Food Friday: Campfire Cooking

Summer is in full swing and this is the weekend to be out by a campfire. That is because the weather is fine, the nights are mild and the Perseid meteor shower is coming. 

Cooking on a fire is truly gratifying from a five senses point of view. The crackling fire is beautiful, the smell is delicious and the taste is unmatched in the kitchen.

It is hard not to be relaxed by a fire. You just can’t rush it. If you try, you’ll literally get you or your food burned. 

Those unfamiliar with fire making need to start by checking their local agencies regarding fire regulations. These my vary by your season and location. You may need to go to a public park or a campground. Or you may need to use a barbecue. Whatever you do, keep it simple and friendly, since that is part of the charm. If possible, give each person some hands on responsibility for their food. 

How is food on the fire cooked ? Well for starters, the same rules of food safety apply over a fire. Keep cold food cold and hot food hot. Check the link below for more details on that. Meanwhile, consider all the ways you can cook over a fire: 

• Food goes on skewers and is set on a grill.
• Food goes directly on a grill. 
• Food is placed on skewers and held over the fire.
• Food is cooked in a pan on a grill. 
• Food is cooked in a Dutch Oven in coals. 
• Food is cooked in foil packets or in its own skin in coals. 

However you cook it, the same rules of safe cooking apply. You must ensure fire safety and food safety. Make sure you have a source of water and that you are not at risk of losing control of your fire. Make sure you have all the right tools so that you will not be tempted to use your hands and burn yourself. Regarding food safety, you must stack the deck in your favor to make sure all foods are thoroughly cooked and yet not burned. Some of you will recall that black char contains unhealthy chemicals. More on that in the link below.

http://drginanelson.com/drginablogs/2015/6/11/food-friday-healthy-barbecue-grilling-and-picnics?rq=barbecue

How can this be accomplished ? 

• Precook foods that take a long time. 
• Cut foods into easily cooked piece sizes. 
• Do not mix short and long cooking foods in one packet. 

Here is my modest album of campfire recipes on my Pinterest: 

https://www.pinterest.com/drginanelson/campfire-recipes/

Truthfully, I am not much of a recipe user anymore. Dutch oven recipes are like crock pot recipes but take less time. Foil packets for grilling are pleasing single serving mixes of fruits vegetables and meats cut small and generally marinated with a basic vinaigrette or butter. Grilled food is similar, but more lightly dressed so as not to burn, and placed on a skewer or on a grill directly. Oh and, if Pinterest is any indication, everything is wrapped in some sort of bacon.  Dessert and treats are less familiar to me, although I have made nice s’mores with good chocolate in my day. Even more intriguing are fruits dipped in marshmallow cream or doughs wound onto skewers and roasted directly over the fire, things I have yet to try. 

About the real dessert: the Perseids are an annual meteor shower, my favorite. It is generated as we pass through the tail of the comet Swift -Tuttle. The shower comes out of the northeast, and as the name suggests, out of the sky in the region of the constellation Perseus. If you are not familiar with the night sky, I recommend getting an app to help. I have had several such apps, but right now am using SkySafari, the cheap version. With it, you can point your screen of your device ( phone or tablet) at the sky and see the same segment of virtual sky, but WITH LABELS ! This year the Perseid forecast is for 200 meteors per hour, which is at least twice the typical average. This is because, this year earth orbit is nearer to the center of the comet tail than usual. 

So take advantage of this good fortune and check out the beauty of the summer sky. And get back to the primitive pleasure of sitting around the fire with friends and family to eat good food and relax. 

Wellness Wednesday: Exercise Specs

Today’s post will keep it simple, portraying just a few simple keys to successful exercise. With the books, shows and classes out there, it is easy to get confused about what you need to do to start getting fit. My simple reminders will hopefully bring it down to earth and help you get started or stay consistent with your exercise regimen. 

Accept your present state.

Back in the day, in some challenging yoga classes, I was, at once, encouraged to master harder and harder poses, but, somewhat paradoxically, I was taught be “ be where I am”. This mean I had to be real about what I could actually do properly at the present moment. I was not to fight or strain my way into a new pose. I was to practice as best I could until it came naturally. This was a very hard concept to grasp. 

At the same time, I want you to embark on exercise in a spirit of happy acceptance. Whatever you do is a plus. You should not make it hard, or certainly not painful. When beginning, it should just feel like mild exhilaration. It should not exhaust you. You are just letting your body and brain get used to the movements and the routine. It takes months to adjust. You will advance in intensity when you want to. You will want to when you are ready. 

Start easy and short.

Research I mentioned on this last Medical Monday indicated that 2.5 hours of moderate exercise a week has measurable effects on heart disease risk in women. This translates into 25 minutes a day 6 days a week. It is true that some fit people exercise for longer for fewer days per week. However I prefer beginners and the inconsistent to workout for less time more frequently since it reinforces the habit more effectively. 

Value initiation over endurance.

Woody Allen once side that 80% of life is showing up. This is certainly true of exercise. You can make things easier on yourself by observing a fairly steady routine. Remember Mr. Rogers ? On his TV program he would arrive home from work and immediately change from his work jacket to his house sweater, thereby prompting him to shift gears and relax. Me, I change into workout gear and somehow there is no going back. Next I get the glass of water, and off I go. Get yourself to start, and you will finish. 

 

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Take one break day per week.

Exercise is to transform your body so that it is healthier, more efficient, stronger and more functional. So give it some time to transform. Never skip your break day. And if you are feeling wiped out, take an extra break day or just choose a milder workout. Having said that, ordinary everyday fatigue should not prevent you from working out. Your exercise will actually help your fatigue, ten times out of ten. If you are feeling overly fatigued after what feels like a mild workout, check in with your doctor. Additionally you should make sure you are giving your body adequate hydration and nutritional support to transform. 

Stay tuned next week for more Wellness Wednesday tips.  

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

The news this week is dominated by virus science.

The first United States baby with Zika related microcephaly has been born in New York City. While this is not surprising, the fact that many women are ignoring Zika related travel warnings is. This summer, over 2000 pregnant women traveled to Zika affected areas and have com back requesting testing. In many cases, they are traveling to the Dominican Republic. AS f the present, cases from the Dominican Republic account for more than a fifth of all US cases. The CDC(Centers fro Disesase Control) and the American Academy of Pediatrics are grappling with how to develop protocols to care for infants who will be born with microcephaly. These infants have serious mental and physical disabilities since the higher portions of the brain are underdeveloped. 

