Medical Monday: Weekly News Update in Obstetrics and Gynecology

Good Monday.

A new study presented at the annual meeting of the American Society of Anesthesiologists suggested light meals during labor may be safe for most women. Ordinarily we would like to restrict intake to clear liquids nothing at all depending on the risk level of the woman. The main concern here is the risk of aspiration which means inhaling food particles from the stomach into the respiratory tract. Pregnant women are at increased risk for aspiration compared to non-pregnant women due to  the pressure from the baby and the relaxation of the esophageal muscles. Moreover, women are often nauseous during labor, increasing risk. The highest concern comes if the patient needs to go to cesarean section. In this instance she needs to be on her back with only a slight tilt, and this increases the risk of aspiration even further. It is unfortunate that the lay reporting makes it sound like we fear that women might aspirate during normal labor. Our concern is mostly having to do with the chance that they will go to cesarean section on a full stomach. 

Shots Blog on NPR covered this interesting tidbit: Babies and mothers exchange cells each others circulation during pregnancy labor and delivery, And they are maintained in circulation thereafter. These are believed to have implications for cancer and auto immune diseases that affect women. It is unclear whether these are beneficial, harmful, or both, depending on the circumstances. 

We know that when people have more testosterone in their system that they are more assertive or aggressive. But we are now finding is that the converse is also true. According to a study published in the Proceedings of the National Academy of Sciences, our testosterone levels rise in response to assertive behavior such as the use of power in a work situation. Study noted that this is especially true in women.

Did you know that tobacco use before pregnancy and in pregnancy is associated with cleft palette and congenital heart defects? The CDC's National Center on Birth Defects and Developmental Disabilities performed a meta-analysis which indicated that 6% of oral clefts and 1.4% of non-syndromic heart defects are attributable to maternal smoking in the first trimester. 

Yet another study underscores the fact that drinking alcohol increases a woman's risk of breast cancer.

Got cold sores? Don’t feel bad. The World Health Organization estimates that half of the world’s population under 50 does too. 

Stay tuned for more news from the world of obstetrics and gynecology, Next week on Medical Monday.

Food Friday: Trick or Alternative Treats

Ever wonder what you could give out instead of just candy ? I have worked on this challenge before at Easter when filling eggs, but have not until now considered what alternatives I could do at Halloween. 

First of all your Halloween alternative offerings should not break the bank. Secondly they should be age specific. In my family and group of friends, everyone from young children to old adults go out for the holiday, usually in costume. Halloween has always been a big holiday for our family, but especially since our youngest child was born on that day 22 years ago. When he was tiny he used to think the whole town came out for his birthday. 

I am for a strategy where you actually hand out the treat rather than have people take it from an unattended bowl on your porch. You will see why when you see my list of alternatives. Some are definitely age specific. Plus you ought to get to know your neighbors.

I think it is important to have some candy at Halloween. Always choose something that is wrapped so that the parent or child can be sure that has not been handled. You might think that the candy would get cherry picked out. This will not be the case if you were the one doing the handing out. Moreover, at Easter, I have found that some of the other non-food items are actually more popular than the candy.

Here's the list:

• Tiny boxes of raisins
• Trinkets you've purchased for cheap at the thrift store
• Interesting buttons purchased by the jar at garage sales or thrift stores
• Tiny spools of thread purchased by the bag at the fabric store
• Craft items such as decorative pipe cleaners or pom-poms
• Glass “Jewels”, meaning the pretty glass rocks you put in the bottom of a vase of flowers, Usually available at the dollar store in a selection of sizes and colors.
• Stickers
• Glow bracelets usually available at the dollar store.
• Poems quotes or sayings written decoratively and in tiny envelopes
• My favorite: beads, especially large ones.
• Tiny rolls of ribbon
• Tiny toy soldiers or animals 
• Office supplies such as decorative clips, rubber bands, tip erasers, or pencils
• Tea light candles

Basically I pick things I would like to get. Speaking of me, as you can see from the picture, I am still working hard on my costume. Guess who I am going to be.  

Have a safe happy Halloween. 

Medical Monday: Weekly News Update in Obstetrics and Gynecology

Good Monday !

I am returning from a great five days back at Stanford with our son Forest, who is now also an alumni. We attended “ Classes without Quizzes” and enjoyed ourselves immensely. We learned about numerous things, including a little about the way the brain functions during early language development, the latest in nutrition research, and a MMOG, yes, a massive multiplayer online game called EteRNA which has become a powerful tool in the design of tiny RNA machines which may be used to treat disease. We also took a yoga Piyo Hip Hop Fusion class, went on a pro multi-ethnic eating tour and saw tons of old friends. 

So now we return inspired, excited to move the needle forward in everything we do, including Medical Mondays ! 

Flibanserin went on sale this last Saturday. Flibanserin is of course the pill to treat low libido in women. It goes by the name Addyi. Does anyone know how to pronounced this ? Someone got paid to think of that name, you know. I can’t wait to see the commercials. For some real information about this drug, please see my prior post HERE. 

This week, in a 2000 word opinion piece in the New York Times, a political scientist Courtney Jung, criticized breast feeding activists for putting too much pressure on women to breastfeed. She states broad based research indicates the benefits of breastfeeding are  “ modest”. Could this op ed have anything to do with the fact that she is releasing a sensational new book called “Lactivism” next month ? Imagine running a 2000 word ad for your upcoming book in the New York Times. I wonder if they even paid her for her ad.

Her subtitle includes many of us: 

How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy

I am just going to go out here on a limb and disagree and say that I do not think breastfeeding is bad policy. I guess I’m kind of a rebel that way. 

The American Academy of Pediatricians has come out saying that "no amount of alcohol is safe for unborn babies". The new guideline “identifies prenatal exposure to alcohol as the leading preventable causes birth defects and intellectual disabilities in children.” It was previously thought that "a small amount" of alcohol is okay in pregnancy. According to the CDC (The Centers for Disease Control), about 10% of women self-report that they drink alcohol in pregnancy. So in my simplistic mind this means that if women comply with this recommendation, 10% of the entire next crop of babies could be significantly developmentally better off than the last group. Wouldn’t this have staggeringly good effects on the population ? 

