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Friends, You post will be delayed due to patient care late in the night. Hopefully when I write there will be not too much in the way of politics, but lots of interesting medical news. I suppose I should not have a preference. It's all important. Until then, happy Monday. 

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Policy News 

People across the political spectrum continue to debate the merits of Brett Kavanaugh for the Supreme Court. Since we now know that the political and judicial systems play such a large role in the health care of women, we’d all best pay close attention to this debate. 

Drug Shortages. We did not used to have them. Now it is common place on routine drugs, even IV fluids. No slight to third world countries, but sometimes it feels like we are in a third world country. The FDA is forming a new task for to more critically and quickly investigate and solve this problem. 

Companies that make formula are multinational. The Trump administration is avowedly pro business and this is particularly evident in the international sphere where of late, this had unsavory consequences. In its zeal to unfetter corporate interests, The Trump administration has taken an anti breastfeeding stance. At present advertisements of formula is limited regionally in areas where it could be misused or hazardous. The Trump administration has desired to “ reopen” these markets, under the auspices of free trade, seemingly oblivious to the perils of selling formula  in places where literacy (ability to mix correctly) and clean water is unavailable . The entire medical and public health establishment has reacted, concerned that breastfeeding continue to be encouraged as the safe and superior method that it is. Many are pointing out that formula manufacturers have no place at the health policy table. This baby feeding battle resurfaced last year when Ecuador proposed a resolution to the WHO (World health organization)  to support breastfeeding. The Trump administration through the US delegation at the World Health Assembly, tried to water down the resolution. When this did not work they threatened Ecuador with a trade war. Can you say “evil empire” ? ACOG (American College of Obstetricians and Gynecologists) and AAP (American Academy of Pediatricians) have responded formally. 

Did you know as little as two months of breastfeeding reduces risk of SIDS ? 

Did you know breastfeeding reduces mom’s risk of breast and ovary cancer, heat disease, and endometriosis ? 

Did you know the US ranks 26th among industrialized countries in breastfeeding ? 

The Trump administration seems to want people off the ACA. They have reduced the “navigators” fund from 36 to 10 million per year. Navigators are those who help people enroll in the ACA. The Trump administration says private health insurance agent and brokers do a better job. Do private brokers and agents get a fee for this ? 

 

Medical News 

Abortion facts were highlighted by NBC this last week: 

Death by childbirth is 14 times greater than death by abortion. 

Banning abortion does not reduce its incidence. 

Free birth control reduces abortion rates. 

Before legal abortion, 5000 women per died through complications of illegal abortion. 

Depression is not the only feature of postpartum depression. A new review has highlighted the fact that anger is often a big component of post partum depression. 

Your microbiome is the population of microorganisms that you have on your body and in your gut. This is affected greatly by what you eat. In pregnant women this microbiome is passed to the baby. Thus, what pregnant women eat can influence the microbiome of their child, for better or for worse. Newer research in multiple fields are beginning to describe the role of a healthy microbiome to overall health. 

The US birth rate is at an all time low for the second year running. Some site child care expense, wanting to spend time with existing children and concerns about the economy as chief reasons to wait. Germany and Japan have addressed their falling birth rates by putting better child care policies in place. Falling birth rates are not necessarily a bad thing, as they are associated with greater savings and higher levels of educational attainment. It is certainly an oversimplified falsehood to think that a larger population means a better economy. 

 

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

 

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These Summer days are very busy for me and my family. So I am going to keep to an abbreviated or bullet version this summer. A little later, I’ll let you in on a fun little secret about why I am so busy. 

The biggest policy new has to do with the need to fill the vacancy in the Supreme Court created by the resignation of Justice Kennedy. The most contentious issue thus far has been abortion, Thus, all conceivable candidates are being scrutinized for their views the subject. Justice Kennedy had been a more liberal justice, and Trump has promised to install an anti abortion justice who would then contribute to the making of law for the rest of their tenure. At present, under Roe V. Wade, abortion is legal. Prior to that it was not, yet many many women and caregivers defied the law, often at great peril. My late father in law, an Obstetrician Gynecologist minted in the early 1960s remembered the days before legal abortion, and while no friend of abortion, told us cautionary tales about the complications that illegal abortions could produce. 

The ACA (Affordable Care Act) has more users now than it did last year. As of this last February, 3% more people paid for ACA plans than the prior year. This is especially noteworthy since the Fed decreased funding for outreach about the plan by 90% and halved the enrollment period. 

Starting in 2019 the Joint Commission ( a chief governing body for hospitals) will require accredited hospitals to have a newborn identification protocol. Details to follow, though we know it will require “ two factor authentication”. 

