The Medical News Report

#90

July, 2019

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

Dear Readers, please read!

  CVS has plans to enlarge their stores to include dieticians, help people monitor chronic disease, and add community rooms for activities such as yoga classes. They will open 1500 locations across the U.S. in the first wave. I expect Walgreen’s and Walmart to follow suit. Big Pharma continues to increase their presence in healthcare.

  There has been a national movement for pharmacists to become more involved with management of medications (even prescribing). This is no surprise, since primary care physicians will dwindle in the future and likely be run by nurse practitioners and PAs, while there will be less access to private primary care doctors. Welcome to urgent care, doc in the box, and telehealth.

  What this means for our medical care remains to be seen, but mark my word, but the future of healthcare is being based on the selectivity of access to care by millennials (not Medicare patients), as they prefer easy access to care (in drug stores, malls, and free standing facilities) and half already do not have a primary care doctor. This is the future of healthcare as outpatients.

  Big hospital groups will surely follow suit with added services in their satellite offices. It remains to be seen what kind of care we will receive in the future, especially if we adopt single payer care (Medicaid for all). Embrace and stay with your doctors for as long as you can, because practices are filling up and many doctors are either retiring or closing their practices to new patients thanks to overcrowding, federal regulations, and changing attitudes about healthcare.   Dr. Sam

Subjects for July:

1. Temporo-mandibular Joint Syndrome (TMJ)

2. Breast cancer screening --confusing guidelines from different medical organizations—Do your homework!

3. Body tremors—Neurological diseases

4. Management of cholesterol—new updated guidelines

5. Abortion, Miscarriage, and Premature Birth in the U.S.; Pregnancy risks for older parents, maternal health

6. New medication for Post-partum Depression; Teens with IUDs (after pregnancy) not using condoms to prevent STDs

Celebrate Our Independence Day

IMPORTANT REMINDER!!!! PLEASE READ!!!

  I remind you that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your doctor, and decisions about your health require consultation with your trusted personal physicians and consultants.

  The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns.  You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding health issues. Feel free to share this information with family and friends, but remind them about this being informational only. You must be proactive in our current medical environment.

  Don’t settle for a visit to your doctor without them giving you complete information about your illness, the options for treatment, care instructions, possible side effects to look for, and plans for follow up. Be sure the prescriptions you take are accurate (pharmacies make mistakes) and always take your meds as prescribed. The more you know, the better your care will be, because your doctor will sense you are informed and expect more out of them. Always write down your questions before going for a visit.

  Thanks!! Dr. Sam

  1. Temporo-mandibular Joint (Jaw) Syndrome (TMJ)

  Jaw joint pain is very common and may present with an earache, difficulty chewing, clicking and popping with chewing, temporal headaches, and painful spasms, which can cause dizziness and ringing in the ear (Costen’s Syndrome), difficulty opening the mouth widely, and in some cases chronic pain.

  Remember Burt Reynolds? He was thought to have HIV-AIDS because of his significant weight loss. He had to come out and admit he had severe TMJ syndrome and could not chew solid food for weeks until he sought help. Having seen many cases of this syndrome in my practice, I can vouch for what a quality of life issue this is for patients seeing many patients with this issue in my practice. Seeing a motivated, experienced dentist and oral surgeon is the key to managing these cases.     

  The drawings below show the jaw joint, its proximity to the bony ear canal, and ligaments and muscles (temporalis, masseter and pterygoid) that allow the mouth to open, chew, and clinch the jaw. These anatomical structures are why many of the symptoms occur.

Notice there is an articular cartilage present in the joint (above drawing) that cushions the jaw bone in the jaw socket (glenoid fossa) of the temporal bone of the skull and also allows the jaw joint to slide forward and backward. Loss of this cartilage (just like in the spine) sets up real trouble and can create dental malocclusion and pain. The upper and lower teeth need to be in good alignment for the jaw joint to fit perfectly in the joint. This is called equibration of the teeth, and dentists should always check for this (they have you clamp down on that purple paper to check where the teeth strike each other).

  For the jaw to open, the jaw bone needs to slide forward on that articular cartilage with relaxation of the jaw muscles surrounding the jaw seen in the drawing above and below. Notice the jaw joint slides completely out of the fossa when opening wide.

It is very important to analyze how the jaw joint functions with opening and closing the mouth. The above drawings show how the jaw bone actually moves out of the fossa (the indentation in the skull) and back in.

  Dislocation of the jaw (lockjaw) may occur requiring skilled manipulation to return the jaw back into the joint.  

  Injury to the jaw joint can occur from being hit by a fist, in an auto accident or any blunt trauma to the side face or mandible. Over time arthritis of this joint also can occur.

Rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, and psoriatic arthritis can also occur in the TMJ.

  Grinding (bruxism) or clenching the teeth during sleep (stress induced) also can cause undo pressure over time causing inflammation and arthritis.

