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

After a season of crisis with the Zika virus, the director of the CDC, (Centers for Disease Control) Dr. Thomas Frieden, has stated that the Zika virus is not “ controllable with current technologies.”. He has also indicated that he believes Zika "will become endemic in this hemisphere.” He states a Zika vaccine is probably 2-3 years away. 

Delays in public funding to combat the Zika virus in Florida have motivated private and corporate donors to step up. Pfizer, contributed $4.1 million, and Community Health Charities and March of Dimes will contribute and fund raise. 

The CDC (Centers for Disease Control) and ACOG (The American College of Obstetricians and Gynecologists) have identified use of long acting lot reversible contraceptive, or LARCs, inserted in the immediate postpartum period as key in curbing unintended pregnancy. Happily, many states are changing Medicaid regulations to cover IUDs inserted immediately after delivery. LARCs are highly effective safe methods of birth control which require little in the way of maintenance or remembering on behalf of the patient. The complication rate is low but not zero. Complications that do exist are well described and manageable.

At my institution, we practice evidence-based medicine. Moreover, Obstetrics and Gynecology is a very highly studied and regulated field. Because of all of this, many of our practices for example on the labor unit our policy driven. For example, we permit and encourage laboring in water because the literature shows that has clear benefits and no known side effects.. Others have also advocated, In the absence of any supporting data, for birth in water as well mistakingly assuming that amniotic fluid is similar to water. Indeed, as regular water is irritating to your respiratory passageways, so it is as well to the respiratory passageways of a newborn. Based on this,we do not endorse water birth. Updated guidelines from ACOG indicate that the first stage of labor may take place in water but when it comes time to push women should get out.

American College of Obstetricians and Gynecologists sponsored a special briefing last week in Washington DC on the subject of us maternal mortality rates. United States overall maternal mortality rates are actually increasing in contradistinction to the rest of the world. They are increasing disproportionately among minority women particularly African American women.

A recent study by Harvard researcher Dr. Julie Silver indicates that female physicians are still chronically underrepresented as healthcare leaders. She indicates that this may contribute to the persistent salary gap that exists between male and female physicians.

While women and men are still not equal in many ways, equality has been gained in one category. The British Medical Journal recently presented research which indicated women are now drinking as much alcohol has men. The differences between men and women in three categories, any alcohol use, problematic alcohol use, and alcohol-related harms, are diminishing.

We have two items in the "We are already knew this” department. First, education and support may help women stick with breast-feeding. This groundbreaking research was supported by your tax dollars through the Department of Health and Human Services Agency for healthcare research and Quality through the US Preventive Services Task Force. Were we unwilling to provide education and support to potentially breast-feeding mothers before the dawn of this research conclusion? I think not.

Secondly, scintillating new conclusions published in the Journal Menopause indicate that women experiencing menopause symptoms may do better in a comfortable workplace. They break this down and indicate that the workplace should be comfortable. Moreover the patient’s boss should be supportive. Another victory for common sense and human decency !

In the possibly actionable department, a new study finds that good pain relief during labor may be associated with lower postpartum depression scores. An observational study presented at the annual meeting of the American Society of Anesthesiologists has found this result after evaluating 201 postpartum women. Studies of this nature are suggestive but not conclusive.

Here are a couple Halloween party food pictures that I promised. Have a happy and safe Halloween.

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

As the northern hemisphere encounters fall and winter weather, mosquito activity and the risk of Zika infection by mosquito falls but does not go to zero. Of course, sexually and birth related (perinatal) transmission are not affected and can continue unabated. 

Researchers at the University of California, San Diego, have honed in on the mechanism of action of the Zika Virus on human cells. It appears that Zika virus alters our RNA directly. 

We now know that Zika can persist in vaginal secretions for two weeks after onset of infection. During this time, a woman can pass infection on to a partner. Additionally, it has been determined that Zika is detectable in serum ( the liquid portion of blood) for a week. However it is present in whole blood for at least 80 days. These insights have been made possible through the contribution of one particular patient infected with Zika since the beginning of the epidemic. Through frequent and repeated testing on her, we have been able to ascertain these findings. We use a debt of gratitude to this female Zika patient who has allowed herself to be the subject of invasive scientific study since the beginning of the crisis. 

Everyone has heard of menstrual migraines. Some happen right before the period and some happen during the period. Those preceding the period are believed to arise from sharply falling estrogen levels. It turns out that the late-cycle migraines may be related to low ferritin levels from the blood loss of the period. This could lend insight into prevention, which of course might involve ongoing iron supplementation. 

In the things-we-already-knew-but-had-not-yet-been-conclusively-documented department, research published on the Arthritis Care and Research site indicated that systemic lupus wanes during pregnancy and flares in the postpartum period. Nonetheless, the research is quite welcome in that it sheds concrete insight into the baseline mechanisms of lupus and autoimmunity in women. Autoimmune disease as a whole is prevalent and predominantly affects women. Most patients are on current treatment strategies which decades old and are rife with significant side effects. This lupus patient applauds any sound research into autoimmunity in general and lupus in particular. 

Also in this same journalistic department we are now assured that smoking and alcohol are linked to 11 of 15 of the worst cancers. By worst, we mean those cancers most "responsible for premature death and loss of healthy life years”. Any second year med student can assure you conclusively of this. 

Pediatricians are being encouraged to change their counseling of parents about the HPV (Human Papilloma Virus) vaccine. Instead of highlighting the prevention of sexually transmitted HPV infection which can lead to warts, they are being encourage to highlight the cancer prevention aspects of the vaccine. It would be nice if we could simply explain that the HPV virus causes genital warts, precancerous changes on the cervix, which can then develop into cervical, vaginal, penile and even oropharyngeal (mouth and throat) cancer. I am tempted to think that we oversimplify subjects too much for people. People are capable of understanding a great deal if someone takes the time to explain it to them. 

In related news, new data has demonstrated that those children who obtain the HPV vaccine before 15 years of age only need two shots rather than three. Even more incentive to gets your kids done ! 

New research from the Agency for Healthcare Research and Quality have show that the C section rate for low risk patients is about 16%, whereas the C section rate for high risk patients is about 76%. Intellectually, I am a splitter rather than a lumper. Consequently, thinking about C section rates in this way is much more useful that saying, the C section rate in the United States is about 32%. I think information presented in this way will help patients understand their own risk factors, and how to prospectively stack the deck in their favor in the future. 

Here is some sobering but critically important news that I suspect will be woefully underreported. Maternal body mass index (BMI) is inversely correlated with newborns’ telomere length. Whoa, what does that mean ? Basically, the heavier a mother is, the less robust her newborn’s DNA strands will be. DNA is protected at it’s ends by segments known as telomeres, and when they are short, DNA is more apt to be damaged. Shorter telomeres means shorter DNA lifespan, which most likely means shorter lifespan overall. 

We have all heard by now of the micro biome, which means the healthy or not so healthy populations of bacteria and other organisms that populate our body. Women mostly focus on the micro biome of the vagina, knowing that if it becomes disturbed, yeast or bacterial vaginosis can result. However, the vagina is not the only concern. It turns out that the breast has a micro biome. Moreover, it turns out that breasts sampled and found to have benign disease versus those with cancer have very different micro biomes. This could be a clue to something, I’m not sure what. But is is a new and interesting concept. 

In disappointing news, the CDC (Centers for Disease Control) reports that rates of common sexually transmitted diseases have reached all times highs. This include syphilis, gonorrhea, and chlamydia. I’m going to give a shout out to bad parenting and network TV here. Thanks so much, guys. Oddly, syphilis was at an all time low in 2001, and gonorrhea was as recently as 2009. 

In surprising news, 43% of those with no type of health insurance could qualify for either Medicaid or coverage through the Affordable Care Act exchange. The reasons for this are unclear. I will say that some people seem to have quite a bit of trouble filling out the forms online. I have joked to my office staff that the government  should outsource both health care and the elections to reliable companies like Amazon or Google who can design a nice reliable website. 

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

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

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

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

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

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

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

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

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

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

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

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

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

Wellness Wednesday: Fitness Redux

Wellness Wednesday was originally conceived as a place to post about fitness. While I am glad it has morphed into a space about all kinds of wellness, I’d like to take this moment to focus back on the one thing that is the

best illness prevention,

best mood enhancer,

best fat burner,

best strength builder,

best beauty treatment of all: 

exercise, of course. 