Florida is one of the most vulnerable states in the Union to the Zika virus. Authorities estimates over a quarter of a million women are at risk in Florida. Various research indicates that a Medicaid expansion there would help reduce the risk of pregnancy women to Zika. There is also a push to require employers to take measures to limit their pregnant employees exposure to mosquitos. 

As of mid July the CDC is tracking around 1300 cases of pregnant women with Zika. Fourteen were sexually transmitted, and the rest acquired through travel. 

There is also a Utah case on record this week of a man who acquired Zika through close family contact. He was taking care of an elderly man who had acquired Zika due to travel. 

Hepatitis C is on the rise, both in women of reproductive age, and not surprisingly, in their children under 2. There is no vaccine yet for Hepatitis C, but very recently, a very good treatment has been released. 

In other viral news, work has been done showing that certain vaginal flora (Prevotella BIVIA) make it easier to transmit HIV. However, a silicone ring imbued with antiviral drug may help reduce the risk of transmission. Pregnant women with HIV have now been shown to do better if their therapy is continued postpartum. 

Finally, in some other good news pertaining to viruses, the American Cancer Society has endorse the vaccination of all preteens, boys and girls against HPV (Human papilloma virus.). 

Say tuned for more riveting news from the word of Ob/Gyn next week on Medical Monday. 

Food Fridays: Summer Eating Digest

Summer cooking and eating is a special case. Here is a handy review post for you to access all of your summer tips I have written so far in one convenient place. Some are for safety, and some are for taste. You’ll be glad you looked at this quick review. Click on the links to see more. 

The Picnic Post:

http://drginanelson.com/drginablogs/2015/6/26/food-friday-picnics?rq=food%20safety

This has the most explicit information on food safety in the site, plus some helpful links. 

The Healthy Barbecue Post:

This is right on time for your next outing. There’s a fair amount here about how not to burn the house down or end up in the emergency room. 

http://drginanelson.com/drginablogs/2015/6/11/food-friday-healthy-barbecue-grilling-and-picnics?rq=barbecue

The Summer Drinks Post:

 You not find beer or sugary soda in this eclectic list. 

http://drginanelson.com/drginablogs/2015/7/10/food-friday-drink-?rq=cold%20drinks

The Cold Food Post:

This is a recent post here in case you missed it: 

http://drginanelson.com/drginablogs/2016/7/1/food-friday-hot-weather-cold-food?rq=cold%20food

The Salsa Post:

This is one of my favorite older posts I really enjoyed making: 

http://drginanelson.com/drginablogs/2015/9/10/food-friday-the-healthy-junk-food?rq=salsa

The Cold Dessert Post:

http://drginanelson.com/drginablogs/2015/8/28/food-friday-cold-desserts?rq=cold%20desserts

Anybody hungry yet ?

( My apologies to those in the Southern hemisphere who are in the middle of their winter.) 

Wellness Wednesday: Sleep Hygiene with Sketches

It is summer in the far north and the days are long...so long they stretch into the night. Farmers work until 11 pm and dinner is at about 9pm in broad daylight. Then the evening comes, and by 11 pm you feel the evening is just getting started. A movie is chosen and whoops, you are up way too late, especially since the sun comes blazing in shortly after 5:30am. 

So I though I would take this opportunity to share with you some sketches I did for my wellness reminder cards that pertained to the importance of good sleep hygiene. Each card will hopefully remind the user of a key principle, with the image on one side, and the reminder on the other. 

1. Adequate Restorative Sleep 

With few exceptions, adults need 7-8 hours of sleep. You should wake, almost spontaneously, and feel rested. That is the meaning of restorative sleep. 

2. Consistent Wake Time

Having a consistent wake time actually helps you fall asleep properly at bedtime. 

3. Consistent Sleep Time

Once you get in a routine, you will start to get sleepy at the right time. 

4. Correct Sleep Environment

The room should be dark, quiet and cool, without electronics or snoring people. 

5. Medical Evaluation of Necessary

Most major hospitals have a Sleep Center or Department of Sleep Medicine. There is now the recognition that sleep health underscores all health. Rigorous studies can be done to assess sleep problems, and treatments are available. 

To learn more see our webpage on sleep HERE. 

Next week on wellness Wednesday we will continue with more wellness reminders. 

Nighty Night !

Wellness Wednesday: Healthy Habit Formation

Healthy habits are the basis of peak wellness. Heathy habits are something we can develop. Whether the healthy habit is taking vitamins, being grateful, exercising, or eating fiber, the practice only works if it is done over and over for extended periods of time. This repetition is achieved through habit formation. 

What does science say about how habits are developed ? 

The brain is designed to form habits.  New behaviors or tasks can be challenging. Over time, the brain “chunks” small possibly difficult behaviors into automatic routines which becomes easy or even effortless. This is a habit. Habits are adaptive and have helped us survive. Habit formation is our brain’s way of automating certain key behaviors, so more conscious attention can be paid to novel situations.  If we understand how this works we can form new habits at will. 

What do we need to form new habits ? 

In simple terms there are three steps: 

1. Cue
2. Routine
3. Reward

This is called a habit loop. These are well explained in Charle’s Duhigg’s book "The Power of Habit”.  The cue triggers the routine, and the routine triggers anticipation of the reward. For example, my exercise routine is cued by changing into exercise clothes. From there, I go downstairs to workout, and the reward is the endorphins and the satisfaction. There is no doubt that at first, it is hard to link the steps. But it becomes easier with each cycle. To be realistic, it takes somewhere between 6 weeks and 3 months to form a new habit. 

What about bad habits ? They too have cues, routines and rewards. Basically, they have to be understood in terms of their rewards, namely, what you get out of it. In many cases, smokers smoke to get a moment of peace in a busy day. This is obviously legitimate. However, the cigarette is unhealthy and chemically addictive in addition to being behaviorally addictive. It turns out we should not exactly delete bad habits since this leaves a void. Instead we are better off to overwrite them with good ones. To illustrate, a smoker could use patches to wean down on the addictive nicotine, while overwriting her smoking habit with a healthful tea drinking habit. Perhaps to make it more engaging, she would brew the tea from loose leaves. Her reward would be the moment of peace, the taste, smell, and mental clarity that followed. 

