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

These Summer days are very busy for me and my family. So I am going to keep to an abbreviated or bullet version this summer. A little later, I’ll let you in on a fun little secret about why I am so busy. 

The biggest policy new has to do with the need to fill the vacancy in the Supreme Court created by the resignation of Justice Kennedy. The most contentious issue thus far has been abortion, Thus, all conceivable candidates are being scrutinized for their views the subject. Justice Kennedy had been a more liberal justice, and Trump has promised to install an anti abortion justice who would then contribute to the making of law for the rest of their tenure. At present, under Roe V. Wade, abortion is legal. Prior to that it was not, yet many many women and caregivers defied the law, often at great peril. My late father in law, an Obstetrician Gynecologist minted in the early 1960s remembered the days before legal abortion, and while no friend of abortion, told us cautionary tales about the complications that illegal abortions could produce. 

The ACA (Affordable Care Act) has more users now than it did last year. As of this last February, 3% more people paid for ACA plans than the prior year. This is especially noteworthy since the Fed decreased funding for outreach about the plan by 90% and halved the enrollment period. 

Starting in 2019 the Joint Commission ( a chief governing body for hospitals) will require accredited hospitals to have a newborn identification protocol. Details to follow, though we know it will require “ two factor authentication”. 

The Senate has approved 50 million dollars in funding to reduce maternal mortality. Most of this will go to the Federal Maternal and child Health Bureau to expand life saving evidence based programs. Some will also go to the CDC and some will go to Healthy Start programs for mothers and babies. 

The Senate also has approved three new bills pertaining to maternal and child well being. In particular the money will be used to reopen closed programs which aim to prevent preterm birth. 

One major piece of the maternal mortality puzzle is the lack of Obstetricians and Gynecologists. It is tough job with tough call and its pay lags behind that of similar surgical specialists. It is estimated that there will be a shortage of nearly 8800 Ob/Gyn in just TWO YEARs, in 2020. The shortage is very likely to keep growing. 

Medical News

Non-European women with ovary cancer seek genetic testing less than their peers. Genetic testing after ovary cancer may help identify risk factors for other members of the family dn may define the patient’s tumor type in such a way as to tailer its treatment and make it more effective. 

Flight attendants have been found to have a higher incidence of many various types of cancers. The findings were published in the Journal Environmental Health. It is unclear why this is the case. Theories include increased exposure to ionizing radiation, circadian rhythm disruption , or to other carcinogens. More study is needed. 

Many older women or their caregivers begin to lessen the frequency of their bone density screenings after about 65 years of age. I have never liked this approach as it smacks of marginalizing older women. Many older women begin their final decline with a hip fracture that could’ve been prevented. Now, new recommendations from the USPTF, US Preventive Services Task Force has produced evidence saying it could be worthwhile. This is true because there are many meaningful potential treatments, which when instituted, could help prevent bone fractures and the debility that those entail. 

Probiotics. They are for gut health, right ? Turns out a new study has shown that probiotics given to women protect against the loss of bone density. See the Journal of Internal Medicine. 

There are nine vaccine which pregnant women may receive. ACOg has recently released a single page list of these and his encouraging all pregnant women to speak with their physician about these. 

Smoking. It’s bad. How bad ? Well its bad enough to increase your risk of miscarriage…. even if it is just your partner who smokes ! Yes, second hand smoke from a partner is associated with an increased risk of miscarriage. 

In separate research, smoking also appears to double your child’s chances of having hearing loss. 

In clinic, most people report being active. And yet, the CDC report s that fewer than 23 % of US adults are meeting federal standards for time spent exercising. 

In rather disturbing news, over 1 in 4 girls have harmed herself in the past year, often by cutting or burning, compared to 1 in 10 boys. 

There is more good news about vitamin D. It turns about high levels of vitamin D may help prevent breast cancer. Vitamin D levels in our lab should sit between 30 and 80 to be considered normal. However, there is more and more evidence that sitting on the higher end of that spectrum may have benefits. New research has indicated that having a level near 60 confers 80% lower risk of breast cancer compared to a level near 20. Associated risk factors were depression, suicidal thoughts, buying and substance abuse were risk factors. See the recent edition os American Journal of Public Health. 

