Medical Monday: Part Two

Medical Monday: Medical News Section 

Pregnancy related death continues to rise in at a fairly steady rate in the US. As of 2013, we sit at 17.3 women per 100,000 live births with a rage of about 12 per 100,000 for whites and 40 per 100,000 for blacks. Cardiovascular diseases of various kinds accounts for about 40% if these deaths. About 9% are due to pulmonary embolism, and 7% are related to high blood pressure and preeclampsia. The rest pertain to infection, hemorrhage and rare disorders like amniotic fluid embolism. 

Teen births are statistically high risk. It turns out that high teen birth rates cluster in certain cities. Analysis of the data shows these clusterings are not random and are not related to poverty to education. Most generally, the clusters are in the southern states, but they also exist in Denver, Fresno, and Yakima. San Antonio has the distinction of being the number one urban center with a teen pregnancy cluster. These findings my begin to help shed light on what is no doubt at least partly a cultural phenomenon. 

Breastfeeding has been touted has having numerous benefits, including health benefits to the mother. It turns out that prevention of uterus (endometrial) cancer is one of those benefits. Breastfeeding EVER confers an 11% reduction of risk. The longer the breastfeeding the more the risk was reduced, until risk reduction peaked at somewhere around 6-9 months of breastfeeding. 

Polycystic Ovary Syndrome (See PCO section HERE) is a complex of problems which include problems with ovulation (producing an egg), as well as obesity, excess male hormone, and difficulty metabolizing carbohydrate. A given patient may have one, all, or just a selection of the features of this varied disease. Generally, doctors have assumed that obesity and carbohydrate intolerance goes together. However new research has shown that even normal weight patients with PCO have have significant insulin resistance. This points for the need to counsel normal weight patients to eat a very high quality diet rich in protein, vegetables and fruit, and healthy fats. 

The overall incidence of depression in teens in higher than once previously believed, coming in at about 14% for those between 12-17. Of note, by 17, girls had a three fold higher incidence than boys. 

In the vice department, the news is sobering. New research from the Journal of Drug and Alcohol Dependence has shown that children born to women who smoke as few as 10 cigarettes per day have problems later in life. In particular, they have increased problems “learning and thinking”. 

The British Medical Journal has published research showing that even small amounts of alcohol produces changes in brain function which play out as poorer performance on language related tests. This data comes from research on 550 men and women over a 30 year period of time. 

Hard data is in from last year’s mosquito season in America (including Puerto Rico). Zika virus, which is transmitted by mosquito, produced birth defects in about 5% of babies who’s mothers became infected in pregnancy. This number was higher for those infected early, and lower for those infected late. We should learn even more this  year, and hopefully get one season closer to a vaccine for this dreaded disease. 

For those in Zika- vulnerable states: Remember, DEET is safe in pregnancy. Zika is not. 

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

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

In this week’s policy news, focus is on The Contraceptive Mandate. This is the part of the Affordable Care Act (ACA) which requires all insurance companies to cover birth control at no cost to the insured. The New York Times has reported that the Trump administration is working on broadening the criteria through which employers and insurers may refuse to provide contraception as a benefit within their health insurance.

Initially, one company, Hobby Lobby, went all the way to the Supreme Court to argue that based on their religious principles, they had a right to decline to provide insurance which covered contraception for their employees . They argued that contraception is against their religious principles. The Trump administration would like to expand the criteria for which companies can claim a moral or religious objection to the provision of contraception.

The President of the American College of Obstetricians and Gynecologists has spoken out in multiple ways against this trend and has added his objection to discussions pertaining to the elimination of the necessity to cover maternity care. Can you believe it? Attorneys at the American Civil Liberties Union have begun to elucidate a very powerful argument that these policy trends violates the separation of church and state. Moreover they constitute discrimination based on sex.

At the present time approximately 55,000,000 women receive contraception through this no cost benefit. The scientific data supports the Democratic assertion that there is a clear and evidence-based correlation between The Contraceptive Mandate of the Affordable Care Act and the historically low unintended pregnancy rates, teen pregnancy rates, and abortion rates.

Women are not the only target in the latest round of discussions on healthcare policy. A certain group of GOP senators I'm working on a revision of the Affordable Care Act which will no longer classify employer purchased health insurance as a tax deductible expense. This appalling antibusiness and anti-healthcare piece of legislation threatens the 177 million Americans who have their health care coverage through their employers. Additionally anybody who has a pre-existing condition or who has to watch their health care expenses is at risk if any of these GOP draft revisions to the health care bill are enacted. 

On to the medical news. Did you know that there is no safe level of alcohol consumption pregnancy? People widely assumes that the rule of moderation applies to alcohol and pregnancy but this is not at all the case according to the CDC, (the Centers for Disease Control and Prevention), the National Institute of health, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. No alcohol should be consumed in pregnancy. Not a popular message. 

An increasing number of states have legalized the use of marijuana. Accordingly pregnant women have gotten the skewed message that this sends and have been using marijuana in record numbers. No one seems to be listening to the repeated messages coming out of scientific circles such as the American College of Obstetrics and Gynecology indicating that marijuana use in pregnancy is associated with brain development problems in the fetus. A whopping 14% of pregnant teenagers ages 12-17 use marijuana. Dumb and Dumber. That is my fear. Also not a popular message. 

It is Zika virus season again in North America. To date 64 babies have been born in the US with Zika related birth defects. Diagnosing infections and tracking the spread of the virus is of paramount importance, together with enacting virus prevention measures such as spraying and education. All this costs money, and funding is tighter than ever this year, pursuant to the policies of the current administration. Zika virus, when contracted by pregnant women, produces a high risk of severe brain damage in the baby. Zika virus is spread by certain species of mosquitoes which live in the southern portion of the United States and points further south, most notably Central and South America. Florida already has 43 documented cases of Zika virus infection in pregnant women. 

Finally, in the good news department, women who breast feed their children for at least six months reduce their risk of endometrial cancer by over 10%. Of course they do their babies an infinite number of goods from improving their teeth to improving their brain development, but who knew there could be such tangible and profound effects on the health of the mother. 

Stay tuned next week for more sensational news from the world Obstetrics and Gynecology, right here on Medical Mondays.

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

Forty prominent groups concerned with women’s health have written a letter of complaint to the new administration. The recipients include President Trump, the Secretary of the Department of Health and Human Services Tom Price, White House aide Ivanka Trump. The letter has criticized each of the major changes that the present administration has either enacted or proposed, for example replacing Obamacare, cutting funds to Medicaid, reducing access to women's healthcare by shutting down Planned Parenthood as well as the "global gag rule”, also known as the “ Mexico City policy”  which prevents international organizations who offer abortion as part of their services from receiving any US funds. The letter further alleges that women's healthcare needs have been traded for political benefit. The letter went out during Women's Health Week to call attention to the issues. In order to begin addressing these concerns, Ivanka Trump has begun meeting with various groups concerned with women’s health, including female Democratic leaders. 

Imposition of the global gag rule may cut off millions in funding to combat other conditions like HIV/AIDS and malaria, leading to a global health crisis. 

In a move long opposed by Republicans, the Trump administration’s budget proposal will include 6 weeks of paid family leave for both mothers and fathers. 

Texas is still trying deal with having shot itself in the foot. Texas took a stand against abortion and removed Planned Parenthood from their Federal Funding recipients. By doing so under the Obama administration, they lost their Federal funding for the Texas Medicaid Women’s Health Program. Texas has the highest maternal mortality rate of all the States, and a very high percentage of uninsured people. They want their Federal funds back. 