I don’t think it gets the press time or the limelight it deserves in the the halls of modern medicine, or in our public media space. There are studies are out there to support exercise for both prevention and adjunctive treatment for disorders from A to Z. These studies are not glamorous and not really media worthy, because in many cases they are confirming things which we already strongly suspected. So the results of these exercise studies are not sensational in any way. So the media is partly accountable for not continuing to remind us of the central importance of fitness. Medical caregivers are to blame since their focus is elsewhere and they themselves have insufficient knowledge and experience with fitness. Most importantly, the public is to blame. They would much rather read about a pill to cure obesity than read about how a consistent regimen of 30 minutes of daily exercise can reverse diabetes and heart disease.

I would like to take this opportunity point you back to my website pages on fitness, and encourage you to read through all the links.

Fitness

That way, in about 5-6 minutes you can get the important points in a short period of time. But for those of you who are not link clickers, I will give you the nutshell version here: 

• Those with medical problems should obtain medical clearance to exercise. 
• Exercise should be engineered and planned into your day like an important meeting. 
• Start with brief easy sessions 6 days per week to build a habit. 
• Determine why you need to exercise.
• Resolve to make exercise fun. 
• To begin, pick at least 3 easy fun routines or an exercise which requires little thinking on your part. Do not go over about 30 minutes per session on your first 3 months of exercise. DVDs or a class are ideal. Chose workouts that include concurrent cardio and resistance. Until you know what you are doing, go with a professionally designed workout which is safe, effective, balanced and includes warm up and cool down. My favorite library of workouts is Beachbody on Demand. I also love Jillian Michaels workouts. 
• Pick a place of exercise that is time and weather independent. This could be a 24/7 gym, the outdoors, or a DVD in your living room. 
• Arrange accountability through an app, a log, or a friend. 
• Arrange self tracking through an app or a log. Include, weight, waistline, type and duration of workout. Do not measure your weight and waistline more than once per week. 
• Have comfortable and flattering exercise wear. 
• In the first three months go mellow to let your body begin adjusting. After that ramp up in intensity to your tolerance, provided you are tired but refreshed afterwards, rather than wiped out. 
• Hydrate well all day long and have water during every workout. 
• Remember that it takes 3 months to build a habit. 
• Focus on how good you feel when you are finished. 

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

It turns out that Dr. Peter Hotez, the Dean of that National School for Tropical Medicine has been thinking about the interplay between Hurricane Matthew and the Aedes mosquito which spreads Zika. His informed speculations were that the Hurricane could provide an initial respite from the mosquitos, being essentially blown away by the tremendous winds. However, the enormous amount of standing water afterwards would provide ideal breeding ground for the virus carrying mosquitos. 

Though the Federal government has passed a limited Zika funding measure, the bulk of the costs have fallen on States. The 1.1 billion dollars recently approved requires the development of a spending plan which the Department of Health and Human Services are required to complete by the end of the month. One hundred and fifty two million will go toward vaccine development. The rest will go to local labs to speed up testing, as well as for prevention efforts like mosquito control, and education campaigns. 

Much of the press about Zika focuses rightly on its effects on pregnant women, namely microcephaly and other severe effects on the fetal and neonatal brain and nervous system. However, Zika virus effects non- pregnant women and men by increasing their chances of Guillain Barre Syndrome, post viral paralysis. In the recent new wave of such patients, 97% of these patients had symptoms of Zika 4 weeks prior, further cinching the relationship of the virus to the syndrome even further. 

At least 808 pregnant American women have Zika. It is likely that there are many more since the infection can be asymptomatic, and testing results are much delayed. Physicians and Institutions are trying to ready themselves for the increase in special needs children which will come as a result of the Zika epidemic. 

New Zika recommendations indicate that both men and women wait six months to get pregnant after Zika exposure. 

In other virus related news, studies have shown that parents are more likely to ask for HPV ( Human Papilloma Virus) vaccine to be given to their children if their child’s caregiver discusses it with them in a certain way. In particular, if caregivers highlight the parent’s role in preventing HPV infection, parents are more likely to agree to the administration of the vaccine. HPV vaccine is grossly underutilized. Researchers and physicians are trying to increase HPV vaccine utilization rates by funding the vaccine with others and by giving it in school based programs. HPV is a virus which causes serious and sometimes fatal disease processes ( cervical cancer)  for which there is an effective vaccine. Yet many will not utilize it. Once we are fortunate enough to have a Zika vaccine, I wonder if some will decline that too. 

Speaking of inadequate utilization of vaccine, over half of millennials do NOT plan to get the flu vaccine this year. Half of these people do not believe it is effective and 29% think it will give them the flu. The data do not bear out these concerns. 

Here is some bad news that is, at the same time, interesting and useful. First, people in most modern countries gain weight during the holidays. The amount and time frame varies by country. In the US, our weight is at its lowest in October, right after summer, and increases in the ten days preceding the holidays. It appears that holiday related weight gain, regardless of country, takes about FIVE months to lose. That’s right people, gain it in ten days, lose it over five months. 

In other bad but fascinating and hopefully helpful news, stress contributes to aging in a very particular and profound way. A large human DNA study has demonstrated that “ adverse events in childhood ...hasten …telomere tear down." I once read telomeres are the protective shoelace tips to our DNA shoelaces. Telomeres keep DNA from fraying as it were, and this prevents premature aging. They were able to determine that each significant stressful event in a person’s life increases the risk of shorter telomeres by 11 percent. DNA codes for what we are… in a very immediate tissue sense of the word. Damaged DNA leads to all kinds of diseases including cancer, and basically the failure to heal and renew properly. We have to start taking the prevention of childhood stress much more seriously. 

State Medicaid expansions are most costly than previously anticipated. This is because more qualifying patients have signed up, and they are sicker than had been anticipated. This should be cause for increasing the funding to the expansions, says this fiscal conservative. Why ? It is because preventive care and treatment that is earlier rather than later ALWAYS is cheaper in the long run. Never mind that it is more humane and the ethical thing to do. 

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

Food Friday: Disaster Relief Food

If you do not know about Hurricane Matthew and what it is doing, then stop reading this blog post right now and check out this link on the weather channel: 

https://weather.com

This is one of the most devastating storms our nation has ever faced. Hurricane Matthew is a Category 4 of 5 hurricane. This ratings are done by the wind speeds observed in the storm and these are currently at 130 miles per hour, enough to tear the roof off a house. It is not terribly uncommon for a hurricane to achieve this category. What makes the potential for damage so great in this case is the path that this hurricane is likely to take. It will travel straight up the populated Florida coast, passing over Cape Canaveral and onto the southern part of the Eastern Seaboard. These are low lying populated areas.

We are told the main hazards are wind, as wind, but also as a fringe of tornados at the edge of the hurricane. Other hazards are the sheer volume of rain and flooding, powerful waves at the coast battering the shoreline, but even more so the so called storm surge, which is like a monstrous high tide coming far higher and more inland than it should, amidst everything else, complicating the task of dealing with buildings compromised by wind and falling debris. 

Power will be lost, and food likely spoiled. Tap water may not necessarily be safe. Food will be a challenge. In the aftermath, people may eat the spoiled food and get sick. Water born illness may spread, as may common maladies like pneumonia, since people will either be without shelter, or in crowded shelter where illness is easily acquired.

The Red Cross is the preeminent organization for disaster relief in this country. For this reason I have devoted food Friday to a link to direct you to their donation page. I was going to talk about Kombucha, a delicious probiotic drink, but I cannot get my mind off the hurricane and its victims. 

When I was a little girl, ages 6-12, I lived in St. Petersburg, Florida. I lived through hurricanes Agnes and Camille. Camille was class 5, though it merely sidelined us. I have many vivid memories of being in a hurricane. Oddly, all of them are pleasant. 

For kids, a hurricane was all excitement. There was no school. It was 1967, and everyone gathered around the TV to watch Meteorologist Roy Leep track the storm. He was kindly but authoritative, with the air of a scientist. Where the colorful and dynamic realtime satellite images are now, there was a large very much analog wall map full of symbols, isobars and moveable pieces. Almost all children had a hurricane preparedness booklet. I  even had a felt map of Florida, and had cut out the official symbols for tropical depressions and hurricanes so I could move them along the map.  I was familiar with the tracking terminology. I tried to predict time and place of landfall. 

Once during a hurricane my mother made me sit on the couch in the middle of the house with her and would not permit me to get near the windows as I wished.  In that same incident, large lightning strikes caused sparks to come out of the wall outlets. Eventually the power went out and we lit candles, which I though was wonderful. We got to eat snack foods, which were normally not allowed. 

