which do not met the minimum ACA (Affordable Care Act) requirements. Critics have several issues with this legislation. First, it decreases money in the collective pot used to cover anyone with a catastrophic illness for which a large payout is required. Second, it will drive prices up disproportionately, hurting mostly older Americans. 

Perhaps more impactful is the Administration’s decision to stop making federal subsidy payments to insurers. It is effective immediately. The President has further said that it may continue subsidy payments if a bipartisan agreement is made on health care. This last bit may illuminate the whole issue. When I first heard this announcement about cutting of subsidies, I ascribed it to wholesale lunacy. However now I view it more as blackmail. Without subsidies, the insurers will either bail or fail. Then the economy will follow, according to many analysts. No administration wants this. A bipartisan agreement has been impossible to craft, thus far. However, opposition to this move, and even opposition to the President himself may cause a high degree of motivation to compromise. Leading Republicans have called for continuing payments to insurers. As you read this on Monday, I wager you will be hearing fierce objection from both sides of the aisle. 

Hot off the press is an announcement that the current Administration will allow health insurance sales across State lines. Many of us did not realize that health insurance is sold within a given state. Insurers and their plans must be approved within that State and must answer to that State's Insurance Commissioner. Trump and many other Republicans have endorsed this before. They have asserted that, through increased competition,  premium prices will drop across the board. However, the National Association of Insurance Commissioners has called this a "myth". They have warned that this will start a " race to the bottom" wherein Insurance Companies will choose more lenient State regulators. Such regulators would require less and less coverage to consumers in order to maximize profits. This would result in healthier people getting cheap policies that cover little, and everyone else needing standard coverage getting steep rate hikes to compensate for the insurance company's loss in revenue. 

Unbeknown to most of us, the insurance industry was the Wild West before the ACA came along. Most of us only knew about insurance in their own State. But, it turns out there were different levels of what was covered, different caps on out of pocket, and different limits to premium prices. That all got more standardized with the ACA. That standardization is now being deconstructed bit by bit by changes like this plan of selling across State lines. 

The Department of Health and Human Services has put forth a couple of deeply controversial issuances. They have issued new rules on contraception. Without data or authority they have stated that “ Imposing a coverage mandate on objecting entities whose plans cover many enrollee families who may share objections to contraception, among some populations, affect risky sexual behavior in a negative way.” Importantly, this sentence uses confusing syntax. The subject of the sentence is “ a coverage mandate”. The verb phrase is “would…affect” the object is “risky sexual behaviors”. Thus the gist of the sentence it, a coverage mandate would affect risky sexual behaviors. Perhaps they meant to say the following: contraception WHICH could, among some populations, affect risky sexual behavior in a negative way. I suggest this because they have taken this position before: that contraception promotes sexual activity, particularly teen sex activity. A mass of available up to date and well derived data indicate otherwise.  For example, no-cost contraception is associated with a decrease in the number of partners. Additionally, contraception is NOT associated in a rise in sexually transmitted infections. Available research data clearly show too that rates of abortion and pregnancy fell among teens, when no-cost birth control was provided. ACOG (American College and Obstetricians and Gynecologists) has voiced it’s objections to the weakening of the contraceptive mandate. They have shed light on the patently false claims of the Administration about contraception. Many States have sued the Administration over the weakening of the contraceptive mandate. 

The second controversial issuance by the Department of HHS, Health and Human Services, has been to define life as “beginning at conception”. It has done so through a strategic plan document. This draft reads “HHS accomplishes its mission through programs and initiative that cover a wide spectrum of activities serving and protecting Americans at every stage of life, beginning at conception.”. Defining life at conception is not arguable in scientific terms. That is because it is a belief. In fact, it is a religious belief. As such, one might ask whether including this language in the strategic plan document of the HHS violates the separation of church and state. Clearly this language was advanced by those whose religious beliefs preclude abortion. 

I do not believe there has ever been a time in history when government has been so intimately involved in matters pertaining to Obstetrics and Gynecology. 