Health insurance is not just about a single subscriber, or even a single family. It is a funding pool that we agree to make together, that lets us all have predictable manageable health expenses, even if something really bad and expensive should happen. It also is a way for everyone in society to help safeguard the future, by contributing to the care of the next generation. This is done by contributing to a pool that pays for the care of women and children. This elementary and beneficial concept behind health insurance seems to have escaped Republican Rod Blum from Iowa who believes men do not need to contribute to an insurance pool which covers pregnancy. He was jeered off the stage in a town hall meeting. 

And now for a piece of news that cinches the connection between policy and health care. Research presented at the annual meeting of ACOG (The American College of Obstetricians and Gynecologists) has shown that the Affordable Care Act (ACA) under Obama led many pregnant women to get prenatal care earlier and that led to better perinatal outcomes. Of course this is in jeopardy now. 

Researchers with the American Cancer Society have presenting new findings indicating that increased access to care under the ACA led to early detection of some cancers. These included breast, colon and lung cancers. Early diagnosis leads to more cures and longer survival. The biggest changes occurred in states with significant Medicaid expansions. These gains too are in jeopardy. 

A recent study has shown that women under fifty doubled their survival time in recent years. I suspect mammograms played a role in this. There is controversy on when mammograms should start: 40 versus 50. ACOG recommends 40. So do breast cancer survivors under 50. Cancer patients over 50 also saw increased survivals, but not quite so dramatic. 

The World Heath Organization has presented the shocking news that pregnancy complications are the leading cause of death for teenage girls worldwide. The biggest causes were hemorrhage, complications  from abortion, and obstructed labor. 

Lancet, one of the world’s premier medical journals produced research on “ Amenable Mortality”. “Amenable Mortality means deaths that could’ve been avoided through timely or effective medical care. American scores 80 on the heal care quality index (HAQ) and that is at the bottom on the second decile, on a par with Estonia and Montenegro. 

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

This week, the health care sector spent most of its time digesting the health care policy news from the end of last week. Reactions are coming in regarding Theresa Manning, Trump’s head of Title X family planning program. Here is a woman who criticizes the American College of Obstetrics and Gynecology (ACOG) on its endorsement of Plan B, the morning after pill, and who openly claims that contraception doesn’t work. 

Did you know that 22% of pregnant Texans under 18 have had multiple children ? Texas, the State recently enacting several curtailments to women’s reproductive services, is now grappling with it’s varied distinctions such as having sky high maternal mortality rates, and the highest repeat teen pregnancy rates in the Union. In a near comical about face, Texas is now considering a bill to provide free contraception to minors without parental consent. They have just now figured out this will reduce maternal morbidity, mortality, abortion rates and Medicaid costs. WOW. 

Reactions at a town hall meeting on New Jersey were quite clear, as participants boo’d their elected Senate Representative Tom MacArthur as he explained that rape victims could potentially be excluded from coverage. Talk about adding insult to injury. 

Pregnancy stands to be much more expensive under the ACHA. Those with prior Obstetrical complications such as C sections may fall under preexisting conditions and be charged exorbitant premiums. 

Senate Conservatives plan to drop millions of adults from Medicaid, which they say will reduce health care spending. They had originally said that tax credits instead would help people pay for health care, but now they wish to limit those on the fear that some may use their tax credit cash to pay for abortions. Paranoid much ? Moderate Republican Senators wish to keep the Medicaid expansion, citing it’s many benefits to their States. 

The Congressional Budget Office still appears to have teeth. They are the nation’s bean counters and they have yet to weigh in with REAL FACTS not #alternativefacts on how much the current administration’s ACHA (American Health Care Act) health care proposal will cost. This will include not only the cost of the insurance, but the uncovered health care costs incurred by those who lose their insurance. Polls show support of the ACHA is waning, and is down to around a third of Americans. 

A new study has shown that the credit card debt jumps for women but not men after a year of major medical expenses. Combine this with the fact that women have, on average, 20 % less income and spending power compared to men. Still ? 

As the weather gets warmer, Zika is back in the news. The CDC is now recommending all women at risk for Zika get a baseline Zika blood test. Once pregnant, they are to be retested every trimester. The CDC anticipates that this proactive schedule of testing will unearth many more cases of Zika this year. 

Hepatitis C has tripled its incidence between 2010 and 2015. Federal officials feel that the heroin epidemic is driving this. Among pregnant women, the infection rate has doubled. 

Perhaps in response to all the anti-contraceptive politics or perhaps for a variety of other reasons, the use of LARCs (Long acting reversible contraceptives such as IUDs) has increased seven fold between the years of 2008 and 2013. These are considered very good but still  underutilized methods. 

A new study presented at the annual meeting of the Association for Research in Vision and Ophthalmology states that marijuana smoked by pregnant women could damage the retinas of unborn children. The study utilized an animal model which showed this effect. 

Research presented at ACOG’s recent annual meeting indicated that patient information presented on Society Websites is too advanced for patients. These education materials do not meet the so-called health literacy standards, which are meant to ensure that information reaches it’s target. This is of particular concern to me as medical writer whose aim it is to convey information to a lay public and to my patients. 

What do you think ? Would you rather information be a little too simple or a little too complex ? It is quite hard to get it just right. 

Stay tuned for more breaking news next week on Medical Monday. 

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. 

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

First, the policy news. 

Trump has tied tax reform to health care reform. He has stated that there cannot be tax reform unless there is health care reform. Those that stalled the last proposal, the “ Freedom Caucus", an ultraconservative branch of the GOP, are reportedly in negotiations to prevent a stalemate as before. 

Negotiating with Democrats is another matter. Trump has once again threatened to withhold health care subsidies that fund the ACA (Affordable Care Act) to get Dems to the table. This would entirely destabilize the health care insurance markets. At the same time, the new administration moved to finalize rules to stabilize the ACA marketplaces as they now currently exist. These rules were drawn up by CMS, (Center for Medicare and Medicaid Services) who oversees these and other Federal Health care programs. The intent of these rules is to ease the what insurance companies say is an undue burden placed on them by the ACA. It will shift some of the cost of care back to the consumer, ostensibly making insurers more likely to stay in the market, i.e offer health insurance at all. For example, these rule would allow higher deductibles, larger out of pockets, and increased prices for insurance. It is hard to conceive of health insurance companies needing a “break “more than the common consumer. However, they need to stay solvent in order to make sure there are enough such companies in the market to make it competitive. 

Trump has signed a law withholding Federal Funds from clinics that provide abortion. This of course will also take down those providers from providing the general medicare care, birth control visits and cancer screenings that they would normally provide on a regular basis. 

In good policy news, a bill has been introduced in Connecticut which would make pregnancy a “qualifying event”, meaning it would enable pregnant women to enroll in the ACA anytime, instead of just during the specified enrollment periods. 

Aren’t you grateful when your medication can be purchased as a generic ? I am since it saves lots of money. Drug companies trying to recoup their losses try to keep generics out of the market as long as possible. Regulators such as the FDA ( Food and Drug Administration) intervene when the need for the drug is great or the company is believed to have recouped their expenses, or the cost of the drugs is simply too high. A bipartisan effort is underway to ensure timely access to generics. This could save the public billions of dollars. 

Human Papilloma Virus (HPV) is on the rise in the US. Those who have been vaccinated are not part of this rise. Surprise ! 

A new study indicates that many primary care doctors and Ob/Gyns are continuing to recommend mammograms after 40 rather than begin them after 50 as the USPSTF (US preventive Services Task Force)  recommends. That is because the USPSTF gauges effectiveness by death rates, rather than years of life. Death rates from cancer or non-cancer are low for women in both the  40s and 50s, and comparisons to not yield adequate numerical differences. Furthermore their metrics do not incorporate the value of early detection on the reduction of MORBIDITY (complications short of death)  or the enhancement of quality of life. The USPSTF is comprised of epidemiologists and not clinicians. ACOG ( American College of Obstetricians and Gynecologists) recommends that screening mammograms begin at 40. 

