tag:blogger.com,1999:blog-50440736992353064032024-03-06T15:02:23.684-05:00Dr John W Marcus MD Ob/GynWhy do I write this blog? Because I feel that Ob/Gyn doctors are very often misunderstood. Maybe I can help bridge the gulf of misunderstanding. I want to improve communications. I wish to share my knowledge and skills. And writing this blog is fun. Please note that this blog is not medical advice. Medical advice must come from your personal physician who knows you best. Please note that patient identities are protected by changing many of the details. Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.comBlogger51125tag:blogger.com,1999:blog-5044073699235306403.post-89868048024303673002017-06-06T10:15:00.000-04:002017-06-06T11:54:57.464-04:00<h2>
<u>Important Tuna Recall</u></h2>
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This morning I was looking at the news and found an article about a tuna recall. As you know people, especially pregnant women, need to keep an eye on the news for public health and food issues. </div>
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Today the FDA has recalled some frozen tuna because it has hepatitis A in it. The FDA recommends that people exposed to this fish get a Hepatitis A vaccine if they are between 1-40 years of age, or a immunoglobulin shot if they are outside of that range. </div>
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Frozen Tuna is in sushi. And you can get it in restaurants. This tuna was shipped to restaurants in Texas, Oklahoma, and California. It was sent to New York State but not distributed there yet. </div>
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This tuna comes from Philippines and Vietnam. It comes via a Hawaii based imported called Hilo Fish Company. </div>
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Once again I wouldn't want to impugn the Hilo Fish company. They should be awarded for checking the fish and cooperating with the recall. It is the fish companies that don't test that we need to be alert for. I have seen really giant tunas that caught by recreational fishers. These big tunas get distributed immediately to sushi shops. That kind of distribution is what we want to worry about. </div>
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So for now, don't eat any frozen or uncooked tuna, and check the FDA's web site for further news and lot numbers, etc. This tuna was dated April and October apparently. </div>
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I am not aware if cooking the tuna adequately will sterilize the Hepatitis A, but certainly it cannot be eaten raw or undercooked. Unfortunately I really like sushi. </div>
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Thanks </div>
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Dr John Marcus </div>
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89 North Maple Ave </div>
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Ridgewood NJ. </div>
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Blog at doctorjohnmarcus.blogspot.com</div>
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Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com6tag:blogger.com,1999:blog-5044073699235306403.post-65024553184825152932017-04-02T16:01:00.002-04:002017-04-02T16:54:39.843-04:00<h3>
<u>Medical Science and Statistics</u></h3>
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One thing that most people don't understand is that most medical science is very weak from a statistical and mathematical point of view. </div>
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Another thing that doctors don't understand at all is the concept of Predictive Value of a test result. </div>
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Lets go through both here. </div>
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The medical journals are voluminous. There are many studies done. They are mostly done in a fairly uniform format. (such as Title, Abstract, Methods, Summary, Conclusion). There is a ton of complicated language that is familiar only to the professors who read and write these studies. </div>
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The biggest problem with medical studies is the issue of bias. There are a ton of problems with bias. Most studies have bias. If a scientist wishes to prove something, then they will attempt to make a study that proves their point. It is rare for a study to be done that doesn't have bias. Because a truly neutral scientist is not going to be motivated to produce a study and article at all. Pharmaceutical companies are biased because they want to make money. And meds are worth billions of dollars. </div>
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Here is a publication that describes much of the bias in medical science: </div>
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http://fhs.mcmaster.ca/surgery/documents/HandoutGrimesAssociationforResearch2of07Oct2009.pdf</div>
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The same article is here: </div>
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http://thelancet.com/journals/lancet/article/PIIS0140-6736(02)07451-2/abstract</div>
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The best way to avoid bias is to gather a study group of people, and randomize them. This produces the least selection bias. Then the two or more groups of people are treated differently and someone analyzes if the outcomes are different. If the study is "Double Blinded and Randomized" then there is strong evidence that the different treatments created different outcomes, and the knowledge base of the human race has increased. </div>
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But even the best randomized trials still have bias. One of the strongest biases is publication bias. You see, the studies are designed to create a "P Value" of 5 percent. This p value means that there is only a 5 percent chance that the outcome is due to chance variation. This kind of p value is easy to calculate for people who are trained in this kind of statistical work. There is software to calculate p values based on simple input numbers, such as study size, expected effect, etc. </div>
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Here is a summary of how to calculate p value: </div>
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http://www.wikihow.com/Calculate-P-Value</div>
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It looks really complicated and confusing. But it makes a ton of sense to people who know how to do it. I don't suggest you try to learn the details. Just know that the p value tells you how likely the research results are true, and not chance. P value of .05 is the standard and that means there is only a 5 percent chance the study results are just randomness. </div>
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But here is the kicker, and it is a huge problem: </div>