  X-rays (panalipse) of the jaw should be taken to evaluate the entire jaw for abnormalities.

A CT scan can evaluate the jaw joint best, however, an MRI can be used to evaluate if the jaw is in proper position with movement.

Prolotherapy for pain relief

Interesting treatment

  Thought to be a sham treatment in the past, injecting irritating fluid into the jaw joint, supposedly helped TMJ pain in a double blind study reported by the Mayo Clinic in May, 2019.

  Injecting 20% hypertonic dextrose (sugar) plus lidocaine was injected into half (21) of the patients and the other half (21) lidocaine alone. These patients had an average pain level of 8 (out of 10).

  After 3 injections (once a month), those with hypertonic dextrose injections had an average drop in pain 3-4X better than the lidocaine group including 3X improvement in function of the jaw (chewing, etc.).

  The presumed mechanism is thought to occur from the irritant that creates formation of a cellular reaction layer which covers the joint surface and helps with movement of the joint and relief of pain. This study is isolated and must be reproduced before considering it an acceptable treatment in patients. Mayo Clinic Proceedings, May,2019   

Many dentists specialize in various aspects of dental care, and oral surgeons (sometimes called maxillofacial surgeons) along with orthodontists are necessary to treat these patients if resistant. ENT surgeons often play a role especially in diagnosing these patients.

  Most patients can be treated with dental treatments (crowns, bridges, braces) including a night splint especially those who clench or grind their teeth, anti-inflammatory medications (NSAIDs—ibuprofen, Aleve, etc.), heat and ice packs, soft diet, avoid hard foods or chewing ice, and mild stretching exercises opening the mouth to relieve spasms in the jaw muscles. Even anxiety medication (Valium) may help to relieve stress, as anyone under stress may grind or clench their teeth.

  Night splints or guards can be made by your dentist, although, there are splints that can be purchased at the drug store, but are inferior to the dentist’s splints.

  Physical therapy using massage and TENS units (electrical stimulation) may be helpful. Ultrasound treatments, and trigger point injections (with cortisone) may also be helpful. Radiowave treatments may also be helpful.

Surgical treatment

  Addressing a deformed or previously injured joint may require actual surgical treatment, including endoscopic management of abnormalities. Although most can be treated more conservatively, those who need more aggressive treatment must see someone experienced in this specialized problem.  

Congenital deformities—Under or Overbite of the jaws

  Patients with asymmetry of the face, short or long lower jaws commonly will have TMJ syndrome. Surgery to address these jaw deformities is called orthognathic surgery and will help the jaw joints function more properly and address facial deformities.      

Overbite

Underbite

Overbite and Underbite deformities

  To define whether the face had an over or underbite deformity, requires looking at the position of the midface and upper teeth. Thus if the midface (maxilla) (not the mandible is projected too forward compared to the lower jaw, it is termed overbite deformity. By the same token, if the midface is shortened, it creates a lower jaw that appears too prominent, this is called underbite deformity.

  There are times a chin implant can be placed for more minor short lower jaws or the prominent lower jaw can be shaved down (I performed many of these procedures in conjunction with rhinoplasties and face lifts with liposuction-see below), however, if the jaw joints are involved, more aggressive orthodontic and or orthognathic surgery may be necessary.

Orthodontic braces are usually required in addition to actual surgery to move the lower jaw forward or backward.

  Orthognathic surgery to position the maxilla and or mandible in harmony so that the teeth fit in a normal position is the goal of this type of surgery. If braces are insufficient to correct the deformity, it involves an  osteotomy (special cut in the bone) of the mandible (lower jaw) to slide the lower jaw forward as seen in the left photo. This is to correct an overbite as seen in these drawings.

Underbite deformities  mandible projects forward of the maxilla. This is called a prognathic jaw. Note the lower jaw is cut and moved backward to shorten the jaw as shown in left lower drawing. The right photo demonstrates a before and after.

The proper placement of the facial and jaw bones will also place the jaw joints in correct position.

  Most of these patients will wear dental braces for some time to get the teeth to fit correctly followed by splints at night.  

  Many of these deformities should be addressed as a child, because orthodontic treatment will prevent these deformities from worsening and can prevent serious facial deformities and TMJ problems.

  A gummy smile is caused by an elongated upper jaw and requires surgical removal of some of the front part of the maxilla (upper jaw) plus braces. Below is an example!

2. Breast Cancer screening guidelines—medical organizations differ—Do your homework!

  I have spent the past several years working on the screening guidelines for the major cancers with the National American Cancer Society. Every 5 or so years cancer screening guidelines need to be reviewed and edited based on new evidence from the medical literature. These guidelines are designed for the general healthy population without significant risk factors.

  Currently the ACS is working on guidelines for breast cancer screening for high risk women because of new genetic information and other factors on risk. We now know that genetic mutations, dense breasts, family history, and other risk factors can increase the risk of developing breast cancer.