According to the CDC ( Centers for Disease Control) Texas has the highest repeat teen pregnancy rate in the country. Numerous voices in the State are calling for a state based no-cost provision of birth control. Why does this not make sense to everyone ? 

On that front, it is not widely appreciate that long acting birth control such as IUDs can be places right after the baby is born. This is especially useful for patients who might not show up to their postpartum appointments. 

In perhaps the most most important opinion piece of the week, the Catholic Democrats President Steven Krueger has described a problem in the Democratic party. He has noted Democrats seem reluctant to talk about ways to reduce abortion since it may imply they do not believe access to it is a fundamental right. He believes Democrats should come to the table with proposals to reduce abortion, thereby gaining ground on issues like birth control and provision of health care in general. 

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

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

In policy news, things are moving at a slower, more measured pace. Moreover, the policy pendulum is swinging back to a more moderate place. In a move striking many as too little too late, the House GOP has proposed adding $15 billion to their now failed ACHA (American Health Care Act) making it more palatable to centrist republicans. This money would be pad to reimbursing health insurance companies for high cost patients. The intention is that this would help states reduce health insurance premiums for clients starting in 2018. The Kaiser Family Foundation has estimated that health insurance premiums will go up for the average ACA (Affordable Care Act) client by 19% if federal subsidies are withdrawn. Even with this 15 billion dollar amendment, the GOP did not have enough votes to pass their bill, and now Congress has adjourned for spring break recess. 

According to the Gallup poll, the majority of Americans now support the ACA. This is now the case for the first time since the ACA became law seven years ago. Though 55% of Americans now support it, many feel it could be improved. Centrist Democrats, calling themselves the “ New democrats”  and moderate Republicans,  “the Tuesday group”, are beginning to work with one another on small feasible improvements to the ACA which could benefit everyone.

Senator Bernie Sanders has promised to propose a bill for a single payor system, the so-called “ public option”, also known as “Medicare for all”  in 2018. 

Sixteen State’s Attorneys General have filed an Amicus brief against a new Ohio law which prevents health care providers who offer abortions from receiving any federal funds for any services. A US District Judge in Missouri has reversed a similar law in Missouri. 

In other abortion news, the 2013 Texas House Bill 2 required doctors to have admitting privileges in order to provide abortions. It also required them to do so in ambulatory surgical centers. Finally, it decreased the limit from 24 weeks to 20 weeks. The first two requirements put many midlevel providers in office settings out of business. About half of all abortion providers were put out of business. 

A new study in JAMA, the Journal of the American Medical Association, looked at the changes in practice since this law has taken effect. It turns out there were 20 % fewer abortions performed in that time frame. It also turns out that the abortions performed were done at a later gestational age. The researchers also calculated that an increased umber of abortions were performed illicitly. 

In medical news, the WHO (World Health Organization) has data indicating that fully 10% of all deaths worldwide are due to smoking. The number is believed to be underestimated since the effects of second hand smoke have not been accounted for. 

Death rates from the main types of cancer for all types of people have declined between 2010 and 2014. The decrease washout 2 %. 

In other good news, TDAP vaccine given in pregnancy is associated with lower rates of pertussis in babies later. (surprise ! ) 

Looking back at Zika, new data has shown us that 10% of women with Zika infection in pregnancy had a baby with a serious birth defect. The number may be higher since not all babies born to mothers with Zika have been given neuroimaging. Also in Zika news, a vaccine under development is progressing to phase two testing.  

In other vaccine news, according to the CDC, as of 2014, about 42% of all people carry the virus. A large new Scottish study of 20,000 women has shown that the HPV vaccine has been associated with a 90% fall in the prevalence of the virus.

Stay tuned for more breaking news from the exciting world of Ob/Gyn here, next week on Medical Monday. 

Thanks for your patience with my delay during Passover ! 

Here is may first ever angel food cake, made gluten free from scratch. It is served with a dairy free chocolate ganache, lemon curd, and cherry berry sauce. 

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 from the world of Obstetrics and Gynecology

It is true that some of us were wishing the American Health Care Act would just go away. Friday has shown us that sometimes wishes do come true. 

Medical Monday per se will be delayed one day in order to better report on this momentous news of late Friday. We will want to see reactions from all the various sectors on this important development.

The Affordable Care Act, also known as Obamacare, represented progress. It gave us the individual mandate, requiring us all to have insurance or pay penalties. It gave us the contraceptive mandate, which data clearly shows saves money and unplanned pregnancies. It gave us subsidies and more.  However it is unclear how sustainable it will be since it is costly. The new more fiscally conservative administration, at their very best, could scrutinize the program further for cost saving measures. 

While we are wishing, I will put out some of my best thoughts on the matter. 

"Best Practices Health Care Act" 

(This title implies policies will be driven by data, and not politicians.) 

1. Keep the individual mandate and make the penalties stiffer. (Similar to auto insurance.) Give it real teeth. 

2. Keep the contraceptive mandate. This means birth control will have no copays. Drive prices of contraceptives down by allowing the government to negotiate drug prices. 

3. Separate abortion services out of Planned Parenthood and continue to fund the great preponderance of what services remain. 

4. Keep children on policies until 27. Consider allowing even older family members, but raise premiums accordingly. 

5. Charge increased premiums for risk factors ( similar to life insurance) such as smoking, alcohol use, obesity, drug use. Also charge increased premiums for high risk sports such as skiing, paragliding, horseback riding, etc. Charge increased premiums for those with bad driving records. 

6. For Medicaid recipients, require small copays and, for the able bodied, work and/or service. 

7. Government may negotiate prices on all drugs. 

8. Fully fund preventive services without copays, i.e. encourage and reward prevention in every possible way. This would include annual exams, cancer screening, dexa scans (screening for osteoporosis or bone thinning) and vaccinations. 

8. Create a combined sliding scale of subsidies for the poor and tax credits for the rich. 

9. Keep low risk and high risk patients together in one pool. 

10. Reward participation (lower premiums) in accredited health programs. 

11. Manage medical malpractice expenses aggressively, keeping as many health care dollars out of the hands of lawyers as possible. This might involve caps on lawyer fees, and caps on malpractice awards. This might mean mediation is required before litigation. 

This is just a start of ideas, that I, as a physician, think we need to think about. Stay tuned to see what the rest of the world thinks about this development. 

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

The health care policy package proposed by the new administration must pass through several committees before actually passing to the House and the Senate. One of these is the Budget Committee. This last week House Republicans brought the American Health Care Act (ACHA)  through this committee by vote of nineteen to seventeen. However three GOP lawmakers voted against it, showing a house divided. Centrist Republicans who approved the bill did so providing the tax credit system change to better benefit the working poor. Nonetheless it is the working poor and older workers who will experience a disproportionate rise in premiums. This is because of the substitution of tax credits for subsidies. Those who have low wages have low taxes and tax credits mean little to nothing to them. As previously reported, tax credits help those with substantial tax burdens, i.e., those with higher incomes.  

Analysts believe premiums will likely rise for a number of reasons. Principally the lack of the individual mandate will keep a lot of money from entering the pool, and this needs to made up somewhere. The premiums from 24 million consumers are likely to come out of the pool,as 24 million are likely to lose insurance with the repeal of the ACA.  This alone is believed to account for what is expected to be a 15-20 % hike in premiums. Those of us who obtain health insurance coverage will make up that staggering shortfall. Moreover, when the uninsured hit the hospital, we will also pay for them in rising medical costs, since the care providers will be left holding the bag. 