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Studies that prove nothing, with elevated p values, don't generally get published. Those "worthless results" might be considered a waste of time. But if you do the study 20 times, then one of them will give a false result. (one in 20 is 5 percent, or p value of 0.05); The result will appear excellent, but it is wrong, fake, biased, incorrect, garbage, dangerous. You might think that this is a stupid criticism of necessary science. But I can tell you that it is huge. There are studies that are done where the data is looked at hundreds of different ways. Not all of those ways are published. Only the significant results are published. So if a study looks at the same data one hundred different ways, and the p value is 0.05, then 5 results will show a fake but convincing effect. Worse yet, some studies do "early look" at the data. This should be condemned entirely. An early look at the data erodes the quality tremendously. Not only is there less data to look at, but it more than doubles the risk of a false p value. There will be a <u>more than 10 percent chance</u> of a false finding. And if one looks at the data 10 different ways, then it becomes very likely that there will be a false presentation of statistical effect. The study will show a false truth. This certainly happened with the "Woman's Health Initiative". There was an early look and there was a possible false finding of a cause of breast cancer. That study cost many millions of dollars. And it turned the previous data on its head. There was ultimately one table in that study that will show the possible truth, The "life table" analysis, which showed the incidence of breast cancer in the hormone group vs the nonhormone group, across time. If you look at that table, the incidence of cancer was higher in the early data in the estrogen group. But the incidence lines were about to cross, consistent with older data, at the 2 year early look. Despite the fact that the data was poor, the study was cancelled. The p value declared secure. And people believed that estrogen, a natural normal female hormone, is toxic. It might take another hundred years before someone does this study properly. The early look and the multiple analysis gigantically eroded the value of the data. And in any case, the effect of estrogen was a few cases in 10,000. It became easy to vilify estrogen to the point of wrecking woman's lives. </div>
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Also, there is the effect of "study group". A study that is done in one setting will not apply in another setting. A study done by midwives can be perfect scientifically, but it will not apply to obstetricians. Because obstetricians treat their patients differently. A study done on men might not apply to women. A study done in a poor area of Chicago might not apply to Mormons in Utah. For instance, lets say you are doing a vitamin D study and your group is in far north Canada. They might not get sunshine for half the year. This will certainly not apply in Ecuador (which is named for being on the Equator), and has near vertical sunshine year round. (Vitamin D is created by sunshine on the skin). There are a lot of vitamin D studies. One should look carefully at the study population to see if the study applies to yourself or your population. </div>
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One example of study population affecting results is C Section closures. In a university, C Section closure techniques were studied. Staples vs Subcu dissolvable. In this study the results were proven to be equivalent. Staples and sub cu had the same scar outcome. But, the kicker is, this university also published a very high surgical skin infection rate. If I remember correctly, it was as high as 15 percent. This study cannot apply to me, because my surgical infection rate might be 15 times lower than that. I practice at a hospital that has infection control procedures down pat, with highly experienced personnel, laminar flow operating room air, etc. So that study simply doesn't apply to me. I have to make my own decisions about C Section closures, unless I do my own study. The bottom line is that I will close a C Section in a way that the patient finds best, In other words, the patient will help decide. Some don't like staples. Some have had very good results with staples. Some want dis-solvable stitches, even though those stitches takes weeks to months to fully dissolve, if ever. </div>
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Now lets move from statistical medicine to the doctor patient interaction. </div>
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<u><b>Predictive Value:</b></u><br />
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Lets say that I ordered a pregnancy test. And it is positive. But, the test was done on a boy, or a virginal gay woman, or a virginal nun. What is the value of that test result? It will not be valid. It will of course lead to a lot of stress, maybe recriminations, and some terrible feelings. But the value of that test is nearly nil. The predictive value of a positive pregnancy test depends on the study population. Lets say for the sake of argument that this particular test is 99 percent accurate. That leaves a lot of room for error. Because there are women who cannot get pregnant. If we test them, all of the results are inaccurate. Or at least misleading. A test can be inaccurate for a number of reasons: tumors, ovulation, HCG injections for a number of indications. I've even had patients who were ALWAYS POSITIVE. They've never had a negative pregnancy test in their life. Sorting that out is a challenge. Lets hope a 14 year old is not disowned by her father while figuring that out. We might figure that there was a tiny bit of placenta left over from her own fetal days, stuck somewhere in her body. Wherever it was, it did not seem to harm her and she wasn't worried.<br />
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So to calculate the predictive value of a positive result, the most important factor to consider is the pre-existing chance of the problem studied for. A good test has a 80 percent "Sensitivity". This means that, in the presence of the condition tested, there is an 80 percent chance of the test showing it.<br />
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Take a look at the Wikipedia page as of today:<br />
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https://en.wikipedia.org/wiki/Sensitivity_and_specificity<br />
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There is a lot of math there. We don't need to know the math, but we have to know the idea. And if we don't, we mess up.<br />
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For instance, I might order a "Comprehensive Metabolic Panel" from the lab. This test has about 20 different natural chemicals on a person. For instance glucose and sodium (salt) are usually at the top. It is really tempting to order this test as it gives a ton of good info about a patients chemical status. The lab can print this out in minutes to hours. The problem, and it is not a big problem, is that the normal ranges are set at 95 percent normal ranges. That means that if we do the test 20 times, there will be on average one that falls outside the normal range, in an otherwise completely normal person. For instance, they ate a jelly donut and their glucose is high. That is a bad example because most people won't eat a jelly donut prior to a lab test, but in an emergency, the ER doc might not be able to ask the patient when they ate. So, on average there are 20 measurements, with a 95 percent "confidence interval", that means that a normal person has about one test outside the normal range. This is a completely false positive. And it is normal.<br />
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Notice the similarity here to the 95 percent confidence interval, or 5 percent false positive rate. This is identical to the 5 percent false positive rate assigned to medical studies. It seems that medical scientists are somewhat favorable to the 5 percent/95 percent confidence interval.<br />
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Where this gets really complicated is when we have tests that are 80 percent confident, or less. This is high for a screening test. A pap smear in the old days prior to HPV testing has a confidence of about 5-10 percent. A glucose screening test in pregnancy has about a 10 percent positive predictive value. In other words, 90 percent of positives are false. So we deal with low predictive values all the time. The tests still have a lot of value but alone mean nothing.<br />
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<b><u>Low Predictive Value:</u></b><br />
