National Healthcare Reform; City Fresh Food Initiative; the Impact on Women

a little bit more about our speakers.....



Dr. Berkson joined the College of Medicine in 2006 as the program director of the Family Medicine Residency Program and an assistant professor in the Department of Family, Community and Preventive Medicine. He received his M.D. from Pennsylvania State University, then completed his Family Medicine residency at Abington Memorial Hospital and a Sports Medicine fellowship at the University of South Carolina, Palmetto-Richland Memorial Hospital in Columbia, S.C. Dr. Berkson is board certified in Family Medicine and Sports Medicine and is the chief medical officer of Pennsylvania Senior Games and the team physician for Monsignor Bonner High School in Upper Darby. Dr. Berkson received the Degree of Fellow from the American Academy of Family Physicians in 2005. He gives national presentations and, most recently, was awarded the Heroes of York County Award from the American Red Cross for helping save the life of a high-school athlete whose heart stopped.



Aletheia Donahue is a fourth-year medical student at Drexel University College of Medicine specializing in women’s health and health policy. She worked as a consultant on the proposed Fresh Food Tax Credit in the office of Philadelphia City Councilman Bill Green. Aletheia acted as a liaison between small grocers and city government to create policy that incentivizes healthy food sales. Her work included research on food access disparities and diet in Philadelphia and how these problems have been addressed in cities throughout the country.
Prior to starting medical school Aletheia was active in clinical medical research at Massachusetts General Hospital and The University of Pennsylvania’s Abramson Cancer Center. She earned a BA in astronomy and physics from Smith College.



Christine V. Soutendijk, M.D., is the assistant director of the Center for Women's Health, and has been an assistant professor of medicine at Drexel University College of Medicine since 1998. She is a graduate of Indiana University School of Medicine, where she received the John I. Nurnberger Award for Most Accomplished Student of Psychiatry in her graduating class.
Her interest in women's health began in medical school while writing a literature review on the psychosocial impact of breast cancer. She completed her internal medicine residency at Good Samaritan Regional Medical Center/VAMC in Phoenix, Ariz., and has been certified by the American Board of Internal Medicine since 1997. She continues to be interested in the effect of disease on mental health and quality of life, and has special interests in osteoporosis, menopause and metabolic syndrome.

Polycystic Ovarian Syndrome and Infertility

Polycystic ovarian syndrome is a common disorder causing androgen excess, ovulatory dysfunction and polycystic ovaries. PCOS can only be diagnosed if other potential causes of androgen excess are first ruled out (Congenital adrenal hyperplasia, Cushing’s, androgen tumors, etc) Thus, PCOS is a diagnosis of exclusion. In the developed world, PCOS is the most common endocrine disorder causing androgen excess and affects anywhere from 4-12% of all women. It appears to affect all races and nationalities.

In order to diagnose PCOS, the Rotterdam consensus of 2003 states that 2 out of the 3 criteria must be met: 1) elevated circulating androgens 2) oligo or anovulation 3) polycystic ovaries on ultrasound. Some controversy exists regarding the last criteria, since as many as 25% of females with normal androgen levels and regular menses may have polycystic ovaries.

Image from the Florida Department of Health webpage

Most commonly, women with PCOS present with menstrual dysfunction. Other clinical manifestations of PCOS may include signs of virilization such as hirsutism, male pattern balding, oily skin and persistent acne. Women with PCOS appear to have a higher incidence of insulin resistance. Many such women also have metabolic syndrome: obesity and dyslipidemia. Approximately 30-40% of women with PCOS have impaired glucose tolerance and approximately 10% have type 2 diabetes based on 2 hour glucose challenge test results. In the long term, PCOS patients have increased risk of endometrial cancer, Type 2 Diabetes and cardiovascular disease.

Frequently, women with PCOS will present to the gynecologist with complaint of infertility. Although the precise mechanism in which PCOS causes anovulation is unknown, an understanding of the pathophysiology of PCOS will illuminate some aspects of its impact on normal ovulation. Disruptions of the pulsatile GnRH release leads to a relative increase of luteinizing hormones (LH) over follicle stimulating hormones (FSH). This imbalance creates excessive androgen production with decreased conversion of androgens to estradiol. FSH paucity leads to follicular atresia and subsequently anovulation. The LH:FSH ratio is elevated, and over 2 in 60% of women with PCOS. At present, insulin resistance is hypothesized to be another major factor in anovulation.

Most of these women are not infertile, but only sub-fertile. First line treatment and counseling should including weight loss, careful diet and nutrition, and regular exercise. If lifestyle modifications are initiated in earnest and weight loss is achieved, some women with PCOS can see resolution of hyperinsulinemia and ovulation dysfunction. For other patients, lifestyle modifications alone are not enough and may need to be started on medications such as clomiphene citrate and human menopausal gonadotropins and insulin sensitizing agents. For some women, the combination of metformin and clomiphene citrate works well in regulating ovulation and ultimately achieving fertility.

PCOS remains a multi-factorial and complicated disorder. However, many different treatments and therapies are now available to resolve the clinical manifestations of this disease. Primary care physicians and gynecologists should be consulted first if one suspects PCOS. The appropriate referrals can then be made to reproductive endocrinology for more extensive workup.