Despite all this Health and Human Services Secretary Tom Price still says that the ACHA is “ intended to make health insurance feasible for every single American.” He and others in the new administration insists no one will lose coverage with with transition from the ACA to the AHCA. 

The Department of Health and Human Services budget will be cut by 15 billion, 18 percent. And yet, there will be sizable block grants for the opioid crisis and a “ Federal Emergency Response Fund.” The President’s new budget will cut funding to the NIH by 5.8 billion dollars. 

President Trump wants to give the States ability to alter their own Medicaid. On the table are copays, work requirements an premiums. 

Readers will recall from last week that Representative John Shimkus cited a “War on Men” and decried the mandate that men must purchase insurance which covers prenatal care. He does not believe that men should have to contribute to a general insurance pool if it includes funds for the prenatal care of women who also purchase that insurance. He is the same man who has sponsored anti- abortion bills out of his concern for the well being of fetuses. Connect the dots much ? 

That place where the federal government buck always stops is the Congressional Budget Office or CBO. According to the CBO, defunding Planned Parenthood would increase the number of Medicaid births, decrease overall Medicaid spending, but increase unplanned pregnancies. As unplanned pregnancy rates rise, so do abortions. 

And now for the highlights in medical news. 

Gardisil, the vaccine against Human Papilloma virus, is effective. It turns out that two doses are affected as the currently recommended three, good news for everyone including those kids who failed to get their third dose. 

When I was in training there were no limitations on length of our shifts. We routinely worked 36 hours at a stretch, and in my big training center, most of the time, we have no sleep at all. Shortly after I finished residency in 1994, an 80 hour per week working standard was set. Additionally the limitation of 18 hours per shift was instituted. However now concerns about continuity of care have caused the number to swing back to 24 hour shifts. However, The 80 hour week per limit for residents at all levels remains in place.

Preterm birth remains a serious problem in this country. We've developed various methods to try to predict its likelihood including cervical length ultrasound and fetal fibronectin testing. It does have some utility, together with the clinical judgment. However, it turns out that, according to a recently published study in the Journal of the American Medical Association, they have limited utility in first-time mothers.

Over 400,000 physicians from various disciplines compose the Medical Society Consortium on Climate and Health. Associations who participate include the American College of Physicians, the American Academy of Allergy, Asthma, and Immunology, the American Academy of Family Physicians and American College of Obstetricians and Gynecologists. The group has identified eight threats whose increase is related to climate change which will doubtless have serious effects on human health. They are, extreme heat, extreme weather, air pollution, ticks and mosquitoes, contaminated water, contaminated food, mental-health, and nutrition.

On that sobering note, I would encourage you to get more active in political, social and environmental activities which concern you. Your elected officials are truly easy to reach by phone or email. 

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

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

In the most important news of the week, the ACA replacement plan was unveiled this last Monday, March 6th. It’s official name is “The American Health Care Act”. 

The bullet points: 

• Federal insurance subsidies are replaced by individual tax credits and state grants. 
• The individual mandate to have insurance will be scrapped, and replaced by a 30% surcharge the next time you try to purchase insurance. 
• The Medicaid expansion would end. 
• Protection of those with preexisting conditions will stay.
• The ban on lifetime coverage caps will stay.
• The ability to insure children until age 26 will stay. 

Initial reactions were negative to tepid, even among Republicans.  Analysts have noted that the tax credits will range between $2000 and $4000 based on age, rather than income. Tax credits will, of course only materialize for those who pay taxes, and the full credit will be utilized only if the patient pays enough tax to use it. Assuming even that the whole credit is received, it is still not as much as current subsidies. In many cases it will not cover deductibles. In short, the ACA replacement plan lowers prices for the more well off and increases prices for the poor. 

The bill was strongly criticized by very conservative lawmakers based on budgetary concerns. Conservatives and moderates also voiced concerns regarding widespread loss of coverage that will occur. Assuming there are no Democrats who approve the bill, there can be no more than 22 Republicans who disapprove of it for it to fail. 

By the end of the week, two key House Committees, Ways and Means, and Energy and Commerce did approve the bill. Nonetheless, many Republicans are against it as is every doctor group, every health care group, and every consumer rights group. 

Trump is reaching across the aisle on the issue of prescription drugs. He, together with most Democrats, favor allowing Medicaid to negotiate with drug companies on prices. Republicans have long opposed this. Hopefully it will save costs but not detract from research. 

Many continue to worry about the loss of contraceptive benefits by one means or another. One nonprofit called “Child Trends” has come out with an estimate that keeping contraceptive access for all women would SAVE $12 billion yearly. They also estimate this strategy would be accompanied by drops in unintended pregnancies, unintended births and abortions by 63-67%. 

In #alternativemedicalfacts news, many authorities are decrying the Indiana law requiring that the “abortion reversal procedure “ be discussed with patients. Medical authorities including ACOG (American College of Obstetricians and Gynecologists) have been very vocal about the fact that the procedure simply does not work, does not exist, and is not real. Utah has passed a similar bill. 

In Pennsylvania, one bill is seeking to ban the abortion pill. This pill is used to effect very early abortions without surgery. However, it is also used to stop hemorrhages after deliveries or miscarriages. Difficulty getting this medication would be an unmitigated disaster. We use it every day on our Labor and Delivery unit and it literally saves lives there and the world over. 

Kentucky has passed a bill defunding Planned Parenthood even though Kentucky Planned Parenthood does not provide abortion. 

Maryland has devised a bill to fund Planned Parenthood on their own, should it otherwise be defunded. 

Nevada democrats are testing the judicial waters by introducing a bill which would require insurers in the state to cover contraception regardless of religious objections. Of course this would be in opposition to the Supreme Court decision prompted by Hobby Lobby which states that businesses “with religious objections”. supplying insurance do not have to cover contraception. Go to Michaels or Joannes instead but stop by Michaels to tell them what you think. #canabusinesshaveareligion ? 

New Mexico has installed state law requiring that all insurers cover contraception at no out of pocket costs. They have gone a step further and added Vasectomy to the list of covered services. 

The US Preventive Services Task Force (USPSTF) has again questioned the utility of the annual pelvic exam. This has happened  before. As before, ACOG has maintained its validity as a screening tool. I personally find all kinds on things on routine screening pelvic exams on asympmotmatic patients. Perhaps the devil is in the details. Perhaps the utility or sensitivity of the exam depends on the examiner. A general surgeon friend of mine one told me with a wry look, “the pelvic exam is not sensitive in my hands”, meaning he really does not know what he is feeling, even though he is an excellent general surgeon. Perhaps if the USPSTF compared the utility of the pelvic exam for ob/gyns to the pelvic exam for other caregivers, they would see a difference. 

Beyond that, I want to know why the routine pelvic exam is being so rigorously studied. Is it costing the taxpayer a disproportionate amount of money ? Is it harmful ? Is it generating false positive results ? Is there a problem ? Aren’t there more pressing problems in health care that deserve our attention ? Why are women’s health care procedures always first on the chopping block ? #waronwomenshealth

We have a new department in Medical Mondays. You’ll love it. It is called “Outrage of the Week”. Let’s hope we do not have one every week, but something tells me we will. You will not believe this, and I mean you all on both sides of the aisle will not believe this. Republican Representative John Shimkus of Illinois has questioned why men should have to pay for insurance covering prenatal care. The Washington Post has reported that, among critics of the ACA, this is not the first time this question has been posed. #waronwomenandchildrenshealth

In the human nature department we report the following: The percent of overweight and obese patients has increased from 53 to 66 % in the last 3 years. However, the percent trying to lose weight has decreased from 59 to 49 %. These patients are invariably very expensive, medically speaking.  Should insurance prices account for weight or other health habits ? Should insurance give breaks for those who do not have issues or those who show documented effort to resolve their issues ? 