The American Cancer Society has revised its recommendations for mammograms once again stating that they should start at age 45 in a patient of average risk, and go to every other year at the age of 55, provided that the woman is expected to live at least 10 more years. The purpose here is to "eliminate false positives and over treatment’.

Has anyone ever considered asking the question, How bad is the badness of a false positive? And what do they mean by overtreatment? Do they mean biopsies which turn out to be benign or do they mean lumpectomies or mastectomies? Most physicians do not consider a biopsy to be a treatment. Most patients consider a benign result a great relief. I have never heard of a patient saying ”Doctor, my biopsy was benign. It looks like I really didn't need that biopsy after all ”. If biopsies were taken out of the “over treatment “ calculations would there really be any unnecessary “treatments” left to lament ?

The American College of Obstetricians and Gynecologists (ACOG) has maintained their stance on mammograms every one to two years from the age of 40 forward. It also recommends a clinical breast exam annually. The American Cancer Society is dropping their recommendation for an annual clinical breast exam since it has not"been shown to save lives.” They say nothing about whether it extends lives. Is important for readers to know that there are many studies designed to determine whether or not a certain intervention prevents death in the course of the study. Preventing death is the same thing as saving life, no matter if you die at one year or ten years after treatment.  Studies geared to show an interventions ability to save life do not necessarily have the power to show it extends life. ACOG keeps its position on mammograms and clinical breast exams because earlier more frequent mammograms and clinical breast exams are associated with earlier diagnosis and longer life after breast cancer. 

I had better stop writing since there is steam coming out of my keyboard and my ears again. 

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

Medical Monday: Weekly News Update in Obstetrics and Gynecology

Did you know that some insurance companies offer rebate incentives to get indicated mammograms ? A recent editorial in the Journal of the American Medical Association called this “ an ethically disconcerting distraction”. What do you think ? I think advanced breast cancer is far more expensive than early cancer caught and cured. 

A new study from the University of Minnesota School of Public Health has shown that less than half of new mothers returning to work have adequate space and time to pump. Meanwhile, in related news, the Army now requires commanders to allow breastfeeding soldiers to have time and space to pump. To clarify, many soldiers stay stateside or in non-hostile countries with family on bases and serve in technical or support positions. 

One article and two more separate recent studies indicate a higher infant mortality for non- hospital births than hospital births. ACOG estimates risk at two to threefold across the board. Remember there is also evidence demonstrating a 14 fold incidence of first Apgar of ZERO in those delivering their first baby at home. All this seems self evident to me given all my eyes have seen. 

The American College of Physicians has come out against routine pelvic exams in the the asymptomatic woman. The American College of Obstetricians and Gynecologists has made it clear it supports annual pelvic exams. Recall that pelvic exams need not always include a pap, since a pap is the collection of cells from the cervix to be evaluated in the lab. Pelvic exams confer a wealth of information about infection, pelvic relaxation, masses in the uterus, masses in the ovaries, etc. Ask any ob/gyn; They will tell you they find significant things on pelvic exams in asymptomatic women all the time. It looks like this needs to be formally studied. 

Uh oh, more bad news for Essure, those little coils placed in the tubes for sterilization. (Darn it, this seemed so promising. ) A new study in the British Medical Journal evaluated over 52,000 women sterilized with Essure. These women were 10 times more likely to go to surgery in the following year than those that were sterilized with a traditional tubal sterilization procedure. It is interesting to note that the FDA ( Food and Drug Administration) did NOT require documentation of Essure’s performance though a RCT ( randomized controlled trial). 

A study in the Journal of the National Cancer Institute has shown 61% of women obtaining mammograms will have at least one false positive report. They are advocating that physicians do more to educate and reduce anxiety associated with these results. 

In the good news and empowerment department, a Norwegian Study reports that pregnant women who exercise regularly in the three months prior to pregnancy report less pelvic pain in pregnancy that their non exercising counterparts. And this is making me smile: High impact exercise was the most strongly associated with decreased pain. So, did these women go through life feeling less pain to begin with thus tolerate exercise and pregnancy better, or did the performance of the exercise change something about the way they perceive pain ? A study like this cannot answer these questions, but they are interesting to ask. 

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

Structure Sunday: The Structure of Prevention

Here’s a simple question: Is it hard or easy to stay well ? 

Staying well is two things: avoiding disease and optimizing health. I’ll be the first to tell you that there are some diseases you simply can’t avoid. I’ll also be the first to tell you that most diseases are a preventable. 

What is prevention ? Is prevention hard or easy ? Prevention is not one thing. It is collection of different actions. Most importantly, these are done over time, on a meaningful schedule, and so we call them habits. I find that lots of people do certain few healthy things once in a while. Oftentimes these same people wonder why they do not see gains in health or fitness. What they are missing is the element of time. Taking one, two or ten habits and performing them in perpetuity over time is what makes the changes. If I could change just a few ideas in my patient’s minds, this would be one of them. 

Prevention requires you to harness the element of time. Time gives your actions power. Most prevention habits are simple easy acts in and of themselves. By themselves they don’t so much. Multiply them by months and they make significant and long lasting changes. 

Here are some super simple acts which you can multiply over time. 

Mind: 

Record three things for which you are grateful before you go to bed. 

Read them upon arising. 

In a conversation, listen first then respond with “I” statements. 

Think and take two full breaths before responding during a conflict. 

Meditate for 10 minutes per day. 

Have about 6 close friends. 

Consider having a partner. 

Have a pet of whom you take good care. 

Ensure your work is meaningful. 

Don’t overspend. 

Take your allotted vacations. 

Body: 

Wash your hands at work and when you get home. 

Get your required vaccinations. 

Sleep at least 7-8 hours a night. 

Wear seat belts. 

Use sunscreen.

Eat three meals and three snacks each with protein and produce. 

Avoid simple refined carbohydrates. 

Use olive oil and green tea. 

Ban soda, smokes and drugs. 

Limit to one wine or beer per day. 

Drink 3 liters water per day. 

Brush twice a day, floss and use a peroxide mouthwash before bed. 

Exercise for half hour 5-6 times per week combining cardio and light resistance. 

Incorporate yoga every week. 

Super basic, right ?

Super powerful.