For more information about PCOS as well as information about latest treatment guidelines and support groups, check out http://www.soulcysters.com/

and  http://www.pcosupport.org/

Common lab tests and treatment found here

Infertility resource center found here

Submitted by Emily Yen, Class of 2011, Women’s Health Pathway Student

References:

Legro, Richard., “Polycystic Ovary Syndrome, Hirsutism and other Androgenic Excess Disorders,” PRECIS: Reproductive Endocrinology, American College of Obstetricians and Gynecologists, 2002

Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG, "Chapter 17. Polycystic Ovarian Syndrome and Hyperandrogenism" (Chapter). Williams Gynecology: McGraw Hill Companies, 2008

It’s THAT time again…..

Flu IQ

         

Every fall doctors and nurses talk about getting a flu shot and every year patients have lots of questions about the flu shot. What is it? Do I need it? Who shouldn’t get it? What’s with the nasal vaccine? Should my kids get it? Can it hurt me? So here are some answers!


1. What is in the Flu Vaccine?
The flu vaccine is a medicine that is very similar to the influenza virus itself. When your body sees gets vaccinated your immune system learns how to fight off viruses that are like those in the vaccine. That way when you get exposed to the flu your body already knows how to handle it and you do not get sick.

 2. What about the Swine Flu (H1N1)?
Every year people at the United States Center for Disease Control try to figure out which flu viruses will be the worst and most dangerous. Last year they left one out, the H1N1 swine flu. That is why last year there were 2 different flu shots. This year they included the H1N1 swine flu into the regular seasonal flu vaccine. There are also other strains of flu in this year’s vaccine.

3. What is the Nasal Flu Vaccine (FluMist)?
FluMist is actually a live flu that is changed so that it does not make you sick. It is a nose spray instead of a shot. You must be over age 2 and younger than 49 to get this form of flu vaccine. However, some people should not get this form of vaccine. Kids with asthma, and people with poor immune systems and risk for complications from flu as well as people who have close contact with other people who have poor immune systems.

4. Who should get it? See list here
Odds are you should get a flu vaccine. The Center for Disease control includes more people every year in the group that should get vaccinated. Everyone who is over 6 months old who does not have a medical reason that they can’t get the vaccine should get it. People who are allergic to eggs can’t get the flu vaccine. Kids getting the flu vaccine for the first time need two doses!  Rates of infection are highest among children, but the risks for complications, hospitalizations, and deaths from influenza are higher among persons aged 65 years and older, young children, and persons of any age who have medical conditions that place them at increased risk for complications from influenza.

5. But I got it LAST YEAR!
I know! You have to get it EVERY YEAR. The pesky thing about the flu is it changes every year and so your flu vaccine from last year isn’t protecting you anymore.

6. Should I get it if I am pregnant, breast-feeding or trying to get pregnant?

YES! It is super important to get the flu vaccine when you are pregnant. For reasons that we don’t understand pregnant women are very susceptible to getting very sick and even dying from the flu. It makes many women nervous to get vaccines if they are pregnant but, there is no evidence that the vaccine hurts the baby.  In fact, not getting can result in harm to both mother and fetus!

7. What happens if I don’t get it?

If you do not get vaccinated there is a higher risk of getting flu and of having complications from the flu. The flu can cause serious medical problems and death. These include bacterial pneumonia, ear infections, sinus infections, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes.

8. Are there risks associated with getting the flu vaccine? Here's safety information from the CDC  There are risks to the flu vaccine. There is a rare neurological problem called Guillain-Barré syndrome, which about 1 in 100,000 people will get with the flu vaccine.

9. Who is contraindicated to get this? People with egg allergies; infants under 6 months; individuals who got Guillain Barre (neurologic disease) within six weeks of getting immunized; moderate or severe infection (with/without fever) People in this last category need to resolve their infection before they get immunized.

SO WHERE DO I GET IT?  There are flu shots all over, if you have a doctor, call your doctor to ask abour flu shots. You may also be able to get one at work or school. They have flu shots in grocery stores and pharmacies as well!

So go get your flu shot….And Remember ….

                                                               The FLU ends with U!

For more information on the flu vaccine and immunization try:

http://www.flu.gov/

http://www.cdc.gov/flu/

http://kidshealth.org/parent/growth/medical/immunization_chart.html

Active Lifestyle May Help Counter Obesity Genes

TUESDAY, Aug. 31 (HealthDay News) -- Exercise can reduce a person's genetic predisposition to obesity by 40 percent, finds a new English study.

Researchers looked at 20,430 people in Norwich and focused on genetic variants known to increase the risk of obesity. Most people had inherited 10 to 13 of these variants from their parents, but some had more than 17 while others had fewer than six.

The participants also provided information about their levels of physical activity.
Overall, each additional obesity-related genetic variant was associated with an increase in body mass index (BMI) equivalent to 445 grams (0.98 pounds) for a person 1.70 meters (5 feet, 6 inches) tall. BMI is a measurement that takes into account a person's height and weight.

However, this effect was greater in sedentary people than in active people, the researchers found. For those with a physically active lifestyle the increase was 379 grams (0.84 pounds) per genetic variant. That's 36 percent less than the increase of 592 grams (1.3 pounds) per genetic variant for inactive people.