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What is the chance of an 18 year old getting cervical cancer? It is very low. If we do a pap smear, the chance of a positive pap smear meaning cancer is next to nothing. That is because pap smears have a high false positive rate, in a population that is very low risk. Back when I used to do paps in 18 year old women, I only intervened when the biopsies showed severe risk. This did happen, and I kept my interventions very light, like a gentle laser surgery to remove only the surface of the worst areas. But it turns out that even that is unnecessary. The incidence of cancer is so low as to make the positive pap smear nearly worthless. The positive predictive value was near zero. So, as per the new protocols published by the ASCCP, I have stopped doing paps in women under 21 years of age. The paps simply don't help. The predictive value is low. It is like doing pregnancy tests on a boy. Or doing a vaginal sonogram on normal woman, which has been proven again and again to be worthless to dangerous. The predictive value is most likely below zero. In other words, it harms women.<br />
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18 year old women can still get checkups, or checked for problems, of course. It is just that the pap is not part of the checkup, unless there is a specific reason. (the reason might be the woman or her mother really wanted it).<br />
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But please, don't assume that sonograms themselves are worthless. In fact, woman should have more of them. They should present early and often for pelvic pains, pressures, bloating, or any other symptom. An indicated sonogram can save a life. And we all need to do better detecting ovarian cancer. <br />
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I haven't given up on medical science. But there is still a lot of room for what is called the Art of Medicine. That is keeping people healthy, preventing disease, eliminating risk and pain. And doing it while keeping people feeling safe, comfortable, and happy. And I do that to the best of my abilities.<br />
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Comments are appreciated. And let me know if there are any errors.<br />
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Thanks<br />
Blog at doctorjohnmarcus.blogspot.com.<br />
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<br />Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com2tag:blogger.com,1999:blog-5044073699235306403.post-17263133192353231432017-02-15T21:26:00.000-05:002017-02-15T22:27:00.310-05:00<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">LOONEY MONTHS </span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">I came home from work today just after sundown and I saw a full moon rising. A family friend was over. I mentioned it offhandedly and said full moons were fun. She looked at me straight faced and asked why? so I started thinking. Why indeed? As an OB I of course think of the busy obstetrical unit. Full moons are busy nights right? The ancient lore is that full moons make for very busy labor units. This has been suspected since the beginning of time. The reality is that there may be a small increase of maybe a percent or two, but the lore is very strong. Is there something to the ancient lore? May there be a reason to think that Ob units are busy on full moon nights? Is there some ancient anthropological principle involved? So I did a little investigating. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">I started listing for myself why I thought the full moon was fun and interesting. </span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">First the full moon always rises in the east and looks very very full.. It appears to be giant when rising in the east over a distant horizon. Photos of this effect are striking. You can easily search for these photos. Do a google search for full moon rising, switch to the images tab, and look at the striking photos. </span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Second a full moon always rises at sundown. This means everyone sees it at the end of a workday when they are tired and hungry and ready for dinner. It seems most impressive then. When it rises most people are not thinking they’ll be looking for the full moon tonight. It just pops up huge and bright on the horizon. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Third a full moon strikes people's mood. It is what is meant by loony, lunatic, lunacy etc. </span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Fourth, the ob unit at the hospital always groans that a lot of labors are going to come in. The feeling is that full moons means more laboring women. We all say “uh oh get ready”. It'll get crazy. It'll get looney around here. But the purely logical folks say that is just an old wives tales. It means nothing right? Which prediction wins, logic or lore? Will the unit be busy or is it just an old wives tale? (midwives tale might be a better term) </span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Fifth a full moon is the brightest night of the month. The moon shines bright and full. Moreover it shines brightest right at midnight. Why? A full moon is always exactly opposite the sun from the earth. That is pure astronomical geometry and that is why the moon is full. So the darkest part of night becomes the brightest. And it is brightest right at midnight. That is just weird at midnight. It is like it is not even night. Especially on a winter night with snow on the ground. It is astonishingly bright on some full moon midnights. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">There are a ton of human endeavors that are tied to the idea of a month. Paychecks, rent checks, contracts, meetings, mortgage payments, menstrual cycles, birth control pill packages, and tons more. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">So there I am thinking why would ob units get busy on a full moon night? This is very strong old lore. Maybe there is an old truth to be discovered here. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Now that I have thought about it I think the answer is obvious. </span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">But first you'll need to come along with some math again. This time we will do date and time math. </span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">You see a human pregnancy lasts just about 40 weeks. We have pregnancy dating wheels that show exactly 40 weeks. We Ob’s always bemoan that everyone calls it 9 months. It is hard to make 9 months out of 40 weeks. We would more likely make it 10 months, if the month is defined as 4 weeks. Many months are defined as exactly 4 weeks. A cycle of birth control pills is exactly 4 weeks, or 28 days. Many paycheck cycles are 2 weekly or 4 weekly. Now think about a pregnancy of 40 weeks. 40 weeks is exactly 280 days. 40 weeks is exactly 10 months, if a month is defined as 4 weeks. This is 280 days from the first day of the last menstrual period. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">But conception happens 2 weeks later. Or 14 days after the first menstrual day. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">So labor happens, mostly, about 266 days after conception. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">So then I'm thinking what happens on bright full moon midnights? Walks on the beach… can't sleep… too bright … romance…. conception. That is what happens. Romance and conception happens. So if conception happens on full moons… where is the moon when labor happens? Where is the moon? </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">So I looked up how many days happen between full moons. I found it online. 29.53 days happen between full moons. That is a lunar month. There are a ton of different kinds of months. Calendar months are obvious. But lunar months is what I am interested here. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">What is 266 days divided by 29.53 days? </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Hold your breath… </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">9.007 moons happen. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">This is astonishing. It is not astonishing that there are 9 moons. That is ancient lore. It is pretty cool that the ancient lore gets a boost here. But, what is astonishing, is that, on average, a baby conceived under a full moon will, on average, labor under a full moon. In fact, labor should occur within a few minutes of 9 moons later. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">So there you have it. The first real explanation ever given as to why the lore of Ob/Gyn’s and midwives expects extra work on a full moon night. It is the same reason so many songs are written about romance under a full moon. </span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">If you doubt this then think about evolution of the human species. We have been on the planet as genetically and anatomically modern humans for 250,000 years. For more than 200,000 of those years, a moonless night would have been abjectly absolutely dark. A person would not have been able to find their spouse or their baby, even if they wanted to. They would likely have not even seen their hand in front of their face. So romance, conception, and delivery of babies, would have been really difficult. And very dangerous for the baby. The new mother would have really struggled without effective assistance from any midwives that might have been there. Babies would be far more likely to die. There would have been a very strong Darwinian Evolution pressure to not deliver on dark nights. Bright moon filled nights would have been no problem. For the 200,000 years before humans had fire the human race might have arranged for biology to make conceptions on full moon nights, and labors exactly 9 moons later. </span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">40 weeks has nothing to do with 9 months. Maybe more like 10 months. But ancient midwives 10000 years ago might have known that a bright moon now meant labor in nine more moons. Or, if not that, they certainly would have known that full moons meant more babies were to be born. That is something we talk about even today in a modern Ob unit. We usually joke about it. But this may be the ancient history of the 9 moons connection. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">This 9 moons time frame is too much coincidence for me to ignore. Babies are generally laboring to within minutes of 9 moons after they are conceived. This is crazy. This is lunacy. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Thanks for reading. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Comments are of course welcome. And questions are welcome as well. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Ridgewood NJ 07481 </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Phone 201-447-0077</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Fax 201-447-3560. </span></div>
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Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com2tag:blogger.com,1999:blog-5044073699235306403.post-22221259617774497502016-12-07T15:27:00.003-05:002017-02-15T22:40:33.245-05:00<i><br /></i>
<u><b><i>Family Powers of Two</i></b></u><br />
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I have just come back from The Valley Hospital where I delivered a beautiful baby boy, a first baby, to a wonderful couple. The baby came out right onto the mothers chest and abdomen, and he was moving around, pink, and of course crying. He took his first 5 breaths, which are mostly in breaths, before he started crying from being born. I think that babies do not like being born. It is like getting evicted from a warm easy 98 degree bath that one has floated in for 9 months. I can't imaging getting evicted like that. And then babies have to do the hard work of actually breathing and digesting. It is called transition by the baby care staff. Transitioning is important, and it can be difficult for babies that are born in a stressful manner. Difficult or stressful births might be a premee or an infection. This could include influenza or strep sepsis, for instance, or a placental abruption. Transition is also sometimes a bit difficult for C Section babies that have not experienced labor. I think that the babies that don't get squished or compressed by uterine contractions have a harder time with transition. They breath harder and faster, and sometimes need oxygen, suctioning, and stimulation. They have more amniotic fluid in their lungs that needs to get expelled somehow. We call this transitioning difficulty "Transitional Tachypnea of the Newborn". Here is the Wikipedia page as of 2 PM on December 7th. https://en.wikipedia.org/wiki/Transient_tachypnea_of_the_newborn. Notice that Wikipedia calls it transient tachypnea. That is another name.<br />
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But as a mathematician and a amateur philosopher I have been thinking about generational genetic math again. One of my patients has done the 23andMe genetics service and has found out some genetic history. This may be very valuable to someone who has no known family history. It can elucidate particular genetic risks, and will be valuable for the whole family, and her kids. (I can use the pronoun "her" because I only have female patients, as per my board certification rules, which disallow male patients under most circumstances).<br />
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Lets think about generational math. Realize that you have two parents. Your parents have two parents, meaning you have 4 grandparents. Your grandparents have two parents each. This means that you have 8 great grandparents. Notice that each generation has a power of two. Powers of two have very easy calculations, especially for a computer scientist as they deal with powers of two all the time. 2 to the 8th power is a byte, and there are 256 different bytes, starting at zero and ending at 255.<br />
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Anyway, lets continue. Two to the 16 is 65,536. This means you have 65,536 great great... 16th generation... grandparents. And so does everyone else.<br />
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Powers of two have an "exponential" growth rate. There is an astronomical amount of power in an exponential growth rate. Two to the 32 is 4, 294, 967,296. <span style="background-color: white; color: #252525; font-family: sans-serif; font-size: 14px;"> </span><br />
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Here is the first kicker. 32 generations ago, was how long? If we allow 20-25 years per generation, we get 640 to 800 years. There was not 4 billion people on the planet back then. This was the European middle ages, the Ottoman empire, the Shogun's of Japan, the natives of the America's, which came over from Asia via multiple routes during the last Ice Age 10,000 or more years ago. <br />
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The Earth only got it's first 1 billion people as of the year 1800 or so. So how can you have 4 billion ancestors if there were much less than a billion people on the planet? The answer is that people share ancestors. This is another way of saying that we are all related. <br />
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Using this kind of math, we can show that in General, of the 8 billion people presently on the planet, we are no more than, maybe 64th cousins. This is a highly conservative estimate, because 2 to the 64th is 1.8 times 10 to the 20th power. This is trillions of times more than the number of people that have ever lived. <br />
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Or, another way to look at it, is that 2 to the 33 is about 8.6 billion. This is way more than the number of humans that existed 33 generations ago. Therefore, we all must share a lot of ancestors to get this high number. <br />