That’s what these habits are when repeated over time. 

Prevention doesn’t hurt, it’s not expensive, and you can do it anywhere. It does take a plan to carve out the small slots in the day to do these things, but it really isn’t hard. Just keep the list handy, do the items, and you will wake up in a few months and notice some pleasant changes. 

Weekly News Update in Obstetrics and Gynecology

Good Monday news readers. 

This week, card carrying Ob/Gyns the world over are going all green on us. The World Health Organization and no less than 6 other international Ob/GYN professional societies have “ come out” calling for “ providers to incorporate environmental health screening as a part of routine practice." They have also asked that clinicians become active on a local, national, and global levels to advocate against exposure to toxic chemicals in the environment. 

In sensational news, a Finnish study reports that discontinuation of hormone therapy may increase the risk of cardiovascular death. This news comes as one of many postscripts to the large Women’s Health Initiative (WHI) study designed to assess the effects of two forms of hormone therapy (HT): combined therapy with conjugated estrogens plus synthetic progesterone, and unopposed estradiol in those with a hysterectomy. Until the WHI, conventional wisdom was that HT prevented heart disease, but fostered breast cancer. Surprisingly the WHI showed women in the combined HT group had small but significant increased risks of both heart disease and breast cancer. Those in the estradiol alone group had neither. 

In Finland, which has a highly regulated and uniform brand of socialized medicine, the use of HT took a steep dive upon the release of the WHI. ( It did in the US too.) Examination of this time period a few years ago in Finland has yielded these new insights. No one knows precisely why this is the case, but the authors speculated that it is because only estradiol, either with or without progesterone, is used in Finland. No conjugated estrogens are used. 

 It turns out that the average age of the women in the WHI was 63, a good 12 years older than the average age of natural menopause. These were women who might have accumulated atherosclerotic disease before even starting the HT. Authors of a related recent Finnish study speculated that estrogen may be good for clean vessels, but bad for atherosclerotic ones. This is physiologically plausible since estrogen encourages turnover of the vascular lining, which is where plaques happen. The plot on HT thickens again, but maybe in a good way. Stay tuned. 

Cup half full or half empty ?  The CDC reports that there has been a 44 % increase since last year of hospital policy driven encouragement of breastfeeding within one hour of birth. The trend is good ! However, the respected blog “ Shots”  at NPR ( National Public Radio) decried the findings, pointing out that most hospitals still are not doing a good enough job promoting breastfeeding and most hospitals give formula despite mothers wishes.The cup has some water in it….errr milk. 

Aren’t there some animals who ovulate in response to intercourse ? Kitty cats ? Animal lovers help me here. A new study in the Journal Fertility and Sterility has identified intercourse induced changes the immune system that are pregnancy favorable. Researchers have stated “... sex outside the fertile window is still important for triggering important changes in a woman’s body that may promote a healthy pregnancy.' Meow. 

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

Wellness Wednesday: When NOT to work out

Last week I “exercised” poor judgement. I knew it right away, since my natural consequences were swift and sure. 

I had an exhausting week at work. I had kept up on my regular workouts, and got a moderate amount of sleep. Then one morning very early, really in the wee hours of the night, I had to go do an emergency delivery. This dovetailed right into the day. As I worked into the afternoon, not surprisingly, I felt off, a little ill. However, it was the night of the big Zumba Master class, with the awesome teacher from out of town. It was not to be missed. 

I felt like it was all I could do to get my zumba clothes on. Maybe that was a sign. If you can’t get your sports bra on you should not work out. Anyhow, I got there, and it was packed. A nurse friend of mine told me I looked tired. She told me I’d feel better after the workout. Then the new instructor started  in and she was dynamite. It was great dancing; stuff I had not seen before. I did feel better. 

Somehow I had gotten into a little clutch of instructor types in my section of the crowd and everybody could actually dance. That made it even more fun, but you had to really put out. And put out I did. By the end I was drenched, which is unusual for me. My face was red as a beet, also unusual. And then I stepped into the cold night air and felt sick. Weird sick. I was pretty sure I had whacked my electrolytes. 

When I got home I felt strangely weak, and super thirsty. I drank slowly, ate some chips and salsa for salt, and soaked in a tub. I got better, but it took until the next afternoon for me to feel ok. 

Moral of the story ? Remember that working out is for health. If doing it will not be good for you then don’t. Other moral ? Listen to your body. 

So I thought I would take this occasion to give you ( and me) some reasonable criteria for postponing your workout. 

• The neck rule: You may do a light or “ recovery “ workout if you have the simple sniffles or head cold (cold above the neck) and you are otherwise healthy. 
• You should pass if your respiratory infection is below your neck in your chest or you feel systemic symptoms such as body aches and fever. 
• If you have actual Influenza, do not work out. 
• Do not work out if you are having an asthma flare. Consult with your physician on how to treat your flare and when to return to exercise. 
• Do not work out after a concussion until your doctor releases you. 
• If an old injury is acting up don’t just tough it out. Perhaps do a workout where it is not involved at all, or just get in to be treated. 
• If you went without sleep, i.e. less than 5 hours… then just do a light session, eat, shower, then hit the hay. 
• If you are really sore from a prior workout, go light on some different type of workout. 
• If you are dehydrated, then hydrate up, wait a couple hours, then you should be ok. 
• If you are pregnant without complications, you should be able to continue to exercise, but you will have to modify in later weeks. Consult with your physician about this. 

If you work out in a gym it is particularly important to stay away when you are sick, to prevent the spread of your illness. Likewise it is prudent to wash hands, use sanitizer and avoid touching your face so you don’t get what others have brought. Consult with your doctor about this season’s immunizations. 

Regular moderate exercise stimulates the immune system in a good way. But hard exercise to “ get you to the next level” can actually temporarily suppress immune function. During mild illness, a light workout or yoga session will not result in you losing fitness. When you are under the weather, switch your emphasis from training to self care. You’ll be glad you did. 

References: 

WebMD

Greatist

MayoClinic 

Medical Monday: Weekly news updates in Ob/Gyn

Did you know that not all breast cancer is the same? Breast cancer is of course cells from the breast which have become abnormal and behave in an unregulated destructive manner. We can study specific breast cancer cells to determine their particular nature, for example, whether or they have hormone receptors. When we study breast cancer cells for their particular traits what we are really trying to determine is what therapies would be the most effective against that particular breast cancer cell type.

