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

MEDICAL POLICY NEWS 

The new budget has blown the top off the old budget, and this, from conservative lawmakers. It exceed prior spending caps, and suspended the debt limit for a year. As part of the package it did refund CHIP (Children’s Health Insurance Program) for four years. 

CMS is the Center for Medicaid Services. According to their actuaries, health spending in the nation will increase by about 5.5%per year to $ 5.5 trillion dollars, nearly a fifth of the economy. The fastest growing sector of health spending is prescription drugs, estimated to grow by over 6% per year in the next decade. Due to the Affordable Care Act, (ACA) personal spending for health care has been at historic lows, though it is projected to increase, even under the ACA, at over 2.2% per year, which is over the cost of inflation which is 1.9%. Whether or not this is good, bad or indifferent, I cannot say. As a mother and as a physician, I feel we undervalue our health care and its costs. We spend on electronics, vehicles and vacations, which are important, but forget that health is at the foundation of it all. 

The Trump Administration is disinclined to regulate drug prices. However, they propose “easing government regulations (read: protections) to “spur innovation” to “lower drug prices”. They also proposed expanding drug coverage and  placing a cap on out of pocket spending for Medicare recipients. While the federal government will not regulate drug prices, it will allow up to five states to band together to negotiate drug prices. 

The ACA has a dependent provision saying that children up through the age of 26 may stay on their parent’s health insurance policies. A study recently published in JAMA, the Journal of the American Medical Association, has revealed that this provision resulted in increased rates of prenatal care, early prenatal care, and reductions in preterm birth. As an Ob/Gyn I can tell you that one of our holy grails is finding a successful approach to preterm birth. Looks like having health insurance might help. 

Maternal Mortality is four times higher for black women than white women in our country. Access to prenatal care is believed to be part of this. A recent New York Times editorial  featured a free Obstetrics clinic in Florida who accepted clients regardless of ability to pay. They were able to document a 40% reduction in preterm labor and low birth weight in this group. 

I reported earlier on the Utah bill which will provide for the use of Medicaid funds to provide family planing services to low income women. Part of the genius of this is that these are not just any poor women. These are women who are below the poverty level, but who are not so poor that they qualify for Medicaid. They are the so called women in the gap. Lawmakers would save everyone money if they gathered data about the lowest income at which one can reasonably afford private insurance, and made that the same level at which one qualifies for the Affordable Care Act. From there, the ACA should cover straight down to incomes which qualify for Medicaid. Then there would be no gaps. Rocket Science. 

Health care is a case of pay now or pay later. By now, everyone including consumers and lawmakers should understand that attending to health and paying for it up front saves both money, productivity and suffering in the long run. This is the single most important message I can tell you. 

Planned Parenthood has been under scrutiny, defunded in parts, and under continuing threat of more defunding. Planned parenthood provides many primary health care services at very low cost, not just family planning services. Their services disproportionately benefit women. Many associate their defunding in certain states like Texas, with increased rates of Maternal Morbidity and Mortality. This last week, leadership of Planned Parenthood announced they will begin a campaign of legislative action in key states. 

West Virginia is attempting to supercede Federal Law. Their Senate has passed the “no constitutional right to abortion” amendment, and it now heads to their House. All this is despite the federal law Roe Versus Wade which guaruntees the right to abortion within various age parameters. One opposing Democratic senator, a physician, simply read ACOG’s (American College of Obstetricians and Gynecologists) statement of opposition to the measure as his response. 

The Trump Administration has developed a “Conscience and Freedom” division of the Department of Health and Human Services. Since when did a Government office dealing with health care need a “ Conscience and Freedom” division ? It sounds very "morality police" to me. Encompassed in this type of approach would be protections for physicians who withheld certain treatments, and punishments for physicians who administered them. This move has also raised concerns in the hallowed halls of academic medicine. Professors from the Bixby Center for Global Reproductive Health and the Department of Obstetrics and Gynecology at UCSF (University of California San Francisco) have written an op ed against the formation of this committee and its enforcers. They have asked the Administration “to stop politicizing medicine and interfering in the judgement of medical professionals.” 