The Senate has approved 50 million dollars in funding to reduce maternal mortality. Most of this will go to the Federal Maternal and child Health Bureau to expand life saving evidence based programs. Some will also go to the CDC and some will go to Healthy Start programs for mothers and babies. 

The Senate also has approved three new bills pertaining to maternal and child well being. In particular the money will be used to reopen closed programs which aim to prevent preterm birth. 

One major piece of the maternal mortality puzzle is the lack of Obstetricians and Gynecologists. It is tough job with tough call and its pay lags behind that of similar surgical specialists. It is estimated that there will be a shortage of nearly 8800 Ob/Gyn in just TWO YEARs, in 2020. The shortage is very likely to keep growing. 

Medical News

Non-European women with ovary cancer seek genetic testing less than their peers. Genetic testing after ovary cancer may help identify risk factors for other members of the family dn may define the patient’s tumor type in such a way as to tailer its treatment and make it more effective. 

Flight attendants have been found to have a higher incidence of many various types of cancers. The findings were published in the Journal Environmental Health. It is unclear why this is the case. Theories include increased exposure to ionizing radiation, circadian rhythm disruption , or to other carcinogens. More study is needed. 

Many older women or their caregivers begin to lessen the frequency of their bone density screenings after about 65 years of age. I have never liked this approach as it smacks of marginalizing older women. Many older women begin their final decline with a hip fracture that could’ve been prevented. Now, new recommendations from the USPTF, US Preventive Services Task Force has produced evidence saying it could be worthwhile. This is true because there are many meaningful potential treatments, which when instituted, could help prevent bone fractures and the debility that those entail. 

Probiotics. They are for gut health, right ? Turns out a new study has shown that probiotics given to women protect against the loss of bone density. See the Journal of Internal Medicine. 

There are nine vaccine which pregnant women may receive. ACOg has recently released a single page list of these and his encouraging all pregnant women to speak with their physician about these. 

Smoking. It’s bad. How bad ? Well its bad enough to increase your risk of miscarriage…. even if it is just your partner who smokes ! Yes, second hand smoke from a partner is associated with an increased risk of miscarriage. 

In separate research, smoking also appears to double your child’s chances of having hearing loss. 

In clinic, most people report being active. And yet, the CDC report s that fewer than 23 % of US adults are meeting federal standards for time spent exercising. 

In rather disturbing news, over 1 in 4 girls have harmed herself in the past year, often by cutting or burning, compared to 1 in 10 boys. 

There is more good news about vitamin D. It turns about high levels of vitamin D may help prevent breast cancer. Vitamin D levels in our lab should sit between 30 and 80 to be considered normal. However, there is more and more evidence that sitting on the higher end of that spectrum may have benefits. New research has indicated that having a level near 60 confers 80% lower risk of breast cancer compared to a level near 20. Associated risk factors were depression, suicidal thoughts, buying and substance abuse were risk factors. See the recent edition os American Journal of Public Health. 

 

Oh… my fun little secret ? I am starting a traditional French Bakery and Bistro. No, I will not be baking. Yes, I will continue full time Obstetrics and Gynecology. It has always been a dream, and, along with a great team of people, I am getting to realize it. Stay tuned. We will open in late August. Visit me at 

 

bonjourbakeryandbistro.com 

 

to learn more. And...stay tuned for more news from the fascinating world of Obstetrics and Gynecology, here, next week on Medical Monday. 

 

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Gentle readers Medical Monday's reporting of last weeks news will come out soon. 

Happy Monday. 

 

 

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Efforts continue around the country to prevent changes to Title X funding. Title X funding is meant to supply federal funds for family planning and preventive health services. However, since those services have historically included birth control and abortion, the current administration is seeking to redirect these funds. In particular, the Trump administration would like to see those funds go to programs that promote abstinence only, which is not an evidenced based measure. Opponents of the changes including Planned Parenthood are arguiing that such charge are unconstitutional since they have not gone through a federal rule making process. 

The House has passed a bill allowing Medicaid to pay for inpatient drug treatment in case of cocaine and opioid addiction. The bill is contested on both sides, with some Democrats saying its focus it too narrow. 

The House has also passed more bills pertaining to the opioid crisis, mot notably by extending access to mental health and substance abuse disorder services to children and pregnancy women under CHIP, the Children’s Health Insurance Program. 

“Association Health Plans” are potentially bare bones health insurance plans which may be obtained by groups of small businesses even across state lines. The idea there is that lower cost can be achieved by forgoing benefits like birth control or pregnancy care, things which have been mandated under the affordable care act (ACA). Many feel the omission of what are now defined as “essential services” is short sighted and will contribute to the weakening of health care markets overall. 