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How many generations of humans exist? Anthropologists and geneticists believe the humans evolved from a herd of homo sapiens consisting of about 40 woman, tracked through the mitochondrial genetics. This herd lived somewhere around 250,000 years ago, centered somewhere in Africa, and expanded from there. 250,000 years, divided by 20 years per generation, gives 12,500 generations. So your 12,500th grandfather, is most certainly the same as mine, no matter where you are in the world. The only way this could be different is if your family came from a different planet. <br />
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No matter how you do this math, the numbers will add up somewhere in the same ballpark. <br />
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We are likely no more than 35th cousin, and we are not possibly more than 12,000th cousin. No matter who you are in the world. <br />
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Can 12,000 generations evolve humans so differently? Pale skin was necessary in northern latitudes because humans would die of rickets without vitamin D. Pale skin was necessary to survive the low sunlight levels of northern latitudes. <br />
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Pale skin in equatorial Africa was similarly dangerous. A person like myself can get a sunburn in under 20 minutes of hot unmitigated sunshine. Everyday all day without coverage from the Sun and I would eventually get a tan, but I would be seriously challenged by the burn, the blisters, and the cancer that would likely ensue. A darker neighbor would most likely be healthier and have more successful reproduction. I believe that even a few generations like this would evolve humans to have different pigments. So yes, this many generations can evolve a lot of differences. <br />
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So, the bottom line, is that we are all related. All Europeans are no more than maybe 32nd cousins. All Asians similarly. All Africans similarly. But, assuming that the races of humans split up at the exact moment of creation of the species and didn't mix since, we can be no more than 12,000th cousin. I believe those conditions were not true, and that humans intermixed over history, so it would be difficult to find humans that are, say, more than a thousandth cousin.<br />
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We are all related. We are all one family.<br />
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Thanks for reading.<br />
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http://doctorjohnmarcus.blogspot.com </div>
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Phone 201-447-0077</div>
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Fax 201-447-3560 </div>
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Member of Medical Justice </div>
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Member of the U.S. Woman's Health Alliance at http://uswomenshealthalliance.com/index.php</div>
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Member of the American College of Ob/Gyn at www.acog.org </div>
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Board Certified by American Board of Obstetrics and Gynecology at www.abog.org </div>
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Member of The Valley Hospital Medical staff Department of Ob Gyn </div>
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Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com3tag:blogger.com,1999:blog-5044073699235306403.post-73101470804241721322016-11-20T15:05:00.000-05:002017-02-15T22:42:57.388-05:00<h2>
<u>LISTERIA ALERT</u></h2>
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<u>Listeria is an infectious bacteria that is particularly dangerous to a pregnant woman's fetus.</u></div>
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Watching the news today I came across a story that all pregnant woman will have to know about. Listeria is once again in the news. </div>
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Every once in awhile there will be a public health alert about some particular food that has become a danger to the public. The American Food and Drug Administration has the mandate to keep our food safe, identify the risks to the public, and eliminate or mitigate the risks somehow. Frequently that will mean recalls. Often the recalls will be some kind of vegetable. I can remember spinach, melons, packaged salad, and very frequently frozen hamburger meat. Once in the past it was Hummus. This time it is some kinds of Sabra hummus. Here is a link to the CNN article. I am sure this article will be updated as more information becomes available. </div>
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http://www.cnn.com/2016/11/19/health/hummus-sabra-recalled/index.html </div>
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Oddly, the article does not mention pregnant woman. In pregnancy the infection to the mother can be a relatively mild flu like illness, but the bacteria gets into the fetus and severely, permanently, or fatally injures the fetus. It is very difficult or impossible to identify the illness in the early stages. The most common diagnosis is on culture of the infected fetal tissues. By then, the damage is to late and many times irreversible. </div>
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The best defense against listeria monocytogenes is avoidance. There are particular food rules that most pregnant woman are aware of to never eat certain foods. Like unpasteurized soft cheeses. This is a basic rule of pregnancy. I think I am going to survey my pregnant patients about this knowledge. And report the results here. Results to be announced. </div>
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Here is the wikipedia page. I last looked at this on Sunday November 12th at 2:30 eastern standard time. (wikipedia pages can change all the time). </div>
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https://en.wikipedia.org/wiki/Listeria_monocytogenes</div>
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Sabra is my favorite hummus. Hummus is vegan, extremely healthy, and really yummy. I will not stop buying it. But please throw away any of the listed versions. And for now, pregnant woman should avoid this Sabra hummus. </div>
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It would be too easy to say that Sabra Hummus company is committing a malfeasance by producing hummus like this. I would ask all of you to consider an alternative view. My view, and your view should be, that Sabra is making an effort to keep their food safe, and doing this voluntarily. How many companies do quality control like this? It was not long ago that a peanut butter company did quality control but hid the results and shipped the infected food anyway. This led to unprecedented criminal charges against the leadership of that company. </div>
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But worse, how many companies don't do quality control so effectively? How many don't do it at all? Large egg farms, for instance, have the hens living in poultry barns where there feces exist. This is utterly unavoidable as the birds cannot be potty trained. And keeping the birds on a grid to let the feces fall will only hurt their feet. </div>
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And smaller companies (and restaurants) that make smaller batches or more "homemade" like food will have no quality control at all, other than the skills and cleanliness of the chefs and workers. There are many instances of Norovirus spreading from mildly infected workers. Workers should voluntarily stay away from work when they are ill, but that will be looked upon as a black mark on their occupational record, and might lower their paychecks. Alternatively, workers should be rewarded for due care to protect the food and their customers. I don't know how employers can commit to this. Personally, I don't come to work when I suspect that I might harbor an illness. And, don't be too surprised, physicians and nurses do get sick. I remember the look of shock once when a delivery man came to my house when I was sick and raised his eyebrows when he saw that I was on a sick day. He said "doctors don't get sick" in surprise. I laughed and said I wish that was so. </div>