My subject in this post are the cues. In simple terms, they are reminders of health habits. I decided to expand my set of reminder cards to include not only the subject of nutrition, but also the subjects of sleep, exercise, communication, and creativity. I believe these are some of the elements in total peak wellness. Here are my cue phrases so far. 

Sleep 

The Power of Habit: Why We Do What We Do in Life and Business

$9.18

By Charles Duhigg

Buy on Amazon

•      Adequate restorative sleep 
•      Consistent wake time 
•      Consistent sleep time 
•      Correct sleep environment 
•      Medical evaluation if necessary 

     Exercise 

•      Start easy and short 
•      Warm up
•      Cool down 
•      Value initiation over endurance 
•      Good gear 
•      Eat for exercise 
•      Hydrate for exercise 
•      Tunes for exercise 
•      Podcasts for exercise 
•      Exercise daily 
•      One break day per week 
•      Stretch after exercise 
•      Buddy exercise 
•      Track your exercise 
•      Explore HIT 
•      Include yoga 
•      Mix it up 
•      Use good form 
•      Consult professionals 

Creativity 

•      Get inspired through people travel and media 
•      Find your styles 
•      Express creativity in your personal space 
•      Make a space for your creativity
•      Take time for hobbies 
•      Take time for Travel
•      Take time for recreational reading 
•      Pick a hobby and learn it well
•      Share your creative work

Work 

•      Always work
•      Honor work in and out of the home 
•      Chose meaningful work 
•      Become expert at your work
•      Give work boundaries in time, space, and thought
•      Do you best at work 
•      Communicate effectively at work
•      Reach out often at work
•      Play as a team 
•      Ask for appropriate compensation

Communication 

•      Breathe and think before speaking 
•      Use Honesty 
•      Use courtesy
•      I statements
•      Precision of speech
•      Closed loop communication
•      Listen more than speak 
•      Listen actively
•      Repeat back clarification 
•      Acknowledge others’ point of view
•      Build common ground

You can find nutrition reminders HERE discussed in a prior post. I plan to devote a few wellness Wednesday’s to the development of these reminders or cues. 

For more reading : 

http://jamesclear.com/three-steps-habit-change

https://www.psychologytoday.com/basics/habit-formation

https://www.sciencedaily.com/releases/2014/08/140808111931.htm

http://www.scientificamerican.com/article/power-of-habit-excerpt/

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

Women in Latin American are more likely to get Zika than men. We presume they are exposed equally to Zika carrying mosquitos. This difference appears once girls become sexually active. How do you put it together ? Here is what doctors and researchers think. They believe sex may spread Zika more than was previously believed. Furthermore, getting Zika though sex is easier for a woman than for a man. Other sexually transmitted infections follow this pattern and in their case, it is because sex in women causes undetected micro abrasions which allow greater access to the bloodstream. 

President Obama has come out and said that Congress should not recess for summer until Zika funding is secured. With this funding, a vaccine will be produced sooner. Some speculate that the issue of Zika calls to mind issues of contraception and abortion, and that is why Congress is unable to deal effectively with it. Zika is bringing reproductive rights into focus. ACOG ( American College of Obstetricians and Gynecologists) representatives have noted that the southern states likely to have the most Zika are the same ones which have high unintended pregnancy rates and poor access to family planning resources. But Texas is taking a different angle anyway. They are trying to scratch up enough funds on its own to provide mosquito repellant to it’s poor women, budgeting 2 bottles per month per women.  

In other news, US maternal mortality rates have doubled in the last 25 years. Black women fare the worst, with mortality rates quadruple that of white women. 

The president of ACOG has come out stating that we should have a much more critical attitude toward chemicals in the environment which may cause birth defects. Project TENDR has been created from a variety of expert disciplines to advocate for greater government oversight on the chemicals. TENDR stands for Targeting Environmental Neurodevelopmental Risks. 

Newborns get about two months of flu protections from a shot given to mom during pregnancy. 

Despite the demonstrates efficacy of the HPV vaccine, it is still woefully underutilized. Moreover, HPV related cancers are on the rise. Between 2008 and 2012, they have increased about  17 %. HPV cancers are not just cervical cancer in women. They also include head and neck cancers in both men and women. 

Finally, in the good news department, an eight study meta-analysis out of Europe has shown that obese infertile women who have trouble ovulating do better with lifestyle intervention than fertility drugs. Six months of interventions resulting in weight loss were four times more likely to conceive than their counterparts who used fertility drugs alone.  

Wellness Wednesday: Summer Safety Kit

Here is a convenient comprehensive kit to keep you safe this summer. It recaps some posts from the recent and more distant past, all in one convenient place and on the theme of having a safe and happy summer. 

Reclaim your Summer

This deals with the importance of time off and the concept of summer vacation for adults. 

Weathering the Heat

Contains some amazing facts and figures about heat stroke.

Five Steps to Mosquito Protection

This is especially important to review in this season of the Zika Virus.

Wellness While Gardening

Tells of the little known perils of playing in the dirt. 

Hydration 101

This critical post has concrete information to help you stay out of trouble this summer. 

Stay tuned for next week on Wellness Wednesday, when we will talk about the Summer of the Mind.  

Medical MondayL Breaking News from the World of Obstetrics and Gynecology

In Zika news, it has become clear that we do not yet know the length of time that Zika stays in the reproductive tract of a man. Thus, we do not now how long he may be able to transmit it sexually. 

In a recent poll, 73% of Americans feel Congress should pass the funding to fight the Zika virus as recommended by the Obama administration. However, reflecting a poor grasp of the situation, only 46% feel they need to pass it immediately. 

In the we already knew this department, ACOG ( American College of Obstetricians and Gynecologists) has issued new evidence based guidelines to help prevent perineal lacerations. These include using episiotomy selectively, and well as using warm compresses before birth. 