Pap smear frequency is again becoming controversial. As usual, the minimalist and government funded USPTF ( US Preventive Services Task Force) has interpreted the available data to mean the need for less frequent screening. They seem to consistently overemphasize the harms of screening (extra false positives, extra office biopsies) and consistently underweight the harms, i.e. more cancer cases. ACOG, various other cancer organizations, and patient advocacy organizations, give less weight to extra false positives and biopsies, with more concern focus on catching cancer early. ACOG still states that paps and HPV testing should go together from 30 to at least 65 years of age, and that for an average risk patient. Smokers, for example, would be screened, even more often. 

In the we-already-knew-this department, a new study shows that epidurals do NOT prolong second stage (the pushing part) of labor. The study, published in Obstetrics and Gynecology, also show no adverse effects of epidural on mother or fetus. 

Also in the we-already-knew-this department, a new study shows that women who have their fibroids embolized may need additional procedures. In particular, they have a fair chance of still needing a hysterectomy later. These women who go from embolization to subsequent hysterectomy were still better off in terms of complications than those getting myomectomies (removal of the fibroids from the uterus) to begin with. 

Finally for a trifecta in we-already-knew-this department, we feature a new study which indicates that “intensive exercise may attenuate excessive gestational weight gain for obese pregnancy women”. Excessive weight gain in pregnancy increases the odds of gestational diabetes, large for gestational age babies, and need for C sections. Research elsewhere also indicates that exercise in pregnancy also produces many other good effects, such as increased likelihood of vaginal delivery. 

Somewhere between politics and medicine we find people and society, and society has a lot to do with health. This week those in the entertainment industry have been reeling from all the revelations of sexual abuse and misogynistic workplace bullying by Harvey Weinstein. It has been sickening and yet illuminating to read the accounts of the women involved. The victims were abused in various ways. Those that escaped unscathed, had career setbacks by failing to acquiesce. They all suffered the shame and anger associated with such encounters, and even now are having to answer for why they did not disclose sooner, why they acquiesced, why they did not have more sense to begin with, etc. etc. 

see: 

http://www.vulture.com/2017/10/the-harvey-weinstein-sexual-harassment-assault-accusations.html

It is widely believed that Harvey Weinstein is not the only such perpetrator in Hollywood. It is also well known that Hollywood is not the only industry where this occurs. Although Weinstein's victims were generally celebrities, most victims are not. Yet even these celebrity women were caught off guard and were made to feel powerless and vulnerable. How much more so must the average woman feel, working a standard paying job on which they depend. 

Harvey Weinstein’s methods were outrageous. The vaster number of abuses in the workplace today are far more subtle. They are microaggressions. They are just enough to make you uncomfortable, but not enough make you realize it is abuse, much less move forward to report it. All of this adds up over time, and it takes a toll professionally and personally, and on stress levels, which eventually impacts health. I had one patient who developed certain medical problems. In taking care of her and getting to know her better, it turned out she had an extremely hostile workplace environment. We encouraged her to speak to people at the local department of labor. After a lot of effort and gumption on her part, the case went to the courts, where she prevailed. She emerged empowered and eventually healthy. But it had been years that she had suffered before she understood what she had actually been dealing with and where it fit on the spectrum of normal social interactions. 

Sometimes we do not realize that what we live with may not be normative. Our standard for what is acceptable behavior may be skewed due to a rough upbringing, or a innate tendency to think that we ourselves are the problem. If you think you may be living or working in some kind of an abusive environment, reach out to a trusted physician, attorney, local social services agency, community health center or mental health professional. Life is too short to let your quality of life or health suffer. 

Stay tuned for more news from the work of Obstetrics and Gynecology her, next week, on Medical Monday. 

Please remember to contact your elected officials to tell them what you think about all of this. 

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

Historically a new President is evaluated at the 100th day in office. This day comes next week, and for this reason there is a special emphasis on trying to get a Republican health bill pushed through next week. The various key features of the new proposal must please not only moderate Republicans but hard line conservatives. 

Anxiety remains over whether or not the Trump administration will continue to pay health care subsidies to insurance companies. These government subsidies to insurance companies is what allows them to offer coverage to their ACA clients at such low rates. This last week, the National Association of Insurance Commissioners indicating that these are “ ...essential for keeping insurance markets stable next year”. Last Tuesday health insurance representatives met with Trump administration officials but received little assurance that the subsidies would continue. House speaker Paul Ryan indicted he would consider continuing the payments until the end of the year to avoid “…disruption”. 