Once, when I lived on a small residential island on a bayou, we had a tremendous hurricane related storm surge. I slept through it, and the next morning it was bright sunshine. I, together with all the other children in the neighborhood took to the streets... in boats. There were also pool toys like floating seats. Everyone got out and had a grand day, and were all the happier when we learned that the one bridge had washed out. We all swam like fishes in the first place, living there. We all had pools, and seawalls, and boats. But now, our boats banged awkwardly against their pylons whose lines had been slacked, and our pools had all become contiguous with the ocean waters which had come over the seawall and across the lawn. 

Somehow I think the adults did not have the same experience. As I got older, more toward two digits, I didn't either. I learned in retrospect, that during Camille, two states away, many had lost life. Our Florida houses were made of concrete and screened porches, but in the old south, they were made of wood. Homes and lives had been lost, and would be again and again. 

I got to where I could readily discern that strange green light in the sky which precedes the hurricane and occupies the eye. I could literally feel the lightness of the fall in barometric pressure. Once here in Montana my daughter and I were taking our groceries to the car during a bad windstorm.  Though it had been over 40 years, I remembered that green light in the sky, so beautiful. I told her if I didn't know better, I could feel the lift of the whole atmosphere. I told her about the funnel clouds I'd seen over the Gulf of Mexico, and how they started as a dark grey V shaped little buds off a big cloud. We looked around and thought maybe we saw one. As we got home, ten minutes away, we passed by what had been a stand of massive old cottonwood trees. Now there was just a giant pile of sawdust and twisted roots. The three homes in proximity including ours were untouched, though people in the neighborhood said the wind had been a deafening roar. We later learned that two small tornadoes had been believed to touch down. I was heartbroken for the magnificent trees, but then ashamed of my sentiment compared to what victims of violent storms must feel. 

By morning, the Red Cross will be badly stretched for resources of all kinds. We all need to do what we can to help. Here is their link. 

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

Congress has finally passed legislation allocating $1.1 billion to fund the fight against Zika. This will cover primarily vaccine development, but also mosquito control efforts. This is very good news; however many would argue that this is too little too late.  The director of the Centers for Disease Control (CDC), Dr. Anthony Fauci, has indicated that more fundamental research on Zika "will need to be cut back.

There are over 2000 confirmed cases of Zika among American pregnant women. The majority of these are from Puerto Rico. However, the true number is probably under appreciated, due to lack to testing or delays in getting testing results back. Zika Virus may be transmitted through the bite of the Aedes Mosquito, but also via body fluids. By body fluids they mean tears or sweat, not only blood and sex related secretions. Zika virus causes numerous serious abnormalities in the developing fetal and neonatal brain, and can cause post viral paralysis ( Guillane Barre Syndrome) in non pregnant adults. 

A scandal is developing in Florida. Officials in Miami Dade County are accusing the Florida Department of Health of keeping the mosquito capture sites secret, a charge which the Health Department denies. This all started when the Miami Herald sued to find out the location of the traps. 

Texas, which has not yet experienced a confirmed case of Zika, is still expected to be at risk. This is because such epidemics travel in a delayed fashion. Dr. Peter Hotez, Dean of the National school of Tropical Medicine at Baylor College of Medicine, Has stated that we will not know if we've had local transmission of the Zika virus in Texas until seven or eight months from now, when babies are born with microcephaly. He noted that detecting the virus is difficult because most people who are infected are asymptomatic.

ACOG’s Journal of Obstetrics and Gynecology has published a report indicating that from 2000 to 2014 maternal mortality in the Continental 48 states has increased 27%. A 2015 report from the World Health Organization indicated that the US has a higher maternal mortality rates than Iran, Libya, and Turkey. This is been reported in previous weeks, although these new numbers put it in better global perspective.

In the good news department, the use of antenatal steroids in women at high risk for preterm labor has been expanded. Until recently we used such steroids to accelerate lung maturation in unborn babies through 34 weeks of gestation. For reference, 40 weeks is the due date and 37 to 41 weeks is considered full-term. The period of 34 to 37 weeks was considered preterm, but until recently there was no proof that the use of antenatal corticosteroids helped this group of babies. Now there is. Accordingly the American College of Obstetricians and Gynecologists has published an updated committee opinion on the use of these medications. With this expanded therapy, it would be reasonable to expect fewer breathing complications in this group of premature babies. 

In the "proud of my college" category, The American College of Obstetricians and Gynecologists (ACOG) has been solicited by the Federal government to "review and recommend updates to" several preventive health services for women under the Affordable Care Act. ACOG’s draft recommendations states that “ women should be able to get free mammograms as early as age 40 and if any follow-up is required, like a biopsy, it should be considered an integral part of the screening and also covered at no cost.” ACOG has also recommended that male birth control be covered as well.

Also in the good news department, the death rate from ovarian cancer decreased 16% between the years 2002 and 2012. 

In the vaccination success department, the World Health Organization (WHO) has declared America free of measles. The WHO Director General Dr. Margaret Chan has indicated that the Americas is the first region in the world to eliminate measles. It has achieved this after a 22 year vaccination campaign. As the measles may be imported from elsewhere, vaccinations for measles should continue as per usual.

Also in the vaccine success department is this: A recent study indicates that the recent introduction of a prenatal TDAP booster vaccination has been effective. This booster can prevent both the development of pertussis ( whooping cough) and decrease the severity of neonatal pertussis infections that do occur. 

Our last bit of news this week is also in the good news category. Teen pregnancies have declined over the last 10 years and the most recent data is even better. Data from 2015 indicate indicate that the teenage birth rate in the United States has hit a new record low, according to a report from the Centers for Disease Control and Prevention. The rate had a one year decline of 8% falling to 22.3 births for every 1000 women between the ages of 15 and 19. Experts attribute this to teenagers having less sex, using more reliable contraception, and being more aware of the difficulty of having a child while still a teenager.

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

Food Friday: My Strategic Foods

I am a 54 year old woman with Systemic Lupus. Sounds dismal, huh ? Actually, I am healthy, working, and recreating full time. I hate to say it, but my lupus may have caused me to take better care of my health than I would have otherwise.

I am one of those people who pursues optimal health. I feel I have to, since I am obliged to set a good example for my patients, and because I have a family who relies on me. 

I can’t afford to do anything but eat optimally. I can’t afford to do anything but workout regularly. At my age, with my condition, going backwards is really hard to make up. Going forwards is extra slow, since I also cannot overdo it, so I have to make gains really gradually. 

I love good food and cooking, and I love working out and how it makes me feel and look. So these things are not hard sells for me. I try very hard to convey to my patients and readers the joys of these things, but you may certainly relate when I tell you that most people are not where they would like to be on their fitness and nutrition. So instead of me just sharing how I feel, I would like to tell you a few simple things that I do that help me keep my nutrition in line easily. This is Food Friday, and we are going to talk about my strategic foods. 

With my lifestyle, workout, goals and medical condition, I need more protein that the average 54 year old woman. To help me get that conveniently, I start every morning with about 16 ounces of skim organic lactose free milk mixed with about 2 scoops of whey protein powder. That gets me nearly 30 grams of protein, a reasonable start to the 80 grams per day that I shoot for.

At about 10 am, I make some oat bran cereal, one of my strategic carbohydrates. I include this for the fiber it provides. I take a page from the Giada DiLaurentis' playbook and dress it with about a Tablespoon of olive oil and some kosher salt. It is reminiscent of buttered popcorn. I usually have a bowl of decaf green tea matcha which is full of antioxidants. 

At lunch I usually have fish, chicken or red meat with veggies, which are usually leftovers brought from home. I try to eat lunch with water, either cold or hot. I may also have fruit. I favor blueberries and strawberries, which is good because they are nutrient dense, and low on the FODMAP scale. ( More information on FODMAPS HERE)  I bring them in a little tupperware. These generally leave home frozen and thus by lunch they are just right. 

Mid afternoon I try for some more protein with some kefir ( cultured probiotic milk) or a meat stick. Additionally, in the afternoon, I have taken to drinking a Kombucha which is a fizzy  probiotic drink. 

When I get home from work I need a little something before dinner, and it is usually a little fruit and drink. This sets me up to work out, which I do before dinner. Sometimes I or someone else starts dinner, and I work out while it is cooking. I drink sips of water all though my workout. 

Dinner is, not surprisingly, meat, fish, chicken or eggs, with vegetables and fruit. And here I use another strategic carbohydrate, brown rice. Between the fiber in that and the oatmeal, things “ go well”. Again, I drink water with the meal to aid digestion and keep me hydrated. When I am cleaning up dinner, I fix my lunch and two snacks to take to work, since I am not a morning person. I also fix my protein drink in a “ shaky” bottle so it is ready to grab in the morning. 