  The American College of Physicians recently presented their guidelines for breast screening with a significant change in breast cancer screening for normal populations that goes against some of the current recommendations for women developing breast cancer.

  Since healthcare reform began, the medical literature has been bombarded with articles from federally funded research about the harms of testing which is important to understand when considering screening.

  Obamacare implemented better coverage for cancer screening with no copays to increase the numbers of screening.

  It is appropriate that doctors discuss the benefits and risks of screening when contemplating any medical test or procedure.

  The broader the guidelines, the more people get tested, but it also increases harm from screening, including unnecessary biopsies and anxiety for patients. And no test is 100% accurate.

  Some spots on a mammogram may look like cancer and must be biopsied, but in fact, are not cancer. That is termed a false negative test. Some biopsies can be difficult to tell cancer from precancerous lesions (carcinoma in situ), and if they are diagnosed as cancer and in the end are not cancer, this biopsy is called a false positive test. Either way, patients have to have procedures to prove or disprove whether cancer is present or not.

  Screening should equate with saving lives, and in most cases, they do. But we also now know much more about cell types of cancer, and some are now known to be more slow growing and less aggressive. Many patients will die from other diseases before a cancer could cause death. Prostate cancer is the best current example, and many of them are now being followed rather than treated, especially in older patients.

  The American College of Physicians (ACP) just published their new guidelines on breast cancer screening

These guidelines differ from other cancer organizations.

The CDC has a chart showing the difference in recent guidelines for breast cancer screening from the different major medical organizations:

www.cdc.gov/cancer/breast/pdf/BreastCancerScreeningGuidelines.pdf

  The ACS and other organizations have found in the medical literature that more women are developing cancer earlier (colon cancer too), and certainly women need to have a frank discussion with a well informed primary care doctor to decide screening earlier than 50. Some organizations (including ACS) recommend routine screening at 45 for the low risk woman in contrast to the above ACPs guidelines.

  Also, stopping routine screening at age 75 is somewhat in vogue, but is associated with those who have less than a 10 year survival expectation (average age of death for women is 80). We are dependent on national longevity statistics, and we certainly know women can develop breast cancer after 75, but we also know women are living well into their 90s. Therefore, having serious discussions with a person’s doctor is a must when discussing cancer screening for the normal population. If a woman has a higher risk, then these guidelines do not apply.

  As genetic information helps us to decide who should be screened earlier than others, some of these answers will be clearer in time, but for now, do your homework and insist on a session with your doctor about screening.  Know the pros and cons of any test, exam, or procedure and know the risk factors such as the BRCA gene, family history in mother or sisters, dense breasts, etc.  

3.  Essential Tremors

  Demographics

  1% of the worldwide population have tremors. Although these tremors can begin in childhood, most begin in the 6^th decade (equally in men and women). If these tremors begin after 65 years of age, there is a greater likelihood of developing progressive physical and cognitive conditions and may be the first symptom of an underlying neurological disease.

  Tremors are an involuntary and uncontrolled oscillation of one or more parts of the body. It can occur in the hands,

arms, head, face, voice, abdomen, and legs (hands most common).

Causes of tremors

 1-Tremors can be caused by neurological diseases, such as multiple sclerosis, strokes, and brain trauma.

  2-Neurodegenerative diseases such as Parkinson’s disease can also cause tremors.

  3. Alcohol or drug abuse.

  4. Side effects of medications and stimulants (antidepressants, corticosteroids, asthma meds, valproate-an anticonvulsant, sympathetic stimulants-adrenalin, dexadrine, etc., and lithium), caffeine, mercury poisoning, etc.

  5. They can be innocent and hereditary.

Areas of the brain that regulate body movement

The Thalamus and Cerebellum can be involved

  The brain’s thalamus (located between the cerebral cortex and the midbrain) has several functions—relaying sensory information and motor functions, and regulation of consciousness, sleep, and alertness. A specific area of the thalamus is mostly involved in body movement—the subthalamic nucleus, which is very near where the substantia nigra is located (the area which is abnormal in Parkinson’s disease).  

  The cerebellum lies at the posterior base of the brain and also is necessary for balance and body movements.

Symptoms of tremors

  Symptoms include rhythmic movements of the hands, head, arms, legs, or torso; shaky voice; difficulty with writing or drawing; problems with handling utensils.

A tremor is diagnosed basically in three ways:

   1- Whether the muscle movements occur at rest or in an  action.

   2- Where the tremor occurs, and if it is on one or both sides of the body.

   3-  The tremor frequency and how strong.

Different tremors

  There are different ways to differentiate tremors—the medical literature uses this nomenclature—

1-Essential tremors vs. essential tremor plus

2-Intentional vs. unintentional tremors.