Some tests we do on breast cancer cells are gene tests. A new gene test called Oncotype DX "accurately identifies a group of women whose cancers are so likely to respond to hormone blocking drugs that adding chemo would do little if any good while exposing them to side effects and other health risks”. This test allows certain patients identified by this gene test to skip chemotherapy, and have results which are basically just as good as the corresponding patients who did have to get chemotherapy.

You may have heard that there is increasing support for homebirth in the United Kingdom. The United Kingdom of course has socialized medicine and a completely different medical care and medicolegal  infrastructure than the United States. For example, British homebirth midwives are highly trained graduate-level professionals who have trained with Obstetricians in hospitals. They use modern equipment, can prescribed medications, and are constrained to doing homebirth in very close proximity to hospitals with emergency capabilities. More importantly, they are very careful at patient selection. Finally, medical malpractice liability is handled through the National Health Service. 

None of this can be said for homebirth professionals in the United States where only a high school degree or GED is required along with an online test, care of home birth clinic patients and an observation of a small number of homebirths by a similarly trained person. These “direct entry” or “lay” midwives in the US are not required to carry liability insurance. 

For many reasons including all of this, the American College of Obstetricians and Gynecologists (ACOG) maintains that the safest place to give birth is the hospital or a birthing center. It is interesting to note that because of medical privacy laws and reporting laws of the state, complications of homebirth are vastly under reported and understudied. Those of us who manage complications from unsuccessful home births are very concerned about these things.

Has anybody noticed that the brouhaha over Planned Parenthood has not prevented the government from continuing to function?

A meta-analysis study out of New Zealand  and published in the British medical Journal has once again raised the question of whether or not calcium supplements are useful for strengthening bones. Their study indicates that while supplemental calcium is indeed associated with increases of bone density up to 2%, they conclude this increase was not enough to meaningfully reduce a person's risk of fracture. It is worth noting that in this study they did not actually measure fracture occurrence in the groups over time.

A second study in the the same journal actually showed a slight reduction in people’s fracture risk with calcium supplementation but researchers concluded the change was not enough to make a statement about the effect. Of course the media reported both of these studies as saying that calcium did not strengthen bones. Oversimplify much ? 

In the conventional wisdom department, new research suggests that women who"begin hormone therapy toward the beginning of menopause may have a lower risk of developing heart disease”. Apparently women who start hormone replacement therapy within five years at menopause stayed free heart disease for a longer time than non-users.".

This is exactly what we thought would take place before we studied the matter in the large very important Women's Health Initiative study, which released in 2002. The Women's Health Initiative study or WHI, demonstrated that those on combined estrogen and progesterone hormone replacement therapy actually had slightly increasing cumulative risk of adverse cardiovascular events after menopause. This was not what researchers expected. Conventional wisdom had always been the hormones like estrogen protected against cardiovascular disease, accounting for the commonly observed phenomenon of that premenopausal women rarely had heart attacks, compared to men or postmenopausal women. Unfortunately the Women's Health Initiative was a bit of a lumper, (as opposed to a splitter) in that it evaluated postmenopausal women of all ages all at once. Moreover, the average age of the test subjects was 63. Thus these women for far more than five years after the average age of menopause which is 51. These women would be likely to have already developed pre-existing cardiovascular disease, in the years after the onset of menopause but before the onset of their research protocol hormone replacement therapy.

Many researchers have speculated that there is something disadvantageous about starting hormone replacement therapy once the patient is long into menopause. Conversely clinicians everywhere have noticed positive effects on health and well-being in those who are able to take hormone replacement from the beginning of menopause and into old age. It will be interesting to see if evidence based quantitative science catches up with or remotely matches the conventional wisdom on the streets.

The Federation Internationale of Gynecology and Obstetrics (FIGO) is stepping up its research on the relationship between toxic environmental chemicals like BPA and problems like miscarriage and cancer.

Finally, in the good news department,  the American College of Obstetrics and Gynecology (ACOG) “recommends pregnant women without obstetrical or medical complications exercise at least 30 minutes a day most if not all days a week, just like the rest of the population.” 

Stay tuned for more fascinating news from the world of obstetrics and gynecology next week on Medical Monday. 

Food Friday: Fasting and What To Do Instead

Fasting and cleansing make headlines. They are dramatic trendy measures taken by those seeking improved health. But do they work ? Are they safe ? 

Fasting is generally regarded as going off food for at least a day. Cleansing involves the same but with some sort of liquids and juices added back. Sometimes enemas are part of the “cleanses”.

Proponents state that they get past their hunger, and that they eventually feel good, even high. They state their bowel movements show they are getting cleaned out. Their stomachs flatten and they feel light. Who wouldn’t want all this ? 

Unfortunately, it doesn’t last. Our physical and mental vitality depends on a flux of matter and energy through our body. It is true that our body is designed to weather the temporary hardship of relative drought or famine, but under these conditions it cannot thrive. 

So many people participating in cleanses or fasts are doing so to achieve optimal health and high performance. However, to really thrive, we need optimal nutrition and optimal activity as much of the time as possible. Fasting and cleanses are not compatible with this. 

What do fasting and cleanses really do ? In many cases, they are dehydrating. This can be dangerous, especially if subjects are very young, old, or unwell. The body does burn fat and glycogen for energy, but in more prolonged fasts, muscle mass is lost. This types of metabolism actually produces more “ toxins”. It does not detoxify. 

All this provides a substantial stress on the body. Stress hormones are activated. Neurotransmitters  which help us cope with stress are activated as well, accounting for the feeling of elation and capability. 

Weight does indeed get lost, but mostly in the form of water, stool, fat and and muscle. When a normal dietary and fluid intake is resumed, most of the weight is regained. Muscle of course can be rebuilt, but this requires exercise and surplus protein in the diet. 

Colon cleanses can be dangerous. The colon has a normal bacterial flora. The importance of the balance of this flora is becoming better understood these days. Colon cleanses disturb this balance and can lead to problems with digestion, dehydration and serious electrolyte abnormalities. 

