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

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health insurance premiums will go up for the average ACA (Affordable Care Act) client by 19% if federal subsidies are withdrawn.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

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

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

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

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

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

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

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

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

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

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

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

Thanks for your patience with my delay during Passover ! 

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

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

House Speaker Paul Ryan has confirmed that this administration is bound to continue funding the benefits to those under the ACA (Affordable Care Act) and is likely to do so through 2018. Tom Price, Secretary of HHS ( Health and Human Services) echoed this sentiment saying he would uphold it as long as it was the law of the land. However, at the same time the GOP will continue it’s lawsuit against the ACA on the grounds that they believe the ACA is unconstitutional since it was not approved by Congress. 

Meanwhile States are acting of their accord to tailor heath care to their particular needs. California is considering a single payor system. Kansas’ Governor just vetoed a bill to expand Medicaid that had bipartisan support in its House and Senate. 

Did you now the NIH, the National Institute of Health, is facing a 20 % budget cut ? The National Institute of Health is the nation’s premier research institution. And yet, Representative Tom Cole ( R- OK) chair of the subcommittee that oversees HHS says the CDC (Centers for Disease Control) and the NIH are just s important as national defense. What do you think ? Tell your members of Congress. 

Tanning beds. They cause cancer. Many children under 16 use them. Guess who brings them there ? Their mothers. A new study was published in JAMA (Journal of the American Medical Association) Dermatology. The researchers were surprised at this appalling finding. 

Older people are more sensitive to alcohol than others. Women are more sensitive to alcohol than men. These are some of the reasons why it is so alarming that older women are drinking more than ever. Binge drinking is increasing at a rate of 4% per year for women. 

Are you flossing ? Gum disease in women 55 and older is associated with a 12% increased risk of dying from any cause. Stay up to date with your dental care. It will make you smile. 

In the not surprising department, smokers who undergo radiation treatment for breast cancer have more complications than nonsmokers. Was do they mean by complications ? They mean lung cancer and heart disease. Ask your doctor how you can quit. You can, you know. 

In the good news department, yet another study has shown that oral contraceptive pills are protective against three major cancers: ovarian, colorectal, and endometrial ( cancer of the uterine lining).That protection lasts at least 30 years. 

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

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

By now the whole world knows that Trumpcare version 1.0, the American Healthcare Act (ACHA) has failed. For now, Obamacare, the Affordable Care Act (ACA), remains the law of the land.

This last Friday, the ACHA bill went to the floor of the House for a vote. However, all day negotiations proved fruitless to bring over Democrats or close the deep divisions between House Republicans. House Republicans broke rank with the President, but did so in two camps. First those on the far right “ The Freedom Caucus”, withdrew support because they felt the bill was still too costly and still too much like Obamacare. Moderate Republicans withdrew support because the ACHA gutted federally funded Medicaid and is widely believed to lead to the loss of insurance for a great many people, putting that burden on the States. Paul Ryan, recognizing the tally, pulled the bill before the vote. 

House Speaker Paul Ryan has indicated the GOP will keep working on heath care. One little publicized option is for the Whitehouse to sue to stop the Fed from paying insurers for work done under the Affordable Care Act. This tact was going on before the ACHA was brought to the House. Their argument is that these contractual payments from the Fed to insurance are invalid and illegal. 

One of Trump’s major campaign promises was to reform healthcare, indeed to provide “universal coverage”. Progressives favoring Universal Coverage may attempt an uneasy alliance in the service of this goal. Senator Bernie Sanders plans to unveil such a proposal entitled “ Medicare for All “. 

Policy news is moving at light speed and I recommend everyone start reading it from various reliable sources. I also recommend people familiarize themselves with their elected representatives and give them and their staff regular meaningful input. 

On to actual medicine. 