  1- Essential Tremor vs. Essential Tremor Plus 

  The International Parkinson and Movement Disorder Society differentiates these two groups. It usually begins in middle age and usually affects the hands.

    a) Essential tremor

  This is a syndrome with isolated movements of both upper extremities lasting 3 years with or without tremors in other areas of the body such as the head, larynx, or lower extremities. These tremors do not have other neurological signs. This is often a hereditary condition (autosomal dominant). These are considered inconsequential in most cases.

    b) Essential tremor plus

  In contrast, essential tremors plus may be associated with additional mild neurological symptoms and signs such as ataxia (difficulty walking with imbalance), posturing of the extremities, and memory difficulties. This syndrome  would include dystonia, Parkinson’s disease, and other forms of ataxia.

  2- Intentional versus Unintentional tremors.

   Intentional tremor implies that there is a tremor that is not present until the hand tries to pick up a glass (for instance), and then the tremor begins which makes using the hand difficult to use. Once the glass is put down, the tremor stops. This intentional tremor is the type seen with an essential tremor.

  Unintentional tremors occur at rest and continue until the person tries to use the hand to pick up that glass. When they do, the tremor goes away while holding the glass. This occurs in Parkinson’s disease and this disease was discussed in this previous report; click on:

Neurochemistry of tremors

  The latest research on tremors indicates the abnormality for some essential tremors comes from dysfunction in the cerebellum of the brain.

Magnetic resonance spectroscopy has revealed that there is a chemical deficiency in the cerebellum called n-acetyl-aspartate. Other studies has shown decreased numbers of Perkinje cells in the brain that show abnormalities. There have also been reports of increased levels of GABA (gamma-aminobutyric acid), a neuroreceptor. There also appears to be increased cerebellar metabolism with rest and decreases with arm movements.

10 most common Causes of Tremor  

1. Essential Tremors—The term “essential” implies the cause is unknown when the tremor first starts (midlife) and is the most common type of tremor.

  It can occur from a disease in the thalamus and the cerebellum. The tremor is the central sign of the condition and not associated with other diseases. These are also known as intentional tremors (tremor comes on when reaching for an object) reaching as described above and are brought on by emotional and physical stress. The hand is the most commonly affected and makes it difficult to pick up objects.

2. Parkinson’s disease, a neurodegenerative disease is the most common disease that creates the unintentional tremor. They have the classic “pill rolling” movement at rest, but when they reach for an object the tremor goes away and they can grasp objects. This is a tremor at rest. Parkinsonian tremors can occur with drug users, and those with neurological infections. 70% have tremors.  Parkinson’s disease patients:

Muhammad Ali’s Parkinson’s disease was caused by constant trauma to the brain as a professional boxer.

3. Physiologic tremors are caused by stimulants such as caffeine, low blood sugar, and drug withdrawal. They are  relieved by getting rid of the stimulant or issue causing the tremor.

4. Dystonic tremors are caused by contraction of the muscles. Medications are necessary to relieve these tremor including Botox injections into the muscle contracting. Common causes include eyelid spasms (blepharospasm) and torticollis of the neck muscles.

5. Psychogenic tremors are caused by the sudden onset of stress.

6. Orthostatic tremors occur when one stands up causing uncontrollable contractions in the lower extremities.

7. Cerebellar tremors are unintentional tremor much like Parkinson’s, but can be caused by other diseases in the cerebellum.  

8. Rubral tremors can occur from strokes and cause sudden and uncontrolled body movements, and fortunately are rare.

9. Intention tremors occur from neurological diseases such as multiple sclerosis, brain tumors, and neurodegenerative diseases. These occur when the person moves with intention to pick up an object but can’t. (this is opposite from the unintentional tremor of Parkinson’s disease.

10. Palatal tremors occur when the soft palate in the mouth and head and neck musculature contract rhythmically, most common seen in brain hemorrhage or trauma to the brain.  

Special test to detect Parkinson’s disease

  There is a test that distinguishes Parkinson’s disease from an essential tremor (a computed tomogram using the  isotope I-123 ioflupane) which measures the level of dopamine (a neuroreceptor chemical) in the brain.

  These studies are used to distinguish different categories of tremor including rhythmic cortical myoclonus, functional tremor and enhanced physiologic tremor.

I have reported on Parkinson’s disease; click on

www.themedicalnewsreport.com/54

Treatment

  Treatment depends on the diagnosis and severity of symptoms. Three categories of treatment are available: medications, surgical, and non-surgical

1) Medication—propanolol and primidone

  Propanolol is a beta blocker (a heart drug)--120-240mg daily. Side effects can be slowing of the pulse and bronchospasm, therefore, asthmatics cannot take this medication.

  An anti-seizure medication such as Primidone at doses of 250-750mg daily can reduce the tremors by 60%. It is used when the beta blockers don’t work.

A combination of both drugs may be necessary.

Benzodiazepines (tranquilizers) such as alprazolam and clonazepam.

Parkinson’s drugs including levo-dopa and carbidopa, and dopamine agonists (Miraplex, Apokyn, Neupro skin patch, and Requip). There are new drugs that help when Levodopa quits working or symptoms break through (Xadago, Comtan, and Tasmar). There are drugs that slow down the breakdown of Levodopa (Azilect, Eldepryl, Emsam, and Zelapar).