The researchers also found that each additional obesity susceptibility variant increased the odds of obesity by 1.1-fold. But this risk was 40 percent lower for active people compared to inactive people, the findings revealed.

The study shows that adopting a healthy lifestyle can benefit people at increased genetic risk of obesity, the authors explained.

"Our findings further emphasize the importance of physical activity in the prevention of obesity," “Our research proves that even those who have the highest risk of obesity from their genes can improve their health by taking some form of daily physical activity. People don’t have to run marathons to make a difference either - walking the dog or working in the garden all counts. It goes to show we’re not complete slaves to our genetic make-up and really can make a big difference to our future health by changing our behaviour." Dr. Ruth Loos, of the Medical Research Council's epidemiology unit in Cambridge and colleagues wrote in the August 31st 2010 article published online in PLoS Medicine.

CHECK OUT:

The U.S. National Heart, Lung, and Blood Institute offers a Guide to Physical Activity.

Download  BMI calculator here

Women and overweight obesity data info here and resources here

                  Women lag in time spent in leisure activity (weights, calisthenics) as compared to men,  2008 data

Anti-HIV gel is declared breakthrough for women

By Steve Sternberg, USA TODAY

Researchers say they've achieved the first AIDS prevention breakthrough for women.
More than a decade of failure and frustration ended Monday with a report that a new vaginal gel gives women the power to reduce their risk of contracting HIV and genital herpes without relying on their male partner to use a condom.

The experimental gel is made with Gilead Sciences' antiviral drug tenofovir, which is widely used for treating HIV, the virus that causes AIDS. Applying the 1% tenofovir gel 12 hours before and 12 hours after sex reduced a woman's risk of HIV infection by 39% over the course of 2½ years.
The gel also reduced the risk of genital herpes by 51%, an unexpected bonus because women with herpes are twice as likely to be infected with HIV.
"We now have a product that can potentially alter the epidemic and save millions of lives," says Quarraisha Abdool Karim of the University of KwaZulu-Natal in South Africa, who co-wrote the study with her husband and university colleague, Salim Abdool Karim.
At this level of protection, the researchers say, widespread use of the gel could prevent 1.3 million infections and more than 800,000 deaths in South Africa alone over the next 20 years. The findings were to be released today at the 18th International AIDS Conference in Vienna and in the online edition of Science.
AIDS researchers and advocates who have grown accustomed to failure, or worse — one promising vaginal gel actually was found to boost the risk of infection — hailed the report.

"This is good news," says Yasmin Halima, director of the Global Campaign for Microbicides, an advocacy group that has championed the approach. "Women are vulnerable to HIV across the world. Just having condoms for men is not really a viable option."
In the study, 889 sexually active women ages 18 to 40 were given either the tenofovir gel or a placebo. Thirty-eight of the women in the tenofovir group were infected with HIV, compared with 60 in the placebo group. Of 434 women who did not have herpes at the start of the trial, 29 of those using tenofovir became infected vs. 58 using a placebo.
The gel worked best in the women who used it most consistently. Women who used the gel at least 80% of the time were 54% less likely to become infected, cutting their risk of HIV by more than half.
Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases, says the study marks a "significant conceptual advance" in efforts to give women the tools they need to protect themselves.
"The level of protection isn't as high as we hoped it would be," Fauci says, "but there are a lot of things we can do to change that. The degree of the effect was related to the degree (to which women used the gel.) You may want to use it more often. You may want to put it in a vaginal ring."
Halima noted that the pipeline of microbicides may include drug combinations similar to those now used for HIV treatment. Fauci says his institute is sponsoring a complex trial that compares patients using tenofovir gel daily with those taking oral tenofovir or Truvada, a combination of tenofovir and Emtriva, also made by Gilead Sciences. Results won't be available for at least a year, he says.

Read more here

Bloggers Note - Despite significant challenges in developing an immunization for HIV, this advance may be critical to saving lives for women.  Additionally, this success will stimulate industry and research for additional advances.

HIV terminology
HIV positive - evidence of exposure to HIV
AIDS - evidence of disease from HIV infection
ARVs antiretrovirals;

HAART Highly Active Anti-Retroviral Therapy (HAART) consists of 3 or more highly potent anti-HIV drugs (usually need three to 'contain' the virus and prevent development of resistance)        Click below to enlarge

NRTIs, NNRTIs, PIs and Others

Distress and Sexual Health

Female Sexual Dysfunction includes disorders of desire; arousal; orgasm and sexual pain. Desire disorders include hypoactive sexual desire disorder and sexual aversion disorder. To make the diagnosis of Hypoactive Sexual Desire Disorder two key elements must be in place (hypoactive sexual desire and marked distress - personally or interpersonally as a result of the condition) Additionally, we exclude depressed desire that is due to medications, substances or general medical conditions or those due to another Axis I disorder.
How prevalent a problem is this? Research tells us that there is a range 9-26% and a mean of about 10% of women with HSDD.(Leiblum)- this include premenopausal and postmenopausal women.
Is this an isolated sexual health concern? No - data shows that women with HSDD are generally less healthy than their non-HSDD counterparts. They have less vitality, more bodily pain, poorer physical, social, emotional functioning. It is likely that women will come into the office with diffuse feelings of body aches and feeling unwell as part of their presentation. Sexual health affects both the physiology and psychology of women.