And though it is so trendy it is outdated, I am still crushing on kale. I eat it dried, and I eat it chopped and sautéed either in olive oil or coconut oil. I like to toss in tomatoes for color and a bright flavor. I have learned to salt and season after it is finished since it shrinks down so much. You have to start with a heaping pan full to get a couple servings. I use lemon pepper very liberally, as well as Mirin, rice wine, or rice vinegar. Balsamic vinegar also works nicely on kale. 

At bedtime I usually get a little dark chocolate. My recent favorite is a raw Mexican chocolate from Taza. It is spendy, but you only need a little bit. I also get something more to drink. 

Yes, it’s a lot of time spent, and a fair amount of preparation, but it makes me feel good and I like it. Try these strategic foods or develop your own favorites. Remember, small healthy habits, done over long periods of time, make health. 

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

By a margin of 89 to 7, the Republican dominated Senate voted to move forward and develop a bill to avert a government shutdown and fund the Zika crisis. So, yes, they approved a bill to approve a bill. 

Meanwhile the public ought to be aware that money has been taken from other important sources to fight Zika. The Federal Government has taken money away from funds to fight malaria, tuberculosis, ebola, and more recently, and tragically, cancer, diabetes, heart disease and mental health. Some of this money will be going to continue the development of a zika vaccine. 

The CDC ( Centers for Disease Control) has spent another 2.5 million for Zika lab testing. Getting definitive Zika test results can take 4-6 weeks in the current system. 

The news has prominently publicized the well delineated areas in Miami where the Zika virus is active. However many experts believe Zika is active all around the Gulf Coast. Experts including some within the CDC believe other Gulf cities are experiencing Zika outbreaks without realizing it since the testing is taking so long. 

As of several days ago, Puerto Rico has  20,000 documented cases of Zika, including close to 2000 pregnant women. 

In the not surprising department, those with no out of pocket expense for birth control have fewer unplanned pregnancies. 

Also in the interesting but not surprising department, stress may erase the effects of a healthful diet. It also decreases one’s chances of getting pregnant, especially if it occurs near the time of ovulation. 

About 1 in 5 or 20% of all women will suffer from depression and one point or another in their lifetime. That percent is higher in the 40s and 50s. 

Last week I reported on the appalling maternal mortality rates in Texas. The Institute of Heath Metrics and Evaluation has released data indicating that the United States as a whole has suffered the same trend. We are now considered an outlier among rich nations in this regard. Some of this is attributed to obstetric ( pregnancy) complications arising out of increased background rates of obesity and diabetes, whose rates have skyrocketed in this country. 

In the probably good news department, mammograms received by Medicare beneficiaries increased in the first three years after the enactment of the Affordable Care Act. It is a bit too early to tell if this will result in a reduction in morbidity or mortality from breast cancer, but I am betting that it will have. 

In the definitely good news department, it has now been established that the incidence HPV related anogenital warts is on the decline due to the HPV vaccine. This is true despite the woefully low utilization of this safe and effective vaccine. The HPV vaccine is meant for young people, both boys and girls from ages 9 to 26. 

In the phenomenal and amazingly good news department, Mark Zuckerberg, founder of Facebook, and his wife, Pediatrician Dr. Priscilla Chan, have pledged 3 Billion dollars over the next years to essentially cure or manage all disease by the end of the century. If I had not just attended Stanford Medx this last week and been heartened by all the new technologies and methodologies that people all over the world are bringing to bear for these goals, I would have thought their goal unrealistic. But now I believe it is simply a matter of time.. and money. 

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

Wellness Wednesday: Stanford Medx

I just knocked something off my bucket list. 

Stanford Medx is a multi-day conference on innovation in health care. The conference is akin to it’s older and more popular cousins TEDx and TED, programs which are available online to everyone and which deal with topics in technology, entertainment and design, really all the big issues. 

Medx brings together people interested in moving medicine to a new and better place. It’s themes are people, technology and design. I would like to share with you some of the material that I encountered and the people that I met, together with a few images. 

On Wednesday my first day, I travelled. It is always an entertaining shock to change biomes so quickly, going from the alpine to the sonoran in little more than a couple hours. From cool pine I went to warm eucalyptus. After getting settled, I attended presentations and a workshop at the D school - The Design School on the Stanford Campus. There I met designers, architects and medical people all coming together to make buildings, objects, and even procedures which would make getting medical care more effective and pleasant for patients and caregivers. I met a women who is involved in renovating the Women’s and Children’s hospital at Stanford, just as I am at my hospital. I also met the grandson of Charles and Ray Eames who reviewed principles of design though a survey of his grandparents’ work. I also met the mother of an unexpectedly premature baby who had struggled with expressing colostrum. She had, as a result, developed a clever and inexpensive device to modify existing pumps to make them more effective. We expect its use to become widespread. 

Day two was a workshop on shared decision making. This was meant to be decision making between anyone and anyone else: doctor-patient, doctor-nurse, and family member to family member. Shared decision making was a key theme which dovetailed into one of the main themes of the conference, EVERYONE INCLUDED.

Decisions from the top down can be problematic, and partake of hierarchy. Hierarchy for its own sake is to be banished from medicine. Effective communication, and therefore better results, satisfaction and even safety grow out of shared decision making. This was amply explained an demonstrated across all the varied content of the conference.

Communication needs more than clarity. To be optimal, it is two way, and involves empathy. EMPATHY was another key theme echoed over and over again. As physicians, engineers and designers, we must employ empathy in all our thinking. We need to ask the patients and the users for input at all stages of development. Such a process creates more user satisfaction and better results. 

On day two, we partnered up. Our group was composed of the professionals I mentioned, but also of special “ e-patient scholars”. These were medically sophisticated patients with serious chronic medical conditions who could speak to us about their long experience in the medical system. They were there to help us see through their eyes. I was paired with an older woman in a wheelchair with end stage MS and lupus. Since I have lupus we exchanged notes about that. But it was her MS that was making the critical problems. She spoke about her end of life plan. Even so, she was as pleasant and sparkling as a person could be.

On days three four and five we had presentations from morning until evening, often rapid fire. That is when the conference really took on a life of its own. The conference designers were smart. They had substantial breaks every hour or two, and provided food, and tables, and encouraged everyone to live tweet the conference. The session to break ratio was optimally dialed for stimulation and interaction. All the speakers made themselves accessible, so not only did you hear these phenomenal stories, you met the phenomenal people. Bread was broken and contact information was exchanged. 

Key themes were as follows: 

• open medical data, especially genetic data
• open research data 
• the quantified self 
• gamification of healthy lifestyle goals
• getting patients, doctors and researchers together, often through the internet
• patient education, often self education, through apps and the internet
• collaborative and integrative medicine
• collaborative end of life planning

A lot of this came together under the topic of PRECISION MEDICINE. This means care tailored to one's precise condition, down to the genes if possible. It also means giving exactly the right amount of medical care, not too much, and not too little. It also means care tailored precisely to the patient’s wishes. Finally it means oversight so that care dollars are used optimally. 

By far the most stunning presentation was that of Dr. Lucy Kalanithi, the widow of Dr. Paul Kalanithi, Stanford neurosurgeon who wrote “ When Breath Becomes Air”. Her presentation detailed the reality of love and connection despite suffering and death in a way that I have never imagined. Her presentation had more power than any I have ever heard. I recommend the book. 

Besides being stunned, I was also charmed. I got to meet so many delightful people who were also talented beyond measure. The same people were uniformly willing to share their insight and experience. Noteworthy among these was Dr. Wendy Sue Swanson, Seattle Mama Doc. She is a Pediatrician, mom, and writer extraordinaire. Check out her website, blog, and book " Mama Doc Medicine".

It was also great to meet Dr. Kyra Bobinet, who shares my interest in helping patients realize their goals in fitness, nutrition and health in general. She told me that everything she knows is in her book, " Well Designed Life". I didn't believe her but I can't wait to read it. 

Medicine is moving forward folks, and you will want to come with it. Medicine needs your input to be what it needs to be. Monitor yourself. Get your health data. Try to connect with your caregivers. Tell your story. Listen and see an alternative point of view. Have a discussion.  This is the basis of the future of medicine, medicine 2.0. 