In the common sense department, a new study has confirmed that paid medical leave is associated with higher breastfeeding rates. The ACA stipulation that businesses of a certain size provide time and space for breastfeeding has also been associated with increased breastfeeding rates. 

We have a new study on marijuana in pregnancy. According to a new large survey based study from the National Institute on Drug Abuse in Bethesda Maryland, US teen girls are more than twice as likely to smoke marijuana if they are pregnant. The rates are at 14% versus 6% in those aged 12-17. The ratio is reversed if all ages of pregnant women are considered. In that case, 4% of pregnant women smoke, versus 8% of non pregnant women. Researchers speculated that pregnant teens use marijuana medicinally to treat nausea. However, others have opined that risky behaviors such as marijuana use and teen pregnancy run together. 

Currently no specific pattern of malformation (anatomic or structural) has been uniquely associated with marijuana use. However, sustained use of marijuana has been associated with a trend toward decreased birth weight. Additionally, reported childhood effects of marijuana use in pregnancy include lower scoring on verbal and memory testing, and difficulty analyzing and integrating specific cognitive processes.

Some authorities believe that the use of pot by any kind of teen is more dangerous than use for adults. This is because there are more consequential impacts on the teen's still developing brain. According to Dr. Seth Ammerman at Stanford University and Lucile Packard Children’s Hospital,  just telling teens about the risk of pot may be enough to get them to quit. 

The Trump administration has announced they will follow through with the $485 million dollar grant approved last year to fight the opioid epidemic. 

The Trump administration has also extended the “Veteran’s Choice Program” which enables some veterans to receive care from local doctors and hospital rather than travel to VA hospitals for their care. 

Breast implant linked lymphoma is again in the news. The FDA (Food and Drug Administration) has identified 359 women with a rare cancer called ALCL or anaplastic large cell lymphoma. It seems to occur with women who have had textured rather than smooth implants. Though over 350 cases have been identified, the incidence is very low at about 1/30000 women with textured breast implants. Those with implants should seek regular annual exams and mammograms making sure that their caregiver knows about their implants. 

A recent review in the Annals of Internal Medicine revealed a problem. This is a problem that could be 100% solved, and that could help patients with any disease that they are treating. The problem is medication non-compliance. Studies show that 20-30% of medications are never filled, and that of the ones that are, 50% are not taken or not taken as prescribed. It goes a long way to explaining why some patients don’t get better or relapse. The reasons are many from cost, to wanting to “be natural”. Patients may believe need for medication reflects weakness. They may avoid it since they don’t want to be reminded of their disease. Solving the medication compliance problem would save over a hundred thousand deaths and hundreds of billions of dollars every year.

By now most of you know that Serena Williams is pregnant. Perhaps you don’t know she won the Australian Open while being so. A recent editorial in the American Journal of Obstetrics and Gynecology highlights the fact that healthy pregnant women need not curtail their exercise. This is in line with the ACOG Committee opinion document on physical activity and exercise in pregnancy. Recommendations are that pregnant women engage in aerobic exercise for 35-90 minutes 3-4 times each week. Those with any high risk factors should consult their doctors first. By the way, Serena wasn’t the only one to compete at this level; eighteen pregnant women have competed in the Olympics. 

Earth Day and March for Science have recently taken place. In an unprecedented move, 25 medical organizations including ACOG (American College of Obstetricians and Gynecologists) issued a joint statement for March for Science. They stated that they are issuing a “….nonpartisan call for the appreciation of scientific evidence, education and investment”. 

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

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.

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

The genome of the Zika virus has been isolated. This is an essential step in learning about the virus and how to stop it. 

Meanwhile Zika virus continues its spread in southern Florida with three Zika transmission zones identified. Readers would do well to remember that Florida is still recovering from Hurricane Matthew and all the floodwaters are still receding. Florida has called on the Federal Government to help fund their fight against Zika. 