Botox injections are used most effectively in head tremors. It can be used in almost any tremor but most effective in dystonic tremors. After radiation to my neck for a throat cancer in 1991, the nerves to my neck muscle (platysma) were damaged and when they grew back over the years, they created spasms that could draw my head down, which is called torticollis (mentioned above). Botox injections worked for about 3 months at a time. After a couple of years of those injections, I had that muscle cut and it took care of the spasms permanently. I had a dystonic tremor.

2) Surgical treatment (thalamus)

Needle placed in thalamus

Deep brain stimulation or a sterotaxic thalamotomy (similar to treatment for Parkinson’s).

  The thalamotomy targets the part of the brain called the thalamic nucleus ventralis intermedius. Deep stimulation appears to be more successful. These are recommended in medical treatment failures and are effective in selected patients, although symptoms can return after a few years. Adverse effects of deep brain stimulation include dysarthria (slurred speech), ataxia (difficulty walking), parasthesias (numbness and tingling), and impaired balance.

3) Ultrasound thalamotomy

  A MRI guided focused ultrasound thalamotomy treatment has been approved by the FDA and has been mostly successful in a small study of 76 participants. This is considered by some authors as a good second choice to deep brain stimulation.

  4) Physical and speech therapy is very necessary to focus on strengthening of various muscles involved.

Prognosis 

  Although not life threatening, social disability is a real problem for some. And if the tremor develops after 65, there is an increased risk of developing a neurodegenerative disease. Essential tremors do usually worsen with age.

  For more information, contact these websites:

The National Institutes of Health and Michael J. Fox Foundation  www.michaeljfox.org and www.ninds.nih.gov

NEJM, May 10, 2018  (New England Journal of Medicine)

  Activebeat.com

  www.ninds.nih.gov/Disorders

4. Cholesterol management—updates on new guidelines

  Elevated fats (cholesterol) in the blood cause cardiovascular disease, fatty liver, etc., and I have reported on this subject several times, including the basics and treatment, however, there are always updates that need to reported. Previous reports:

www.themedicalnewsreport.com #24 and #55

  Triglycerides are another type of fat that is important for cardiovascular disease, and many who have a hereditary elevation also have high cholesterol, but cholesterol is the key to cardiovascular disease, plaque formation in arteries, blockage of vessels with resulting serious consequences wherever they are blocked (brain, heart, extremities, gut, etc.). Triglycerides are treated with Omega 3 fatty acids (4 grams a day). Diet is always important. Triglyceride levels can be extremely high and need to be maintained at 150mg.dl.

  The statin drugs have revolutionized treating cholesterol. There are even more recent drugs to treat resistant cholesterol called (PCSK9) inhibitors (extrememly expensive). The LDL-cholesterol is the bad cholesterol and HDL-cholesterol is the good one. Most patients should maintain LDL-cholesterol at or near 100mg/dl. And if there is active cardiovascular disease, a level of 70mg/dl is best.

  Recently cardiologist use CT scans of the coronary artery to estimate the amount of calcium in the vessel wall (Calcium score), which is another way to estimate potential future coronary disease. Doctors like to see a score of 100. It, however, does not diagnose narrowing or blockage of a vessel.

  Another important drug if the cholesterol can’t be reduced to 100mg/dl is ezetimbe (Xetia—pronounced zetia) to lower cholesterol even further. Ezetimbe (Xetia), a fat blocker in the gut, can be effective especially in those with cardiovascular disease and the *metabolic syndrome (defined in bullet 2).

  These guidelines are used by clinicians to reduce the risk of cardiovascular disease. Diabetes is one of the most potent risk factors for CV disease. Read these bullets below.

NEJM-Cardiology, Dec 5, 2018

5. Abortion, Miscarriage, Premature Birth; Pregnancy risks in older parents

 A. Abortion

   Few subjects polarize this country faster than the subject of abortion. Since Rowe vs Wade (1973), which allowed abortions,  the dignity of life has been altered by the U.S. Supreme Court and created one of the most controversial issues in this country. Now the Hyde amendment is causing controversy (federal funds for abortion). Abortion restrictions abound in most states. Funding has been cut to Planned Parenthood in many states, and only 22% of reproductive age women live in states considered supportive of abortion rights. Abortions in the first trimester cost about $500 and are usally paid for out of pocket. As of June 1, 2019, 26 abortion bans have been enacted in 12 states with many more states to follow.

  While in medical school, I had rotations in OB/GYN and had to deal with difficult issues regarding preserving both mother and baby. There are difficult decisions in certain cases when, early in a pregnancy, because of the health of the mother, termination of the pregnancy was necessary. This was always a decision made by the senior staff.

  Abortions were performed similar to a D&C. Dilation of the cervix was followed by scraping the contents of the uterine wall. Later abortions involve some form of suction device.