Not nearly everything from the conference is uploaded, but a Stanford MEdx youtube channel exists. Check out the link below and I know you will be inspired. 

https://www.youtube.com/channel/UCK1chhgXNHf7iB5mlqzXODA

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Well Designed Life: 10 Lessons in Brain Science & Design Thinking for a Mindful, Healthy, & Purposeful Life

$12.00

By Kyra Bobinet MD MPH

Buy on Amazon

Mama Doc Medicine: Finding Calm and Confidence in Parenting, Child Health, and Work-Life Balance

$13.12

By Wendy Sue Swanson

Buy on Amazon

When Breath Becomes Air

$15.00

By Paul Kalanithi

Buy on Amazon

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

Greetings from the heart of Silicon Valley. Please excuse the blog silence over the last few days as, believe it or not, I have suffered from sporadic Internet connection. I have been attending a very busy conference, Stanford MedX, on which I will fully brief you later. I could not blog at the conference but I took a lot of notes and pictures and they will serve as the basis for my reports to you sometime late on Wednesday. Where I stayed was a beautiful residence deep in a grove of old-growth trees so dense that it interfered with us cellular and local Wi-Fi coverage. So I right now without pictures, I will make this dispatch to you because I think medical Monday is so important. Text will go, but pictures will have to wait.

Some continue to doubt the association of the Zika virus infection with the development of microcephaly. However this latest study should put this to rest. The Journal Lancet Infectious Disease reported work that studied newborn Zika babies both with microcephaly and without. It turns out that babies with microcephaly we're 55 times more likely to have been infected with the Zika virus in utero. However, none of the 62 newborns in the comparison group who appeared normal showed any sign of infection.

Of chilling significance is another story published the Journal of Emerging Infectious Diseases. Those authors note that "for infants about four months and up to eight months of age" babies were "born on average on measures of weight length and head circumference" but "fell even further below average as time passed".

The CDC (Centers for Disease Control and Prevention) has now indicated that Zika virus can spread through "contact with bodily fluids such as tears, discharge from infected eyes, saliva, vomit, urine or stool." This has obvious implications for those living with and caring for those affected by the Zika virus.

Florida may offer free Zika virus testing, but that does not mean women are getting results. Apparently results that take a private lab a few days to report are taking weeks for the state run service. Time is of the essence when inquiring about Zika virus infection in pregnancy, since many women consider the option of abortion if there is evidence that their baby could be or is infected. Access to abortion is more restricted in what now could be called the Zika belt of our country.  Women consider this drastic measure because central nervous system manifestations of Zika virus in pregnancy are often devastatingly severe. We now know they're also potentially progressive even after the baby is born.

A recent poll suggests that the risks of Zika virus to pregnant women have caused some Americans to soften their view on abortion. 62% of voters living in the 10 battleground states in the south and along the Gulf Coast have said that they "support abortions after 24 weeks if a doctor believes there is a serious possibility that a woman's fetus could have severe birth defects from the Zika virus."

As of this writing the funding to combat the Zika virus is virtually spent. The Obama administration as well as the CDC, the American College of Obstetricians and Gynecologists and others have appealed to Congress to put aside partisan politics and fund the fight against the crisis

It is worth reiterating news from last week coming to us from the Zika belt state of Texas. Texas maternal mortality spiked from 18.6 maternal deaths per 100,000 live births in 2010 two more than 30 per 100,000 into thousand and 11 and remains at that level through 2014. This statistic may not seem huge but it has increased dramatically and is a higher rate than anywhere else in the country. It is also higher maternal mortality rate than in most other industrial countries. Numerous writers, ACOG and the State Heath Services of Texas maternal mortality task force all recommend an increase in health care services to women as the solution.

Global maternal mortality rates are not where they should be. The United Nations sustainable development goals (SDG) indicate the rate would have to fall by nearly 70% to meet the target globally of 70 maternal deaths per 100,000 live births. It is felt that this should be accomplished by adding an estimated 18 million Women's Health workers including midwives and obstetricians.

A new study by the Urban Institute has indicated that only 31% of women know about the most effective forms of birth control, the LARCs, the long acting reversible contraceptives. ACOG has said that such IUDs and implants are the most effective reversible contraceptives available and are safe to use by almost all women of reproductive age. Of note, weeks ago it was reported that Puerto Rico, which is greatly affected by the Zika virus, had been given a large supply of IUDs but was unable to fully utilize them due to the lack of providers trained to insert them. LARC use in Texas is on the rise.

The rest of the news in brief:

US preventive services task force recommend screening all nonpregnant adults and adolescents at risk for syphilis, which is on the rise.

The British medical Journal reports that pregnant women with higher ambient glucose levels who are not meeting the criteria for gestational diabetes still have an increased risk of complications. These complications would include preeclampsia and overly large infants (macrosomia). Additionally, related complications are noted, such as shoulder dystocia, which is the condition where babies are dangerously difficult to deliver due to a larger girth at the shoulders.

The national Cancer institute is once again encouraging all children adolescents and young adults 26 years of age or younger to obtain the vaccine against the human papilloma virus, HPV. Only 40% of eligible girls and 21% of eligible boys have received the vaccine. Vaccination rates in Australia and the United Kingdom are in the range of 75 to 92%

In the good news and we already knew this department, an article in the Annals of Oncology has reminded us that use of oral contraceptives decreases ovarian cancer risk by 50%. For the record, having children and breast-feeding them also decreases this risk.

In the good news department, The number of Americans without health insurance has fallen to a recent level of less than 10%. This is attributed to people buying insurance on the Affordable Care Act (ACA) exchange.

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

Travelling !

I'm on my way to Stanford MedX conference and I'm very excited. My usual blogging format will give way to posting as I go, so you can experience some of the amazing things that this trip will bring. Our journey starts in just a few hours ; )

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

Vice President Biden has called for the Congress to separate the issue of funding Planned Parenthood from the issue of funding the war against Zika. He has addressed the Republic led Congress in the strongest possible terms. He went so far as to point out the irony of the the fact that the people ostensibly most concerned about the unborn, anti-abortion Republicans, being the least willing to take measure to protect the unborn. Earlier this week, the Senate rejected a 1.1 billion dollar funding bill. Sixty two percent of Americans feel that Congress should approve additional funds to fight Zika, rather than pull them from other programs. 

The CDC (Centers for Disease Control) has reported that Brazil has already noted a doubling of their rate of nervous system defects, including but not limited to, microcephaly. The rate of Guillane-Barre or post viral paralysis has tripled. 

In the mice model, there is some evidence that Zika resides in the eyes. There is speculation, therefore, that it can be spread by tears. 

The WHO ( World Health Organization) has modified their advice for those in or returning from a Zika affected area. Men were to practice safe or no sex for 8 weeks. Now, that recommendation has extended to the same time frame for women: 6 months. This recommendation stands whether or not the couple is trying to conceive. Only 58% of people in the United States know Zika can be spread by sex. 

Not all South American Countries show cases of microcephaly after Zika infection in pregnancy. Not all mosquitos can transmit Zika. For example, Columbia, has had fewer than three dozen cases of microcephaly whereas Brazil has had 2000. Culex mosquitos, which are  20 times more common than Aedes mosquitos, cannot transmit Zika. The sooner basic research is done to find out the reasons behind these observations, the sooner we may get some control over Zika. 

There is other big news. The FDA, Food and Drug Administration, has banned 19 chemicals commonly found in antibacterial soaps, saying not only do they not do any good, but that they actually may do harm. There is concern especially over triclosan and triclocarbon in that they are now felt to promote antibiotic resistance. There is also concern that they may be endocrine disruptors, meaning they may interfere with sex hormones like estrogen and testosterone. Soap and water are the best ways to get clean. While I advise the frequent soaping of hands at work, and routinely upon arriving at home, I prefer my patients avoid soap on the face or any delicate tissues. 

In the good news department, we have several items. First, MRI without contrast appears to be safe in pregnancy. MRI is useful for taking care of pregnant women with many important conditions. 

HPV vaccine provided in the middle school setting met with an 86% adoption rate. This is much better than “ in the wild”. Research of this kind may provide insights into improving vaccine utilization. Maybe some of it boils down to convenience. 

Recent research indicates that use of hormones, in both oral contraceptive and postmenopausal hormone replacement forms, may be responsible for decreasingly mortality rates from ovarian cancer.  Hormone use is known to suppress the ovaries which also seems to suppress the development of this type of cancer. Ovarian cancer is one of the most dreaded Gyn cancers. This is for two reasons:  It usually presents at an advanced stage, and the screening tests for it are not very good.

Help for ovary cancer treatment is coming from an unusual source. IBM’s supercomputer Watson is utilized in a program called Watson for Genomics wherein the genes of known cancer patients are sequenced and uploaded to a database. Personalized treatment plans can be developed for each patient. In the future, this data might be used for better early risk assessment and detection as well. 