In chilling news, a new study out of Brazil indicates that Zika can affect a baby’s brain even if the mother contracts the infection a week or two before giving birth. This begs the question of whether newborns or even toddlers or beyond can incur damage to the growth of the brain by becoming infected. 

Breast and ovary cancer, among the most dreaded female cancers, both have new and promising therapies on the horizon. In the case of ovarian cancer, a whole new class of drugs called PARB inhibitors is showing improvement for all women with recurrent ovarian cancer. For breast cancer, an investigational drug Ribociclib combined with the older Letrozole, is showing significant improvement in PFS (progression free survival) for those with hormone responsive cancers. Such drug “cocktails" are becoming increasingly useful in the fight against many difficult diseases such as those from viruses or cancer. 

Researchers at Johns Hopkins Kimmel Cancer Center have created a free web based app to guide clinicians in their treatment of breast cancer. In these days of precision medicine, tumors can be subjected to ever more detailed molecular and genetic analysis to determine the best possible therapy. These are costly, which hopefully will change. For now, this app helps clinicians decide whether or not these more detailed tests are necessary. 

Have you ever heard of de-prescribing ? Me neither. Apparently this is when a physician takes a patient off medications. Physicians are increasingly trying to help patients avoid medication interactions or unnecessary medications altogether. I can imagine this being important in an internal medicine practice where patients have medication lists a mile long. 

Once again the value of mammograms is being questioned. This time it is in an article in the New England Journal of Medicine. Once again the concern cited is “ ...needless anxiety, treatment and expense.” Let’s be clear here, by “ treatment”they are referring to biopsy. And now that I think of it, use of this language is really irresponsible. Biopsy is not treatment in the case of breast disease. The authors indicated that over half of breast cancers diagnosed on mammogram are a case of mistaken identity…”. First of all, breast cancer is not a radiographic diagnosis. It is a TISSUE diagnosis. So, they could rightfully say, over half of all mammograms which are suspicious for breast cancer, are actually not on biopsy. This, to me is a cause for relief. Understand that if they want to decrease the mammogram frequency, they will increase the number of women with cancer who are picked up late rather than early. How many inconvenienced women are worth one who gets an early and more curable diagnosis of breast cancer rather than a late one ? I’d say many. Very many. How much inconvenience and expense is worth a life ? 

We are continuing to expand our understanding of how maternal obesity affects babies in utero, newborns, and even children into adulthood. Four recently published studies are showing these risks, and they include increased risks of stillbirth, diabetes, and blood pressure disorders of pregnancy. More interestingly, risks for children born to obese mothers of these same types of diseases persist into adulthood. 

Our national increase in maternal mortality is of paramount concern. Poor maternal health and the conditions which produce poor maternal health are undoubtedly to blame. Accordingly, experts are increasingly beginning to teach that women should attain a healthy weight and attain control of all their medical conditions before attempting pregnancy. 

In that spirit, I will report on a relevant and encouraging story coming from the International Olympic Committee. They have found that “ ...strenuous exercise during pregnancy doesn’t appear to increase the risk of most pregnancy complications for mom or baby”. ACOG (The American College of Obstetrics and Gynecology) has recommend institution or continuation of “ moderately strenuous” exercise during pregnancy as well. 

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 funding. It comes down to this. Even as Congress has reached its planned seven week summer break, there is still no Zika budget, the United States faces its first couple deaths from Zika virus, one in Utah, and the other in Puerto Rico. The AP ( Associated Press) reports that the main hang up was Democratic objections to GOP language which would block Planned Parenthood clinics in Puerto Rico from receiving money to fight the virus. Shame on them all. 

The Imperial College in London has presented a bad news/good news scenario. Their modeling has indicated that Zika will likely last in Latin America for another two to three years. At that stage, herd immunity will hopefully develop. 

The CDC (Centers for Disease Control) is working on preparing a protocol for the first locally transmitted cases of Zika. One of the biggest challenges is that 80 percent of Zika infections area symptomatic. Almost all stars of the Union are at risk including the northernmost United States of Michigan, New Hampshire, Washington state and Minnesota. There are currently 346 pregnant women with Zika in the United States. 