SCOTUS ( Supreme Court of the United States) has struck down a restrictive Texas abortion law. This law would have required that abortions be provided at an ambulatory surgical center by a physician with hospital privileges. There is no scientific data saying that either of these elements is necessary for safety of the procedure, which is normally done in an office by a midlevel provider such as a nurse practitioner. Many abortion clinics would have had to close had this law stayed o the books. The Court ruled by a 5-3 vote largely along gender lines that these laws placed an undue burden to women seeking legal forms of health care. 

In other SCOTUS news, the Court has refused to hear a legal challenge to the Washington State rule that pharmacies must deliver all prescribed medications, even emergency contraception. This ends a nine year legal battle in which some pharmacists and a pharmacy refused to stock or fill the morning after pills. The Court voted 5 to 3 not to accept the case. Four Justices must agree to accept a case if it is to be heard. 

In the pendulum swings department, there are two items. First, Obs are giving serious consideration to the optimal time for delivery. In the past, 42 weeks was considered a reasonable time for induction. In my tenure, this has become 41 weeks. Now 39 weeks is under consideration. 

Secondly, women with a statistical risk of ovary cancer of 4% or more who is over 40 may be better off with her ovaries and tubes removed. When I finished residency in 1994, we encouraged women facing a hysterectomy to have the ovaries out as well if they were over 45. In recent years, this has become more of a patient choice. Now, we are refining this judgment to include family history and other risk factors in a statistical model to determine the best course, and it may favor removal of the ovaries earlier than previously recommended. 

Once again the USPTF (US Preventive Services Task Force) has cited the lack of evidence supporting the annual pelvic exam, and how it should be done only when symptoms are present. And yet, when examining their published statements, one sees that they do not highlight the fact that there has been nothing done to prove or disprove the utility of the exam either way. This is because doctors the world over have taken it as common sense to do the exam, thus no study has been done. The public should know that saying that there is no proof that something is not useful is NOT the same as saying that something has been proven TO BE not useful. Personally I find important things every week if not every day I do a pelvic exam, and that includes both speculum and bimanual exams. Furthermore, nobody is traumatized by their exam. Children and those with disabilities who need exams and who might be traumatized are examined with the aid of anesthesia supervision. 

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

Wellness Wednesday: Hydration 101

Summer has finally arrived in the northern hemisphere.

Our part of the planet is pointed much more directly at the sun and you can feel it. Sun protection and hydration become critical. Last Wednesday we covered mosquito protection and this week we will recap hydration. 

A July post from last year has some facts that bear repeating: 

• 2 Liters = the amount of fluid a non pregnant woman needs per day
• 3 Liters= the amount of fluid a pregnant woman needs per day
• Add 1 Liter for temps over 85 degrees
• Add 1 more Liter for activity like hiking. 

So… the fluid requirement for a pregnant woman hiking on a hot day is 5 Liters !!! 

And to recap…

Consider a woman weighing 154#=70kg

• 60% of the body=water =42 kg or 4.2 Liters for our 70 kg woman
• 1% loss of fluid = 42 ml impairs thermoregulation and causes thirst. 
• 2% loss of fluid - discomfort and loss of appetite 
• 3% loss of fluid - dry mouth appear
• 4% loss of fluid- work capacity decreased 
• 5% loss of fluid- reduced concentration, headache, and sleeping 
• 6% loss of fluid-tingling and numbness of extremities 
• 7% loss of fluid-collapse 

Taken from the World Health Association (WHO) website 

Hydration does a number of great things

Firstly, it protects you from harms: 

• Urinary tract infection
• Kidney Stones 
• Preterm labor 
• Headache 
• Helps prevent heat stroke 

see Weathering the Heat 

Finally, hydration makes you feel good and look good. 

It’s fun to get creative with your healthy drinks.

Break out of the old routine of sodas and beer which do nothing but dehydrate and put fat on the belly. 

Try these instead : 

• Plain Club Soda with a little splash of 100% fruit juice and twists of citrus 
• Mocktails like a Virgin Mary or a not so sweet Virgin Daquiri
• Herbal iced tea or Sun tea, sweetened with a little fruit juice 
• Healthier frappes made with ice, one pump of chocolate, and your milk of choice 
• Green smoothies 

Drinking a tall cold glass of something healthy and fun is good for you both physically and mentally. It gives you a little creative outlet, and a chance to sit down and take a micro break. 

Be sure to catch all of our blog posts at 

www.drginanelson.com/drginablogs  

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

Good Monday. This week the news is again dominated by the specter of Zika. I reported earlier that the Puerto Rican chapter of ACOG (American College of Obstetricians and Gynecologists)  is working hard to deliver donated contraceptives to women in this vulnerable population. However, IUDS are not common there due to cost, and as a result, few doctors know how to insert them. Approximately 60,000 IUDS and 80,000 packs of birth control pill packs have been donated by Bayer, Allergen and Medicines 360. The donor companies have also started training physicians to use and presumably teach the use of IUDS. However, their dispensation is held up since the CDC has yet to line up a licensed distributor in Puerto Rico.

This sounds like a problem that can be solved. IUDs are not that hard to put in. I cannot help but think that telemedicine, i.e. videoconferencing, could not help train doctors to put in IUDs. By some accounts there are about 150 Ob/Gyns in Puerto Rico, and about 138,000 women there who are vulnerable to pregnancy.

A little more Googling on my part indicated that the Puerto Rico Obstetrics and Gynecology is holding a “ Sunshine Seminar”  August 4-7 this year at the Wyndham Grande Rio Mar Beach Resort and Spa. Really ? Instead of studying morcellators and bioidentical hormones, maybe conference attendees should put some gloves on and start seeing as many patients as they can. 

I am going to contact the chair of the Department of Obstetrics and Gynecology Dr. Sharee Umpierre at the University of Puerto Rico and see what she has to say about the situation. 

The New England Journal of Medicine reports an increase in abortion medication in Zika affected South American countries. 

In some good news, the FDA has given the go ahead on human clinical trials on a Zika vaccine known as GLS-5700. The safety and immune response will be studied in about 40 subjects. Thank you very much you brave souls. 

In more good news, the NIH ( National Institute of Health) have started a massive study on Zika in affected countries. 