In medical good news department, we report on easy cancer prevention. In a two decade study of 60,000 women, published in the International Journal of Cancer, the Mediterranean diet has been found to be of benefit. In particular, it is estimated that about a THIRD of estrogen receptor negative cases of breast cancer would never happen if women were to adhere to this particular diet. 

On that tasty note, we will conclude, and hope that you will have the stomach for next week’s Medical Monday. 

Medical Monday: Breaking News from the World of OB/GYN

Contraception: Get yours while it's hot ! 

GOP leaders again met to discuss repeal of the ACA (Affordable Care Act). The same measures were discussed this week as last: health savings accounts, tax credits, and state high risk pools for the chronically sick. A bill is anticipated next week. 

A measure passed in the House which enables States to pull funding from any facilities who perform abortions. This funding is not specific to paying for abortions. It pulls funding from the facility altogether for all the care it provides, whether it is flu testing, mammograms, or pap smears. This will directly defund Planned Parenthood. In the short term, i.e. one year, it will save money, but in the long term, researchers estimate it will cost much more than current expenditures because of diseases untreated, disease caught later, and and of course, due to unplanned pregnancies and the costs they incur. 

Indiana is voting on a so called “ abortion reversal” procedure which has no basis whatsoever in scientific fact. The American College of Obstetricians and Gynecologists have weighed in, saying that it has “ not been scientifically proven to work”. There is no reason to believe that it would. 

Many states are working on measures to reduce abortion at a time when abortion rates are at a modern low. Today's rate is the lowest since Roe versus Wade was made law in 1973. According to the a broad base of research data from around the world, restrictive abortion laws do not prevent abortion. They simply prevent legal abortion, and lead to illegal abortion and it's consequences. Moreover, research has shown that access to contraception DOES prevent abortion. However, distressingly, these same states who are moving to pass restrictive abortion laws are also moving to restrict access to contraception. Teens have the highest rates of unintended pregnancies. Teens are also the most likely subgroup with unintended pregnancies to get abortions. Data from the Contraceptive Choice Project have shown that when teens have access to the free birth control of their choice, abortion rates plummet. In this study of 9000 subjects, the abortion rate went from 41.5 abortions per 1000 teens to 9.7 per 1000. 

In the fake out department, The current administration is introducing rules to help keep insurers in the ACA (Affordable Care Act) . This is ostensibly being done to stabilize the market. This sounds good, right ? However, it is being done in such as way as to make criteria for inclusion in the ACA stricter. Additionally the enrollment period will be reduced from 3 months to 45 days. Tightening the criteria and shortening the enrollment will shift costs onto patients and off insurers. 

The ACA will lose its teeth. Why ? The Trump administration no longer plans to withhold tax refunds from those who ignore the requirement to have health insurance. Instead these uninsured people can show up on the doorsteps of hospitals everywhere with God only knows what needs, get them promptly and properly taken care of.  As uninsured people, they then either pay their medical bills regular price out of pocket (fat chance, especially with something costly like heart disease, diabetes, cancer, trauma or worse) or leave hospitals, caregivers, and ultimately taxpayers and those of us that pay for insurance in the lurch. Meanwhile data has come in for 2016 that the uninsured rates dropped to record lows in 2016, to 8.8% to be particular. This is felt to be due to the ACA. 

In medical news, two new studies show that scalp cooling cuts chemo related hair loss in half. This study was done on women with early stage breast cancer. Hopefully it will reduce some of the insult that comes with this all too common injury of breast cancer. 

There is a widespread shortage of ObGyns in rural America, with only 6% of us working in the rural setting. People decry this and classify this as an “ access to care” issue. However, it makes sense that Ob/Gyns do not want to work in isolation, far from hospital and community resources. Truthfully, birth should take place within a community, however small, which has access to surgical services and support people of various kinds. I believe people who live remote even from these small scale services should plan according and make arrangements to “stay in town” when they have complications or get near term. I have many such patients who have rudimentary services near their homes on the plains or in the woods, but prefer to come an hour and a half  "to town” for their care. They are clear about valuing the beauty of their countryside or wilderness homes, but also clear about realizing that a modern medical facility just cannot be there. I appreciate their insight on the situation. 

In the good news department, our extreme preemies are surviving not only longer, but better, that they have in previous years. Specifically, they are doing measurably better in their neurodevelopment parameters. Kudos to our friends in Neonatology and the newborn ICUs around the US. Kudos too to all the ObGyns working to treat moms at risk for preterm delivery, and to those researchers who developed antenatal steroids. 

Also in the good news departments, LARCS (Long acting reversible contraceptive such as IUDs) are proving acceptable for the vast majority of users. No surprise there on these elegant and effective methods. 

And finally, in the we-already-knew-this department, exercise is proving effective at improving hot flashes and QOL (quality of life) in postmenopausal women ! 

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

Medical Monday: Breaking News from the World OB/GYN

Policy news is once again front and center this week. For starters the Senate approved the controversial nomination of Representative Tom Price to be Secretary of Health and Human Services. The legislator is an outspoken proponent of repealing the Affordable Care Act (ACA). He has suggested replacing it with tax credits, health savings accounts, and high risk pools for sick costly consumers. 

Meanwhile more than 12.2 million people have enrolled in the ACA despite its uncertain fate. At the same time, insurers are warning that insecurity in the sector by itself could drive up premiums in the near future. 

The current CEO of the American College of Obstetricians and Gynecologists (ACOG) Hal Lawrence III has stated that there have been clear benefits to women's healthcare contained in the ACA. Accordingly, ACOG  is combating GOP efforts to completely repeal the ACA, urging lawmakers to confirm preserve a provision which prevents insurers from charging women higher premiums than men. Key physician groups including ACOG who provide care to women and children went to Washington last week to lobby for retention or expansion of features of the ACA which provide benefits for women and children. They along with increasing numbers of GOP lawmakers are advocating a repair not repeal approach. Nonetheless, House Speaker Paul Ryan has insisted that repeal and replace will be passed this year though acknowledges it may take several years for it to be implemented. Speaker Ryan has given the GOP semantic permission to repair the ACA by stating that repeal and repair  “essentially amounted to the same thing.” 

The federal government has been looking at Medicaid block grants as a way to save money. This means each state would receive a grant of a fixed amount of money and it would be up to them to allocate it as per their state specific needs. Those favoring this approach cite the amount of money that would be saved. Those against this approach, divided, not surprisingly bye party lines, argue that it would result in slashed benefits and increased costs to states.

On medical news, obesity is back in the spotlight. Obesity is epidemic, and it is costly. It also happens to affect fertility. New research from the National Institute of Child Health and Human Development found that among couples where the woman is obese the time taken to become pregnant is longer. When both members of the couple are obese, i.ewith the body mass index of 35 or higher, it takes 60% longer to become pregnant.

Polycystic ovarian syndrome or PCOS is a cluster of signs and symptoms that relate both to fertility, menstrual functioning, carbohydrate metabolism, and cardiovascular health. It is often accompanied by high body fat percentages, if not obesity. New research indicates that disordered eating behaviors are four times greater among those with this syndrome compared with controls. Is already well-known that when PCOS patients lose weight, their menstrual functioning infertility improves.

Obesity is a risk factor for many forms of cancer. New research published in the Journal of Clinical Oncology has indicated the converse. Intentional weight loss may reduce postmenopausal women's risk of uterine cancer.

Is strange and concerning report, it has been discovered that large amounts of maternal licorice consumption during pregnancy may be associated with lower IQ, ADHD like behavior and early puberty in children. This was reported in February 3 online edition of the American Journal of Epidemiology. The study was a community based cohort study of 1049 people in Helsinki Finland. The compound in licorice thought to be the culprit is glycyrrhizin. This substance apparently blocks an enzyme we have which shields the developing baby from maternal steroid fluctuations. More research is necessary. 