Think all this sounds implausible ? Think again. The Iowa Senate has approved a bill to ban abortion after a heartbeat is detected. We routinely detect heartbeats at 5.5 to 6 weeks after the last menstrual period. The bill includes a provision to charge physicians who do such procedures non-emergently with a Class D felony. Opponents of the measure are many. The University of Iowa would lose it’s accreditation of it’s residency program in Obstetrics and Gynecology if this were to be the case. This is because,to comply with the state law, the Program's policies have to comply with medical science and recommendations. This would worsen the problem of the shortage of Obstetricians and Gynecologists. 

MEDICAL NEWS 

In the recent past, Betamethasone steroids were only given to women expected to deliver before 34 weeks. More recently, the recommendation is to expand the use up through just before 37 weeks., the so-called late preterm period. Steroid given in this way decreases pulmonary (Lung) problems in the premature newborn. New research presented at the Society for Maternal Fetal Medicine has concluded that up to $200 million in savings could be realized by following this new recommendation. 

Increasing evidence shows that ovary cancer starts in the tubes rather than the ovaries. You might know this already if you have recently been counseled about a tubal sterilization procedure. In the past, we performed sterilization by tying, clipping, or cauterizing the tubes. However now we offer patients removal of the tubes to confer additional cancer prevention. 

American “fertility rates” are falling. This could be misconstrued as meaning more American women are infertile. However, this is not what it means. It does mean our birth rate is decreasing. Researchers believe this is explained by later marriage, smaller families, better adoption of birth control and fewer births among the unmarried. Their are varying assessments of this trend. Some people believe economic prosperity is dependent upon ever increasing birth rate, but this is an outdated and flawed analysis. Some believe that decreased birth rate alone will rescue the environment. I wish it were that simple. Data shows that income, educational attainment, and savings all increase with smaller families. 

HPV vaccine rates are still low. They are rising, but are still low. It is effective and has nothing to do with the choice to become sexually active. It prevents cervical cancer and genital warts. The side effects are limited to the side effects of an injection. What’s not to like ? 

Juice is out. Juice has been out for some time but many people seemed to have missed the memo. Many people still think that drinking 100% pure (even organic) fruit juice is a healthy thing to do. It is not. It is too much fruit sugar, in too broken down a form, for people to metabolize without spiking their blood sugar and risking fat deposition. A calorie is not a calorie. The RATE at which sugar enters your bloodstream is key. The rate with juice is just higher than our physiology can handle. It is far better to eat the whole fruit itself. The fruit has structure, even once chewed or blended in a smoothie, and it will enter the bloodstream in a slow release fashion. New research has shown that postmenopausal women who have a single 6 ounce serving of fruit juice per day persistently gain weight over the years. Of course many factors probably go into this, but the juice drinking may be a marker for misconceptions they have about nutrition. 

New research shows that who who meet criteria for and get MRI for breast cancer screening get more “invasive” (meaning with a needle or some other sharp object) biopsies. They say it like its a bad thing. Of course they get more biopsies. We see more detail and raise more concerns. The research goes on… fewer of these biopsies result in a cancer diagnosis”. AGAIN they say this like its a bad thing ! It is good to have no cancer diagnosis. What we are seeing here is a natural expectation of increased sensitivity and decreased specificity in the testing. There are more false positives, which we as a society have decided to accept as the “cost” of earlier diagnosis and better cures. So we as a group trade more pokes with a big needle for many women in exchange for greater years of life for a few. Sounds like a bargain to me ! Read these sensational headlines with care people, and don’t be afraid of needles. Sharp objects are your friend. And by the way, they talk about “invasive biopsies” like there is even such a thing as non-invasive biopsies. Spin the headlines much ? 

It is still meaningful to get your flu vaccine. If it does not prevent flu, it still will decrease the severity. If you don’t want to do it for yourself, do it for the unwell, elderly, children or pregnant women about whom you care. They are especially vulnerable and the death toll nationwide is appalling. Anti-vaxxers, take notice. There is cost to what you say. 

Stay tuned next week for more intense 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.