What's the physiology of sexual function in women? The physiology is that of central neuroendrocrine function matched with peripheral intact anatomic and vascular function. Centrally - Desire is augmented by excitation that is driven by dopamine, norepinephrine, testosterone, estrogen and inhibited by serotonin and prolactin. Arousal adds nitric oxide and acetycholine with the above factors and has the same inhibitory ones. Orgasm has oxytocin as an excitatory hormone. External genitalia needs estrogen, testosterone and progestin to function. Vasocongestion needs working and responsive vasculature- thus nitric oxide, norepinephrine, cholinergic fibers and prostaglandin E are excitatory with serotinin as inhibitory.
How do these factors play a role in diagnosis and interventions? Anything that decreases dopamine (or increases serotinin) will have adverse sexual side effects. Anything that lowers testosterone - like hyperprolactinemia, opiates or menopause - will also lower sexual functioning.
What diseases can decrease desire or arousal? Chronic diseases such as Diabetes, Thyroid disease, Cardiovascular Disease, Depression and Renal Failure. Other illnesses - adrenal disease, head injury, neurologic diseases including hyperprolactinemia, bilateral oophorectomy and incontinence can do so as well. (Basson)

What medication or substances adversely effect sexual health? Perhaps most well known are antidepressants that block reuptake of serotinin (SSRIs; SNRIs) Other psychiatric medicines such as benzodiazepines; antipsychotics; mood stabilizers and anti epileptics can do so. Less well known, perhaps, are H2 blockers, NSAIDs, oral contraceptive, thiazide diuretics, non-selective beta agonists. Additionally narcotics and other hormones (estrogen, progestins, anti androgens, GnRH agonists) are involved (Clayton, Kingsberg.) It is important, up front, when we prescribe these medications to make patients aware of the potential side effect!
How do I screen? If you wait for most women to ask about this, there are numerous reasons why they won't ("It is appropriate to talk to the doctor about this?" "How do I discuss this?""Maybe there isn't anything I can do?") The literature shows that docs have to ask and patients want us to. (Stengel) In the ideal, we should include sexual health screening at least on annual exams. There are  tools and surveys you can use: Brief Sexual Symptoms Checklist for Women (Hatzichristou); Decreased Sexual Desire Screener (Clayton); Female Sexual Distress Scale - Revised (DeRogatis)

What can we do about it? First off, sexual health tracks with physical health. So many of the same lifestyle issues we discuss (regular exercise, healthy nutrition, weight loss, smoking cessation, minimizing intake of alcohol) all help sexual health. There are some medications that are used - though none currently FDA approved (and there others in the pipeline to watch for) but most patients are likely to benefit from counseling (education, personal, couples, cognitive behavioral, mindfulness, etc.), lifestyle changes and medication.

The most commonly used medication is bupropion (which increases dopamine and NE)- which is used for non-depressed women with HSDD (it can also be used with depressed women, as well) Testosterone has been used - and a gel is in the pipeline. A melanocortin receptor agonist (this stimulates dopamine) is also in the pipeline.

It seems odd that few people would perceive erectile dysfunction (and associated distress) as 'not real' or not a significant health concern, yet there are those who feel that female sexual dysfunction is somehow different. Women may be more complex, physiologically and psychologically when it comes to sexual health. Remember, if a woman with diminished desire isn't bothered by it, then neither are we! But for many women, sexual health is part of overall health. Physicians need to learn about this health issue, develop skills in communication about sexual health and ask patients on a regular basis. By doing this, we can uncover health concerns that may appear to be 'playing in the background' - yet are the health burden at the heart of the problem.

RESOURCES
Leiblum SR, et al. Menopause. 2006;13:46-56.
Basson R, Schultz WW. Lancet. 2007;369:409-424.
Clayton A, Hamilton D. Psychiatr Clin N Am. 2010;33:323-338.
Kingsberg S, Janata J. Urol Clin N Am. 2007;34:497-506.
Stengel C. Martinez L. http://twshf.org/survey.html. Accessed August 2010.
Hatzichristou D, et al. J Sex Med. 2010;7:337-348
Clayton A, et al. J Sex Med. 2009;6:730-738
DeRogatis L, et al. J Sex Med. 2008;5:357-364

Resources for Reproductive Options Counseling

Here's an example of nuchal translucency on ultrasound

So here's some very useful links (or how to be ready to respond to 'Dr. Google'):
Genetics and Testing:
A very accessible article about preconceptual health issues A primer for those in (or interested in) primary care and genetics testing - Case examples include Tim (the father) who get's diagnosed with familial polyposis and you are asked what should you do with his son Jay...
A searchable genetic reference site
The Online Mendelian in Man (I think it's fine for Woman too!) site - here's the info at a glance about Down Syndrome
This one page fact sheet from the American Society for Reproductive Medicine succinctly puts together a lot of data and has a Reproductive facts webpage  in additional to useful patient education materials
An extensive listing of other web resources
Here's the CDC site Genomics weekly update

For those of you interested in Obstetrics - Drexel is underway to join the current listing of residency programs with a Family Planning Fellowship. Here's the national listing. If you are interested,  email Dr. Montgomery (Chair of Ob/Gyn) or Dr. Woodland (Residency Director) More info on reproductive options is available at ACOG

A May 2010 report discusses the new field of onco-fertility, an area focused on maintaining reproductive options in cancer patients.