Stay tuned next for more breaking news from the world of Obstetrics and Gynecology. Next week should prove very exciting since I will be at Stanford MedX - an amazing conference on innovation in health care. Check it out here : 

http://medicinex.stanford.edu

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

As per recent precedent and priority, we start with the Zika news. 

Three of nineteen traps in the Miami area have trapped mosquitos which have tested positive for the Zika Virus. New readers will note that this virus is transmitted to humans through mosquitos bites and sex. If a pregnant women acquires the virus, it often leads to severe brain damage to the baby most notably in the form of microcephaly, which means small brain. It also leads to hearing loss. Dr. Anthony Fauci of the National Institute of Allergy and Infectious Disease Control and Prevention warned that microcephaly may be “ the top of the iceberg” and that the full impact of Zika may not be apparent until they grow older. Thus it is of paramount public health important especially with regards to the care of pregnant and potentially pregnant women. 

Zika virus infection can also increase the risk of post viral paralysis,Guillain-Barre syndrome, in those who are infected. New research published in the New England Journal of Medicine has confirmed the association with Guillain-Barre in seven different countries.

The FDA has recommended that all donated blood be screened for Zika, even in places where the virus is not present. Zika testing is currently expensive and time consuming, but officials feels this is necessary, given the seriousness of the infection and the fact that many Zika infections are asymptomatic. 

The mosquito vector which carries the Zika virus has a territory spanning only part of the United States. For this reason, officials believe the sexual route of transmission may become more important here that mosquito transmission. 

The director of the CDC (Centers for Disease Control) has stated that federal funds to fight the Zika virus will be exhausted by the end of September. It has already spent $194 million of the $222 million it was allocated. Congress must then act to provide funding to fight the virus effectively.

Postmenopausal hormone therapy is back in the news. Current practice is largely dictated by a landmark study called the Women’s Health Initiative (WHI), which was released in 2002. One of the principal investigators of the WHI, Dr. JoAnne Manson, said the “ WHI findings have been seriously misunderstood and misinterpreted. She indicated that the benefits still outweigh the risk for women of average risk for breast cancer." Aye there’s the rub. To calculate risk, you will need to have a good history taken, including a family history, a physical exam, a mammogram, and maybe even a visit to the genetics counselor. The plot thickens. 

Texas maternal mortality rates have doubled in the last four years and no one knows why. Numerous commentators have now published about this, and most have noted the political and funding challenges to women’s health care there and in the whole bible belt. There is serious speculation as to whether slashing funding for women’s health and the increase in maternal mortality is related.  Some would say that amidst the ardor to defund clinics which provide reproductive health care services like abortion and contraception, that Texas has also weakened its ability to care for pregnant women. In effect, Texas may have shot itself in the foot. It is believed that family planning clinics are an entry point into health care for many women of modest means. It is often the place where pregnancy is diagnosed. Without these clinics, prenatal care is delayed or absent. An editorial in the Dallas Morning News indicated that if were Texas a country, it would rank 31st in the OEC (Organization for Economic Cooperation and Development) for maternal mortality.

Unpacking this further we see that this jump in mortality is predominantly occurring in black women. Heart problems, prescription drug overdoses, and hypertensive disorders of pregnancy like preeclampsia (aka toxemia) are the leading causes of death in these women. I can tell you that to properly follow a women with cardiovascular or blood pressure problems in pregnancy is big undertaking. It involves frequent if not weekly visits, fetal monitor strips, serial Ultrasounds, and social support so the patient can rest. Maternal mortality is the worst complication one can imagine. Complications can happen anywhere, but deaths should be a rarity if care is adequate. According to research in the Journal Obstetrics and Gynecology, Texas maternal mortality rates are the worst in the nation and among the worst in the developed world. Truthfully it’s a disgrace. 

In the practicing medicine without a license department, Ohio passed a law in 2011 stipulating that providers of medical abortion had to use a FDA ( Food and Drug Administration) protocol for the doses of the 2 medications involved, mifepristone and misoprostol. Basically the law required them to follow the package insert, or “ the labelling”. This protocol was developed in 2000. By 2003, specialist organizations such as the American College of Obstetricians and Gynecologists and the World Health Organization, found shortcomings with the protocol and recommended changes in the package insert, allowing for the simpler and more effective dosing protocol, but also the evidence based extension of the gestational age for which the drug would be effective, and the ability for women to take the medication at home. However these changes weren’t made due to political reasons.  It now appears that since the law was enacted, women taking the suboptimal dose are more than three times more likely than before to have complications requiring additional intervention, often surgical. In other states without this law, medical providers would simply follow the most up to date recommendations of their professional governing body, including an up to date dosing protocol, regardless of the FDA labelling. This is called “ off-label use” of FDA approved medications. In many cases, in many fields of medicine, off label use is common and necessary to take the best care of patients. Up until May of this year, however, it was illegal to do so in Ohio. I wonder what they did to the rebel caregivers who gave the correct doses ? It would be tough to be a doctor in this climate. If the law didn't get you for off label use of meds, the lawyers could for knowingly giving a potentially unsafe dose of a medication to a patient. 

In May of this year, the FDA corrected the package labeling to reflect the most up to date science on the subject. Regardless of how you feel about abortion, you would not want to give a patient part of a dose of medication to only evacuate her uterus partially, since this can cause hemorrhage and infection !  Dangerous !

You may recall that a few weeks past I reported on the decline in teen pregnancy. At that time we were not precisely sure why. However, now, parsed the data and we have nailed it down. Drum roll please…..It’s…. you guessed it…. contraception !!! It turns out sexual activity did not vary in that time frame. Use of contraception did. It increased from 86% use from 78%. Science !

Perform labor is in the news. The causation of preterm labor has remained a bit of a mystery. To show you how nascent is our science, I present the findings of two recent studies, both retrospective. The first, published in the Maternal and Child Health Journal examined 400,000 births. Resistance to preterm labor seemed to be conferred by three things: birth spacing, optional weight at the beginning of pregnancy, and appropriate weight gain in the pregnancy. Pretty vague, I grant you. Next, is an NIH(National Institute of Health) study of 200,000 women. In this group  they were able to unearth the uncanny fact that women exposed to extremes of temperature early in pregnancy were more likely to deliver preterm. OK. What if they wore appropriate clothing and used climate control devices ? Gosh that is unhelpful information. Whereas, any old crusty Obstetrician can spot preterm labor risk as it walks through the door. She or he might notice the frenzy with which the patient blew in, the smell of cigarettes, the poor nutritional status, or poor dentition (teeth). We need studies which tell us about factors we can change - not the weather ! 

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

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

Zika again dominates the news in Ob/Gyn. As of Friday, a storm system was approaching the subtropical state of Florida, where 43 are confirmed infected with the Zika Virus. Authorities think the storm may help spread the virus which is transmitted by mosquitos and sex. Meanwhile, the CDC (Centers for Disease Control) does not have enough Zika testing resources. I myself experienced this last week when I was told a specimen we sent to the CDC would take “weeks” to result. We Ob/Gyns are not able to effectively work in time frames like this, and so this week we will have being having some words with the powers that be. 

A new study published in Radiology has shown that Zika can cause many other brain defects besides microcephaly. They have thus far identified 8 major defects. One of the most common was ventriculomegaly, or enlarged ventricles and thinning cortex. 

Thus far the Florida outbreak has been clustered around Miami. However Thursday, an isolated case showed up some 250 miles to the north in Tampa Bay, Pinellas county. It is still unclear how this occurred. On the bright side, modeling done by researchers at the University of Florida has indicated that the total outbreak should limited to under 400 individuals or less, considering all the southern states. They also believe winter will stop the outbreak, which would then recur next summer the same way. It is estimated that 20,000 pregnant women in the Miami area are taking extreme measures such as confinement indoors or moving to avoid Zika infection. 

NewYork officials are noting that travel restrictions to Zika affected area not being properly observed by pregnant or pre conceptual women. How do they expect people to take these restrictions seriously when they gave full sanction to people traveling to the Olympics in Rio? 

Dr. Kristyn Brandi writes that Zika is spreading more rapidly than anticipated in Puerto Rico, and that resources of information and contraception are not adequately available. 

The chair of ACOG (American College of Obstetricians and Gynecologists) has written a strongly worded piece which has criticized how politics has prevented the funding of an adequate Zika response. He and co author, Dr. Didi Saint Louis of Morehouse School of Medicine have called for the full funding of comprehensive reproductive health care to allow women to avoid or delay pregnancy. They have called on Congress to reconvene to deal with this. 