I have noticed that purveyors of these unproven and dangerous methods charge high prices. I have also noticed that they advertise to vulnerable populations, including those undergoing cancer therapy. I find this very concerning. 

The answer to all of this is very simple. It is common sense evidence based medicine and health maintenance. It is Friday, and I am thinking about the weekend. So instead of going on about this downer topic, I would like to tell you my alternative version of a quick health boost. 

I call it a “spa weekend". To me, this means I will arrange to do several key things this weekend in a concerted spirit of boosting wellness. They are as follows: 

• Get the ideal amount of sleep all weekend. 
• Do morning yoga. 
• Drink green tea each day. 
• Drink 3 liters of water each day. 
• Do longer afternoon workouts each day. 
• Have 3 ideal meals and 3 ideal snacks each day all weekend, heavy on protein, veggies and fruit. 
• Soak in the tub each day. 

I might even do my own pedicure. 

That is my idea of a plan to boost wellness. I hope you can take a spa weekend sometime soon. 

Medical Monday: Weekly News Update in Obstetrics and Gynecology

The Republican dominated House voted to defund Planned Parenthood last Friday the 19th. About a week later, the Senate rejected the same bill by a vote of 52 to 47. It turns out defunding Planned Parenthood would have allowed lawmakers to come in on budget and avoid a government shutdown on October1st. Both sides of the aisle are woking on plans to keep the government going after October 1st. I will say this: that meeting budget and funding Planned Parenthood are really two separate issues and should be treated as such. It is not as though Planned Parenthood is the ONLY straw that could have broken this camel’s back. 

The Food and Drug Administration (FDA) held a public hearing this week about the relatively new method of sterilization called Essure. This procedure involves the insertion of small coils into the inner aspect of the the Fallopian tubes as they open into the uterine cavity. Is is an office procedure without incisions, which is its appeal. However there are now 5k plus reports of complications associated with the device and more pregnancies than were intially advertised. A panel of experts criticized both the maker, Bayer Health Care Pharmaceuticals, and the FDA, in the handling of device’s testing.  A long running social media campaign has influenced the convening of this hearing. 

Long acting reversible contraceptives (LARCs) like IUDs ( intrauterine devices) have been found to be 20 times more effective at preventing pregnancy that all other contraceptive methods. In more good news, almost everyone, even childless women and women with medical conditions, are eligible to use them. Their use is up in the last few years from 1.3% to 7.2 %. The American Academy of Pediatrics recommends that they be first-line contraceptives for sexually active teens.

Most women know there is a vaccine available to prevent cervical dysplasia and cancer. But now a clinical trial from Johns Hopkins University School of Medicine has shown effectiveness in a new genetically engineered vaccine to ERADICATE existing high grade precancerous cervical lesions in half of the test subjects. Wow, fantastic ! 

Stay tuned for more news from the wild world of Ob/Gyn in next’s week Medical Monday. 

Food Friday: Soup Stock

Our evening temperatures are beginning to dip into the 30s and yet, our outdoor activities continue unabated. This weekend I'm sure we will be out either observing the lunar eclipse or the Northern lights. This means we're going to get chilly. This means we will want soup. 

Soup season is here again. While I love summer with its fruit platters and salads, I adore the soups of fall. A beautiful soup makes a great centerpiece for a meal, and if made well, soups are healthy and appeal to everyone.

What does it take to make a delicious soup? It takes a well-made soup base. Some people call this broth and some people call it stock. I think when you see how it is made you will understand why it tastes so good.

The first thing you should do is roast some chicken. I realize this sounds daunting to some, but it is actually one of the simplest things you can do in the kitchen. Moreover, whole chickens are one of the most inexpensive healthy foods you can buy. Around here, we can get them from our local farmers or you can get a good whole organic chicken at Costco. You will need a roasting pan, but it need not be fancy. It should have a roasting rack. You can usually get these at secondhand stores. You will also need a meat thermometer and these are available for just a few dollars at any grocery store. This is a small price to pay for food safety. Before you start to unpack your chicken, adjust the shelf in your oven and preheat it to 425°. Read through all the instructions first, and assemble everything you need before you start. In French, this is called “ Mise en Place”, or to put in place. 

Start by reviewing food safety. Recall that raw chicken and its juices are a culture medium for bacteria. Keep everything confined to the sink or nonporous cutting boards. Open the packages in your area and do not reuse any of the utensils or surfaces for anything else without thoroughly cleaning them in hot soapy water. Once you get your chickens unpackaged, remove the giblets and rinse them. Set your hollow chickens onto the roasting rack in the roasting pan. Then, discard the packaging, wash the utensils and surfaces and finally wash your hands with hot soap and water.

Brush the surface of both chickens thoroughly with olive oil. Sprinkle them liberally with good kosher salt and freshly ground pepper. Encrust them with whatever other herbs you like. Add about an inch of liquid to the bottom of the pan. This can be water or white wine. Cover the birds loosely with foil. Roast at 425°until their internal temperature is 165 degrees deep in the flesh. For the last 10 minutes or so, take off the foil and brown the tops of the chicken until they are nice and crispy but not burned. This will serve about 10 people or a  small family for several days. 

To make broth, take all of the chicken meat of all of the bones and serve or store it. You can use it to make sandwiches, chicken salad, main dishes, and pasta. Keep all of the drippings in the pan unless they are burned black. Compress the carcasses down in the pan and place back in the oven and either bake them at high temperature or broil them until they are golden brown and dried but not burned. Take the roasting pan out and add several ingredients which will flavor the broth. Here are some choices:

• Garlic cloves, and onion with their skin
• Chopped carrots, Chopped celery
• Older apples that are still good
• Any fresh herbs and peppercorns

Cover all the ingredients with water and bring to a boil on the stove top. Boil for 10 minutes, then simmer for at least two hours.. When finished, strain and transfer to a clean cool container or containers, preparing either to use, refrigerate, or freeze. Consider adding salt at this time.

If the weather is cold, I like to cool my broth outside. This way I don't have to put hot containers of broth into a freezer or refrigerator, compromising the temperature of other items. Either hot broth or cold broth is safe, but warm broth spoils quickly, and should be stored or used promptly. 