Here's a useful description about fertility risks for men and women
Here's a link to questions you ask of women or men with multiple sclerosis who are considering starting a family

What We Do At WHEP

Universal Screening - Child Maltreatment and Intimate Partner Violence

Screen everyone. When it comes to violence and trauma - screen everyone. One of your classmates used the term 'exuberant' screening - be exuberant. Physicians err on the side of caution in screening when the outcome of missing the diagnosis has a significant impact. This is true for a quiet tender abdomen in a patient with a fever - thus we look for appendicitis so as to not miss a ruptured appy that will result in life long abdominal pain. It is equally true for child maltreatment and intimate partner violence. Screen everyone.
Universal screening is the best way to do this. Universal screening means telling everyone that we do this with everyone.  By creating your clinical habit to ask everyone, you eliminate the challenge of deciding the if, when and who of screening about unhealthy relationships, abusive situations or being abusive to others.
How do you actually ask? Whether of a child with suspicion injuries or upon a first visit with a woman or man consider stating "We ask everyone these questions so that we make sure that people who are being harmed know that we are here to help." "There is a lot of abuse out there and we are mandated reporters." To a child (age dependent) ' You're here because you are hurt - we need to check you head to toe to make sure everything's ok.'
Won't I offend? We (should) ask everyone about use of drugs and alcohol; sexual habits including safe sex; status of HIV screening as well as history of trauma. The concern about offending a patient needs to be on the back burner. If a patient states it isn't an issue to them - it may not be (or it may be that they do not yet feel safe enough with you to divulge this.) If you inform the patient that you need to ask everyone (it's your job!) - then if it isn't true for them, you move on. If parents of a child with a suspicious injury get evaluated because we do it universally as our pledge to keep children safe - those for whom it was unfounded will be unfounded. But for others, we will have kept a child safe. Universal screening means seeing past personal bias of who seems to be at risk (certain groups) versus who really is at risk (every economic class and ethnicity.) - everyone.
How and where do I do this in the medical history? Here's some options -
1) Under Health Promotion issues - Stress screening [e.g. (On a scale of 1 - super mellow to 10 - ready to jump out of my skin - How stressful is work? How stressful is home? When stress becomes 10 or higher - what do you do to take care of yourself?] Has there every been a time when something traumatic happened to you? when something bad happened? What was that? How are you doing now? Has there every been a time when someone forced you to have sex? When they hurt you (hit/kick/punched)? When they kept you away from friends or family?)
2)  Include IPV screening as a dedicated part of the history on health maintenance (including wearing seat belts; alcohol; self breast/testicular exams)  "There is a lot of relationship violence that we see (as well as the health effects from it.)" "Have you ever been in a violent or abusive relationship?"

"When you get upset - how do you handle it? Have you ever felt that you 'lost it' when you got angry? Does this worry or concern you? Do you wish you could deal with frustration better?"
3)Include in the surgical history (Have you ever broken anything and how? Ever hospitalized? What for?)
4)The sexual history - "When was your earliest sexual experience? Did anyone ever force themselves on you? etc."
5) A sleep history - "Do you have good quality sleep? Do you have nightmares or bad dreams?"
6)In the mental health history - "There is a lot of violence and trauma in our world and it influences how people live even after it happened. Was there ever a time when something bad happened to you? How did you handle that?"
There is also some information in the literature that people who present with problems such as chronic pain, GI disorders, functional gyn problems; sexual dysfunction; aversion to dentists/oral health; and chronic headaches should be screened.

Here's a listing of some of our wonderful local Drexel collaborators and experts 

DUCOM
At Women's Health Education Program
     Candace Robertson, MPH Healthy relationship education for teens and IPV health screening
     Ana Núñez, MD IPV health education screening; Philadelphia Ujima - culturally and health literacy    appropriate health outreach
      Jill Foster, MD  Ped/Adol HIV/AIDs Center; St Christopher's Hospital for Children; expertise in the intersection of intimate violence and adolescent sexual health, child maltreatment, sexual health and LGBT youth
      Ted Corbin, MD - ED Physician  Violence Intervention Program "Healing Hurt People"; expertise in outreach to young men with trauma
       Ralph Riviello, MD - ED Physician, Sexual Assault Treatment Center; expertise in helping victims of rape/assault
       Susan McCleer, MD, Psychiatry forensic psychiatry
School of Public Health violence prevention collaborators
  Sandy Bloom, MD - Creating sanctuary: toward the evolution of sane societies and more resources here
  John Rich, MD, MPH - Wrong Place; Wrong Time
DU collaborators
Julie Mostov, PhD International Violence and Women's Advocacy
Maria McColgan, MD, MEd, FAAP Child Protection Program, St Chris (Seminar Series speaker 2010!)