A new study from the Journal of the Academy of Nutrition and Dietetics indicates that most American women do not eat a healthy diet when they are pregnant. This is something we see in clinic on a regular basis. It is worth noting however the many women believe that they are eating healthy diet, even though they are not. These are well-intentioned people who have been taken in by advertising or who are victims of their busy schedules. Unless the physician or nurse midwife takes a detailed dietary history they will not know how their patient is really eating. Merely asking the person whether or not they eat healthy is not enough. People generally say they eat healthy and people generally say they are active or fit. That is because they believe it to be the case. Until people have objective definitions in front of them they cannot reliably answer these questions. Doctors take important shortcuts if they do not delve into a reasonable amount of history taking detail. When patients get specific explanations of exactly what we mean when we say "eat healthy", they're much more likely to do so. One of the problems of course, is that many doctors do not know precisely what it means to "eat healthy”. 

Four prior commissioners of the Food and Drug Administration (FDA) have produced a joint letter warning Congress about the legalization of importing drugs from other countries. Certain members of Congress have indicated that they would support this in an effort to reduce drug costs. In particular, the commissioners emeriti have warned against counterfeit, substandard and contaminated medications, since standards from other countries may not be adequate.

Pregnant women with HIV have a better chance than ever of avoiding transmission of their virus to their children. Preventive treatment including retroviral drugs given in pregnancy account for this progress.

In other viral news, a new gel treatment for genital and perianal warts is under study. These are caused by the human papilloma virus. The treatment is based on nitric oxide. Stay tuned for more on this nascent therapy.

Also regarding human papilloma virus, the American Society of Clinical Oncology has issued global statement regarding the primary prevention of cervical cancer. They recommend that all girls ages 9 to 14 receive two doses of the human papilloma virus vaccine also known as Gardisil. In the last few years there has been definitive evidence that Pap smears combined with this vaccination reduced the incidence of cervical cancer. The vaccine is also available for boys of the same age group.

Yet another study has demonstrated that exercise during pregnancy is safe and beneficial. This most recent study published in the Journal of the American Medical Association is meta-analysis of studies with more than twenty five hundred pregnant women. This is in line with ACOG (American College of Obstetricians and Gynecologists) recommendations which indicate "women without major medical or obstetric complication should get at least 20 to 30 minutes of moderate intensity aerobic exercise… on most days of the week."

In the concerning department, the FDA (Food and Drug Administration) has now linked anaplastic large cell lymphoma (ALCL)  to breast implants. This disease is a rare malignancy in the immune system which is statistically linked to breast implants, particularly those which have a rough versus smooth surfaces. The FDA has issued a statement indicating that women with breast implants have a very low but increased risk of developing ALCL compared to those who do not have breast implants. It is worth remembering that a statistical link does not prove causality. Concerned patients should speak to their plastic surgeon about this matter.

In other cancer news,  new research indicates that breast cancer gene testing is underutilized in America. A simple history in the caregiver’s office can identify whether or not a patient is at high risk of having abnormal genes, i.e. breast cancer gene mutation, or BRCA. Women with two first degree relatives such as a mother or sister are at high risk for having an abnormal gene and should explore the possibility of testing. Those patients with close relatives with any cancer should make sure their caregiver is aware of it. 

New research coming out of the Cancer Genome Atlas Project and the Cancer Research UK Database have indicated that only about a third of cancers are due to a special inherited genetic mutation. This means that two thirds of cancer-causing mutations arise spontaneously and are not able to be inherited by one's children.

We conclude with the good news department. A new device called the Alexis retractor is being tested across the world. Preliminary indications in Europe show reduced infection rates and reduced post operative pain after Cesarean section. 