In the non-Zika news, HPV virus is in the spotlight. This virus is responsible for abnormal paps, and cervical cancer, among other things. It has an effective vaccine which is meant for young people between the ages of 9 and 26. However parents remain wary to give it to their children. Research is being done regarding the prospect of putting it on the list of already mandatory vaccines which must be done before school entry. Surveys show that parents would accept this as long as there was an opt out provision. As of 2014, only 40% of girls and 20% of boys were vaccinated. It will be interesting to see if there will be those who decline the Zika vaccine once it gets developed. 

Breastfeeding is practiced by about 80% of all American women when they leave the hospital. However less than a third keep it up for the recommended time. The American Academy of Pediatrics has recommended that infants should get nothing but breast milk for six months, and that breastfeeding should continue one year. 

Co-sleeping beyond six  months has been shown to produce significant stress on women. Researchers at Penn State note this may be related to fragmented sleep and less time with partner. Perhaps this is related to the falloff in breastfeeding. 

In the everyone-already-knows-this department, researchers at UCLA have discovered that menopause accelerates aging. In all fairness, what they have determined is that methylation increases in menopause, accelerating cellular aging about 6 %.

And in the we-should-have-known department, the “ baby simulator” program in high schools designed to deter teen pregnancy may actually be encouraging it. Graduates of the program with over third more like to have a teen pregnancy. 

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

Food Friday: Rehashing the School Lunch

As a part of back to school week, I am raising the issue of school lunches. The issue of healthy school lunches for kids bears an uncanny resemblance to the issue of healthy lunches for homemakers or working moms. Coincidence ? I think not. 

Yes, parents, you have the power. Yes, you must lead by example. Yes, accomplishing your health goals for yourself and the family hinges on how you shop for food, how you prepare it, and how you manage to eat in a regular civilized fashion, bum on chair, at the table. It also depends on your foresight to cook and prepare extra for lunches the next day. Granted, it depends on many other things, but none of them are difficult or expensive. For example, you must have proper lunch boxes, probably bigger than you think. Because if you and your kids are eating properly, your lunchbox is not going to contain a compact little lunch-able in plastic. It instead will contain fresh perishable food like salad which takes up space and fresh whole fruit which can get bruised. 

In short, producing proper school lunches is a marker for proper parenting and a competent lifestyle. Here are the rules : study up on your subject, in this case, nutrition. ( see HERE) Be reasonable and get interested stake holders involved ( the kids, and your partner). Prepare in advance, and keep to a schedule. This is how you do health. You do one healthy thing, over and over and over until it is an automatic regular routine. 

If you live this way, your kids will grow up comfortable with a calm organized lifestyle. If you are constantly a hot mess, late, disorganized and throw Smuckers Jam and Jiffy peanut butter at them every morning, they may struggle will obesity, and worse, they may struggle with respect for you when they are older. They will love you, but children see all. If your kids live in a calm well run home, they will grow up to prefer that. They will adopt the same lifestyle themselves. 

So yes, you will need to think about protein, fruits, veggies, food safety, taste, appearance, and packaging. You will need to worry about lunch table bullies and the trading of your good food for someone else Twinkies. And it doesn’t stop after grade school. Nor does it stop after high school. Kids in college may have the advantage of healthy dorm food. But oftentimes they do not, and between that and their newfound freedom, the freshman 30 becomes all too real.

Young gentlemen living off campus pose a particular challenge since they are not commonly taught the domestic arts, i.e., they can scarcely boil water. And as I have seen one son through graduate school, and another partway through undergrad, I am determined to make a guide called College Cuisine. You will be the first to hear of it. Meanwhile, I have to be content to pass on some value from others. Here are some awesome resources to help you with the challenge of school lunches: 

My Post:  the Joy Lunch Club

http://drginanelson.com/drginablogs/2015/5/22/food-friday-the-joy-lunch-club?rq=lunch%20box

My Post:  Healthy School Lunches

http://drginanelson.com/drginablogs/2015/9/17/food-friday-healthy-school-lunches?rq=school%20lunch

New York Times:  Why Kids Hate School Lunches

http://www.nytimes.com/2015/09/27/sunday-review/why-students-hate-school-lunches.html?_r=0

Washington Post On Japan’s School Lunch Menu

https://www.washingtonpost.com/world/on-japans-school-lunch-menu-a-healthy-meal-made-from-scratch/2013/01/26/5f31d208-63a2-11e2-85f5-a8a9228e55e7_story.html

Huffington Post:  Photos from School Lunches From Around the World Will Make American Kids Want to Study Abroad

http://www.huffingtonpost.com/2015/02/25/school-lunches-around-the-world_n_6746164.html

Blog of Stanford visiting scholar Karen LeBillion, author of "French Kids Eat Everything", and "Getting to Yum" 

https://karenlebillon.com

Finally, one of my favorites, NomNomPaleo.com Lunch Box Menus

http://nomnompaleo.com/paleolunchboxes

Enjoy lunch and enjoy the school year ! 

Food Friday: A More Complete View of Workout Nutrition

Last week we talked about the basics of targeted workout nutrition. This week we will get specific. And we will not talk about all the glossy prepackaged products on the shelves of stores. It turns out that some simple inexpensive choices which anyone can get at an ordinary grocery store make ideal workout supplements. 

It turns out to be good to divide workout nutrition into three categories: pre work-out, during the work out, and post workout. It is also useful to differentiate between nutrition for mostly weight workouts from that for mostly cardio workouts. 

Many of these differences are summarized nicely in an infographic on Greatist.com, which they have encouraged people to repost. I have included it here since I think it is clever, useful and attractive. 

Get health and fitness tips at Greatist.com

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

We continue to learn more about the way Zika virus affects babies.  It turns out Zika can affect babies late in pregnancy. In fact, Zika related brain changes may not become apparent until months after they are born. The reason for this is that the baby continues to grow all except the brain, which does not. 

Zika also appears to produce joint deformities. This may take the form of curved or crooked legs or arms. 

We are also learning more about the sexual spread of Zika. Men may be able to spread Zika for longer than six months, longer than previously reported. The Obama administration has shifted another $81 million dollars from the Department of Health and Human Services to continue development of a Zika vaccine.

Florida officials continue to deal with more local spread of Zika in the Miami area. Aggressive spraying programs are underway to reduce mosquito populations. Additionally there are plans to release genetically modified mosquitos which will mate with the natural Aedes Aegypti and render their offspring sterile. This has reportedly reduced the Aedes populations in Brazil, Panama and the Cayman islands by 90%. 

Various commentators are now starting to focus on how abortion politics played a role in the Congressional failure to develop a funding plan for Zika. It continues to play a role. Since Zika produces grave birth defects in babies which usually live, it is a condition for which some women might chose abortion. Marc Rubio (Republican from Florida)  has come out this week saying that he “doesn’t believe a pregnant woman infected with the Zika virus should have the right to an abortion-even if she had reason to believe the child would be born with severe microcephaly. “ A recent STAT Harvard poll indicates that 59% of Americans believe that a women should have a right to end a pregnancy after 24 weeks of testing showed a serious possibility that the fetus had microcephaly caused by the mother’s Zika infection. The same poll also showed most Americans are unaware that Congress left for vacation without securing Zika funding. Meanwhile women and health care workers in Puerto Rico are trying to overcome historical cultural barriers to contraception in a territory at very high risk for Zika. 

The Obama administration has shifted another $81 million dollars from the Department of Health and Human Services to continue development of a Zika vaccine in Phase 2 trials. Stage 1 is preclinical development, in labs and on animals. Stage 2 is when the vaccine is first tested on humans. This second stage proceeds first to study safety and then, if it passes, to effectiveness. 

In other news, ACOG (The American College of Obstetricians and Gynecologists) has updated its opinion on home births. New data has prompted the revision. The new Committee Opinion Document states that babies are twice as likely to die and more than three times as likely to have seizures soon after birth, compared to hospitals. I would point out that this is case even when most home birth attendants chose low risk patients to deliver at home. I would also point out that the literature on which this is based only reported on two of the worst outcomes, death and seizures. The many lesser but still significant complications like subsequent learning disability remain unquantified. 

In other sobering news, the US maternal death rate has increased. Between 2000 and 2014, the death rate increased from 19 per 100,000 to 24 per 100,000. It is unclear as to why though more thorough reporting methods are believed to account for much of the increase. However some of the increase is real, and authorities speculate that it is because women having babies are older and more likely to be obese than in the past. This gives rise to more complications such as maternal hypertension and diabetes. 