Oh… my fun little secret ? I am starting a traditional French Bakery and Bistro. No, I will not be baking. Yes, I will continue full time Obstetrics and Gynecology. It has always been a dream, and, along with a great team of people, I am getting to realize it. Stay tuned. We will open in late August. Visit me at 

bonjourbakeryandbistro.com 

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

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

I’d like to take a moment to thank readers for their continued attention to this blog and this site. The Women’s March drove home the point of how important it is for all of us to be aware, and for us to make our voices heard. The beginning is simple: learning what is going on. 

Policy

Up to date policy includes one Alex Azar, who will be the new HHS ( Health and Human Services) secretary. As such he will be in charge of health policy in the nation. He has vowed to consider the interests of both parties. 

The legislature is gearing up to vote on a 20 week abortion ban. I’m not sure how much effect this will have since most elective abortions are far earlier than this. Since Roe versus Wade was based 45 years ago, making abortion legal, approximately, twelve hundred restrictive state laws have been passed. 

The Trump administration is crafting a program called “ Conscience Rights” which would allow a health care provide to deny a patient care based on their beliefs. This care would obviously include controversial procedures like abortions and assisted suicide, but would also extend to providing contraception and sterilization. Numerous physician groups including ACOG have raised substantial objections. I would not like to see health care devolve this way. I already know physicians who disapprove of people who get abortions, and physicians who disapprove of people who don’t practice birth control to have large families “ as many as God will give”, or people who drink, or people who smoke, or people who get fat or get sexually transmitted infections. Is there no end to our judgmental mentality ? I though we were in this to teach, comfort and cure. 

Utah is where I went to medical school. It is also the center of governance for the Church of Jesus Christ and the Latter Day Saints, aka the Mormon Church. In general I found the people there an attractive mix of family oriented, strictly religious, and yet interested in and respectful of science and the diverging views of others. So in this progressive atmosphere it comes as no surprise to me that a Republican legislator Representative Ray Ward, has proposed HB 12, which will enable Utah Medicaid to provide birth control, which it currently does not. He is proposing this to save money by decreasing unplanned pregnancies, abortions and reducing all costs associated with those. Brilliant ! 

Texas lost $35 million in federal funds which it voted to exclude Planned Parenthood from the recipients list. It basically lost $35 million worth of care to Texas women. Could this be related to the astounding increase in Texas Maternal Mortality ? Now Texas legislators are trying to get that money back. They are proposing their own program which will still exclude Planned Parenthood; They are calling it Healthy Texas Women. If they get their money back for their new program, there is concern that other states will similarly overhaul how federal money is delivered to women’s health clinics. 

Meanwhile, nationwide, women continue to flock to clinic to obtain long acting IUDs ( intrauterine devices) to give them birth control in case the contraceptive mandate of  Affordable Care Act is revoked. 

The Trump administration is trying to find more ways to “ excuse” people from the mandatory requirement to have health insurance, the so called “ individual Mandate” part of the ACA ( Affordable Care Act).  For all the world, you would think they want fewer people insured. Oh wait ! They do want fewer people using federally sponsored health insurance plans, since those cost the government money which they would prefer to keep for items on their own agenda. They justify this stating consumers should have freedom of choice, meaning the freedom to save for health care expenditures, as if that is common practice, or you could reasonably expect to do it for a large 5 figure expenditure. Last year, there were 3.2 million more people uninsured compared to the year before. Most of this is reckoned to be people who simply chose not to pay for health care. I cannot understand why it is not simply like car insurance. If you are on the road, you must have insurance. If you do not, and something happens, you will cost others a great deal of money and yourself a great deal of trouble. The same is true if people are too irresponsible to obtain health insurance. 