Finally, many States are following another European lead and introducing baby boxes. Currently Americans put their newborn babies to bed in a wide variety of ways. However, clear research shows that the incidence of SIDS (sudden infant death syndrome) can be significantly reduced if babies are placed on a flat surface on their backs, head uncovered, in a special sleep sac or a one piece sleeper, and WITHOUT any blankets, swaddling, bumpers, padding or or toys. The sheet on the firm mattress should be fitted. The baby box programs are designed to provide all this teaching as well as an actual  baby box and mattress. For those who are not aware, the baby sacs are like insulated zip overalls with a closed bottom, which allow babies to move. They are not to be confused with swaddle wraps, which are also associated with SIDS. Babies typically wear a shirt and a diaper with it. Very cute inexpensive ones can be obtained at Ikea, Target and online. 

Here is an authoritative link from the NIH for those who want to learn more: 

https://www.nichd.nih.gov/sts/about/environment/Pages/look.aspx

Our photo for today's post was brazenly lifted from the pages of the National Institute of Health linked above. 

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

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

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

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

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

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

"Best Practices Health Care Act" 

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

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

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

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

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

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

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

7. Government may negotiate prices on all drugs. 

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

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

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

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

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

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

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

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

The bullet points: 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Policy news continues to dominate. The new administration's efforts to repeal the ACA (Affordable care Act) continue. However, Republican leaders are scrambling to resolve the internal GOP divisions which have developed over healthcare policy particulars.

The American College of Obstetricians and Gynecologists has again gone on record opposing any  changes that will limit women's reproductive coverage in this country. However OB/GYNs in this country also concerned about the so-called"Global Gag Rule”. The global gag rule is a policy that states that advising about or providing abortion disqualifies an international health care agency from receiving funds from the United States. It has been in and out of effect depending on the administration in office over the last 20 years. Dr. Daniel Grossman at the University of California San Francisco has recently published an editorial which sites research indicating that the “Global Gag Rule” actually increases the number of abortions in sub-Saharan African countries, due to reduced access to contraception. This is not a surprise since these international healthcare organizations use their funds for the spectrum of healthcare needs, including contraception. When they lose funds, they lose it for everything across-the-board. 

Dr. Grossman has also published about research on this country indicating that restricting access to abortion though administrative hoops or clinic closures does not reduce the number of abortions. It merely causes the  percentage of later second trimester abortions to increase. In case this is not clear, later procedures have higher risks of complications of all kinds. This is what we call an unintended consequence. 

Again it has come to light that if tax credits replace subsidies to pay for healthcare, the wealthy will benefit the most. That is because they have the most taxes against which to apply deductions. Younger people will also benefit disproportionately, since their premiums are low and the GOP proposal includes  giving the same dollar amount of credit to each person regardless of the amount of their premium. In contrast to these benefits for the young and wealthy, such GOP replacement plans as currently drawn will in increased costs for the majority of middle income and middle aged Americans.

The new administration has made it clear that it does not favor retaining the penalty for those who do not buy health insurance, the so-called “ individual mandate”.  Generally people with chronic health conditions make arrangements to have some form of health insurance coverage, since they know they will need it. It is the young andthe healthy who tend to skip purchasing health insurance since they think they can get away with it. I have two thoughts about this. Number one, They may not realize that if they have anything as simple as a car accident with a broken leg, they may end up with a bill that is tens of thousands of dollars. When they cannot pay this bill, it damages their credit, and the costs are absorbed by the rest of us who have taken the trouble to obtain insurance. Systemwide, their failure to get insurance also has effects. In particular, if the young and healthy tend to go without insurance, they are not contributing to the pool, and this drives up the insurance prices for the elderly and the unwell.

Utah has joined the league of States who now legally require abortion providers to counsel women about a procedure that does not exist, the “abortion reversal” procedure. Members of that House have dissented, saying the procedure is not backed science, and is medically inaccurate.  

A controversial proposal to require Medicaid recipients to work is on the table. A number of Republican Governors are promoting, this, ostensibly hoping people will work themselves right out of their Medicaid eligibility. Medicaid currently ensures one in five Americans. 

The CDC(Centers for Disease Control) has confirmed that American women who were pregnant with Zika  have a 20 fold increase in certain birth defects. The CDC continues to recommend restriction of travel to Zika affected areas for pregnant women. 