The House has approved $1.1 B to fight Zika. This would come from $750M in savings, $107M unused Ebola funds, $100M in cuts to the Department of Health and Human Services (Medicaid and Medicare) and $534M from Obamacare in the US territories. This does not add up. And, it will not pass the Senate or the President’s Desk. 

Ten cases of Zika were confirmed in Dallas County, Texas as of Friday. So it begins. 

In other breaking research news, there is quite a bit of what we already knew or suspected: Cranberry juice may help prevent UTI (urinary tract infection). Physical inactivity increases risk of ovary cancer and healthy lifestyle reduces cancer risk. Leading oncologists push for greater use of the HPV (Human Papilloma Virus) vaccine. Healthcare is more affordable since Obamacare. Age of puberty for girls is going down. Soy isoflavones reduces menopause symptoms. Women who work long hours face more chronic disease. 

Why are studies done on matters that already seem established ? One reason is that prior studies may have been done to get a rough indication of a cause or pattern. Later, better designed studies can establish something closer to proof. However, some of these things are just common sense. If we took full advantage of the knowledge we already have and actually put it into clinical use with our patients, there would be so much more health and so much less disease. Case in point: HPV vaccines usage. 

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

Wellness Wednesday: Five Steps to Mosquito Protection

Mosquito season is here. This has taken on a critical importance in many states in the south and eastern parts of the United States and in all of Central and South America. This is because mosquitos can carry, among other things, the Zika virus, which has been shown to produce serious brain damage in the unborn, and potentially serious disease in adults. Mosquitos also carry other serious diseases, including some which affect dogs and horses. Examples include West Nile virus, Heartworm, Dengue fever, Malaria, and even Ebola.  It is high time to discuss mosquito bite prevention. 

First one must note that mosquitos need standing water to reproduce, and even a tiny amount will do. Natural bodies of water such as ponds, puddles, and sloughs can breed mosquitos. Manmade water collections such as buckets, tarps which have collected rainwater, birdbaths and the like will provide very suitable breeding ground as well. 

Step One:

Eliminate standing water around your home. Get rid of any debris in your yard or patio (e.g. toys, wheelbarrows, pots etc.) which could harbor mosquito larvae. Change the water in your birdbaths at least once per week. Fill in any low spots in the yard. 

For larger bodies of water such as a pond or fountain, purchase “ Mosquito Bits “ or “Mosquito Dunks”. These are pellets or pucks of biological agents which interfere with mosquito reproduction. Once example is Bacillus Thuringiensis, which does not harm the environment. 

Step two: 

Install replace or repair your screens. You will want to enjoy the summer breeze without worrying about the mosquitos. 

Step three: 

Invest in some lightweight cool summer clothes. White gauze shirts with long skirts or lightweight palazzo pants are a pretty option. Most outdoor clothing companies such as North Face or Patagonia offer mosquito resistant shirt which are also usually sun protective as well. 

Step four: 

Buy some DEET based mosquito repellant. This is the only mosquito repellant which has been proven to work. Moreover, it has been shown to be safe in pregnancy. Use your insect repellent correctly. 

• Read the instructions and precautions of your product. 
• Only use on exposed skin and clothing. 
• Do not use near eyes and mouth.
• Apply to face by spraying hands or cloth, the wiping on. 
• Never use on injured skin. 
• Do not breathe it. 
• Do not use near food. 
• Do not use it on animals. 
• Keep out of reach of children. 
• Do not apply to children’s hands. 
• When returning indoors, wash treated skin and clothes with soap and water. 

Step five: 

Stay indoors during the twilight hours when mosquitos are most active. 

Stay tuned next week for more summer health tips on Wellness Wednesday. 

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

The CDC( Centers for Disease Control has revealed that there are 6 cases of Zika related birth defects in the mainland US. These  are those that have delivered so far. Overall, there are 234 cases of confirmed Zika in pregnancy women in the US. All of these Zika infections were acquired elsewhere and brought here. Accordingly, New York has the most cases of Zikaa in the US, being a port of entry. So far there have been no cases of Zika infections transmitted by mosquitos in the US, though Aedes mosquitos are due to being bitting in the Southern states this week. 

Another preliminary study has come out suggesting that contracting Zika later in pregnancy confers less risk of perinatal malformations. This study was done in Columbia where there are over 12000 pregnant women who have the virus. It is interesting to note that about 80% of Zika infections are asymptomatic. These asymptomatic cases cause microcephaly all the same. 

The WHO (World Health Organization) has come out stating that there is little risk that the Olympics will case Zika to spread around the world. I personally question this, but hope they are correct. 

In other news, California Governor Jerry Brown has signed a bill potentially allowing illegal immigrants to buy insurance coverage on the state’s exchange. This seemingly radical idea is interesting to consider, since these people do come in for care. Without this coverage this care goes unreimbursed but still costs the taxpayer money. With the coverage, these people would presumably come in for preventive care or at least for earlier treatment which would mean a savings in both money and human suffering. 

A study released this last week predicts that if the next president repeals the ACA (Affordable Care Act) the  24 million Americans will lose health insurance coverage. Most doctors feel this would cost us more than the insurance in the long run. Speaking of the ACA, premiums may rise as much as 10% next year. 

CMS(Center for Medicaid Services) has adopted a policy encouraging the use of LARCs (Long Acting Reversible Contraceptives). They have concluding that this is good way to reduce the incidence and cost of unintended pregnancy. An article this week in the Atlantic has highlighted how many communities in the south the so-called “ Bible Belt” discourage discussion of contraceptives, especially IUDs, preferring instead “ abstinence curriculums” .

New research published in Obstetrics and Gynecology has indicated that most websites and apps for fertility are inaccurate in predicting fertility window. Really ? This is not rocket science. 

In the good news department, there may finally be some help to prevent vertical ( mother to child) transmission of Hepatitis B. When Tenofevir is used before birth, infant’s viral load and 7 month infections rates are lower than those who did not get the treatment. 

Stay tuned next week for more news from the world of Obstetrics and Gynecology. And don’t forget…. DEET is safe in pregnancy !! 