I freeze our broth in quart containers being careful to leave about three quarters of an inch of head space at the top. Now I have a delicious base for any number of different kinds of soups or sauces. We have used this to make soups with chicken, red meat and all kinds of vegetables.

Mostly we just make soup with what is on hand. The general principle is this: Pick a soup pot of adequate size. Saute your meats, garlic, onions, and hard vegetables one by one in olive oil and spices. Once they are cooked, cover with broth and add the softer vegetables such as tomatoes and greens. Bring to a boil, then simmer until done. Season to taste. To your health ! 

Medical Monday: ACOG weekly news

Headlines proclaim “ Aggressive Treatment for DCIS May Not Save Lives”.This sounds rather dismal. Reading further, what they should have said is “ Aggressive Treatment for DCIS May Not Be Necessary to Save Lives”, which is good news. DCIS is very early microscopic breast cancer, and as such its concerns everyone. Such an alarming headline got my attention. But once I found out the news was actually good, I was a little dismayed.  There must be a chapter in the Journalism textbook where it says bad news gets more attention than good. I don’t know. Read carefully out there ! 

Just to refresh your memory, ACOG stands for the American College of Obstetricians and Gynecologists. They send its Fellows, myself included, news updates throughout week. These are articles of pertinence to women’s health. Each Monday, I pick a small sample and present them to you for your consideration. More such articles can be found at www.acog.org. 

There is such a thing as “ distracted snacking”. The Journal of Health Psychology reported the results of a small study which indicate that distracted snacking results in greater intake even afterwards. I speculate that it has to do with the fact that distracted snacking results in greater intake that say “ mindful snacking “ ( my term)  causing insulin levels to spike more than they would have, and more hunger to be stimulated later. So be mindful about your snacking and remember to always include some protein. 

The venerable diaphragm has gotten an upgrade. A Seattle based nonprofit has developed a new more contoured model. It’s name is Caya. Go to Caya.eu to learn more. It is not yet available. 

Finally, ACOG has released new guidelines regarding the treatment of morning sickness. First line therapy should be in the form of the class A combination of doxylamine and vitamin B6, commercially available over the counter without a prescription in the US as Diclegis. ( Class A is the safest pregnancy category for a drug. ) This is not to say that we are not still going to need Zofran for certain patients. It will still be considered after Diclegis is deemed insufficient. 

When you read medical related articles in the mainstream press, read very carefully. It is tricky to report accurately if you do not have medical background. For more on that please see our section “ Your internet learning toolbox”. 

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

Food Friday: Drink !

I am absolutely compelled to write again about hydration in this, our week of three digit temperatures. I had one reasonable and well intentioned patient who came in with symptoms and was FIVE LITERS short on her hydration ! 

Let us review. Normally, a non pregnant woman needs 2 liters of fluid per day. A pregnant woman needs three. Add another liter for temperatures over 85 degrees, and yet another liter for activity such as hiking. So if you are pregnant and hiking on a hot day, your fluid requirement is easily 5 liters, and that is assuming you are coming to the day adequately hydrated in the first place. 

The human body is about 60 % water. Let's say you weigh 154#. That means you weigh 70 kg. That means you contain 42 kg of liquid or 4.2 liters. Getting short on fluid percentage wise is easier than you think. 

How can you lose so much fluid ? Well there are the obvious ways, but then there is also respiration, sweat, and something short of sweat which is still fluid loss through your skin called insensible loss. It all adds up. Heat and activity increase insensible losses like crazy. 

Here is the interesting stuff: 

" ...fluid loss of 1% impairs thermoregulation (the ability to regulate your temperature), and thirst occurs at this level of dehydration......Vague discomfort and lack of appetite appear at 2 % . Dry mouth appears at 3%. At 4% work capacity is decreased. Difficulty concentrating, headache, and sleepiness are observed at 5%. Tingling and numbness of extremities can be seen at 6%, and collapse can occur at 7% dehydration. " ( reference from the World Health organization) 

Here is the fun stuff: 

Summer is a great time for cold drinks. Try to take the traditional summer cooler and put a healthy spin on it. Here are some examples that will provide you with much needed electrolytes as well as fluid and taste. 

• Club soda with a splash of 100% fruit juice. 
• Mocktails like Virgin Mary, Virgin Daquiris
• Herbal iced tea or sun tea on ice with lemon and mint leaves, sweetened with a little fruit juice 
• Healthy fruit frappes made with fresh fruit, ice, and plain yogurt or kefir. 
• Decaf mocha frappes made with ice, one pump of chocolate, and your milk of choice. 
• Stay hydrated and enjoy ! 

For more information see : 

Drinks in Nutrition 

Weathering the Heat 

Medical Monday: Dramatic Results with Long Acting Birth Control

Did you know that fully half of all pregnancies are unplanned?  Something pretty dramatic would have to happen to slash the rate of abortions and the rate of unplanned pregnancies, right? Actually not.

Hot off the press:

Researchers at Children's Hospital Colorado, through a grant from the Susan Thompson Buffet Foundation, devised a study to see the effect of freely providing long acting reversible contraceptives (LARCS) to teens and women who could not afford them. They did this over a 6 year period. The birth rate for teenagers fell 40% percent! The rate of abortions in that group fell by 42% as well. The pregnancy rate for unmarried women under 25 fell similarly. 

What are LARCs? They are the subdermal (under the skin) implants like Nexplanon, or the IUDs (intrauterine devices) such as Skyla, Mirena and Paraguard. These are well established, well understood devices which have excellent safety profiles. For more information, check our section HERE. 

These LARCs are fairly expensive. This study showed the effects of eliminating expense as a factor. Interestingly, for every dollar of cost of the contraceptive, nearly $6 was saved in Colorado's Medicaid program.

Perhaps more importantly, there are as yet, unmeasured consequences. We know from global data that there is an inverse relationship between education and number of children. We know that women who have children early may postpone or forego their education. We also know that women who are educated have better access to contraception and choose to delay childbearing. Not surprisingly, as a women's number of children rises, her financial dependence increases. On a population basis, as numbers of children rise, so do income disparities between men and women. Finally, as number of children rise, standard of living goes down and rates of poverty go up. It will be interesting to see whether, in Colorado, rates of educational attainment and income go up among young women in this cohort. 