In the good news department, policymakers of various kids are working to secure women’s health care despite the repeal of the ACA. State based bills to preserve services of contraception, prenatal care, STI ( sexually transmitted infection) screening, sterilization and counseling are being introduced around the nation. 

The Virginia General assembly has recently outlawed FMG-female genital mutiliation. FMG is removal of the external female genitalia, including the labia and clitoris. It is carried out between infancy and the age of 15. It has no health benefits and commonly causes chronic pain, and urinary tract issues. At this time, 200 million women in 30 countries around the world have been “cut”. It is widely practiced in Africa, the Middle East and Asia and is considered an extreme form of discrimination against women. It is intended to render women less sexual, less “unclean", less likely to stray, and more marriageable. No religious scripts prescribe it, though practitioners believe the practice has religious support. The World Health Organization (WHO) considers it a violation of human rights. International human rights groups have applauded the Virginia decision. 

In more good news, Colorado has passed laws allowing pharmacists to prescribe oral contraceptives. Medical screening by the pharmacist will be required. ACOG has applauded the measure, citing the safety of the medications, and the improved access to contraception. 

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

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

Republican efforts to repeal of the ACA (Affordable Care ACT) continues to worry many. In particular, the new administration is starting to hear from cancer patients and cancer survivors. These are people who will forever have a preexisting condition. They have been assured with promises to protect people with problems in any forthcoming health legislation. And, yet, no proposal has yet been put forth to sustain the viability of the insurance companies providing the health care. 

Tackling the ACA has, understandably proven to be more difficult than Republicans estimated. Leaders in the House and the Senate have been meeting with patients, hospitals and insurers. With all these legitimate concerns being brought to the table, divisions are developing among Republicans despite the fact that both the House and the Senate are dominated by Republicans. No one said it would be easy. 

Republican led States are petitioning to reduce Medicaid costs by increasing coverage restrictions. These could take the form new small premiums, work requirements for the non-disabled, and time limitations on coverage. This could lead to different Medicaid benefits in different States. Governance of States' Medicaid programs may come under increasing control of individual States, rather than the Federal government. 

Republicans seek to increase utilization of Health Saving’s Accounts (HSAs). HSA’s are basically registered accounts in which people may place money, tax-free, to spend on health care, usually their out of pocket portion of their insurance. The idea behind this is that when people are spending “ their own money rather than the insurance companies’  money” they will be more careful with it. If a person who has low income and therefore a low tax rate has a high deductible, as many do, for example $5000 to pay their deductible out of an HSA is still $5000. However, if a person in a high tax bracket socks away the amount of his deductible in an HSA and is not taxed on it, they make save as much as 35% of that money as saved taxes. As far as I can see, HSA’s will only help people in high tax brackets. 

Popular support of the ACA increased since the inauguration from 41 to 45%. 

The contraceptive mandate, part of the ACA, requires the birth control be covered with no copay. However, it is believed that the new Secretary of Health and Human Services, Tom Price, will try to repeal it since he did not support it to begin with. Again, it is my opinion, and the opinion of many, that the contraceptive mandate is a money saver, and a abortion preventive. There is solid evidence to both effects. Some was cited in last week's blog post. 

A Federal Judge in Austin Texas has blocked the withdrawal of funds from Planned Parenthood in Texas. He stayed that that State did not provide evidence of any violation warranting such termination. This will protect care for about 11,000 of the State's poor who currently get their Medicaid funded care through Planned Parenthood. 

President Trump has vowed to enforce a “global gag rule” whereby family planning funds from the US will be withdrawn from any international organization who so much as speaks about abortion, let alone performs it. By doing so, $600 million will be withdrawn from these organizations providing broad family planning and health services to women. As a response, the Netherlands has started a fund to replace the shortfall, and has been joined by Norway, Sweden, Denmark, Belgium, Luxembourg, Finland, Canada, and Cape Verde. 