References regarding New Jersey maltreatment case

IPV and Curricular Opportunities to Learn About It Update on Intimate Partner Violence and Medical EducationThe Drexel University College of Medicine Women’s Health Education Program is a model for training medical students to screen for and respond to intimate partner violence.
Ana E. Nunez, MD, Candace J. Robertson, MPH, and Jill A. Foster, MD

One Path To Women's Health Scholar

In my first year, the Women’s Health lecture series piqued my interest as a chance to learn about the real-world issues in women’s health. As I continued attending the lectures, I realized I was getting more—I was learning a viewpoint on how to take a critical approach to my education and my career. I decided the Women’s Health Scholar’s program would be a valuable experience in helping me become a better clinician and a better researcher.


Volunteering at the HOP clinics had been my main form of community outreach, and I hoped to connect this experience with my Women’s Health interests. During my second year, two of my classmates developed the “Jump Into Reading” program at the Eliza Shirley clinic to encourage mothers to read with their children. For my community project, I helped secure book donations, facilitate reading space, and of course, I regularly attended the reading program to read with moms and kids.

During one of my lighter third year rotations, I emailed Drs. Núñez, and Kahng about a bulletin board idea. Since it was Lupus Awareness month, I wanted to put together images and clinical pearls to help students internalize the diverse pathology associated with Lupus. Since I was on an away rotation, I got feedback from the Women’s Health team via email, asked Winnie to print the slides for me, and I came back to Philly on a Saturday to hang the images on the Women’s Health bulletin board.

With most of the requirements complete, the 15-20 paper was still looming. Having recently abandoned my previous career choice of OB/Gyn in favor Pediatrics, I felt like I was a half-step behind my classmates who had always known they wanted to work with children. I considered abandoning the Women’s Health Scholar’s path, but upon reflection, I realized that completing a paper on a topic relevant to Pediatrics would allow me to develop an area of interest and feel more grounded.

As a third-year student, I had spent a day in the GROW clinic, where I was fascinated by the multidisciplinary approach to patient care, including extensive social and psychological support for parents. I contacted Dr. Kersten, the director, and he invited me to spend as much time as I wanted in clinic, introduced me to his team, and asked me to participate in data gathering for a research project on failure to thrive. Now that I am writing my paper, I am grateful that I pushed myself to reach out and pursue an interest I might have otherwise left alone.

The most valuable part of the Women’s Health Scholars experience for me has been that I have pushed myself to pursue interests, develop my own ideas, and expand my exposure to different issues in women’s health. I am certain that I will have a better-informed academic and clinical perspective upon leaving Drexel.

Blog submission Stephanie Doupnik, Class of 2011; Women's Health Pathway student

Photo credits Dunes, Namib Desert. S.Doupnik

Heart Health and Women

Cardiac disease is an excellent example of sex/ gender health disparities. Cardiac disease is not unique in women - it is the number one killer of men and women in the US. Women fear dying of breast cancer, but die most of heart disease. So, how is it a disparity? Since 1984, more women have died of heart disease as compared to men (even though it occurs in men and usually ten years earlier!)

DIFFERENT EMPHASIS ON RISK FACTORS - The heart story does not focus on different risk factors - rather different importance in risk factors. For example, the ten year - or 'female advantage' in heart disease is lost if a women is a Diabetic. It's lost if she's a smoker. It's also gone when menses stops (surgically or naturally.)
DIFFERENT WAYS IT CAN PRESENT - Heart related diseases can present differently in women. Yes, women can have the 'classic' findings of obstructive heart disease as men - exertional chest pressure that radiates down the arm and is relieved with rest. But they can have other findings that may be viewed as atypical - yet are typical for women: unexplained fast heart beat (tachycardia); nausea; unexplained fatigue; inability to do housework or typical tasks (esp seen in elderly women) and even more alarming, 1 in 4 women may not have any complaints at all! Thus, we need to screen EVERYONE for heart risk (high, medium and low) and evaluate appropriately.
DIFFERENT THRESHOLDS TO PREVENT AND TREAT - Although, heart health awareness are creating change, women still have lower rates of screening for lipids and heart health as compared to their male counterparts. A well known study created vignettes of 'classic' cardiac symptoms and changed the ethnicity (white versus black) and gender. The scripts were exactly the same. Physicians most likely recommended cardiac catheterization to men over women patients. Another 2007 study found that physicians still intervene less with women and heart disease.
SO WHAT SHOULD WE DO? - Collectively and personally, we all need to be more aware of heart health risk factors - for clinicians as well as for patients be they children, men or women. Getting into the risk assessment habit (high, medium, low and optimal) for everyone helps overcome the selective focus of missing half of the population.

A Sampling of Great Web Resources
 Our webpage (Women's Health Education Program)
 Women’s Health Initiative
 DHHS Office of Women’s Health
 Food information planning site Mypyramid.gov Want to know how many calories you eat? What's in the food that you love? Check this site out.
 Society for Women’s Health Research
 The Heart Truth: Resources for health professionals (videos of patients; patient cases and slides)
 NHBLI: National Heart Blood Lung Institute (great resources on heart health)
 Video on taking a heart health history and the role of gender and ethnicity in heart health risk
– Gender and Ethnic Medicine Cardiac Disease and Women

Reports
– IOM Report Sex Matters 2001 Evidence based report highlighting the difference that sex/gender makes in health.
– Heart Disease and Stroke Statistics-2010 Update, American Heart Association. A ton of great graphs and info here.
– HRSA Women's Databook - each years data book has useful health information on various topics.
Other
 -Sentinel article on heart health and women  Evidence-based guidelines for cardiovascular disease prevention in women L Mosca, LJ Appel, EJ Benjamin, K Berra, N … - Circulation, 2004
-CDC BMI Online Calculator

Intimate Partner Violence - More and Deadlier For Women

Violence against women is an enormous health issue in the United States. According to an FBI report in 2001, nearly a third of female homicide victims were killed by an intimate partner. Intimate partner violence, or IPV, is violence committed by a spouse, ex-spouse, or current or former boyfriend or girlfriend. IPV includes physical violence, sexual violence, threats of such acts, and emotional abuse. Although both genders are affected, the vast majority of this physical and psychological burden is borne by women.

