Tuesday, October 17, 2017

Showing Migraines Who's Boss

At least one in four women suffer from migraines, a staggering number with a not so flattering history. Women who suffered from migraines in the past were considered incapable of coping with stress or suffering from hysteria. Luckily, this ignorant perception was quickly shattered once individuals realized that migraines were debilitating headaches with causes outside of "women being women." Although the exact specifics are still unknown, factors like genetics and environment are known to play a definite role. Also, changes in the brainstem, trigeminal pathway, hormonal influences with hormones like estrogen and serotonin have all been associated with migraine development.
The good news is that instead of curling up in your bedroom, void of any light, there are things you can do every day to prevent or at least reduce the extent of your next migraine! The first is by watching your diet; there are certain foods that may trigger migraines, including aged cheese, salty foods, excessive sweetness, wine, and caffeine. Stress, bright light, changes in sleep cycle and environment can also be triggers. So what can you do, you ask?  Eating these trigger foods in moderation is ideal in conjunction with a high ketone diet. A ketogenic diet is a low carbohydrate diet that helps reduce migraines by blocking high concentrations of glutamate, which is found in migraines and epilepsy. Moreover, the healthy fats found in this diet may also lower cholesterol, hitting two birds with one stone.
Regular exercise also can help to prevent migraines, especially aerobic ones like walking, swimming, and cycling. Ultimately, leading a healthy lifestyle with a regular schedule can greatly help to ameliorate migraines. Here's to beating migraines one day at a time!


Meghana Pisupati
IHS 2018

Monday, October 2, 2017

Cancer Screening in Transgender Individuals


Last year, one of our 4th year Pathway students (Kelly Guttman) created a very informative presentation on Cancer Screening Health Disparities Among Transgender Patients – a topic worth revisiting here.  Many transgender individuals have had negative experiences with the healthcare system, often due to discrimination and lack of provider knowledge.  Many healthcare providers dont know how to screen transgender patients for potential cancers so they are often overlooked.                                                                                                                                                                                   Bottom line:  If they have the “part” (e.g. breast, cervix, prostate), check it!
CERVICAL CANCER
Approximately 80% of transgender men [female-to-male (FTM) patients] have a uterus and cervix and therefore need screening.  Unfortunately, being transgender has been associated with 37% lower odds of being up-to-date with recommended cervical cancer screening.  Inadequate Paps have been over 8 times higher among transgender men, likely due to a combination of factors including histological changes induced by testosterone and patient/provider discomfort. 
BREAST CANCER
Approximately half of transgender men have surgery to remove their breasts while 80% of transgender women [male-to-female (MTF) patients] use estrogens to help grow the size of their breasts.  MTF patients taking exogenous estrogen and androgen antagonists develop breast tissue histologically identical to that of a cis-gender female.  Although studies have failed to show that MTF patients taking exogenous estrogen have an increased risk of breast cancer, there have been cases so individuals still need to be screened.  In addition, for transgender men who have undergone mastectomies, providers need to be aware that not all breast tissue may be removed, especially in a nipple-sparing procedure.
PROSTATE CANCER
Transgender women should be given all the same information provided to cis-males and be allowed to make an informed decision regarding screening.  Although guidelines for prostate cancer screening have changed and prostate-specific antigen (PSA) is no longer routinely recommended, it’s important to note that in the setting of prolonged estrogen exposure, as is the case with many transgender women patients, the PSA may be falsely low and therefore especially unreliable as a screening tool.  Rectal or transvaginal (if a neovagina has been created) exam of the prostate is recommended. 
 
SUMMARY
The American College of Obstetricians and Gynecologists recommends the following:

For FTM Patients - age appropriate screening for breast and cervical cancer unless complete mastectomy or hysterectomy has been performed.  Patients on androgen therapy who have not had a hysterectomy may be at increased risk for endometrial and ovarian cancer and should have a bimanual pelvic exam as recommended.
For FTM Patients - age appropriate screening for breast and prostate cancer


                                                     What you can do for a transgender patient
                                                             Create a welcoming environment.
                                 Be knowledgeable, non-judgmental and don’t make assumptions.
                Have an open discussion with patients about their cancer screening needs and schedule.

                                                                                                                   Judith Wolf, MD  Associate Director, WHEP


Thursday, September 14, 2017

Can flu shots lead to miscarriage?


The timing couldn’t be better - or worse -  for flu shots this year.  Pharmacies, medical offices, clinics and employers are all offering influenza vaccine now to help protect people from the flu whenever it strikes in a few months.  As an Infectious Diseases Specialist, I believe that flu shots are important and can save lives, but what I heard on the news this morning worries me - a report potentially linking an increase in early miscarriages among certain women who received influenza vaccination.  The finding is so preliminary and information so limited that it’s hard to draw any conclusions. 