Last week the Indiana House Public Policy Committee passed a law which will require abortion providers to discuss a procedure which does not exist, namely “abortion reversal”.  I have no idea what they can even say about such a thing since it simply does not exist. ACOG (American College of Obstetrics and Gynecology) spoke truth to power about this, but it did no good. 

This week other lawmakers in Arizona are considering a bill to require lifesaving treatment for babies miscarried or aborted at 20 weeks of age which show some signs of life. Babies at this gestational age can briefly have gasping, or a slow heart rate for a very short period of time, but it does not indicate any potential for surviving. This law would require that these babies receive advanced life support measures, similar to an adult with a cardiac arrest. Again, another impossibility. When will lawmakers acknowledge that scientific reality should have a role in laws ? 

Many lawmakers across both sides of the aisle have taken exception to the new president’s anti-vaccine philosophy. They are beginning to speak out in support of their State’s respective vaccine policies. 

Policy news seems to have overshadowed medical news this week. However, there is something from the “ we-already-knew-this” department. New research published in the American Geriatrics Society indicated that, in older women, central body fat is associated with shortened life, more so that being fat overall. They also discovered that being underweight shortens life as well. 

Finally, ACOG has recommended that all pregnant women be offered genetic screening and carrier screening. Formerly, we based carrier screening on ethnicity. However, now it is believed that a large number of Americans are of mixed or unknown ethnicity, and so carrier screening for specific disease causing genes is indicated for all. 

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

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

Contraception: Get yours while it's hot ! 

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

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

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

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

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

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

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

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

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

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

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

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

Medical Monday: Breaking News from the World OB/GYN

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

The Society for Maternal Fetal Medicine (SMFM)  recently convened a special session to summarize our current knowledge about the Zika virus. Maternal Fetal Medicine Specialists are also known as Perinatologists. They are essentially Ob Gyns who drop Gyn and take a couple additional years of training in Ultrasound and high risk pregnancy management. They also tend to comprise the research side of Obstetrics. They may or may not continue to deliver babies. They, together with general Obstetricians have been the group of health care providers most affected by the Zika epidemic. As such, the group as convened a special session to review CDC (Centers for Disease Control) recommendations pertaining to the Zika virus. Together with the CDC director, they have emphasized the the concern over Zika is ongoing. Pregnant or potentially pregnant women are encouraged to stay away from places where Zika is spreading. They have cautioned that the worst is not over. 

Meanwhile, insights are being gained into the pathogenesis of the Zika related disease process. (Pathogenesis means the particular way something causes disease.) In looking at the Zika virus genome and several important proteins produced by the virus, researchers from the University of Maryland have obtained what they classify as “ really valuable clues for future research”. 

President Obama meets with Congressional Democrats this week to devise a strategy to save the ACA (Affordable Care Act). Meanwhile some commentators have noted that even repealing the ACA will not make it possible to roll back all of the changes the ACA has wrought. Americans have become accustomed to a new standard in the expansion of health care coverage. Meanwhile, the incoming Republican administration has seemingly settled on a repeal and replace strategy. The health coverage of 20 million Americans is at stake. This December, 8.8 million people enrolled in the Federal Exchange. This is more than the 8.6 million of last year. The American College of Obstetricians and Gynecologists (ACOG) and others have come forward with a recommendation that there should be a replacement plan in place before repeal. Yet ate last week, Republican leaders including the House Speaker Paul Ryan as well as Senate Majority Leader Mitch McConnell have asserted that a quick repeal and replacement "within this year" is needed. Senator McConnell classifies the ACA as a “ failed, partisan experiment”. 

A new analysis presented by CNN Money indicates that repeal of the ACA will cost the Federal Government $350 billion dollars over the next ten years. In comparison, the ACA was crafted to be budget neutral. 