In 2003, the CDC published a report on the costs of Intimate Partner Violence and estimated that 5.3 million IPV victimizations occured in adult women each year, 2 million of which were injuries and 550, 000 which required medical attention. The costs associated with IPV totalled over $4 billion for medical services and nearly $1 billion in lost work productivity and earnings. The health sequelae are well-established; IPV is linked to low self-esteem, eating disorders, depression, suicidal thoughts, and harmful health behaviors such as smoking, alcohol abuse, drug use, and risky sexual behavior.

So how well do physicians screen their patients for IPV? An ongoing 2010 multi-center Canadian study (Bhandari, et. al) looked at IPV screening attitudes and behavior amongst orthopaedic surgeons. 87% of orthopods believed that less than 1% of female patients in their care were victims of IPV. This was in stark contrast to prior data from fracture clinics that found one-third of women had been victims of IPV within the past year and 2.5% had presenting injuries directly resulting from IPV.

It also turns out that primary care physicians are slightly better at screening for IPV than orthopods, yet still fall far short of expectations. The American Academy of Family Physicians cites on their website a recent study that estimated that 10% of physicians routinely screen for domestic violence during new-patient visits. Where patients presented with physical injuries from abuse, only 79% of physicians asked patients direct questions about domestic violence. 17% of obstetrician-gynecologists routinely screen, compared with 10% of family physicians and 6% of internists.

Resources on Intimate Partner Violence:
National Domestic Violence Hotline  1-800-799-SAFE (7233), 1-800-787-3224 TTY, or
http://www.ndvh.org/
National Coalition Against Domestic Violence  http://www.ncadv.org/
National Sexual Violence Resource Center  http://www.nsvrc.org/
Family Violence Prevention Fund  http://www.endabuse.org/
When Closeness Goes Wrong - Podcast


 PRevalence of Abuse and Intimate Partner Violence Surgical Evaluation (P.R.A.I.S.E.): rationale and design of a multi-center cross-sectional study.BMC Musculoskelet Disord. 2010; 11: 77.Published online 2010 April 23.

Blog Submission by Olivia Wang, MS4; WH Pathway, Class of 2011

Obesity as a Risk Factor for Early Sexual Debut in Young Adolescent Girls?

The topic of obesity in relation to adolescent girls and sexual activity first arose during a patient encounter of an obese 13-year-old girl, who was asking for birth control pills.  The family physician I was following, mentioned that recently, in the past few years, she has noticed that her overweight and obese adolescent female patients are having sex much more than her normal weight patients.  She prompted me to read an interesting article on the topic on Medscape Medical News, which is summarized below:

“In a recent study presented at the 58^th Annual Clinical Meeting of the American Congress of Obstetricians and Gynecologists by Villers, et al, showed that overweight and obese adolescent girls are more likely to engage in risky sexual behavior than their normal-weight peers.  The researchers evaluated data from the CDC’s Youth and Behavior Survey from 2003-2007 of 21,773 girls in grades 9-12.  The BMI was calculated using self-reported height and weight.  The study analyzed 6 different risky sexual behaviors such as whether or not the teens had sexual intercourse age at first sexual intercourse, number of sexual partners, condom use, and alcohol/drug use during their last sexual intercourse.  The results revealed that obese and overweight girls were more likely to have an earlier age of sexual debut, more sex partners, and were less likely to use condoms than their normal weight counterparts.”

During the women health discussion of the topic at DUCOM, it was noted that the study did not account for history of abuse, socioeconomic factors, and other factors such as self-esteem and depression.  Another interesting point is that obese and overweight girls reach puberty earlier than their normal weight counterparts.  More research needs to be done on why overweight and obese adolescent girls are more likely to engage in sexually risky behaviors than those are normal weight.  Childhood and adolescent obesity is a risk factor for many things from health related ailments to psychosocial limitations, and this recent survey adds to the list of the harmful effects of obesity.

-- Mimi Mak MS IV, adapted from Obesity a Factor in High-Risk Sexual Behavior in Adolescent Girls 
Medscape Medical News , 2010-05-28

Additional Resources Role and Consequences of childhood obesity

AAP Consensus report Prevention of Pediatric Overweight and Obesity Committee on Nutrition

CDC Resources

Healthy nutrition - need to ask about access

When you ask about nutrition - you need to ask about access to food.

During your third year as a medical student,  caring for people in the Philadelphia area, you quickly realize that obesity, hypertension and diabetes are the norm. Diet has a big impact on these health problems.