It has also been shown that the prevalence of certain types of bacteria in the cervix may affect a woman's risk of preterm birth. Bacteria which we have considered normal, such as Lactobacillus, are protective against preterm birth, while other bacteria, specifically several anaerobic bacteria greatly increase the risk. These findings were presented at the Society of Maternal Fetal Medicine’s annual meeting.

There are new recommendations for HPV vaccine. Children less than 15 would obtain it need only get two doses. Older children still need the three shot regimen. TapHOPV vaccine protects against cervical cancer and genital warts and may be given between the ages of 9 and 26.  

Stay tune for more exciting news from the World of Obstetrics and Gynecology, next week, on medical Monday.

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

We start this Monday with the piece of grossly under reported news. few seem to be aware of the fact that prenatal cannabis use is linked with cognitive impairment academic under achievement in children. Both the American Academy Pediatrics and the American College of Obstetricians and Gynecologists advise against its use because best. Many patients assume that because it is legal it is safe. Marijuana’s main psychoactive ingredient THC or tetrahydrocannabinol crosses the placenta to reach the fetus. It not only affects brain development and cognition but also birth weight as well. Have you seen anything about this lately? 

Planned home birth is again in the news. A new study shows that planned home birth  is associated with increased risk of complications, especially in women who are having their first baby or in those 41 weeks or more. This particular study looks at the rate of neonatal death, the most severe complication.  Researchers found that those who delivered with midwives at home had a neonatal death rate of 24.4 per 10,000 birth compared to 5.09 per 10,000 births delivering with a midwife in the hospital. 

300,000 babies are born in United States every month. Typically 273,000 women take time off of work to care for newborn whereas 22,000 men do the same. A recent study in the American Journal of Public Health as shown that maternity and paternity leave rates in the United States have been constant over the last 20 years. This may be related to the fact that only 12% of workers in the private sector have access to pay family leave. This lags far behind other developed nations of similar socioeconomic status.

Recent work from the Pew Research Center revealed the new president's views on vaccines are not shared with the majority of Americans who overwhelmingly support requiring children to be vaccinated before attending school. 82% of Americans support children receiving the MMR vaccine before attending school. 

Representatives from numerous physicians organizations have descended upon the halls of the Senate offices to lobby their respective representatives about the need to retain certain characteristics of the Affordable Care Act (ACA). These organizations include the American Academy of Pediatrics, the American Academy of Family Physicians, The American College of Obstetricians and Gynecologists, and the American College of Physicians, and the American Osteopathic Association. They have placed particular focus on the provisions for the care of women and children as these provide the foundation for lifelong medical care and wellness. They have placed particular emphasis on the need to have a replacement in place before the current plan is repealed. The same groups, representing over half a million United States physicians, sent a letter to the White House and Congressional leaders leaders asking them to ensure that women's health, including preventive prenatal and neonatal care, be protected. 

A subcommittee within the House is beginning to work on replacing the ACA. They are looking at the issue of preexisting conditions, and at age ratings which determine the charges paid for insurance by age. They're also considering a shorter grace period for those who fail to pay premiums on time. The process is contentious between Democrats and Republicans,  but it is also reportedly contentious between different Republican legislators as well. Republican lawmakers nowassert that they intend to “repair not repeal” the ACA. 

Last week, a meeting between State Insurance Commissioner's and brokers met with the Senate Health Education Labor and Pension Committee. They warned the Committee that more healthcare plans are likely to”defect from the Affordable Care Act marketplaces unless Congress and the Trump administration provide concrete assurances within the next two months”. They also warned that those insurers that remain are likely to increase their rates by as much as 20% if this occurs. Specifically, the insurance industry wants GOP lawmakers to ensure that they will fund ACA subsidies in 2018. They need this information so that they can make their budgets for the next year. ACA subsidies are currently the subject of court battle between Republican Representatives and the White House. Amidst all this, the Department of Health and Human Services introduced a rule, the "Patient Protection and Affordable Care Act; Market Stabilization”, which is meant to stabilize the health insurance market for individuals. The GOP appears to understand that it is in everyone’s best interest to stabilize the insurance markets. 

Threat of repeal of the ACA continues to spur women women into seeking long acting reversible contraceptives (LARCs) such as MIrena (IUD) and Nexplanon (subderrmal insert). Month-to-month adoption of these methods is at record highs and continues to rise. Women are also stockpiling prescriptions of contraceptive and the prescriptions Some states such as New York are addressing the problem by requiring State governed insurance agencies to cover contraception with no or minimal copays. Massachusetts has developed a bill to provide free contraceptives to all of its residents. 

The is busy time for women’s health  and health care in general. Find out the names and contact information for your elected officials. Make your views known. 

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

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

On last Monday , President Trump signed an executive order “ granting relief” from the stipulations of the ACA (Affordable Care Act). Among other things, this means the Department of Health and Human Services (DHHS) may reduce what insurers are obligated to cover for patient’s care. 

Planned Parenthood reports that the number of women trying to get IUDs in their clinics has gone up 900% since early November, i.e. the election. IUDs are a very reliable long acting contraceptive.  They are obtaining these IUDs under the contraceptive benefit under the ACA, which they fear will be repealed under the current administration. 

The Democratic Governor’s Association has urged Congress not to overturn the Medicaid Expansion or to convert to block grants. They stand to lose a great deal of coverage and funding for their constituents. 

Two moderate Republicans, Senator Susan Collins of Massachusetts, and Senator Bill Cassidy of Louisiana, a physician, have indicated a partial replacement for the ACA, which would allow states to continue to operate under it if they chose. Under this proposal, states who opted out of the ACA could get a block payment to administer on their own. The authors have emphasized that the bill is a work in progress. 

At the recent GOP policy repeat, a plan was made to have a replacement for the ACA  to the House floor by the end of March. The House Speaker, Paul Ryan indicated that they intend to get these replacement laws made in 2017. 

The US has frozen funding to health care providers in poor countries who discuss abortion as an option. This policy is called “ The Mexico City Policy” and it is been enforced and revoked back and forth through the administrations of Clinton, Bush, Obama, and now Trump. 

The CDC (Centers for Disease Control) reports that consumption of sugar drinks is still “ well above” the recommended limit. Consumption of these drinks has decreased steadily for the last ten years but now seems to have plateaued. 

The South has higher cancer mortality rates that the rest of the country. These are areas of the country where poverty, smoking and obesity are more prevalent, and these factors are believed to be the reasons. Overall, the US health rate from cancer has decreased 20% in the last ten years. 

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

This Monday the world has become a different place. A new Administration has taken office in the United States. But more importantly, women across the country and across the world have become galvanized. Many marches of hundreds of thousands each took place on Saturday. These were largely demonstrations by and for women to make a statement against sexism, misogyny and against the loss of health benefits in the US. I’m not sure the world has ever seen political activism for one goal on such a large scale. 

Democratic lawmakers made a last ditch appeal on Friday, urging that the GOP halt the repeal. They cited the many clauses of the ACA which prohibit practices which are discriminatory to women, such as denying coverage of contraception and coverage for women-only health screenings such as mammograms. They cautioned that this, along with defunding Planned Parenthood, would harm women in every state. 

It is becoming clearer and clearer that many Republican governors do not favor a wholesale repeal of the ACA. They know that repeal would cause chaos in health care, as well as increasing costs for their state programs. 

In the shocking numbers department, it has been determined that HALF of all men have genital infections caused by HPV. One in four of those have viral strains which can cause cervical cancer. 