So why am I worried?  I’m concerned that many pregnant women who may have already been skeptical about receiving a vaccine will refuse a flu shot, placing them and their unborn children at increased risk for severe disease – even death.  And the anti-vaccine movement may seize upon this report, creating panic and blowing it out of proportion to all of the evidence supporting the benefits of influenza vaccination, particularly in the most vulnerable populations (young children, the elderly, those with chronic illness, immune disorders, and pregnant and postpartum women) who are at higher risk for severe illness and complications from influenza.  

The case-control study in question funded by the CDC and conducted from 2010 to 2012 matched 485 women who experienced miscarriages with 485 who delivered full-term. Those who had been vaccinated against influenza 28 days before the miscarriage, and in the first trimester of pregnancy, were more likely to have had a miscarriage if they had also been vaccinated the previous flu season with a vaccine containing the 2009 H1N1 virus (adjusted odds ratio of 7.7), suggesting that repeat vaccination may have led to a potential increase in the a proinflammatory response associated with the H1N1-containing vaccines. There was no association between miscarriage and flu vaccine if a woman had not received a vaccine in the previous year (aOR of 1.3) and no association seen in any other exposure window.

The CDC is looking into this potential signal to determine if there is evidence for true “cause and effect” rather than just an association, so the finding is far from definitive. For example, it would be important to know whether these women had certain underlying medical conditions prompting them to seek annual vaccination that could have also placed them at increased risk for miscarriage.  Only women who had clinically confirmed miscarriages were studied, so the proportion of women with clinically unrecognized pregnancy loss was uncertain. Results could have been biased if women who recognized and sought care for miscarriage were more likely to have been vaccinated in the 28-day exposure window.

Even though routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications, many people avoid getting vaccinated.  The CDC recommends that all women who are pregnant or who might be pregnant in the influenza season receive influenza vaccine. This often occurs during the second and third trimesters, and prior published studies have shown that vaccination during pregnancy is not only safe, but beneficial to both the mother and the baby.  

Despite this morning’s news and preliminary report, I hope physicians caring for pregnant women will “keep calm and vaccinate”!


                                                                                                                                                Judith Wolf, MD

                                                                                                                                       Associate Director, WHEP

 

Donahue et al.  Association of spontaneous abortion with receipt of inactivated influenza vaccine containing H1N1pdm09 in 2010–11 and 2011–12.  Vaccine. 2017; 35: 5314–5322 http://dx.doi.org/10.1016/j.vaccine.2017.06.069



 

Thursday, August 24, 2017

Protecting Preemies...The Implications

Even in this day and age of advanced technology, premature (<37 weeks) births are often cause of higher rates of mortality and morbidity. Approximately 1/3 of infant deaths and 1/2 of cerebral palsy may be attributed to prematurity. These staggering numbers are attributed to a neonate's inability to survive in the environment outside of its womb. In the past, the formation of an artificial placenta, though appealing, has offered limited success. However, a recent study has shown that with a new form of "artificial placenta" that consists of a cardiac circuit, closed fluid, and pseudo umbilical cord  has shown promise with the gestation of lambs.
This fluid filled sac mimics a womb-like environment and is capable of supporting lambs prematurely for up to 4 weeks. So why lambs you ask? The 105-115 day old lamb preemies' development is very similar to that of a 23 week old human fetus. Surprisingly, this study showed that even after a year of birth, the labs had comparable health outcomes to their fully gestated counterparts! This may indicate that human preemies may also obtain a better quality of life.
As with research in the past, this too holds ethical and legal implications. Such issues are raised around the regulation of abortion and paternal rights. Because this artificial womb may serve as an alternative to the gestation of a woman,  rights may change to denying a woman the option to abort, and instead transfer the fetus to an artificial womb within 18 weeks.  Another possibility is that both may be prohibited. Moreover, paternal rights to an abortion were denied in the past (Missouri v. Danforth) because a woman is the physical bearer of the child and therefore more directly affected by the pregnancy. With the use of artificial wombs, this division of rights may also change. 
Regardless one's stance on this difficult topic, we can agree that this progressive research will certainly aid in the life expectancy and wellness of premature neonates with further research!

Let us know what you think!

Meghana Pisupati
IHS 2018

Sunday, August 6, 2017

What does "defunding" Planned Parenthood really mean?

https://twitter.com/PPact/status/817084357907271680/photo/1
As many of us are aware, Planned Parenthood is a non-profit organization that provides reproductive and other health care services both nationally and globally. Political stances aside, the majority of us can agree that preventive healthcare is beneficial.  What many people  fail to realize, however, is the fact that approximately 5 million women and men and children rely on Planned Parenthood for most of their health care needs including immunizations, cancer and STD screening, HIV prevention, lactation support and counseling, in addition to family planning. These individuals are often dependent on Medicaid and Title X, created in the 1970's to specifically focus on funding for family planning and preventive care for low income families.