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So I believe that Sabra hummus is committing to quality control with vigor and commitment. This will make me more likely to buy Sabra, not less. </div>
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Please let me know what you think in the comments below. </div>
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Thanks for reading. </div>
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http://doctorjohnmarcus.blogspot.com </div>
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Phone 201-447-0077</div>
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Fax 201-447-3560 </div>
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<br /></div>
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Member of: </div>
<div>
<br /></div>
<div>
Lifeline Medical Associates at LMA_LLC.com </div>
<div>
Medical Society of New Jersey </div>
<div>
Past President of Bergen County Medical Society </div>
<div>
Member of Medical Justice </div>
<div>
Member of the U.S. Woman's Health Alliance at http://uswomenshealthalliance.com/index.php</div>
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Member of the American College of Ob/Gyn at www.acog.org </div>
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Board Certified by American Board of Obstetrics and Gynecology at www.abog.org </div>
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Member of The Valley Hospital Medical staff Department of Ob Gyn </div>
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-ex Director, Associate Director, Secretary, Chief of Education, Chief of cancer committee. </div>
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- present member of Ob Critical Care Committee </div>
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Member of Hackensack UMC at Pascack Valley Medical Staff at http://www.hackensackumcpv.com/</div>
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Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com0tag:blogger.com,1999:blog-5044073699235306403.post-44386396931282791452016-06-05T12:41:00.003-04:002016-06-05T12:55:11.559-04:00<br />
<h2>
<b><br /></b><b>Why do I ask people about their religion? </b></h2>
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To boil the answer down to a simple one, it is because I don't wish to put people and patients into a state of spiritual strife. Or spiritual danger. If I mistakenly give people a plan of action that they later come to regret, I will feel like an ass.<br />
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My medical decision making can be precisely correct, scientifically sound, and delivered in a clear, compassionate, and skillful manner. Yet still it is possible to wreck someones life. I don't want to wreck anyone's life. From professional point of view it would make me a bad doctor. From a personal point of view I would feel like a jerk. I don't want to feel like a jerk.<br />
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How could a doctor create spiritual danger? It is remarkably easy. And it is sad to say but physicians don't get any education about spiritual issues. I think that leaders in the medical sciences want to say that modern medicine is "evidence based". Medical leaders want to be scientifically sound. They want all medical decision making to be factual. They want to be able to cite actual scientific journal articles to support one decision over another.<br />
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The older generation of docs used to complain bitterly about this turn towards science, towards checklists, and away from the art of medicine. Older docs called it "cookie cutter" medicine. Or "recipe" medicine, or something like that.<br />
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A arrogant young medical doctor might scoff at the notion that a person's religious belief would interfere with sound medical care. A self important doctor might tell a patient that "there is only one way to do this, and it is my way. Religion has nothing to do with it.". This is spiritually dangerous territory. Even for atheists.<br />
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Let's give an example:<br />
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A newly married Catholic woman comes to my office to ask about contraception. She has strong faith. During the consultation I find that she has no knowledge of the Catholic rules pertaining to conception and contraception. If I didn't care for her overall well being I might recommend the birth control pill or an IUD. If I did this deliberately it is even worse. Catholics have some simple and important rules to follow when it comes to contraception. Catholic rules prohibit ejaculation outside the vagina. And even more importantly Catholic rules prohibit interfering with an embryo. If an embryo gets created, then it must be allowed to implant and grow. No one can take any action that prevents embryo implantation. Since the birth control pill will allow rare ovulations, there will be embryos created. But the birth control pill also thins the uterine lining. When the uterine lining is thin the embryo has nowhere to implant. So the embryo menstruates out. The Catholic theology is that an embryo is a human, And obviously no one wants to hurt an innocent human. <br />
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Notice that this is simply an extension of the right to life movement all the way back to sperm and eggs.<br />
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Personally I don't adhere to the notion that an embryo isn't human yet. I think embryos are human. There is no magical point of time when an embryo ceases to be inanimate, and suddenly becomes human. The embryo is and always will be human. It is silly to point out an event and say, now, the baby is human. Before, not so much. Embryos are constantly growing. Whether a person is pro-life or pro-choice, people have to get rid of such misconceptions.<br />
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Discussing these issues is important. These issues are deadly. Of life and death importance, Many gynecologists have been shot or bombed because of disagreement over these beliefs. Many people have died over this issue.<br />
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So yes, spiritual competence is an important skill for a physician to have. And when I ask you about your genetic heritage, ethnicity, and religion, I am simply trying to be a good doctor, and avoid things that might harm you. And if you don't tell me your religion, then I might inadvertently give you bad advise. My advise might be scientifically sound but spiritually wrong.<br />
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As an interesting aside, there are many times during consultations when people claim to not have a religion. They might even get annoyed by the questions. Many people claim to be atheists. But, many times, they are not. They are wrong. They are not atheists. What they really are is agnostic. When a person claims "there is no God", then they are an atheist. That is not so common. Many people really want to say, "I don't know if there is a God". That makes them agnostic.<br />