To learn more: 

http://www.nytimes.com/2014/10/02/science/teenage-pregnancy-and-abortion-rates-plummet-with-long-acting-female-contraception-study-says.html

http://www.nejm.org/doi/full/10.1056/NEJMoa1400506

http://www.brookings.edu/research/reports2/2014/09/generation-unbound

Food Friday: Picnics

Did you know that picnics were once only for the very wealthy? Picnics evolved from outdoor hunting parties in the 14th century in Europe. Such elegant outdoor meals were depicted in artworks and tapestries dating back to the Middle Ages. Picnics themselves became entertainment for the wealthy from the Middle Ages, through the Renaissance, and then into the Victorian era. They epitomized the virtues of the wealthy classes, which extolled sport, social life, the beauty of nature, and elegance. In the Victorian era, picnics became especially popular and extended to the emerging middle classes. 

The Oxford English dictionary defines picnics thus: “Originally, a fashionable social entertainment in which each person contributed a share of the provisions; now a pleasure party including an excursion to some spot in the country where all partake of a repast out of doors; the participants may bring with them individually the viands and means of entertainment, or the whole may be provided by some one who “gives the picnic”. 

Today, picnics are far more casual, though they still retain the aspect of having a festive meal outdoors. In our country, we tend to have picnics primarily in the summer. This poses some risk, since in summer temperatures, food borne illness is more common. Here are some tips to avoid problems: 

Pack safely: 

• Include materials to clean hands, with soap and water, sanitizer or wipes. 
• Pack ice, clean utensils, plates, leftover containers, paper towels and trash bags. 
• Pack cool food with ice packs to stay below 40 degrees. Open infrequently. Pack drinks in a separate cold cooler, since this drink cooler will be opened frequently. 
• Carry coolers in an air conditioned car, not the trunk. 
• If hot food is precooked, do not delay before finishing cooking on the grill. Any time lapse in-between is an invitation for bacterial growth. 
• Cook hamburger and other meats to 160 degrees, and chicken to 165 degrees. 
• Prevent cross contamination with drippings or marinades. 
• Do not reuse marinades. 
• Don’t serve on your prep platter.
• Discard food if left out more than an hour at 90 degrees. 

Pack creatively: 

Consider some alternatives to traditional cuisine. 

Classic American picnic foods, as for Fourth of July 

• fried chicken
• hot dogs
• macaroni, egg or potato salad
• corn on the cob
• iced tea, lemonade
• apple pie 

French picnic foods, as for Bastille Day 

• Baguettes and baguette sandwiches
• pate foie de gras or tapenade 
• Salade Nicoise 
• Perrier Sparkling water 
• macarons
• mousse or pots de creme

Italian picnic food: 

• salads: pasta, caprese, arugula
• bruschetta with toast
• limoncello soda 
• layered torta or pizza 
• salami, ricotta, fresh fruit 

Swedish picnic food for Midsummer celebration:

• grilled marinated lamb
• Gravlax
• pickled herring with sauces 
• seeded crispbread
• cheesecake with berries 

If you don’t recognize the dishes, google them or search on Pinterest. You have some pleasant culinary surprises in store for you. 

References: 

Chow.com

Food Timeline 

Pamphlet: Pack a Family Picnic

Foodsafety.gov

Home Food Safety 

FDA

Medical Monday: Are there really any low risk pregnancies ?

In today's post I report on some recently presented work which questions the validity of classifying pregnant women into either low risk or high risk groups. 

These categories have been important to women and their caregivers since they have used the information to determine the most appropriate site for delivery, from freestanding birth center, to community hospital to university medical center. 

But while Obstetricians have gone along with the use of the category " low risk", we know from anecdotal experience that ANY patient can unexpectedly have complications with out any warning or risk factors. A cross sectional investigation published in the American Journal of Obstetrics and Gynecology, February 7th, 2015, has shown us in precise numerical terms just how often this happens. 

Please note that in this study, those with no prenatal risk factors were classified as low risk. Those with one or more risk factors were classified as high risk. 

Here are their results: 

Of 10,458,616 pregnancies analyzed, 38% were identified as low risk, and 62 % as high risk. 

It turns out that 29% of those classified as low risk had unexpected complications. 

It is not surprising that high risk pregnancies had complications. It turns out that 57% percent of them did. However, 29%, almost a third of the low risk patients had complications. For certain outcomes, like use of vacuum, forceps, meconium and infection, so called low risk pregnancies had a higher incidence than those in the high risk group. 

If you look at all pregnancies and add the 62% who are high risk to begin with and the 29 % of the remaining low risk 38% group who ended up having complications despite their low risk designation, it adds up to 73% of the total group. 

So, according to this large study, 73% of all pregnant women can either be classified as high risk from the get go, or are low risk and going to have a complication. This 73% of all pregnant women are those that belong in the care of Obstetricians or Certified Nurse Midwives working in the hospital under the care of Obstetricians.

Here's the problem. While we can select out those in the high risk group for higher level hospital care, it is not so easy with those classified as low risk. When we consider the low risk group, who are over the third of the whole group, we know about a third of them will have complications. WE JUST DONT KNOW WHICH WOMEN THEY WILL BE. That is the problem. That is why, in my mind, all women deserve access to a high level of care in a congenial but fully equipped setting...the hospital. 

It is imperative that birth be congenial but even more critical that it be safe... 100% of the time. To achieve both does not require taking birth out of the hospital realm, instead it means transforming the hospital birth environment to be all that it needs to be.. comfortable, accommodating, beautiful, as well as fully equipped for any medical or surgical contingency. 

Here is the link to this current research: 

http://www.ajog.org/article/S0002-9378(15)00268-9/fulltext

Food Friday: Healthy Barbecue, Grilling, and Picnics.

Everybody loves to play with fire, especially people who like good food and who don't want to be stuck in a hot kitchen in the summertime. 

Check out this comprehensive list of tips for barbecue, grilling and picnics and you will be the smartest flamethrower on the block. 