ACOG and the AMA (American Medical Association) concur that oral contraceptives are appropriate for over the counter use. The FDA (Food and Drug Administration) is in the beginning steps of this regulatory process. 

There are many patients who have trouble attaining a healthy weight, even some who exercise regularly and eat appropriately. A new study has focused on this group and found some good news. These “non responders” benefit from rotating their exercise routines. Truthfully, I have heard this from many trainers. 

Also in the good news department: a 25 percent decline in cancer death rates since 1991. This is a fresh statistic from the American Cancer Society. They attribute this decline to reductions in smoking, as well as early detection, and better treatment. 

Finally, in the easy and lifesaving department, peanuts are now recommended for the very young. The National Institute of Allergy and Infections Disease has issued new guidelines recommending that parents introduce peanuts into their child’s diet early (before 6 months !) and often. This is to prevent the development of peanut allergy in the future. This recombination is a “ significant departure from the past”. These new guidelines could dramatically reduce the prevalence of this deadly allergy. 

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

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

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

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

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

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

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

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

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

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

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

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

For the first time in many months, there is nothing new to report about the Zika virus. I am going to take this is as a good thing and report on the rest of the news. 

With the end of 2016 approaching, ACA (Affordable Care Act) signups have reached a new high. At the same time many fear loss of their contraceptive method if the ACA is repealed. The ACA as it currently stands, pays 100% for contraceptives. 

The ACA seems to have enabled more people to keep up on preventive care. Also according to a new study, the number of adults who skipped recommended medical care fell about 20 % between 2013 and 2015. Similarly, a new Vanderbilt study showed that patients accessed emergency department care more quickly since cost was not a consideration in choice of hospital.  

Texas has noticed all Planned Parenthood Clinics that it is removing them from the Medicaid Program. This means that no Medicaid recipients may be seen at Planned Parenthood, which normally serves predominantly the Medicaid population. I’m wondering if this will have unintended consequences. For example, perhaps Planned Parenthood will have to start filing their clinics with well insured women, while the private and hospital owned clinics uptown will start to fill with medicaid patients ? It will be interesting to see how this will play out. It almost certainly will mean less access to care and a shift in who sees whom. Planned Parenthood is appealing the Texas Health and Human Services Division. 

ACOG (American College of Obstetricians and Gynecologist) has officially endorsed 30-60 seconds of delayed cord clamping. This procedure allow baby to get more blood from the umbilical cord. This is especially beneficial for smaller, early babies, but can be good for term babies as well. It results in higher blood hemoglobin counts, but also, understandably more jaundice, since jaundice comes from the breakdown products of blood cells. As an obstetrician, I can tell you that this works out most of the time. However, if baby is not breathing well, I get them to the nursery staff right away. Also, if there is excess maternal bleeding, we cut this procedure short, and move to get the placenta delivered. 

On a personal note to readers, I have appreciated all the attention to my posts. However, I plan to curtail my blogging to once a week come January 1st, 2017. I will continue Medical Monday since I believe this information to be very important to you. Additionally, I do plan to put out an occasional digest of existing website pages and posts on selected topics, which I think will be high value. However, based on my numbers of readers and subscribers, it seems clear to me that I need to get my information out in more accessible forms, such as in books or apps. There is so much material on the site now, that most topics are really well fleshed out, though the material is deep in the pages. I will need some time to pull this content out and organize it. At the same time, you are of course welcome and encouraged to access the website anytime via the menu, the search page, or the blog tags on the right of the home page on your own and free of charge. My website will be there free for all as an up to date medical resource.  

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

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

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

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

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

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

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

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

Medical Monday: breaking news from the world of obstetrics and gynecology

Here is some good news on the Zika front. It is been over 45 days without anyone in South Beach Miami contracting Zika virus in from a local mosquito. For this reason Governor Rick Scott has lifted the Zika zone warning in South Beach. Miami's Little River area was cleared earlier this week. Officials are still warning pregnant women to avoid the entire area and to protect against mosquito bites.