Medical News

Hip fractures among women are on the rise. This new study shows what I have considered inevitable. The women of the Diet Coke, Tab and too much coffee age are upon us. Many were smokers, and few drank milk, let alone ate leafy greens. No wonder bones are breaking. Here in Montana, where winter is 9 months long and there are 3 months of bad sledding, vitamin D deficiency is rampant. Vitamin D is crucial to bone metabolism and is manufactured in the skin by sunlight. Pacific Northwesterners and many of us in the Rocky Mountains inland should consider getting checked and supplemented. 

Breastfeeding may protect against type two diabetes in women. The longer the breastfeeding, the greater the reduction in risk. We have always advised that breastfeeding helps moms lose unwanted weight, and of course that in and of itself lowers risk for diabetes. 

Placental insufficiency is just what it sounds like it is. All placentas are not created equal. Placentas deliver oxygen and nutrients to a growing baby. However, various medical conditions or just bad luck will result in a poorly functioning placenta. Just about any pregnancy complication such as high blood pressure, poor nutrition, or smoking will result a placenta of  poor quality and a higher risk of complications for baby. The worst complication is of course stillbirth. A new study has suggested that nearly a quarter of stillbirths could be preventable. Placental insufficiency is usually the culprit, and with standard prenatal care it is not hard to diagnose. When we identify the problem, we increase the surveillance with monitoring and Ultrasound. Any problems with access to good prenatal care will interfere with identifying and treating complications that lead to stillbirth. 

Texas continues to be in the news as researchers and policy people probe the appalling maternal mortality figures. As of this writing we know that many factors are to blame including access to prenatal care, prevalence of black women in the data set, especially those who are underserved, or who have hypertension. Most interesting to me is the contribution of stress from chronic societal discrimination. 

The spotlight is now on my state, Montana. In the case of 14 child deaths in Montana this year, 3/4 of them took place when an infant slept in the same bed as a mother who was using drugs. Our hospital has addressed this by have an active department of Social Services, an Addiction Specialty service, and the Baby Box program. This is modeled after a common European practice wherein a family with a newborn is sent home with a baby box full of safe supplies. The box itself is made to evidence based standards, having a flat firm mattress , a fitted sheet, and no covers. Baby is kept warm in a sleep sack, a kind of gown in which they cannot get tangled or suffocate. In Finland, for example this has been done for over 75 years with good results. Some say it has helped Finland achieve one of the lowest infant mortality rates in the world. The Baby Box program also includes extensive education about safe separate sleeping practices, but it remains challenging to change people’s behavior of keeping baby with them in the bed. 

http://www.bbc.com/news/magazine-22751415

A County Attorney in Big Horn County, Montana has announced a crackdown on pregnancy women who use drugs or alcohol. That office plan to seek civil restraining orders and even incarceration to meet their goals. ACOG has come out against this, indicating it basically keeps high risk women away from prenatal care. Handmaid’s Tale, much ? 

When medicine and policy collide: More women received indicated mammograms when Obamacare, aka the Affordable Care Act, banned copays. If that does not tell you copays are a barrier to screening, I don’t know what does. 

Women skip mammograms for money. But, a new study says women skip paps for embarrassment. Young women in particular could identify embarrassment due to body shape, shape of vulva, or smell. We need to do more to help women and girls feel comfortable in their own bodies. 

A new study reveals that increased long use of oral contraceptive pills confers better and better protection agains endometrial (uterine) and ovary cancer. It also confirms that long term use does not seem to affect risk of colon or breast cancer. You may have in the past heard other studies which have contradicted this. The good news is that our methodologies improve and computing power increases every year, making the quality of our data better and better as time goes by. 

Not-so-fun-fact: New research incites that a women's risk of dying from childbirth is 14 times higher than her risk of dying from an abortion. 

Finishing today in the SUPER COOL department, we have two entries. 

First, those Scandinavians are once again on the forefront of progressive perinatal care, this time using the power of probiotics. A new study shows probiotics consumed in pregnancy lowers the risk of preeclampsia and preterm birth. These Scandinavian countries provide comprehensive prenatal care and keep thorough databases on all patients, enabling them to glean meaningful information of good quality. More research is needed on how to implement this finding. 