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For another example of spiritual danger, consider the Jehovah's Witnesses. Jehovah's Witnesses believe that they cannot take another person's blood into their bodies. If they do, they will not get to go to heaven when they die. Many people are flabbergasted when they hear that someone would rather die then take a blood transfusion. It is only comprehensible when you understand that going to heaven is for eternity, and our life here on earth is only temporary and short. No one wants to make a mistake that would cost them an eternity of happiness. So Jehovah's Witnesses would rather die than take a blood transfusion. So the standard surgical consent form now has a Jehovah's Witness clause. It is an answer to the question, "Will you accept a blood transfusion if it is necessary to save your life?". The question must be asked and answered. Because I don't want to destroy someones long term plans of eternal happiness in Heaven.<br />
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Another example is Ramadan. Many Muslim women want to fast during Ramadan. I can help them. There is some theological controversy about the fast in pregnant women. But if my pregnant patient wanted to fast, I will try give her good advice about how to keep it safe. But I cannot give this advise if I don't know she is Muslim. Ramadan starts today.<br />
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In some religions woman cannot be touched by men. Not even to shake hands. For these women, you will put them in a bind if you offer to shake their hand. Nobody wants to be rude by refusing. But nobody wants to violate their own beliefs either. Again, if I didn't know someone was of that religion there would be uncomfortable moments. Medical care requires physical examination, but does not require a handshake. So there is unnecessary stress over a handshake.<br />
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If anyone asks about me, I am a theist. I am not an atheist. <br />
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Thank you sincerely for reading.<br />
<br />
Dr John W Marcus<br />
89 North Maple Ave<br />
Ridgewood NJ 07450<br />
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Blog is at doctorjohnmarcus.blogspot.com.<br />
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<br />Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com1tag:blogger.com,1999:blog-5044073699235306403.post-31778661679871021812016-02-07T15:56:00.001-05:002016-02-07T15:56:39.655-05:00<h2>
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<u>Latest Zika News</u></h2>
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Zika continues to be in the news. </div>
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The country of Columbia has widespread Zika virus. But Columbia is claiming that they are not seeing the increase in microcephaly that is being found in Brazil. There is no known explanation for this discrepancy. The scientists in Columbia that are not absolutely convinced that Zika causes microcephaly. Columbian scientists think that this connection between Zika and microcephaly might be scientific misdirection based on bad statistics. What amounts to a correlation/causation fallacy. This kind of scientific fallacy has happened plenty of times in the past. As of yet I think that most people believe there is a link between Zika and microcephaly. </div>
<div>
<br /></div>
<div>
Correlation/Causation fallacies are very easy to fall into. I remember when hairy ears were thought to be connected to heart disease. So people would trim their ears, as if that would help their heart. It was ridiculous. And in my field, it was thought that estrogen treatment for older women prevented heart disease. It required many years to correct this wrong idea. We now know that estrogen treatment is preferentially taken by fit women. This explained the fact that women on estrogen hormones had less heart disease. In a randomized trial, there was no protection from heart disease. This false conclusion took many years to correct. </div>
<div>
<br /></div>
<div>
The estrogen link to breast cancer is still not understood at all. Even by very smart people. Estrogen is about as carcinogenic as a nose. It is a normal part of a woman's body. (Please note that noses do form cancer.) In the Woman's Health Initiative it was found that estrogen increased the breast cancer risk in women about 7 in 10,000 cases. But it similarly lowered the risk of colon cancer. So in the worst case scenario the cancer risk is a wash. Also note that changing 7 cases from colon cancer to breast cancer should save lives. In the WHI, after two years, the increased breast cancer risk was just about gone. The risk line was just about to cross over to lowered risk (consistent with many older studies) when the WHI was cancelled prematurely. I would invite anyone to go and read the WHI report and see that the risk for breast cancer was just about to cross over into protection. There is one graph that shows this. Cancelling the study early was a violation of the study protocol and wiser calmer heads should have kept the study going. </div>
<div>
<br /></div>
<div>
The Aedes mosquito continues to spread. It is an invasive species anywhere in the Americas, so eliminating it should not damage the ecosystem in any way. Right now there are plenty of videos of insecticide trucks fogging entire cities, and workers with leaf blower sized backpack devices fogging inside homes. There appear to be an army of them working in South America. </div>
<div>
<br /></div>
<div>
Even though removing Aedes mosquitoes will not hurt the environment, widespread insect fogging may have a detrimental effect on the environment or on human fetuses. It will certainly create resistant forms of other insects. </div>
<div>
<br /></div>
<div>
There is no chance that insecticide is going to remove Aedes. There are just too many of these mosquitoes in too many places. Insecticide will reduce them, but it will not eliminate them. So humans are now seemingly committed to large scale long term continuous insecticide exposure everywhere there are Aedes mosquitoes. </div>
<div>
<br /></div>
<div>
There is a much better strategy that has worked in the past. It is mosquito birth control. There is a British biotech firm, a small firm, that can create sterile Aedes male mosquitoes. These mosquitoes then go and mate with wild female Aedes. The offspring will not grow to adulthood. This British firm has also tagged their Aedes mosquitoes with a color that glows red in the presence of some kind of special light. Maybe a black light. This is a great way to follow the progress of their birth control measures. As a Gyne, I am familiar with birth control. Birth Control sometimes works. </div>
<div>
<br /></div>
<div>
Here is a news story that is right now 3 hours old, at the Independent News in the UK: </div>
<div>
<br /></div>
<div>
http://www.independent.co.uk/news/uk/home-news/zika-british-team-say-they-have-a-remedy-for-the-virus-a6859046.html</div>
<div>
<br /></div>
<div>
So if the sterile males go out into the wild and shoulder aside their more fertile cousins, then the Aedes mosquitoes will not successfully reproduce. </div>
<div>
<br /></div>
<div>
So birth control can work. There are several theoretical problems here. According to the principle of natural selection, the more fertile members of a species should survive. So if there are some female Aedes out there that can smell out their nonfertile mates, and not mate with them, then this won't work for them. Also, fogging of insecticide will kill the Sterile males too, so those two methods will work against each other, not support each other. This exact birth control technique has been used in the past to remove pests from agriculture. It sounds a lot safer than insecticide to me. </div>
<div>
<br /></div>
<div>
I tell my pregnant patients to avoid insecticide while pregnant. There are not enough studies to prove that these chemicals are safe for fetuses. It may be that fogging reduces Aedes, but that pregnant women exposed to insecticide have some other birth defects from the insecticides. Hopefully someone has figured out that risk. Eventually, the scientists will get to the bottom of this. </div>
<div>
<br /></div>
<div>