Meanwhile, New York State is reporting a 50% decline in cervical cancer deaths since 1976. This is attributed to women obtaining regular paps to detect precancerous conditions and the introduction of the HPV (human papilloma virus) vaccine Gardisil. 

It is interesting to note that abortions are at a new low since the institution of Roe versus Wade case law in 1973. Researchers attribute this new low to the increased availability of affordable and longer lasting contraceptives. 

If the ACA is repealed, both these important gains might likely be lost since the ACA has covered contraception and health screening for women. 

As if to add insult to injury, repeal of the ACA would also strip breastfeeding protections from the workplace. These protections are in place through the ACA. 

The ACA deals with more than women’s health issues. The ACA contained provisions to authorize a fund to combat the costliest of our chronic diseases: diabetes and heart disease. Repeal of the ACA could eliminate this fund, which is for state public health programs.

Americans may be divided, but 40% across both sides of the aisle agree that health care should be a top priority for the new administration. Meanwhile, the popularity of the ACA is steadily climbing in the polls. Forty eight percent of Americans strongly approve of the ACA. Of those 22% of respondents who want it repealed, half want to do so only when a replacement is in place. The Congressional Budget Office itself has calculated that if the ACA is repealed, 18 million people will lose their insurance in the first year. Over a decade, 32 million would lose insurance. They also estimate that individual premiums would double. 

In Zika news, officials have been debriefing from the season. They feel the greatest failure has been of prevention in the areas most affected by Zika. They have emphasized that the toll taken has scarcely been counted. 

Fetal alcohol syndrome (FAS)  is still a scourge. Over a hundred thousand babies are born yearly with this condition. Britain has one of the highest rates of FAS in the world, with 40% of British pregnant women drinking during pregnancy. 

The American College of Obstetricians and Gynecologists has continued to take issue with the FDA on their overly conservative and out of context warnings on anesthetics in pregnancy. Their concern is that caregivers and patients will be reluctant to have critical procedures such as appendectomies and gall bladder removals in pregnancy should they become necessary. Surgical illnesses such are these are very much threats to both mother and babies in pregnancy and should be dealt with in the standard fashion. To put theoretical concerns from animal studies ahead of clear and present dangers is missing the forest for the trees. 

Contact your elected officials with your concerns. It is not enough to march. 

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

More than one organization is working hard on vaccines against the Zika Virus. Currently trials are with inactivated vaccine. These take longer to develop than vaccines, with live virus. However live virus vaccine trials are more risky, and it might be difficult to find volunteers for such a trial. And that is all the Zika news for this week. 

Leading the news is the ACA, the Affordable Care act and it’s fate. 

More information is coming in about how the ACA affected us. For one, it’s institution seems to have been associated with increased mammography utilization among older women. Unfortunately the same increase in utilization was not seen with colonoscopy screening for colon cancer. In practice, this is indeed a harder sell, but the truth is, it saves lives, and is not that bothersome of a procedure. 

Senate Majority leader Mitch McConnell has stated that the ACA will be “ replaced rapidly after repealing it”, though he provided no details. He did admit that “ There ought not to be a great gap between the first step and the second.” Many GOP leaders estimate that it will take 2-3 years to devise a replacement. 

Hospitals are continuing to voice their concerns that repealing the ACA could cause a major crisis in health care. Increasing numbers of GOP lawmakers are voicing concerns about a lack of replacement for the ACA. They fear the financial consequences to their states and their constituents, as well as allegations of being reckless and the political consequences that that entails. At the same time President elect Trump has demanded an immediate repeal and replacement. . On January 12th, GOP Senators voted 51-48 on a non-binding measure approving a budget blueprint to repeal the ACA.  Personally, I think it is still worthwhile to contact your elected representatives and tell them how you feel about this. 

Enrollment in the ACA continues to outpace that of last year. As of December 24th, more than 11.5 million people have enrolled. Twenty million Americans altogether have their health care through the ACA. 

Oddly, Mr. Trump made certain campaign promises regarding 6 weeks of paid maternity leave and reductions in child care costs. Last week he held meetings about these issues while urging his party to gut health care. 

Speaking of women’s health care, contraception is currently covered by the ACA. it’s repeal would of course threaten this benefit. However, states have the ability to require insurance companies to cover it entirely. Not surprisingly, many states are moving to establish laws that will resemble the ACA in their coverage of contraception. 

In medical news, the flu is clinically worse this year than in other years. But, good news ! The vaccine this year is a good match, and is very helpful. There is still time to get one. 

In other vaccine news, there is a herpes vaccine under development. It is showing promise to decrease frequency and severity of outbreaks. 

Breastfeeding moms need to take prenatal vitamins, Calcium and Vitamin D. Many people including pregnant women and nursing mothers are low in Vitamin D. All breastfeeding moms should be supplementing their breastfed babies with vitamin D drops. This message is not getting out as well as it should. Consult your Pediatrician. 

 

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

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

Zika is still in the news this new year, but this is definitely the off season. In good news, the CDC (Centers for Disease Control) has released $184 million dollars to the states and territories to fight to Zika virus. The funds will be used to improve testing and to enable the states to track pregnancies and births affected by Zika. In other good news, two studies published in the New England Journal of Medicine and the Journal of the American Medical Association reported that the risk of Zika associated microcephaly maybe less than previously estimated. Microcephaly is one of the more severe side effects of perinatal infection with the Zika virus. However it is not the only side effect as Zika affects many other organs and many other aspects of the central nervous system, many of which are yet be fully quantified. It may be that while microcephaly is less prevalent than previously estimated, serious less well defined or obvious side effects are more common than previously estimated.

New research published in the Journal Gynecologic Oncology indicate that there is a new up-and-coming ovarian cancer drug. In this small study, progression free survival was increased from 6.8 months to 15.4 months. This may not sound like much but it's a step in the right direction which, ultimately, may be combined with other such steps.

Republican Representative from Georgia Tom Price has been nominated for Health and Human Services Secretary. This has been a controversial nomination. Dr. Price is an orthopedic surgeon, and as such has been endorsed by the American Medical Association. At the same time, many in the medical field voiced their opposition to this nomination. Several thousand physicians have signed a  petition indicating their displeasure and stated that the American Medical Association does not speak for them. Meanwhile, the President of the American Congress of Obstetricians and Gynecologists, Dr. Thomas Gellhaus, has expressed concerns that some of the bills supported by Dr. Price would “…not serve women's health well”.

In other political news the GOP is divided on the issue of the ACA (Affordable Care Act). Basically, the two camps are as follows: repeal and do not replace versus revise and rebrand. GOP leaders have tried to assuage concerns about the repeal or revision of the ACA promising that "no one is worse off". There is concern however that ensuring that "no one is worse off" will be difficult to accomplish, given that the GOP intends to repeal certain taxes which have been used to fund the ACA.

In sobering news, alcohol consumption, bingeing and alcohol related deaths are up sharply among American women. This is the case as reported by the Washington Post on analysis of Federal health data. Analyzing the data has revealed that this is particularly true among American white women. At the same time, findings published in the current issue of the Journal Drug and Alcohol Dependence show that between 2005 and 2013 binge alcohol use and alcohol use disorders are increasing among older adults.

The Journal of the American Medical Association has produced new research which has broken down how we spend on healthcare. Not terribly surprising are the first two diseases that cost us the most as of 2013: coming in at number one for $101 billion dollars is diabetes, number two at $88 billion is heart disease and a surprising tie for number two is back and neck pain at $88 billion. These are nontrivial numbers which are generally spent in the hospital setting. Therefore it comes as no surprise that hospitals have been voicing their warnings to the incoming  administration about the possible repeal of the ACA. They have calculated that they stand to lose $165 billion if the estimated 20 million people lose their insurance they gained under the ACA. They warned of “an unprecedented public health crisis" and possible collapse of the whole healthcare sector.