Medical Monday: Breaking news From the World of Obstetrics, Gynecology, and Women’s Health

To follow recent tradition, I will give the Zika update first. The WHO (World Health Organization) has reported that the spectrum of neurological damage to babies with Zika is greater than previously appreciated. Microcephaly is certainly the most obvious problem, but others such as spasticity, seizures, and vision problems are possible. 

This week a new method of acquiring the virus was confirmed. An American lab worker working with the Zika virus has contracted it though a needle stick. 

In the US, funding is still not present to fund the fight against the virus. Nonetheless, scientists at the National Institute of Allergy and Infectious Disease (NIAID) are “aggressively pursuing" a vaccine. 

Research is also taking place regarding how to alter the genes of the Zika carrying mosquitos so that they are sterile. Wiping out an entire species through genetic engineering may have unintended consequences. Researchers are examining this important issue. 

Over thirteen hundred cases of Zika are confirmed in Puerto Rico, but there are probably many more including those who are asymptomatic. ACOG (American College of Obstetricians and Gynecologists) is leading the effort to train physicians on the island to place IUDs for contraception. The WHO this week has finally issued a recommendation to women in affected areas to delay pregnancy. 

Both ovary and breast cancer therapies are in the news this week, and the messages are promising. For starters, research presented a the annual meeting of the American Society of Clinical Oncology has highlighted 11 additional genetic mutations associated with increased risk of ovarian cancer. This may ultimately give us expanded opportunities for screening and treatment of this disease. 

On the treatment side, it turns out that a combination of IV and intraperitoneal chemotherapy is more life extending than either therapy alone, for the treatment of ovarian cancer. Also on the treatment side, it turns out that extending anti-cancer hormone therapy such as Tamoxifen for 10 instead of 5 years reduces risk of recurrence or second primary in older women with early stage breast cancer. 

Syphylis cases have more than tripled in the last decade. At the same time, the majority of sexually active women between 15-25 have NOT been screened EVER for any sexually transmitted infections since they do not believe themselves to be at risk.

The CDC ( Centers for Disease Control) has reported the “ the US obesity epidemic continues to worsen”. Fully 40% of US women are obese. Obese is defined as a body mass index (BMI) at or greater than 30. Do you know your BMI ? 

Wellness Wednesday: Summer reminders #1 Sun protection

More than a few ladies came in to clinic this week looking like lobsters. So I write again to give you the perspective your future self would have wanted your present day self to have. 

Sun protection will reduce your cancer risk. It will also protect from general skin deterioration. We have all seen wrinkles, crepe-y skin, blotchy discolored skin, overtanned depigmentation spots and, yes, skin cancer.  

With the advance of medical care, technology and nutrition, we can expect ever increasing lifespans. This means we have to take of our bodies so that they will last even longer than before.

You might ask why skin deteriorates since the actual matter of our skin recycles about every three months. This is a very interesting question whose answer should motivate you to have good sun protection. 

If you injure your skin with a bad sunburn, one so bad that you peel, new healthy skin grows up from beneath. Aren’t you good then ? Well, the new skin is good. However, unbeknownst to you, the DNA of the deeper cells which have generated the layer has been damaged. This DNA damage is what reduces the error correcting ability of the cells over the long term. Error correction ? Aren't cells identical when one divides to two ? Yes and no. They are mostly identical. But over time, imperfections in the cell division occur and errors are generated and build up. Damaged DNA leads to more errors. This is what eventually gives rise to the skin damage listed earlier. 

The DNA is damaged by the uv light, whether it be from the sun, or a tanning booth. Protection is a matter of timing, clothing, and sunscreen. It is also a matter of the correct use of sunscreen. 

To review this critical information, please see the following posts: 

Skin Deep 

On the Virtues of Hats and Sun Protection

Have a sunny week. 

Wellness Wednesday: How to Tell if You’re a Workaholic

Most people say they are busy. But are they ? Americans are famous for being workaholics (fully 25 % of us). How busy is too busy ? 

I would like to present my thoughts on the issue. Then I would like to present some other sources which are more authoritative.

It is important to understand what is not too busy. If you work full time, but have no time to work out or see your spouse, and yet you have time to game, watch TV or get a professional pedicure, you are not too busy. 

You are not too busy if you find that working at your desk leads to hours of randomly surfing the web or checking social media. You can only assess yourself once you have cut all the unintended time wasting from your life. If you are mindfully watching a film, or checking specific things in social media for a few minutes, that is fine and does not count as time wasting. 

So let’s say you have optimized the way you work and spend your time (a topic for another day). Let’s say you have reviewed your schedule and have decided that everything on it is important and nothing can be cut. Then you have met the “ inclusion criteria” and can ask yourself these questions: 

• Am I getting less than 7 hours of sleep on a regular basis ? 
• Do I feel a constant sense of frustration at not getting things done ? 
• Do I lack time to work out for 30 minutes per day ? 
• Do I lack time to eat three healthy meals and snacks ? 
• Am I getting sick too often ? 
• Is the quality of my work getting lower and lower ? 
• Am I neglecting important relationships ? 

If you met the inclusion criteria and you answered yes to any of these things, you should consider thinking about whether you are overcommitted. These would be the relevant endpoints for me, after 54 years of living with, working with and being an overcommitted person. 

WEBMD

http://www.webmd.com/balance/features/are-you-a-workaholic?page=2

This article places workaholism in its psychiatric context. It is a compulsion to go work, combined with discomfort when not working. So it is much more than working hard, or working a lot. They site signs like trouble delegating, thinking about work while on vacation, or neglecting one’s nonworking life. They indicate that cognitive behavioral therapy and support groups can be helpful. 

US NEWS 

http://money.usnews.com/money/careers/slideshows/17-signs-you-might-be-a-workaholic/2

This feature described signs you might be a workaholic. Noteworthy signs including having no hobbies, working through lunch every day, coming to work when sick, being accessible to work all the time, and consistently overbooking. 

The WORKAHOLICS ANONYMOUS site is a real eye opener. 

http://www.workaholics-anonymous.org/10-literature/24-twenty-questions

Surprises in their list of 20 questions include "Do you regularly underestimate how long something will take the rush to complete it ?” This is a more in depth read and I recommend it. 