Lastly, Apple has roiled out a new feature in the Health App enabling users, meaning patients, to control and transfer their own medical records. Twelve large medical institutions have begun beta testing. This is great for patient empowerment. It is also partakes of the open data movement, which says that in an ideal world, data should be fully shared, without fear of discrimination. When patient and research data can be shared, we can expect a great acceleration of medical progress on the topics which matter most. 

Stay tuned until 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.  

Food Friday: Vitamin D

Vitamin D is in the spotlight. Is this celebrity justified ? 

Vitamin D is a fat soluble compound that is necessary to human health.Interestingly, it is not widely available in our diet. It is however, manufactured in our skin when the skin is exposed to UV rays from sunshine. It is of course available in supplements, supplemented foods, and a few foods naturally. 

You might wonder how we developed to need something that seems so hard for modern people to obtain naturally. I think it is a good bet that pre-agricultural people especially those along the coast got more sun and UV exposure than we do today. I suspect that plus their intake of vitamin D rich fish supplied their needs. Then as people began to move inland, wear more clothes, eat less fish and live long enough to have to protect against skin cancer, their vitamin D requirements became harder to meet. 

 Vitamin D is historically most “ famous” for its role in enhancing Calcium absorption. Calcium is critical for bone mineralization. Deficiency of Vitamin D leads to rickets and osteomalacia, which are failures of the bones to properly form. 

Those at risk for vitamin D deficiency are breastfed infants who aren't supplemented, dark skinned people, people who wear occlusive clothing, the home bound, the elderly, the obese, vegans, and those whose gastrointestinal tracts are inflamed or cannot absorb properly. 

It seems odd to me that breastfeeding does not supply all the necessary vitamin D a newborn needs. This is simply because the Vitamin D content of human milk is related to the mother’s vitamin D status. The infant cannot get vitamin D though UV exposure since it is not appropriate to expose infants to direct sunlight. There has been a big recent campaign to educate breastfeeding mothers about the need to supplement with vitamin D. 

Vitamin D also affects the general functions of cell growth, neuromuscular function, immune function, and the control of inflammation. These features are why there is more than the average amount of buzz around this mild mannered vitamin. Two hundred and fifty studies on vitamin D and various health parameters were done between 2009 and 2013. These were systematically reviewed by the Agency for Healthcare Research and Quality, and to date, it concluded that it is still not possible to specify a relationship between vitamin D and specific health outcomes other than bone health. As the number of studies indicates, there is widespread interest, or even hope that vitamin D therapy will prove useful for a wide variety of conditions, especially those involving autoimmunity. 

Adults need between 600 and 800 IU of vitamin D per day. It is best not to take more than about 4000 IU per day from all sources, unless specifically instructed to do so by your physician. Vitamin D is fat soluble, can be stored in the body and can, in excess, lead to toxicity. 

It is best to get your vitamin D from a combination of foods, fortified foods, and supplements. The best dietary sources of food are fatty cold water fish such as salmon, cod, tuna and swordfish. (As a side note, pregnant women should restrict their intake to salmon and cod, since tuna and swordfish may theoretically have increased levels of heavy metals. ) Besides these, egg yolks, fortified orange juice and fortified dairy products are the best sources. 

If you are concerned your vitamin D levels are low, ask your doctor about testing your levels. We have been screening patients more proactively lately, and have found some astounding deficiencies. The good news is, they are quite easy to fix. 

Here’s my favorite go-to recipe for a great blast of vitamin D and protein: 

Salmon Salad

Simply mix one drained can of coho salmon with 1-2 tablespoons of olive oil based mayonnaise ( My favorite is called “Lemonnaise”.), Add a table spoon of dill relish, a couple Tablespoons of sliced olives, some capers, finely chopped celery, chopped sun dried tomatoes, and whatever else suits your taste. Mix. Do not feel compelled to put it on anything. Enjoy. 

Refererence: 

National Institute of Health Office of Dietary Supplements