Many including me are cheering the relaxation of rules surrounding marijuana research. It is currently being used legally in several states without evidence of its effectiveness. New studies should be able to “ weed” out the legitimate from the bogus uses of which I suspect there are many. 

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

Wellness Wednesday: Couples Wellness

This last weekend our adult kids cross examined us about when we had last done something with just the two of us as a couple. As a result we ended up taking our own hike in Glacier Park, something we had not done in years. This got me thinking about the ever increasing amount of evidence demonstrating how critical relationships are to health. I put two and two together. 

More attention should be given to relationships in the context of health. Primary care physicians including Ob/Gyns should include relationship assessment in their broader health history. They should be able identify serious problems and refer patients for couple’s counseling or whatever it is they need to correct the problems. 

All this can happen in the context of the doctor’s visit. But discussion about the health of our relationships should be a common one, because it is important. We talk about kale, yoga, cardio and even mindfulness. Why shouldn’t the conversation extend to interpersonal skills and healthy relationships ? 

I have spent the last few days reviewing material on the subject of relationships and what can be done to make them healthier. This extends beyond partner relationships to friendships and family relationships. The core skill set in all cases is the same, with variations depending on the relationship. 

Two particular sources were the most helpful. 

The first is an article in Psychology Today which pointed me toward a sweeping review out of UCLA on the effectiveness of couples' therapy. The conventional wisdom in the lay press seems to be that couple's therapy does not work well. This research study served to shed light on this question. It was a major review of the past 40 years of research on couples therapy. It turns out that certain therapy worked, and certain therapy did not. The conclusion of the study was that couple's therapy does demonstrably work IF it follows 5 particular principles : 

1. The therapist must be willing to ask both partners to step back and look more objectively at the facts and patterns of the relationship and actually be willing to change how they each think of the relationship. (The individual partner’s views are not sacrosanct.) 
2. To be effective, a therapist must be wiling and able to change actual behavior in the individuals. They must be able to take concrete steps to prevent one partner from harming the other. This includes psychological services, anger management, or substance abuse treatment. (The therapist must have teeth.) 
3. Effective therapists must bring out the emotions of each partner. 
4. Effective therapy must include the teaching of good communication skills. This includes active listening and responsible “I statements”. 
5. Effective therapy must focus on strength and build resilience. 

In brief, therapy can be effective if it

1. Fosters objectivity
2. Changes behavior
3. Handles emotions
4. Teaches communication
5. Enhances strengths

My second source led me to the famous Gottman Institute founders John and Julie Gottman. They provided a piece in the recently published " Time Special Edition, The Science of Relationships" . As lay reading goes, it is superb. I picked mine up in Costco. In it, they discussed their work and the “ Seattle Love Lab” where they evaluate and treat couples. They also referred to their most recent book, "The Seven Principles of Making Marriage Work”. In this book they present the distilled result of their observations of hundreds of successful “ emotionally intelligent” marriages. They too identified the common patterns in these relationships and have presented them for our consideration. 

They seven principals at work in successful marriages are as follows: 

1. Enhance Your Love Maps
2. Nurture Your Fondness and Admiration
3. Turn Toward Each Other Instead of Away
4. Let Your Partner Influence You
5. Solve Your Solvable Problems
6. Overcome Gridlock
7. Create Shared Meaning 

You could map each of these lists uno the other and find that they line up pretty well. I find it interesting that both research groups chose to study what worked, and that the features held true over large numbers of couples and long periods of time. Finally, it seems that the social sciences are catching up to the medical sciences in prescribing evidence based treatments. 

I encourage you to delve into this literature, regardless of the type or the state of your relationships.

Check these valuable resources out at your local library, your local booksellers, Amazon.com, or even Costco.

The Seven Principles for Making Marriage Work: A Practical Guide from the Country's Foremost Relationship Expert

$9.35

By John Gottman Ph.D., Nan Silver

Buy on Amazon

TIME The Science of Relationships: Better Romance-Modern Families-True Friends

$13.99

By The Editors Of Time

Buy on Amazon

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

Florida has an ongoing Zika outbreak in a Miami neighborhood of Wynwood. The CDC (Centers for Disease Control) has confirmed local transmission there for several days. In response, Florida Governor Scott has pledged that Zika tests will be free for all pregnant women. Apparently there is a Zika test kit shortage and physicians' offices have waiting lists for their use. Pregnant residents in Florida are beginning to curtain their activities and travel in their home towns. Other women are delaying pregnancies, freezing eggs for later, or leaving the area when pregnant.

California has the seen the first births of Zika infected babies. These cases have been from mothers who travelled to Zika affected areas. 

Texas Medicaid has decided to cover the cost of mosquito repellant to women of reproductive age. 

President Obama has asked Congress to reconvene early to work on Zika. Meanwhile the CDC has itself provided an additional  $16,000,000 to 40 states to combat Zika. They had already given $25,000,000 in July. This comes out to and additional $400,000 per state on average and does not sound like much in the scheme of things. The money is meant for developing programs to collect and track data on both the mothers and the babies affected by Zika. I have to say that when money is short, as it is, that making the choice to fight the virus with information seems like the wisest first step. When more money comes in, which hopefully it will, it can go to bigger ticket items like better mosquito control and vaccines. Current mosquito control techniques are poor against the mosquito since it can live indoors or outdoors, can hatch in a tiny amount of water, can bite multiple people, and has eggs which can last for months. 

The CDC has clarified that all pregnant women need to be assessed for risk of Zika. They do not necessarily need to be tested, but their travel history and the travel history of their partner or partners should be assessed. 

The CDC has reviewed data which show that the use of Long Acting Reversible Contraceptives (LARCS) is low in Zika affected States. LARCS are among the most effective means of contraception and considered safe for most all women. 

Finally in encouraging Zika news, The Journal Science has reported that three different Zika vaccines have worked “to perfection” in rhesus monkeys. Each of these vaccines works by a different mechanism to stimulate the immune system to combat the virus. One vaccine uses dead virus, but the other two use two different viral DNA subunits to stimulate an effective immune response. 

In other news, the CDC has reported that adults across the board are about 15 pounds heavier than they were 20 years ago. Boys and girls weigh more as well, though boys' heights have gone up. Girls' hights have stayed the same. The average 5’4 woman weighs 168.5 pounds, which qualifies as a BMI (Body Mass Index)  of 29, nearly going from overweight to obese at a BMI of 30. Normal BMI is somewhere between 19 and 25. See the NIH (National Institute of Health) BMI calculator HERE: 

http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Vitamin D is in the news again. Apparently Vitamin D levels decrease by 20 % after cessation of oral contraceptives (OCs). This has potential consequences not only for women but for any pregnancies that ensue. Because of his new finding, it might be appropriate to check Vitamin D levels after OCs are stopped or before pregnancy is considered. 

In the close-to-science-fiction department, we turn our attention to telomeres. What is a telomere ? Tasciences.com quotes Blackburn and Epel from the Journal Nature, saying that

“ Telomeres are the end caps at the end of each DNA strand that protect our chromosomes, like the plastic tips at the end of shoelaces. Without the coating, shoelaces become frayed until they can no longer do their job, just as without telomeres, DNA strands become damages, and our cells can’t do their job.”.

Telomere length is therefore a marker of cell aging. Cell lifespan shortens as telomeres shorten. We are born with a certain telomere length. The majority of telomere shortening occurs in the first 4 years of life. Little is known about why telomeres shorten. It turns out that early exclusive breastfeeding for just 4-6 weeks is associated with longer telomere length at age 4-5 years. This may have consequences for long term health and overall longevity. The CDC has reported that just about half of all postpartum women are breastfeeding at 6 months. Less than a third were still breastfeeding at a year. The American Academy of Pediatrics has recommended that women breastfeed for at least 6-12 months. 

The Journal Pediatrics reports that “ Breast milk give a boost to premature babies mental and physical development.” Those who received breast milk during the first 28 days of life had measurably better IQ, math, memory and motor skills at age 7 compared to those who received less breast milk. I will comment that to pump breast milk for 28 days while your premature baby is in the NICU (newborn ICU) requires a high level of dedication. Perhaps it is difficult to factor out this maternal dedication as a factor in the better outcomes of the breastfed babies in their study.  These breastfeeding mom’s of preemies either are or become some of the most dedicated and resourceful moms out there, due, at least in part, to what they have to deal with. Maybe the better outcomes are born of the mother’s overall dedication. Hat’s off to you…. dedicated NICU moms. 

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