With over 700 clinics across the United States, Planned Parenthood relies on federal funds for 43% of its budget. However, if the American Health Care Act passes, this organization is at risk for losing the funds from Medicaid totaling approximately half a billion dollars. The funds from Title X on the other hand are grants given to states so $60 million dollars may remain based on state jurisdiction. The millions of patients who rely on health care provided by Planned Parenthood may be left to find a community health center to treat them. Unfortunately, these health centers do not have the ability, providers, or resources as of now to absorb all of Planned Parenthood's patients. Access to healthcare, birth control provision, STD checks and other services would significantly decrease, thus impacting the health of a wide array of individuals.


So what can we do?
Write to our senators to preserve Medicaid and Title X and convey why Planned Parenthood is important to you!




Meghana Pisupati
IHS 2018

Thursday, July 20, 2017

You Are What You Eat – Starting at Birth or Even Before!



The human gut microbiome is an area of active research and rapidly expanding knowledge with potentially significant implications for health and disease.  Yet, even though the field is relatively young, it is not without controversy.  Some studies have concluded that the mode of delivery at birth plays an important role in infant microbiome development.1 Infants born vaginally have a gut microbiome that approximates that of their mother’s vaginal and fecal flora.  However, infants who are delivered by cesarean section tend to be colonized with bacteria resembling their mother’s skin flora.  Their intestinal microbiome exhibits less diversity – a finding that may be linked to human diseases like inflammatory bowel disease and obesity.2     

However, a recently published study by researchers at Baylor College of Medicine found no differences in the microbiome of infants at 4 to 6 weeks of age between those delivered by C-section or born vaginally. According to the researchers, one explanation is that the microbiome may actually have been established in utero from the placenta during pregnancy and even undergone some maturation prior to birth. 3,4  

Infants who are breastfed after birth continue to exhibit colonization and maturation of their gut microbiome. According to a recent study from UCLA5, breast milk contributed more than 25% of the bacteria to the infant gut with an additional 10% coming from the areolar skin - findings that were most pronounced during the first month of life.  More importantly, infants who continued to breast feed through 6 months of age after the introduction of solid foods had a lower incidence of obesity and asthma.  Although these findings need to be corroborated, they potentially add to the body of evidence supporting the benefits of breast feeding.

 

Judith Wolf, MD

          Associate Director, WHEP

 

  1. Yang I, Corwin EJ, Brennan PA, Jordan S, Murphy JR, Dunlop A. The Infant Microbiome: Implications for Infant Health and Neurocognitive Development. Nursing research. 2016;65(1):76-88. doi:10.1097/NNR.0000000000000133.
  2. Mueller NT, Bakacs E, Combellick J, Grigoryan Z, Dominguez-Bello MG. The infant microbiome development: mom matters. Trends in molecular medicine. 2015;21(2):109-117. doi:10.1016/j.molmed.2014.12.002.
  3. Derrick M Chu et al. Maturation of the infant microbiome community structure and function across multiple body sites and  
    in relation to mode of delivery, Nature Medicine (2017). DOI: 10.1038/nm.4272
  4. K. Aagaard et al. The Placenta Harbors a Unique Microbiome, Science Translational Medicine (2014).
  5. Pia S. Pannaraj, MD, MPH; Fan Li, PhD; Chiara Cerini, MD; et al.   JAMA Pediatr.  2017;171(7):647-654. doi:10.1001/jamapediatrics.2017.0378

Tuesday, July 11, 2017

The Attack of Autoimmunity

http://www.sciencedirect.com/science/article/pii/S0091302214000466
It has been estimated that approximately 23.5 million Americans currently live with hidden autoimmune diseases according to the American Autoimmune Related Diseases Association (AARDA) and spend approximately $200 billion on healthcare annually. This daunting number of people live daily with their immune systems attacking their own bodies. Autoimmune diseases essentially occur when the immune system—the line of defense that your body uses to combat viruses, bacteria, and other diseases, fails. This failure comes from our immune cells being unable to distinguish between the self and foreign invaders ultimately causing systemic inflammation.
So why is this important? Because interestingly enough, of the 23.5 million Americans, 75% of those diagnosed with autoimmune diseases are women over the age of 50. The reasoning behind this has in the past been attributed to hormonal, genetic and epigenetic susceptibility, or chromosomal differences. These diseases ultimately impact various organ systems such as kidneys, GI tract, skin, etc.

http://www.genengnews.com/gen-exclusives/infographic-fighting-autoimmune-diseases/77900347
It appears that there are still certain lifestyle choices that one may begin with to prevent the occurrence of autoimmune diseases. These include keeping up with constant check ups for hidden infections and knowing food allergies. Getting tested and making sure to take probiotics and exercise regularly is said to help as well. Moreover, leading a stress-free life is essential for keeping a healthy and functioning immune system. 
Give a shout out to someone you know who is combating these autoimmune diseases and how they are living a complete life for our readers!