Trimesters defined:

Maternal Health

  An interesting 5 year study (5000 participants) found that those who had an abortion (compared to those who waited too long to have an abortion and were refused), were healthier physically long term. Average age was 25, with 1/3 blacks, 1/3 whites, and 22% Hispanics, most of which were unmarried. 20% reported their pre-pregnancy health as fair or poor. 1/3 were below the poverty level. ¼ reported depression and anxiety. 

  Those who were forced to have their baby did have poorer health outcomes citing migraines, headaches, and joint pain as the most common complaints. Those who choose to seek an abortion need to seek consultation as quickly as possible (instead of being forced to have a baby because they waited after the first or second trimester).

  1 in 20 women cite concerns about their own health as a reason for abortion.   

Annals of Internal Medicine, June, 2019

Comment: Why are these women not on birth control? Do they consider their overall health prior to getting pregnant? Have they seen a primary care professional in the last year? Preparing for pregnancy is just as important as preparing for a major surgery. Responsibility for our health starts with the individual. Poor should not equal irresponsible. No wonder the U.S. has poorer birth statistics. Education can only go so far.

Planned Parenthood (PPF)

  The American Birth Control League started in 1921 changed its name to Planned Parenthood in 1942. It was formed to help women have support in a time when women needed assistance with making hard decisions such as abortion.

  It operates 600 health clinics across the U.S. The organization reported seeing 2.5 million patients annually. Adoption was clearly in mind until the Supreme court changed all that. This has coincided with the women’s movements in this country and clearly women have rights over their own body, but the fetus has rights too. This has created an enormous issue for America.

  Services from Planned Parenthood include abortion services (324,000 annually), birth control, the morning after pill to prevent pregnancy, general healthcare including screening services, for women and men’s services to address cancer (1 million cancer services), fertility, sexual dysfunction, birth control (3.6 million services), routine checkups, general health issues including STDs, sexual and reproductive health. HIV services and LBGT services including hormone therapy and transgender services. Pregnancy testing, pregnancy care, STD testing, safe sex education, and vaccines (HPV-Gardasil) are also available. Pelvic exams and cancer screening is also available. About half their revenue is derived from the federal government, primarily Medicaid. Their workforce is primarily volunteer. 16% of their patients are teenagers. A total of 9.5 million annual services are reported.  

  Since 1955, abortion reform has been strongly supported by PPF. Their advocacy efforts are well known and spent $6.5 million in campaign contributions to Democratic candidates in the last election cycle.  

   Lets face it, it was time that women deserved equality, and with that came even more emphasis in women taking charge of their health and making decisions about it. No one should disagree with that. Religious beliefs and the rights movement, also brought light on the fetus’ rights.  

  Access to abortions until recent decades was performed by abortion clinics which stirred emotions beyond belief. Clinics were bombed (even in Pensacola where I lived), people were murdered (Atlanta bomber), and chaos was high. Because of the abortion issue, the other helpful services are overlooked by those who oppose abortions. Sad!

  Abortions for those who have been raped, cases of incest, or in cases of an incompetent mothers for one reason or another is where many have the hardest time deciding which side of the issue they are on. I am sorry it has polarized our thinking about women’s health.

  Stem cell research came along and aborted fetuses were used to obtain cells by PPF until it was discovered that  stem cells could be obtained in other ways. Another hotbed of controversy!

  Access to abortion is not as easy as it may appear. In a recent report in the Journal of OB/GYN, only 24% of OB/GYN doctors surveyed provide that service. Only half of them provided medication abortions (mifeprestone and misoprostal)—95% effective in the first 49 days of a pregnancy, which provides a safe and effective method even in the second trimester. It creates contraction of the uterus and opens the cervix to some extent to assist release of the fetus. Cost is more than $200 per dose.   

Recent state decisions on abortion

  Those who believe life of a human begins from conception or as soon as a heart beat can be found on ultrasound (6-8 weeks), all techniques of abortion are totally unacceptable. Alabama is in the process of making any abortion illegal as are a few other states, but are being challenged in court. Other states banning abortion after 6 weeks include Louisana, Georgia, Kentucky, Mississippi, and Ohio. Missouri is in the process of closing the only abortion clinic in the state. Alabama also included language that would send any doctor performing an abortion to prison for up to 99 years. The Virginia Governor (a physician) stated that infanticide was acceptable even after delivery. These more radical ideologies have really stirred controversy, and it is clear Row vs Wade reform is the ultimate target.

  New York has legitimized infanticide, therefore, the fight will escalate and has raised the bar on emotions and once again aided in polarizing our country even more and will play a significant role in the 2020 presidential election.