Grilling: 

• 7000 people each year suffer grilling injuries. 
• Read your grill's owner's manual. 
• Use propane and charcoal grills outside only.
• Use in a well ventilated area, away from combustible material and at least ten feet from a structure. 
• Ensure the grill is stable. 
• Do not move a hot grill. 
• Have long handled cooking utensils.
• Have fire extinguisher, baking soda, a bucket of sand, or water handy. 
• For propane grills, check fittings to make sure they're tight. Check propane hose for gas leaks by applying soapy water and checking for bubbles. 
• Never turn on a gas grill with the lid closed or you will risk explosion ! 
• For charcoal grills, use a chimney or electric starter. Never add lighter fluid to a flame. 
• Dispose of cool coals in a metal container. 
• Keep younger children away from the grill. 
• Never leave a grill unattended. 

Food Handling: 

• Buy cold foods like meat and poultry last, when you are about to head for home. Bag them so liquids cannot contaminate other foods that will not be cooked. 
• Wash hands with soap before handling food, and keep surfaces and utensils clean. 
• Thaw in the refrigerator or the microwave NOT the counter. 
• Keep raw food separate from cooked food. 
• Marinate in the fridge, not on the counter. Poultry and cubed meat may marinate only 2d, other types 5 days. 
• Trim fat to minimize hazardous flares and unhealthy charring. 
• Consider precooking to shorten grilling times. 
• Consider buying a food thermometer. They're inexpensive. 
• Cook food thoroughly. 

Poultry 165 degrees

Ground red meat 160 degrees

Beef pork lamb and veal 145 degrees, and allow to rest three minutes. 

Reheat cooked meat like hot dogs to 165 degrees. 

• Keep cold food cold and hot food hot. 
• Don't let cooked foods sit out more than an hour if the temperature is greater than 90 degrees. 
• Discard food left out more than 2 hours. 

Healthy Grilling recipes: 

Cooking Light 

Food Network

Eating Well

Fitness Magazine

Food and Wine 

Health

ENJOY ! 

References:

FDA Barbecue Basics

UDSA on food safety

National Fire Protection Safety Association 

Wellness Wednesday: Weathering the heat

Do you know how hot you are ? Do you even know how hot is too hot ? Find out here before things get too hot to handle. 

One of the body's main tasks is to maintain a constant internal temperature. Our physiologic functions depend on it. There may be fairly wide fluctuations in our external temperature, but our core temperature must stay quite steady, near 98.6 degrees F. If it does not, we can suffer heat exhaustion and heat stroke.  Per Outside Magazine (reference)" On average, nearly 700 people die each year from extreme heat. ". 

When are people at risk ? 

• During heat index of 90 degrees or more 
• During relative humidity of 60% or more 
• When working in contact with hot objects, or wearing bulky protective clothing 
• When in places of direct sun with little air movement 
• When they are very young, very old or unhealthy

Heat exhaustion

• Caused by loss of body water through excessive sweating
• Symptoms of heavy sweating, weakness dizziness, visual disturbances, thirst, vomiting, diarrhea, shortness of breath, palpitations, tingling of hands and feet and collapse
• Treatment- cool and hydrate the person by any means possible as quickly as possible

Heat stroke

• Results when the body can no longer cool itself though sweating or other means and the core temperature rises to 104 or higher. 
• Symptoms are confusion, agitation, irritability, seizures, coma and brain and other organ damage. 
• Heat stroke victims usually do not recognize their own symptoms. 
• Skin will be dry if heat stroke is caused by hot weather, but moist if caused by vigorous exercise. 
• Skin is flushed, breathing is rapid and shallow. 
• Heat stroke comes on quickly.
• If heat stroke is suspected, it is imperative to call 911 to get immediate medical attention
• Treatment- Cool and hydrate the person by any means possible as quickly as possible while waiting for the ambulance. 

Engineer shade, breaks and ample hydration into your summer activities to keep everyone safe and comfortable in the heat. 

References: 

http://www.mayoclinic.org/diseases-conditions/heat-stroke/basics/definition/con-20032814

http://www.webmd.com/a-to-z-guides/heat-stroke-symptoms-and-treatment

https://www.osha.gov/SLTC/heatstress/

Wellness Wednesday: Workplace Bullying

All the data I could find indicates that the vast majority of people, have at one time or another, experienced workplace bullying. As I have become a more careful observer of the years, I have learned to ask my patients questions about their work environment. 

What are the tip offs? When I notice increasing blood pressure, more frequent illnesses, less self confidence, more digestive problems, and hear about increasing stress, depression, anxiety and work problems, I suspect workplace bullying. 

When I ask about work, and get into the particular details, I often hear about a situation which would qualify as workplace bullying. But the surprise is this: Much of the time, the patient doesn't even realize that bullying is what is going on. 

What is bullying ? 

Workplace bullying is a systematic pattern of behavior that harms, intimidates, shames, undermines, offends, degrades or humiliates an employee, possibly in front of other employees, clients or customers. It is an abuse of power and a form of emotional abuse. It is a threat to health, livelihood and relationships. 

Once a patient realizes what it is, and a name has been put to it, she can begin to take steps to deal with it. But bullying is a complex human behavior and it is challenging to counteract. It is best to get outside help to deal with it. Most of the time it involves not only the one bully, but an overall workplace environment that is permissive of it. This is because it is difficult for bystanders to call out the bully, lest they become a target themselves. It is also difficult since bullies are generally highly ranking in organizations. Targets often fear for their jobs. Employers, when informed, are in a hard place, since they have not usually witnessed the behavior and moreover, they have an interest in keeping their more highly ranked employees. 

Nonetheless, bullying takes a toll on people and organizations. While bullies are more highly ranked, targets are often up and coming, and they pose a threat or perceived threat to the bully. Targets are often very productive likable workers. Organizations with bullies often start losing their best people. 

As a physician it is very important to me that my patients know about workplace bullying. I would like all of them to be in supportive home and work environments. Failing that, I would like them to have the tools to speak up against this form of abuse, whether it is done to them or to their co-workers. 

The references in this blog post are especially informative. Please take a few minutes to have a look at the resources on this very important topic. 

Stop Workplace Bullying 

Workplace Bullying 

What Workplace Bullying Looks Like in 2014--And How To Intervene

Workplace Bullying Institute