As clinicians we instruct our patients to eat a healthy diet and maintain a healthy weight. When we advise patients in this way we assume that they have access to healthy food. The fact is that many Philadelphians do not have access to fresh healthy food.

In fact the recently proposed Food Desert Oasis Act of 2009 named Philadelphia as one of 20 “Food Deserts” in the US. This means that many of the people who we care for do not have access to fresh food, they many not live within a walkable mile of a grocery store, and may not have transportation to grocery stores in other neighborhoods. This problem disproportionally affects lower income and minority neighborhoods.

So ask!
Before you advise someone to eat more fruits and vegetables ask,

1. Where do you get your food?
2. Do they sell fresh food where you shop?
3. Is it quality and affordable fresh food?
4. Do you have affordable transportation to a grocery store?

Want to learn more about fresh food access in your neighborhood? Check out the USDA interactive food atlas.

Blog submission Alethia Donahue MS4 WH Pathway class of 2011
Photo credits: Homegrown tomatoes Alethia Donahue 2009; Saharan Beetle Juice A. Núñez 2009

Women's Health Ambulatory Experience

Many moons ago when we developed the Ambulatory rotation, we wanted to give seniors an opportunity: for 1:1 face time with mentors and role models; to learn practical issues on sex/gender health disparities and women’s health; to reflect on an (self-defined) interesting topic and become expert on it and; to see how health and illness fit together in the context of where patients live – in their communities. Toward that end the clinical piece, community piece and scholarly pieces were birthed.


Primary and specialty clinical care affords a basis for skills development and reinforcing issues about health promotion and disease prevention. The community piece is rarely (if ever seen) in training – it is the taken-for-granted-wallpaper, yet the context of care, the strengths that arise from families and communities are essential for optimal heath outcomes. Lastly, there is the scholarly piece. We wanted an opportunity for students to work on an issue that they care about or create something that they could be proud of (that was needed and useful!) Originally, it was a paper – a time to reflect on an issue or topic and demonstrate your thoughtfulness and analysis – not a book report or regurgitated list of facts. In time, students asked for an opportunity to ‘make’ something – a bulletin board; a presentation with a powerpoint; a brochure; a training experience on a topic – and now a women’s health education blog opportunity.

During your senior year, we value you as role models for years 1-3 and hope that (beyond Ambulatory requirements) that you will come to events and seminar series when you are in town.

Here’s some tips on getting the most out of your experiences

1. Think about what the clinician can teach you that you ‘need to know’; that would be useful

2. Generate objectives to see if it makes sense (to you and them)

3. Do a midpoint check in with Dr. Kahng or me

4. Think now about your paper or project (you can do it in advance!)

5. Consider what is culturally appropriate behavior in community outreach – what does it mean? What does it look like?

6. Decide what you want more information about (and ask about resources) so that you can get questions answered.

This experience is supposed to be organic - you need to let us know as we go, so we can continue to improve it.

Women's Health Pathway versus Women's Health Scholars and the Seminar Series

Happy Summer - such that it is, being in medical training! Let me clarify two different experiences house here at the Women's Health Education Program - the Pathway and the Scholars experience. The Pathway is open to rising third years/seniors and is an opportunity to spend focused time with us; do student-driven projects and become expert at sex and gender health issues within their specialties (and get aid/advice/support while getting wonderful residencies.) Pathway alumni include more than 70 women and men physicians - in fields such as Internal Medicine; Family Medicine; Ob/Gyn; Peds; Med/Peds; Neurology; Surgery (including Ortho and Urology); Radiology; Anesthesia; and Psychiatry. Our only requirement is the Ambulatory rotation (more on that later) We have eight awesome pathway students and anticipate a terrific year! Our first group meeting is July 20th. After we finish, let me know if you'd like to hang out - my house or elsewhere. I'm not posting any Pathwayer pictures (yet) since all  we have are you entering mug shots - so we'll get better ones on the 20th!

The Women's Health Scholars is an opportunity for all students. The eligibility to become a Scholars is 1)attendance at the majority of the Seminar Series (WHSS) sessions in year 1 and 2; 2) a community involvement activity and 3) a vetted scholarly project that must be completed (optimally in the third year) but no later than early fourth year - so that your Scholars designation can appear in the graduation program. Detailed requirements are here.

The Seminar series commences Sept 14th - but this year, we have a preview of 'Cool Stuff We Did At WHEP' from our summer and research students. Stay tuned for the date!

A Choice Environment

There is a new book out about how we make choices, The Art of Choosing by Sheena Iyengar. In her Voices of the Family interview, she discusses sex/gender differences and states "women have different choice environments than men" in that they have more social implications put upon them (and accepted by them) for their choices ("This blouse or that one?") and usually consider more variables when arriving at a decision. "I want" is answering the question easy or hard? Granted I want is a little different than I pick this or that. Here's sticky chart entitled "I want" from Dave Gray at Communication Nation - in his blog he has an interesting listing of 'wants' from a trainings he does.

In medicine, we ask people to make choices every day (and usually pretty quickly.) How can we best help others priorities and how can we motivate them to make their health a priority?Apparently, in Iyengar's book (haven't read it yet) she recommends focusing upon priorities and eliminating the extraneous. Easier said than done, I think! What are the implications of decisionmaking and anxiety?

BTW - Number of women with disability poll answer is 1 in 5!!