  Kentucky passed the Ultrasound Informed Consent Law that was upheld the U.S. Circuit Court of Appeals that requires females seeking abortion to visualize their baby with an ultrasound and hear the heart beat of the baby before consenting to the abortion. The AMA fought this unnecessary law stating that it underminds the patient-physician consent conversations. If the patient refuses to see the ultrasound or listen to the heartbeat, the physician still must share it or face fines and report to the medical licensing board. AMA News June 17, 2019  NEJM, June, 2019

  Late term abortions are much more hazardous for the mother. This is defined as 14-24 weeks of gestation. Beyond 24 weeks is ill-advised by the medical community. Proper counseling and decision making should always occur as soon as possible, however, there are women who do not even realize they are pregnant for months.

  Late abortions are usually considered when a woman finds out there are serious congenital defects in the fetus or when genetic testing implies these defects. Patients may be diagnosed with cancer, which would require chemotherapy and likely cause a spontaneous abortion. Delaying chemo until after the pregnancy may likely influence survival of the mother. These are very difficult decisions to make. It is hard to separate intellect, religious beliefs, and personal experience when discussing abortion.

  In 2018, over 1 million abortions worldwide were performed according to WHO*, although the number is much greater with an estimated 40-50 million abortions performed annually (125,000 abortions per day world wide). That makes abortion the number one cause of death worldwide.

*World Health Organization

  Planned Parenthood was not formed to provide abortions. It was created to counsel women about being pregnant and making educated decisions about what their health options are. Abortion services are contracted out. Many wonderful women’s services are however made available by PPF and should not suffer because of the abortion issue.     

  2% of women between the ages of 15-44 have abortions in the U.S. resulting in 25% of pregnancies being aborted whether planned or unintentional. Abortions after 20 weeks often have medications injected into the amniotic sac to kill the baby and create a stillbirth. Death rates for mothers increase after 16 weeks.

Viability of a fetus and preterm babies

  This term defines when a baby has developed enough maturity to sustain life outside the uterus. This is usually defined as the 23^rd week. 24 states outlaw abortion after the 23^rd week and 5 states forbid third trimester abortions. Some states allow late term abortion to save the life of the mother. Now New York has essentially made it legal to kill a baby even after birth.

B. Miscarriages

Losing a baby in early pregnancy is a terrible experience for the whole family. 10-25% of pregnancies end up in miscarriages. Second trimester miscarriages usually occur because of an underlying health condition of the mother.

  Symptoms include cramps, abdominal pain, bleeding, vaginal spotting, and expulsion of blood clots and fetal parts.

  Types of miscarriages are noted above. Miscarriages also can occur in an ectopic (tubal) pregnancy as well.

  Most first trimester miscarriages occur usually because there are developmental abnormalities of the fetus. 50% of miscarriages have chromosomal abnormalities. Problems with the placenta can also cause miscarriage.

  Molar miscarriages occur when both sets of chromosomes come from just one parent.

  In cases of multiple miscarriages, men must be tested too, because there are factors such as genitourinary infections, varicoceles (abnormal blood vessels around the testicles), scrotal heat, and obesity that increase miscarriage rates. Some of these cause reactive oxygen species in the seminal fluid with DNA fragmentation in sperm. Older men have DNA sperm issues more than younger (37 plus) and lower testosterone levels. More research is needed for males regarding this issue.  

  Low amniotic fluid levels in the fetal sac occur in 8% of pregnancies. They are indicators of trouble with the baby especially congenital kidney abnormalities, but any number of anomalies may occur. The placenta does not provide adequate blood supply to create adequate amniotic fluid. Later in pregnancy, low levels may occur from leaks of the fluid. Late birth pregnancy can also create low amniotic fluid levels. Dehydration, hypertension, pre-eclampsia, and diabetes may also contribute. Early low levels may compress the fetus in utero causing birth defects. Also it increases stillbirth and miscarriages. Later, it can cause intrauterine growth restriction, preterm birth, cord compression, and require a C-section.

  In certain cases, fluid can be injected into the sac to restore more normal conditions.

  As high as 20% of pregnancies have some vaginal spotting or bleeding, but less than half of the women will have a miscarriage. Even women who have had 3-4 miscarriages, 75% will still go on to have a normal term pregnancy.

  Pregnancy hormones must be tested to confirm a viable fetus. More than half of miscarriages have chromosomal abnormalities which can be tested with a sample od amniotic fluid (amniocentesis). X-rays and ultrasounds are necessary.

C. Premature births

  Being born before the 37^th week defines a premature birth. Over 4 million (1 in 8) premature babies are born in the U.S. each year, and require intensive care in a high percentage, with overwhelming cost.

Pot smokers

  Now that pot smokers abound, studies are beginning to appear regarding pre-pregnancy use of marijuana. A study in JAMA in June, 2019 cited a 12% rate of preterm births compared to 6% in non-users. Cannabis is frequently used even during pregnancy (7% of women) and there are still tobacco smokers who are pregnant (10%). With legalization, it is assumed the rate of use and preterm births will increase. The American College of OB/Gyn recommends pregnant women discontinue cannabis as soon as they know they are pregnant.