In perhaps the most interesting news of the week the American College of Obstetricians and Gynecologists is going head-to-head with the FDA over the issue of anesthesia for pregnant women. The FDA recently issued a warning against the extended or repeated use of "general anesthetic and sedation drugs in infants and toddlers and pregnant women in their third trimester”, indicating these "might damage children's developing brains”.  Their recommendation is based on observational studies on animals. ACOG has issued a statement indicating that they are unaware of data on pregnant women that support the FDA's claims. They go on further to state that these warnings may cause patients and providers to inappropriately reject the use of these medically indicated drugs.” As a practicing Obstetrician, I can imagine the difficulties this warning is going to cause with pregnant women who need surgery for trauma, gallbladder removal, appendectomy, or even C section where spinal blocks or epidurals do not work or are contraindicated. 

Back in the good news department, Texas, of all places, has produced seven lawmakers that have filed bills for the upcoming legislative sessions seeking to "eliminate the sales tax on feminine hygiene products". The state of Texas has a 6.25% sales tax on all retail sales. Additionally certain local entities can impose an additional 2% tax. Currently certain hygiene products such as pads, tampons and menstrual cups are designated as luxury items and as such are subject to the retail tax. Changing this law would repeal this so-called"Tampon tax" which is considered unjust because it targets only women. Besides, everybody knows these items are not luxuries, they are necessities.

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

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

A total of 4575 Zika cases have been documented in the United States including 1172 pregnant women. We are now beginning to collect data on these pregnancies and the resultant births. It turns out that about 6% of Zika infected pregnant women in the US had a baby with at least one birth defect. This new research was published in the Journal of the American Medical Association. The data was gleaned from a total of 442 Zika infected women who completed their pregnancies this last year in 2016. In stratifying this group it was discovered that those who were infected in the first trimester had an 11% chance of delivering a child was birth defects, higher than the average of 6% indicating that Zika poses the greatest risk earlier in the pregnancy. Moreover, these rates are on a par with what is being seen in Brazil at this time indicating that the virus is working in a similar way in both populations. 

Personally I see these numbers evolving as the duration and post natal effects of Zika virus have yet to be fully described. CDC (Centers for Disease Control & Prevention) researchers have indicated that Zika can replicate in the fetal brain for up to seven months after the mother has become infected with the virus. They have noted that babies born to Zika are very likely to have brain damage even in the absence of obvious abnormalities like microcephaly and that the virus may keep replicating long after birth.

The CDC  has added Brownsville Texas to its list of Zika travel advisories. This is because five locally transmitted Zika infections were recently reported. Texas has had a total of 274 Zika cases.

Also in Texas news, it has been discovered that a booklet titled “A Woman's Right to Know" was revised earlier this year to contain misinformation about the relationship between abortion and breast cancer risk. This booklet must, by law, be given to any woman seeking an abortion. 

New research published in the journal Science Translational Medicine as reported that researchers have described two antibodies that appear to be important in the fight against Zika. Apparently these two antibodies were able to eliminate Zika virus in animal subjects in the lab. Hopefully we will hear more about this in the future.

In other news, fears about the repeal of the Affordable Care Act continue. Republican lawmakers are gaining appreciation for the ramifications of a fast repeal including the loss of insurance by over 50 million people and a huge loss of revenue for hospitals across the country, on the order of $165 billion dollars. Even with fear of a repeal looming, sign-ups for the ACA are occurring at a higher rate compared to this time last year. Moreover the Fed is extending the healthcare.gov deadline until Monday, December 19th. 

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

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

Zika has crossed the Atlantic to the United Kingdom. There are 265 known cases there already, including one whose transmission is believed to have been sexual. People traveling from moderate or high risk areas are asked to abstain, or contracept and use reliable barrier methods. HA ! That’s an oxymoron: reliable barriers. 

It is winter in North America, and that includes the US territory most affected by Zika: Puerto Rico. While Zika transmission continues, it is decreased at this time of year, due to reduced mosquito activity. Attention turns now to the pregnant Zika infected women. There have been 2600 confirmed cases of Zika in pregnancy in Puerto Rico. Many have miscarried, but many are yet undelivered. 

Texas now joins Florida as the only continental US state to document a local transmission of Zika. Local transmission means a Texas mosquito bit a person in Texas and transmitted the Zika virus. What this says about the number of mosquitos in Texas which have Zika is unclear, but it says something. Until now, all other Texas cases of Zika have been linked to travel. 

In other news, the ACA (The Affordable Care Act) has top billing. As mentioned last week, the ACA is now integral to our healthcare system and cannot be easily dismantled. Twenty million Americans now depend on the ACA for their health care. It is becoming more widely acknowledge that for the time being, it will have to stay as it is, notwithstanding the change in administration. Enrollment for 2017 is beginning, and it seems, continuing apace, 2.1 million so far, despite GOP’s vows to dismantle it. 

GOP lawmakers have started discussions with insurers to try to prevent a collapse of the insurance market if they pass a repeal of the ACA. GOP lawmakers are now indicating that it may take them “ years” to repeal the ACA, hopefully more than four. 

As a physician, completely unrelated to politics, I am for some form of the ACA. I have seen women whose only health care was during their pregnancy, who can now come in with pride just for their annual. They are able to get the recommended screening tests, and can begin to think about health maintenance and limiting family size if they chose. I know, as a physician, that prevention saves money. I also know that disease caught early and treated is far cheaper than disease caught late. GOP lawmakers MUST factor this in if they are to modify the ACA or create their own plan in such a way as to make it affordable and sustainable in the long run. 

The GOP is mixed on the Medicaid expansion. Many Republican Governors are glad to get so many more or their poorest patients insured. 

New research published in the Journal of Women’s Health indicates that women with chronic conditions do worse without access to the internet. This may have to do with access to information and social connections with others, especially others who share the same conditions. 

Many women and many providers believe that there is an age cutoff after which mammograms are no longer beneficial. I am unaware of such data. New research using data from 6 million mammograms between 2008 and 2014 confirms there is no clear cutoff point. Mammogram decisions should be made between a patient and her caregiver, and factor in the best available data and the patient’s overall health. 

Tom Price, the Health and Human Services Secretary elect is said to be both anti-abortion and anti-birth control. It is beyond me when someone who is anti-abortion is also anti-birth control. The theoretical planned repeal of the ACA will not ban these things per se, but a report out of Kaiser indicates  that the costs of contraception will rise during this time period. Drug costs across the board will likely rise whether or not the ACA is repealed. 

In the good news department, the House, in a landslide vote, passed the 21st Century Cures Act. This provides an increase in finding to the FDA ( Food and Drug Administration) by $500 million, for drug development and testing,  and would also provide $1 billion to address opioid addiction. There’s a billion dollars we theoretically should not have to spend but, we do. This is why we cannot have nice things. 

Planned Parenthood, ACLU, and the Center for Reproductive Law and Policy are filing lawsuits which challenge several laws which limit women’s rights to various reproductive services. The lawsuits are arising as quickly as the limitations these days. 

The House Energy and Commerce’s Subcommittee on Health has taken what I consider to be a monumentally positive step in reigning in the US Preventive Services Task Force. They have recommended that the small, non-clinical committee receive more input on formulating their recommendations, from (surprise!) medical authorities before they make recommendations which influence patient care and insurance coverage of various screening procedures. The bill comes from Republican Marsha Blackburn from Tennessee who has pointed out that USPTF recommendations on many issues pertinent to women’s health including mammograms differ from those of, for example, ACOG, the American College of Obstetricians and Gynecologists. The bill provides for input from both primary care medicine and specialist authorities. Bravo Representative Blackburn, and bravo to you for reading all this. 

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