Half a million people are excepted to travel to Brasil this year for the Olympics. However experts at the CDC are projecting that this will not spread Zika internationally. They have explained their position by saying that this half million represents only about 1% of all international travel to Brasil. 

HERE is the link to the excellent CDC pages on Zika. 

http://www.cdc.gov/zika/index.html

Happily much of the other news this week is good, though a fair amount of it falls in the "we already knew this" category. 

One thing we did not even suspect was that a mouse could have a menstrual cycle. The spiny mouse has a tiny nine day menstrual cycle. Researcher hope the mouse will provide a model to study the reproductive cycle in women. 

Moderate exercise in pregnancy has been shown to benefit both mother and baby. In particular, mothers who do moderate regular exercise in pregnancy have lower rates of hypertension, gestational diabetes, and C section. 

Both mothers and fathers weight during  pregnancy affect the weight of children later in life. This is believed to be true not only by virtue of lifestyle but by genetics. It appears that both mothers and fathers weight influence gene expression in the unborn, which postnatally can affect weight. This knowledge may help us counsel prospective parents and spare their children unnecessary risk and struggle from obesity. 

The Journal of Pediatrics has published research indicating that breastfeeding reduces the incidence of diarrhea and otitis media (ear infections) in infants. At the same time, the USPSTF (US Preventive Services Task Force) used US taxpayer dollars to create recommendations which support but no longer promote breastfeeding. ACOG (The American College of Obstetricians and Gynecologists) has sent their objections in writing regarding this important change. The breastfeeding discussion needs to be continued, and very publicly, since we all have a stake in the outcomes. 

Stay cool this week, and take precautions from mosquitos. Remember, DEET is safe, and safe in pregnancy. 

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

California and Oregon will soon allow pharmacists to screen patients and prescribed birth control pills. While the American College of Obstetricians and Gynecologists considers this a step in right direction, they believe they should be available over-the-counter, plain and simple. While it is true that low dose combination birth control pills can have medical complications in a very small percent of people, by and large their health benefits far outweigh their risks.

As most of you probably are already aware, hepatitis C has a new medical treatment which provides a cure in a very high percentage of people. However, hepatitis B has remained a challenge, and in particular, we have had to deal with the problem of vertical passage of the virus from mother to baby during pregnancy, labor and delivery. However recently at the meetings of the American Association for the Study of Liver Diseases, new research was presented. In the course of a randomized controlled trial, a drug called Tenofovir was shown to be able to reduce vertical transmission. 

Yet another encouraging recommendation about exercise in pregnancy has been released. According to the American College of Obstetricians and Gynecologists, nearly half of US women gain too much weight while they're pregnant. We all know that women who gain too much weight in pregnancy are very uncomfortable. However they also have higher rates of miscarriage, premature birth, stillbirth, and babies with birth defects. They’re also more likely to have heart problems, sleep apnea, gestational or pregnancy associated diabetes, preeclampsia also known as toxemia, and abnormal blood clots. They are at higher risk for cesarean section. So there are ample reasons to find ways to control this weight gain. 

The new memo released by ACOG advises pregnant women to exercise regularly and more often than they currently do. The memo states that while walking is the best exercise, jogging, Pilates, yoga, cycling, swimming, and other forms of exercise are perfectly acceptable. ACOG cautions against contact sports such as skiing, and other specialized sports such as scuba diving.

More good news: it appears that breast-feeding for two months or more reduces a gestational diabetic’s risk of developing type II diabetes later in life by 50 %. Moreover, the risk of diabetes lessens as the patients breast-fed longer.

Finally, here is some good news that initially sounds a lot like bad news. Since 2010, there has been a significant increase in the number of women under age 26 who have received a diagnosis of early-stage cervical cancer. In the next age group, 26-34, the numbers were unchanged. What changed for the younger age group? The answer is the availability of insurance. One of the features of the ACA, The affordable care act, was to allow children to stay on their parents insurance plans through the age of 26. Most likely the increase in diagnoses came from increased compliance with recommended screening, i.e. pap smears. Once again, we are reminded that appropriate screening leads to early diagnosis, which leads to less invasive treatments, fewer complications, and higher rates of cure. 

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