A US District Judge has ruled in favor of two Christian Colleges to bar the enforcement of the contraceptive mandate as it applies to their University sponsored insurance. I understand that many Christians are opposed to abortion, and that many are also opposed to sex before marriage. However, what is the problem with contraception ? 

Many people are not aware of the Pregnancy Discrimination Act. It is a clause to Title VII of the Civil Rights Act of 1964 and is for the purpose of prohibiting “sex discrimination on the basis of pregnancy”. Pregnancy is a temporary disability in the eyes of the law. Violating employment law pertaining to pregnancy wold be treated like violating employment law pertaining to disability. The Act protects women not only during pregnancy, but also during “pregnancy, childbirth and related medical conditions”. 

Medical News

In England there is a public health program. In 2008, an HPV vaccination program was instituted. Ten years later, we cannot see that this has resulted in infections with the most serious HPV viruses, types 16 and 18 fell 86%. Experts speculate that the vaccine could lea to the eradication of HPV related diseases such as genital warts or cervical cancer. 

Focus on the American Maternal Mortality Crisis continues. New data continue to confirm what many have already observed, that black women die at three times the rate of white women from pregnancy related causes. May have suggested hypertension and racism are playing roles, as well as lesser access to quality care. 

New and sobering data are coming in about the common disorder we call “PCOS” or polycystic ovarian syndrome. PCO is complex of hormonal problems leading to problems with ovulation, ovarian cysts, and trouble with androgens, insulin and the processing of fats and carbohydrates. We used to think of PCO  as pertaining mainly to infertility, but PCO related infertility is quite treatable. However, now, more physicians like me are even more concerned about the downstream metabolic effects of this syndrome. The carbohydrate intolerance leads to obesity and the obesity leads to more carbohydrate intolerance. All of this leads tot higher BP and abnormal lipids, setting the patient up fro diabetes and heart disease later in life. In fact, we now know that about half of patients with untreated PCO will have diabetes before age 40. If you think you have PCO, please contact your doctor and ask to be referred for appropriate medical and lifestyle management. 

Obesity in pregnancy is known to be associated with an increased rate of a number of pregnancy and brith complications. However, it now appears, that offspring of obese mothers are considered a high risk population for endothelial cell dysfunction, meaning cardiovascular problems. In fact, either maternal smoking or obesity predisposes daughters with PCOS. When will the nation and the medical profession come to terms with the obesity epidemic ? 

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

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Policy News 

Yet another Federal Judge has put a stop to the defunding of a regional Teen Pregnancy Prevention program. This time .a district court judge in Washington, DC has ruled that that HHS (Department of Health and Human Services) must process the grant for $3 million dollars which provides for 20 health educator jobs and provides for teen pregnancy prevention education.

Many voices have come out in opposition to proposed changes to Title X funding. Title X funding is meant to ensure access to reproductive health care. However, funds are due to be cut from any provider who mentions abortion even as an option. Proponents of the measure say parenting and adoption will also be promoted. Opponents say this is being sought to placate anti-abortion elements of the electorate as well as to close programs and clinics, thus decreasing federal health care spending for those on the lower end of the socioeconomic spectrum. 

Thirteen governors have signed a “ sharply worded letter” sent to HHS secretary Alex Azar opposing the proposed Title X changes. The letter cites “reckless policy” which “upends decades of bipartisan cooperation”. 

Texas which has struggled mightily with appalling maternal morbidity and mortality, has voiced particular concern that changes to Title X could undermine efforts to combat impact rampant maternal complications in the State. 

Medical News 

Newer gene testing is allowing doctors to better target therapies to individual patients. In particular, we are now gaining insight, through genetic analysis, about which tumors in which patients are likely to respond to chemotherapy, and conversely, which are not. Gene testing is allowing some patients to skip chemotherapy and the complications that that entails. 

Also in breast cancer news, immunotherapy is being brought to bear in the fight against breast cancer. In one case study a 49 year old woman who had failed all other therapies received immunotherapy with a large clone of her own best cancer killing immune cells. These were produced by identifying and removing theses cells, and then amplifying them to 100 billion then using them as a treatment. This patient, who had no further treatment options, is now three years with NED- No evidence of disease !!! 

In similarly encouraging news a pairing of new ovarian cancer drugs have shown themselves to be effective against heretofore drug resistant ovarian cancer. 

Zika virus is again upon us in the South and authorities in Florida are taking precautions. Thus far there have been cases noted, but none have been of local origin. Zika Virus is transmitted by certain mosquitoes and is prevalent in tropical and subtropical climates such as in Florida, Central and South America. Zika virus contracted in pregnancy can make serious birth defects in the central nervous system of the unborn. 