Five babies in New York City have been born with Congenital Zika Virus Syndrome. Interestingly, eight other infants have tested positive for Zika virus in New York City but have not shown evidence of the syndrome.

Zika remains a threatening and somewhat mysterious disease. A woman in Columbia has been the subject of study because her Zika virus infection lasted so long. Normally the disease is mild and runs it's course over a few days time. However the pregnant patient in question tested positive for Zika for 107 days after the onset of symptoms. Because of this, researchers speculate that the baby may serve as a reservoir for the virus. When this baby was ultimately born at 37 weeks gestation, it did indeed show microcephaly, indicating that it had been infected by Zika as well. However, interestingly, the baby tested negative for Zika in serum, urine and cerebrospinal fluid. Even though the Zika virus had done it's damage as evidenced by the babies microcephaly, the baby had already developed Zika antibodies prior to birth.

Three experimental Zika vaccines are under development. One of them has finished the first round of human testing then will move to phase 2 trials in the first quarter of 2017. Four or five more Zika vaccines are expected to begin development next year.

Perhaps the most important comments about Zika came from a Dr. Antonio Crespo the Chief Quality Officer at Phillips Hospital at Orlando Health. Writing in the contributors blog for The Hill, Dr. Crespo indicates the northward migration of Zika virus is probably the first of many such diseases. He cautions that the nation's response to Zika and the outcomes that we will see should be studied in preparation for future such threats. 

In other news, youngsters are not the only ones skipping their vaccines. Older people are more vulnerable to influenza, pneumonia and shingles. Vaccines are available for all of these things. 

Young people between the ages of nine and 26 should be vaccinated against the human papilloma virus (HPV). However, vaccination rates in this case fall short of ideal. A new study indicates a counterintuitive result. It turns out that short conversations between Dr. and parents or Dr. and patient are more likely to result in vaccine utilization than are long conversations. Researchers have interpreted this finding by speculating that long conversations raise more doubt than short ones. I would speculate, by contrast, that when a patient shows reluctance or asks questions, the conversation goes longer. Such patients who are disinclined to vaccinate to begin with are less likely to vaccinate even after the conversation takes place. I think the conversations between caregivers and patients need to be as long as they need to be and they certainly very greatly between patients and circumstances. I'm going to file this in the chickens and eggs category.

Also in the chicken and eggs category is the following study. It turns out that researchers have identified a link between pubic hair grooming and sexually transmitted infection (STI) risk. There is a direct relationship between pubic hair grooming and sexually transmitted infection risk. In fact, there is nearly 4 times the likelihood of having an STI among those who are groomed as infrequently as weekly. I ask myself, is this because grooming inherently makes the tissues more vulnerable? Honestly I doubt this. Do those who groom have more partners? Do those who have more partners groom more ? Which comes first?

Officials from the incoming Republican administration have reiterated their plans to repeal the Affordable Care Act (ACA). However reporting on more detailed discussions among leader elect reveals a realistic understanding that this change might take two or three years. They even have a name for their strategy: "repeal and delay".

Meanwhile the American Hospital Association has warned the new administration that "repealing the affordable care act could cost hospitals $165 billion by the middle of the next decade" And "trigger an unprecedented public health crisis". 

Similarly the Urban Institute has reported that 30 million people stand to lose coverage if the Affordable Care Act is repealed without putting anything in place to replace it.

Many women are aware of the likelihood of some form of curtailment of the ACA, particularly of reproductive health care coverage. A Kaiser study indicates that many women are flocking in to obtain contraceptives, including longer acting methods to see them through a longer period of time.

In the good news department, the Senate has passed a landslide vote ratifying the 21st Century Cures Act. This is a $6.3 billion measure to "increased federal support for medical research, mental health care, and controlling the opioid epidemic". The bill had strong bipartisan support and cleared by a vote of 94 to 5.