FORBES 

http://www.forbes.com/sites/deborahlee/2014/10/20/5-signs-you-might-be-a-workaholic/#430847d833d1

Forbes showcases a very worthy article about work-life balance, citing some interesting statistics including the following : "Americans put in more hours than workers in other wealthy countries and are more likely to work nights and weekends.” They alsogive an introduction to Bryan Robinson’s book “ Chained to the Desk”, which is available on Amazon. 

The follow up articles in the same series 

http://www.forbes.com/sites/deborahlee/2014/10/20/6-tips-for-better-work-life-balance/#5ae8fd25dbc9

details 6 tips for a better work like balance. The two tops which appeal to me the most are “ Letting go of perfectionism” and “ Limit time wasting activities and people”. 

SCIENCE DAILY

https://www.sciencedaily.com/terms/workaholic.htm

This site highlights some more surprising aspects of workaholism including the observation that workaholics lose track of time. They also highlight some chilling aspects of workaholism including the problem in Japan, where early death related to workaholism has its own word, karoshi. We all know that workaholism takes a huge toll on mental and physical health, but death by karoshi is hard to fathom. 

I am going to strive in the next few weeks to make my posts more brief. I will feature more outside sources. It is my hope that these posts will be easier to write and easier to read. This is one step I will be taking toward a better work like balance. 

Send me your thoughts on the matter. I would love to see what you think. 

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

Zika infections in the US have taken sharp uptick of late, presumably due to the weather and mosquito activity. Zika infections in American pregnant women now number around 300, the largest number of which are located in Puerto Rico. Numbers are also up since the initially reported numbers did not reflect asymptomatic infections, which can affect fetuses as well. The CDC ( Centers for Disease Control) estimate about 80% of Zika virus infections are asymptomatic. 

The Zika virus is transmitted by mosquito bite and by sexual contact. Consumer Reports has studied the so called natural mosquito repellants and, sadly, found that they last no more than an hour. DEET is much more effective, and has been found to be safe in pregnancy. 

The CDC and Harvard Public Health have analyzed preliminary data. Women who get Zika in section in the first trimester have about a 13% chance of having a baby with microcephaly. The background incidence of microcephaly is on the order of .02 to .12% in the US. So far, it appears that infection in the second or third trimesters is not as consequential.

I wonder if Zika related brain damage is either present or not present, versus a spectrum of damage. If it is spectrum, what do the other 87% of babies have that we should know about ? 

The CDC director has made an impassioned plea to Congress. The House and Senate each have separate Zika funding plans, but they cannot agree. Meanwhile days could make the difference as summer approaches. 

A new study out of U Penn indicates that pregnant women who use marijuana increase their risk of preterm labor by five times. I am more interested in what it may be doing to the brain of both the mothers and the babies, and would be glad to see more research done on this important topic. 

The whole pelvic mesh situation is seemingly going from bad to worse. Mesh sheets are used in surgery to reinforce tissue. Various types of mesh in sheets or ribbons are used for hernias and for urinary incontinence. Johnson and Johnson developed mesh for use in pelvic prolapse patients. However, complications started arising including migration or erosion of the mesh. People were indeed injured, and lawsuits arose.  Washington and California are filing lawsuits against Johnson and Johnson, alleging that the company misrepresented the risks of its use. 

Now some of those same pelvic surgeons who installed mesh are removing it. Is is fitting and customary for a surgeon to handle any of her or his post op complications However in this instance, American Medical Systems has recently alleged that some physicians and lawyers are “ persuading” women to remove their mesh implants in order to make money and inflate damage claims. They also explain that there are now lending companies who work with physicians to fund these mesh removal cases. For shame !!! I will be following this story closely.

I have used Monarc “ ribbon” to suspend the bladder to help incontinence. It has an acceptable complication rate. However, years ago, when a fellow doctor friend of mine and I went to get trained on Monarc insertion, we were also asked if we wanted to train on mesh. I distinctly remember that moment when she and I looked at each other and made bad faces. It gave us both the creeps. We said no because our gut impression told us it seemed prone to complications. Lucky guess. Or maybe it was that the idea of having a piece of screen door sewn just under your vagina skin did not sound OK to us. 

The Republican Governor of Oklahoma Mary Fallin has ignored the party line, and vetoed the recent bill making abortion a felony. This brave politician described herself as “ the most pro-life governor in the nation” but vetoed the bill on the basis that it was “ambiguous and vague" and “ would not survive a constitutional challenge” , i.e. it would be illegal. The Governor was under great pressure from the Christian right to pass the bill. She also received information and pressure from the Oklahoma State Medical Board, the American College of Obstetricians and Gynecologists (ACOG), and the Center for Reproductive Rights.

Acting this presidential could get you a nomination. Similar bills are being put forth in South Carolina and Louisiana. 

Many of you have read my rants about various and sundry public health generated guidelines about women’s health screening tests. These would include mammograms, paps, annual exams and the like. My rants have generally been about the more lax approach seen by generalist governing bodies like the American College of Physicians, and the American Academy of Family Physicians. ACOG guidelines are more stringent, and I believe this is because we rely on more rigorous data produced by specialists in the field. Even so, generalist guidelines hit the press just the same as ACOGs, and it is difficult for a layperson let alone a community physician to understand why the recommendations are so different. 

As an example, ACOG believes the evidence supports mammograms in the 40s for women of average risk, whereas the American Preventive Services Task Force does not advise them until the 50s. In a nutshell, this is because the APSTF did not choose their study endpoints in the most meaningful way. Their harms included trivial things like fear of mammograms, and their endpoint was death rather than years of life. The public and many providers were thrown into confusion. 

Fast forward to the present for some good news.. ACOG will now be partnering with these same organizations to develop what will hopefully be an evidence based rigorous set of Women’s Preventive Services Guidelines. 

Stay tuned for more news next week on Medical Monday. 

Wellness Wednesday: Healthy Boundaries

Boundaries are essential to our physical and mental health. And yet, they are rarely discussed in everyday conversation. This post is to put the concept of boundaries on your radar, and into your vocabulary and to encourage you to learn as much as you can about them. 

Boundaries can be physical, mental, emotional, or even functional. At essence, a boundary is the line between you and everything else. To have good boundaries means that you maintain a truthful view of yourself. You know how you are distinct from others and honor that. Additionally, you take responsibility for all that is yours, from the state of your body, to your thoughts, your emotions, your skill sets, and the way you perform in life. 