Many women are identified as having pregnancy associated diabetes. They may require medication or dietary modification in pregnancy. New research now indicates that such patients may benefit from a postnatal lifestyle intervention program. Such women with a history of gestational diabetes are at increased risk for diabetes later in life. 

In concerning news, a new meta-analysis has indicated that hypertensive disorders of pregnancy such as chronic hypertension and preeclampsia may be associated with a higher risk of autism spectrum disorders and ADHD (attention deficit hyperactivity disorder). Women with untreated chronic hypertension, over weight women, and others have a higher risk of having hypertensive disorders of pregnancy. Maintaining normal weight and fitness before pregnancy can decrease the incidence of hypertensive disorders during pregnancy. 

A new and encouraging study has shown that resistance training helps stave off depression. Most of the exercise literature now supports the combination of light resistance training women for women, especially older women as it preserves muscle and burns fat. The combination of cardio and light resistance is often called HIIT or high intensity interval training. Low hanging fruit ! 

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

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Policy News

The “Global Gag Rule” is a rule which prohibits international health care organizations from counseling about abortion lest they lose their aid money from the USA. More recently Title X funds are being withheld from groups in the US who perform abortion or mention it as a choice. Many feel this amounts to a domestic gag rule. However, the Trump administration is back peddling, saying it only relieves Title X recipient caregivers of the requirement to mention abortion as an option. These are two very different things. I wonder which is really the case. I wonder too, if this means the Title X grant givers will requests the medical records documenting patients' visits to see what caregivers and patients are discussing. ACOG (American College of Obstetricians and Gynecologists) has called this an “egregious intrusion” in the doctor patient relationship.  Analysts point out that, additionally, these new rules will give those “health clinics" which oppose abortion and birth control easier access to Title X funds.

Medical News 

The Chair of ACOG New York has produced a guide to the Gyn annual exam for the New York Times. In it, she has explained what to expect, including the holistic nature of the visit. Many people think of the annual Gyn exam as just a pap. However, it is wellness and preventive check that addresses the overall health of the patient. Pelvic exams are performed as indicated according to protocol. Patients are also reminded about what should not take place, such as more touching than is necessary. Patients are reassured that they are entitled to an explanation for everything that is done. 

Texas is starting to take the bull by the horns. Maternal mortality and morbidity in Texas has been egregious. Authorities are now honing in on the contributing factors, and devising strategies to address it. The Texas Medical association has drawn up a list of recommendations including statewide legislation to improve health care coverage for pregnancy women, to increase access to long acting reversible contraceptives (LARCS), and to increase the quality of record keeping on maternal complications. 

Tobacco smoke from a pregnant women damages the unborn baby’s lungs (among other things). New research indicates that vitamin C may mitigate this risk. The changes from smoking do not simply harm the baby in that time frame. In utero exposure to those chemicals induce changes in the baby's genes (epigenetic change) which may persist throughout life. 

SIDS (Sudden Infant Death Syndrome) has been a worry for some time. I remember when it was first defined. At that time, we had no clue about its cause. It remains incompletely understood. However we now understand that the odds of it are greatly reduced when the parents do not smoke, and also when the baby sleeps on their back. This knowledge has given rise to the “Back to Sleep” movement which promotes putting babies to sleep on their back. We have also since learn that avoidance of loose bedding and avoidance of co-sleeping is protective. This means newborns must not sleep in the same bed with parents, despite what may seem like convenience. Nonetheless, NPR has recently reported on the disconcerting trend of increasing co-sleeping. AAP the American Academy of Pediatrics has come out again against co-sleeping which iss highly the associated with an increased risk of sleep related deaths in babies under 4 months of age. 

The Institute of Clinical and Relational Science at UCSF (University of California San Francisco) has produced research indicating yoga may help incontinence and anxiety in older women. Findings were presented at the American Urological Association in San Francisco. 

Marijuana in pregnancy is again in the news, with yet more reports coming out about its disruption of fetal brain development. It is also linked to smaller birth weights and irritable behavior in infants. It is also linked to higher likelihood of still birth. And yet, 70% of Colorado dispensaries are recommending marijuana to pregnant women for nausea in pregnancy. Conflict of interest and flagrant irresponsibility, much ? 

Lung cancer in young women has now surpassed that in men. Lung cancer in men and women has decreased over the last two decades, however it is decreasing more rapidly in men. 

There is now good data that air pollution is related to infertility and preterm birth. A new study on the subject shows that the closure of oil and coal plants boosts fertility in nearby communities. 

There’s an app for that. Maybe. There are many apps pertaining to birth control. There may even be one that can help predict the risk of preeclampsia. However, before you go relying on one of these, Please check with your doctor about the validity of such an app. Quality varies, so buyer beware. 

 

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

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