  Cannabinoids easily cross the placental barrier. This study cited other studies that pre-pregnancy users have increased stillbirths, lower birth rates, and an increased admission to neonatal ICUs. There was a slight decrease in pre-eclampsia and hypertensive disorders in pregnancy, and possibly diabetic episodes, so not all bad news!! More research is badly needed.

  Some of the causes of premature birth are pre-eclampsia with hypertension, premature rupture of the fetal sac membranes, diabetes, fetal growth restrictions, etc. resulting in a higher incidence of neurologic fetal abnormalities, handicaps, cerebral palsy, vision and hearing problems, breathing problems, etc., with a higher death rate.

  Family genetics can cause prematurity. Smoking increases the risk, and having an older father as mentioned also as a risk factor. Intrauterine infections and maternal illnesses and substance abuse all play a role.

  Prenatal care and education is key to prevent these issues if at all possible. Proper nutrition, and vitamins (folic acid) are very important to prevent any pregnancy related issues.

D. Pregnancy risk in older aged parents

  The trend today for white professionals is have babies later in life when it is more convenient for their careers and income. While most women physiologically slow their clock in their 30s, men keep going. Since the 1970s, the percentage of births to fathers over 40 has doubled and by 2015, 9% of births had fathers over 40.

  The problem is there are increased difficulties with births as age advances advancing far beyond the concern of mongolism, to include increased congenital diseases (dwarfism and psychiatric illnesses such as schizophrenia, bipolar disorder, and autism). There is an increasing risk of premature births, low birth weight, low *Apgar scores, and risk of seizures, as well as the chance of the mother chances of gestational diabetes. BMJ, 2019

*Apgar scores=defining health of the baby 1-10.

  Although older women are meticulously screened for possible birth issues, father frequently are not and should be. Semen quality, DNA abnormalities, volume of semen, motility of sperm slows, and other issues that increase risk.

  Smoking, obesity, chronic diseases, alcohol consumption, and other diseases can also affect the viability of a pregnancy.

  Of course, there are potential benefits having children later in life, such as financial security, more time spent with yonger children, attend more events with children, a greater appreciation of being a parent, more life experiences to share with children, more stable relationships.

  This also is countered by generation gaps, kids with older parents get bullied, diseases in parents, taking care of elderly parents while having younger children, and children’s grandparents being very old. Fatigue in older parents and being set in their ways can also be obstacles.  Verywellfamily.com

6. New medication for Post-Partum Depression; Teens with IUDs after pregnancy are not using condoms to prevent STDs

Post-partum Depression

  A new medication has been FDA approved to treat severe post-partum depression, called brexanolone (Zulresso). 1 in 9 women suffer from this debilitating disorder. Symptoms include sadness, anxiety, depression, agitation, loss of appetite, pessimism, cognitive difficulty, sleep difficulty. and self-harm including suicidal thoughts. It occurs more commonly in younger mothers 19 and younger.

  This medication is a type of gamma-aminobutyric acid (GABA), a major central neurotransmitter inhibitor. Its main role is to reduce neural excitability. It is also responsible for muscle tone. It can be taken as a dietary supplement, and also exists in fruits, vegetables, teas, and red wines. Now that is recommended as an IV treatment, it has been FDA approved. Before it was not approved, and the research is still sketchy regarding effectiveness as a dietary oral supplement. WebMD warned patients about taking it if they have high blood pressure.    

  Zulresso is administered in the hospital over a 3 day period in a certified facility by experienced clinicians. It rebalances the female hormones which is thought to be the cause of the syndrome.

  True post-partum depression is different than the “baby blues”.

  This medication is still very new and even though they have had a clinical trial for 900 women showing major improvement, it is certainly a drug treatment that must be discussed with a OB/GYN specialist who uses this specific treatment in a certified hospital facility treating post-partum depression IV over 3 days. The cost is said to be $34,000, and I suspect insurance will not cover this treatment until its use is much more validated.

Teens after pregnancy with IUDs not preventing STDs

  Education seems to be failing for pregnant teens who are given IUDs or other forms of long acting contraceptives shortly after delivery do not insist on their partner using condoms to prevent STDs (sexually transmitted diseases). Providers and parents are not educating these women sufficiently and need closer follow up with these young people that pregnancy protection does not mean venereal disease protection.

  The Journal of Pediatrics and Adolescent Medicine in May, 2019 cited a study that found half of these teenagers are not protected from STDs. The STD epidemic continues because of poor education, lack of motivation, and poor followup in these patients.

  Parents and even friends of these girls and women should bring up the subject if they are sexually active.

This completes the July, 2019 report. Next month, the August report will include:

1) Low back surgery—new developments

2) Migraine headaches

3) Impulse disorders

4) Medical Updates (measles, mammograms, gluten, healthcare, Medicare for all)

5) Health Fads, Failures, and Fixes

6) Drug crisis update

Stay healthy and well, my friends, Dr. Sam