Bad boundaries allow numerous problems to occur. For example, weak boundaries allow one person to tolerate mistreatment from another. Another kind of weak boundary allows one person to blame others for their problems. Bad boundaries produce abuse, resentment, chronic victims, pleasers, controllers, bullies, the overcommitted, enablers, entitled freeloaders, martyrs and guilt trippers… The list is endless. 

Boundaries are established as we grow up and have life experiences. We may learn from experience that standing up to a bully causes them to leave us alone. Or we may learn that it makes the situation worse. We may learn from parents that misbehavior has clear consequences, or we may learn that we can get away with anything. We may learn that when we apologize, it is accepted and life goes on. Or, we may get a never ending stream of resentment. All these types of things can affect the integrity of our boundaries. 

Those who have suffered abuse have particularly damaged boundaries. They tend to tolerate much more mistreatment than they should. In fact they may not even know to classify mistreatment as mistreatment since they do not even know what healthy relationships look like.  To them, an abusive relationship is sadly normative. And since boundaries are like fences in that they have gates, abused people have trouble with gates as well. Is particular,  abused people often shut out those trying to help. 

Few people have perfectly healthy boundaries. To have healthy boundaries, one has to be aware they even exist, if only on an intuitive level. To really understand them requires examples. Having healthy boundaries is about setting limits for oneself. While it is not about setting limits for others, it is about setting limits on what one will tolerate from others. Likewise, it is not about reacting to others. Rather, it is about communicating clearly specifically directly and honestly from a first person point of view ( "I statements") and giving responsible feedback to others. 

We all need to be aware of our personal boundaries and how to keep them healthy.

• First is to realize boundaries exist.
• Second, we must realize we have an innate right to maintain our boundaries.
• Third we must become self aware of our own thoughts and feelings regarding what we are comfortable or uncomfortable with in ourselves and others.
• Fourth, we must be honest and realistic about our needs, and employ self care to meet them.
• Fifth we must be willing to enforce our boundaries if they are violated. This is done for the long term good, but we must realize that in the short term it may cause conflict.
• Sixth, we must reach out for support and knowledge as we strive for healthy boundaries. This is because we are trying to learn that which, by definition, we did not know before. It is also because we may encounter resistance from those who encroached on our boundaries before. Sometimes, this requires professional counseling or a supervised support group. 

Healthy boundaries are critical to our self respect, integrity and optimal functioning. Here is some great reading to learn more:

http://psychcentral.com/lib/10-way-to-build-and-preserve-better-boundaries/

http://tinybuddha.com/blog/how-to-set-healthy-boundaries-3-crucial-first-steps/

http://www.essentiallifeskills.net/personalboundaries.html

https://www.ipfw.edu/affiliates/assistance/selfhelp/relationship-settingboundaries.html

https://www.psychologytoday.com/blog/prescriptions-life/201311/7-ways-protect-your-energy-enforce-healthy-boundaries

http://www.loveisrespect.org/healthy-relationships/setting-boundaries/

http://www.huffingtonpost.com/jennifer-twardowski/6-steps-to-setting-boundaries-in-relationships_b_6142248.html

http://greatist.com/happiness/how-to-set-boundaries-in-relationship  

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

Zika Virus was front and center at the annual meeting of the American College of Obstetricians and Gynecologists (ACOG) this last week. Hospital protocols are being developed to handle Zika affected births. Additionally, research continues into the the way that the virus affects babies, some utilizing the placenta. 

The annual ACOG meeting also presented a medical legal panel which presented evidence that latest cluster of TRAP (targeted regulation of abortion providers) laws were not based on medical indications. Many such laws are introduced under the auspices of medical necessity, where the available medical literature does not indicate such. It seems to me that abortion opponents should be truthful about promoting pieces of legislation based on their moral and religious views, and not medical science, for which there is none. 

In Brazil, where Zika virus is rampant, abortion is illegal, even for anomalies. Recently, evangelical politicians there have introduced stricter penalties there for those who illegally are found to have aborted a baby with microcephaly. There are nearly one million illegal abortions in Brazil each year. The number of women who are hospitalized for complications from these illegal abortions is ten times the number of women who are not. 

Oklahoma just passed a law making it illegal to have an abortion. It is a felony there, punishable by up to three years in prison. Physicians performing abortions would have their medical license revoked. 

And no matter where you stand on the issue of abortion, it comes as good news that abortions in the US and other developed countries have significantly declined since the 1990s. In my experience, abortion is a tough decision for people and is fairly hard on women. 

Also in the good news department, new research in JAMA (Journal of the American Medical Association) indicated that exercise wards of a variety of different types of cancer, even in those who smoke or are obese. There is a 20 % risk reduction for about 13 different types of cancers including esophagus, lung, kidney, stomach, endometrium and others. 

And in some news which I consider to be outstandingly good news, a panel at ACOG has generated a strong statement of consensus that 39 weeks is the optimal time to delivery a baby.  They have stated that there is little to gain and considerable to lose thereafter. We Ob/Gyns are committed to practicing evidence based medicine, and so I have managed patients according to the existing algorithms of the day supported by the best available evidence at the time. But, as my 22 years of practice have ticked by, I have had a stronger and stronger hunch about this 39 week point. Now there is finally a high level consensus about it. The presentation was so strong the the 63% opposed to the consensus before the talk turned into a 81% for the consensus by the end of the meeting. Inductions at 39 weeks had a lower complication rate than previously appreciated, and the C section rate did not increase. 

The vaccine rate for HPV (Human papilloma virus) has been low in this country. However, it is more than it has been in last years, and the rates of high risk HPV disease are decreasing. To really stamp out cervical cancer, we need to achieve the so-called “herd immunity” conferred by near universal vaccination. 

More good news…. In 2010, 16 % of Americans were uninsured. In 2015 this dropped to 9.1 % of Americans. Of course this is related to the ACA, the Affordable Care Act. Of course this has a cost. But, as a physician, I would like to remind the non-medical public that it is much cheaper for the taxpayer to pay for early prevention of illness and pregnancy than to pay for delayed treatment of illness and unintended pregnancy. 

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