We will finish with a fantastic study on the relationship between optimism and health.The Nurses Heath Study is a very long running and large study of 70,000 women between 2004 to 2012. It is been mined for all kinds of research. In this most recent study released out of Harvard Public Health, those with the most optimism had 40% lower risk of heart disease and stroke compared to those with the least optimism. Optimism was linked with lower inflammation and healthier biomarker levels including lipid levels. Researchers concluded that the correlation between optimism and longevity was the result of optimistic people having healthier lifestyles such as diet, sleep patterns, and other factors.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The World Health Organization will have convened on Friday to evaluate whether Zika is still to be classified as a “ public health emergency of international concern.” I am not sure of the criteria for such a classification, but it does not seem to me that we have yet seen most of the consequences of Zika in those yet to be born. Furthermore, it is not clear how Zika will fare though the turn of the seasons. 

The effects of Zika are generally serious to devastating. It is fascinating and confounding that these effects vary by geography. This means Zika has different effects depending on where the infection is contracted. The American Society for Tropical Medicine recently convened and examined this question which needs much more formal study. 

Women are more likely to get Zika from men than men are to get it from women. This is because the virus is now believed to suppress the vaginal immune response (Vaginal immune response ! Who knew ? ) and thus go undetected so it can establish infection in both mother and baby. 

Blood banks in affected states have been screening for Zika. Only 40 out of 800,000 positives have been found. This is not meant to represent an assessment of Zika prevalence in these states since the people who come to donate are screened and kept from donating if they have risk factors for the infection. 

In other news, there is another option for women with vaginal atrophy. Many older women and those who have had cancer have vaginal atrophy, which manifests as dry, thin, inelastic tissue. It also manifests as pain during intercourse. Fourteen percent of all women have low equal desire and sex related personal distress. Part of this in older women may related to vaginal atrophy. Unfortunately, this is not always addressed at the doctor’s office. Many such patients are not able or wiling to use vaginal estrogen. They may now use DHEA, dehydroepiandrosterone, an adrenal androgen, as a daily vaginal capsule, to help with this. The trade name will be Prasterone and it has recently been approved by the FDA ( Food and Drug Administration) for this use. 

The idea of using vaginal estrogen in breast cancer survivors has, until recently, not been considered due to concerns that the hormone enters the systemic circulation and might cause increased risk of recurrence. However a recent study published in JAMA Oncology has shown that estradiol secreting vaginal rings and intravaginal testosterone cream are both safe and effective therapies in those breast cancer patients who are receiving aromatase inhibitor (AI) therapy. 

In insurance news, President elect Trump has indicated that he favors preserving the prohibition against insurers denying coverage due to preexisting conditions. He also favors allowing parents to keep children on policies until the age of 26. An article in the Wall Street Journal recently opined that keeping these provisions without keeping the universal mandate (requirement for everyone to have insurance or be fined) and the funds it would bring in, would strain the coffers of health insurance companies bound to keep the first two provisions. 

At this point, hearsay reigns in matters of the new administration’s policies. Before the election, Republican politicians spoke of eliminating the individual mandate on health insurance. Now, there is talk of revamping it. Similarly, and more realistically, it is said that Medicaid under the new administration is more like to be altered than it is to be shrunk, as Republican candidates suggested. 

This column has covered the falling teen birth rate. Recent analysis of this data has shown that this is the case much more in urban compared to rural areas. Between 2007 and 2015, the teen birth rate fell 50% in cities, but only 37% in rural areas. Teen birth rates fell most among white and hispanic girls. 

In related news, a recent study in the American Journal of Public Health showed some interesting relationships between childbearing and longevity. Over 20,000 women were followed for over 16 years. Researchers discovered that a larger number of children is associated with less longevity in black women, but more longevity in white women. They also found that women who delay their first birth until at least 25 are more likely that their counterparts to live until age 90. 

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