Thanks for reading. </div>
<div>
<br /></div>
<div>
Dr John Marcus </div>
<div>
blog at doctorjohnmarcus.blogspot.com </div>
<div>
<br /></div>
<div>
89 North Maple Ave </div>
<div>
Ridgewood NJ 07450 </div>
<div>
<br /></div>
<div>
Comments are welcome. </div>
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<br /></div>
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<br /></div>
Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com0tag:blogger.com,1999:blog-5044073699235306403.post-21305238285704966672016-02-04T16:17:00.000-05:002016-02-04T16:17:04.118-05:00<br />
<br />
<h2>
<span style="font-weight: normal;">Surgical Skin Closure, Staples vs Sub-cu</span></h2>
<br />
Yesterday I posted about Zika virus and how it is dangerous to neural tissue, especially for a fetus. This Zika problem will be with us for a couple of years until we can get a handle on it. I've seen pictures of the "war room" at the CDC where the epidemiologists have their daily meetings. I think the CDC is in Atlanta but it might be located at least partially near Washington DC.<br />
<br />
Today a patient came in for her PP visit and we discussed her surgical closing technique. I had a doctor covering my practice who is a very skillful and caring physician. The patient needed a C-Section and I wasn't on.<br />
<br />
My covering doc closed her skin incision with cosmetic subcuticular dis-solvable stitches. So my patient has had the skin closed both ways now. First with staples, second with sub-cu. And she now has a strong preference.<br />
<br />
I know that the staples are a bit more work, and patients are worried about the removal. The removal is usually almost painless as the staples slide ride out once they are unbent. <br />
<br />
Why are the staples beneficial?<br />
<br />
-They are completely removable.<br />
-They are very smooth and shiny, so no germs can get a hold of them.<br />
-They never break down and fail their job of holding the skin<br />
-When they are gone, they are utterly gone, leaving nothing behind to dissolve.<br />
-When they are gone there is skin touching skin and nothing else in between. This is far more comfortable, softer, and smoother.<br />
<br />
Why don't people like staples?<br />
<br />
They feel and look unsightly while they are in. And they have to be removed.<br />
<br />
In my opinion staples just do a better job and are worth the extra work.<br />
<br />
The science does <u>not</u> show a preference between between staples and subcu dissolvable sutures. There have been a number of randomized trials. Obviously the trial cannot be blinded because the doc doing the stitching can see what they are doing. I suppose the incision can be evaluated later by someone who is blinded as to the closing technique.<br />
<br />
In any case the studies showed no difference in the quality of the skin incision outcome. Of note, though, the studies that I read were done in academic medical centers where the infection and complication rates were far higher than a private community hospital. The academic centers infection rates were about 8 times higher than my hospitals. This surgical complication rate is a reflection of the socio-economic stress of poverty, the higher workload of the staff, and the riskier patient mix. I doubt if the less experienced staff has anything to do with it, but it remains possible. It is possible that the older facilities have less modern infection control technologies, such us laminar flow air handling in the operating room.<br />
<br />
I think that if that same study were done in a place like my hospital, there is possibly a different outcome.<br />
<br />
In my experience the staples provide a better outcome. Once they are removed they provide a far more comfortable and smoother incision.<br />
<br />
Every once in awhile a patient will pick a doctor based on their known closure technique. I would like everyone to know that I will do whatever technique they want. I will give them my advice and then honor their wishes. Hopefully that will satisfy the needs of those who don't like the idea of staples. I am perfectly qualified to do cosmetic sub cu. I studied 6 weeks of cosmetic surgery at the Cook County Hospital in Chicago Illinois. That was a great time for me. I learned a lot. And I have been doing surgery every since.<br />
<br />
So if you don't want staples, then I will do the sub cu. But if you want the best, then ask your surgeon if they can do metal removable staples. (The dissolvable staples are more like the sub cu).Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com0tag:blogger.com,1999:blog-5044073699235306403.post-5913366675490465012016-02-03T21:14:00.000-05:002016-02-03T21:14:11.232-05:00<div>
<br /></div>
<div>
<br /></div>
<div>
Zika Virus in Pregnancy. </div>
<div>
<br /></div>
<div>
Zika Virus has been in the news quite a bit. It seems very bad. How bad is it? </div>
<div>
<br /></div>
<div>
7 days ago there were very few cases known and published in the US. </div>
<div>
3 days ago there were 33 cases. All were cases caught outside the US, and brought here. </div>
<div>
Yesterday was the first case caught in the US, given from one person to another by sexual exposure. Sexual transmission seems to be a previously unknown method of transmission of Zika Virus. </div>
<div>
As of yet, there are no known mosquito transmissions in the mainland US. Although Puerto Rico, Guam, etc may be at higher risk, because of their tropical climates. </div>
<div>
It seems inevitable that there will be mosquito borne cases in the US. </div>
<div>
<br /></div>
<div>
In Brazil, there are 4000 cases of microcephaly in newborns. This is a huge increase, and is thought to be possibly from Zika infections. Zika seems to have an outsize affect on neural tissue. Zika gives adults a case of Guillen Barre Syndrome: </div>
<div>
https://en.wikipedia.org/wiki/Guillain%E2%80%93Barr%C3%A9_syndrome </div>
<div>
Guillen Barre is a disorder of neural tissue. </div>
<div>
And in fetuses, it somehow affects the neural tissue of unborn children. Somehow the neural tissue is destroyed. I have seen the CT scan pictures, and the brains are seemly destroyed, at least partially. It is a real disaster for these children, families, and societies. I don't think anyone knows for sure how the neural tissue is destroyed but it is certainly possible that the virus gets into the cells, grows there, and kills the cells. Once the brains are destroyed, the head stops growing, and the child has a small head. This is called microcephaly.<br />
<br />
There are no antizika antiviral medicines.<br />
<br />
There is no Zika vaccine. </div>
<div>
<br /></div>
<div>
The official position of the Brazilian Government is that women should put off being pregnant until something more is known about Zika Virus. This will take some time. Delaying an entire countries childbearing has not been done in recent memory. Again, this is something new. </div>
<div>
<br /></div>
<div>
As of this moment, there are far more questions than answers about Zika. </div>
<div>
<br /></div>
<div>
Here are a few helpful links: </div>
<div>
<br /></div>
<div>
http://www.cdc.gov/zika/pregnancy/question-answers.html<br />
<br />
http://wwwnc.cdc.gov/travel/page/zika-information<br />
<br />
http://www.cdc.gov/ncbddd/birthdefects/microcephaly.html<br />
<br />
http://www.cdc.gov/zika/pregnancy/index.html<br />
<br />
http://mothertobaby.org/fact-sheets/deet-nn-ethyl-m-toluamide-pregnancy/pdf/<br />
<br />
There are a few facts:<br />
<br />
Eliminating mosquito bites will likely eliminate risk. How can we eliminate mosquito bites?<br />
-Keep doors, windows, and screens closed.<br />
-Don't travel to tropical climates right now, without precautions.<br />
-Don't have unsafe sex with anyone who has been to a Zika prevalent area.<br />
-When summer comes use air conditioning. Mosquites prefer the warmth. Cold keeps the mosquitoes out or inactive.<br />
-If outside, use long tight pants, sleeves, socks, etc.<br />
-Use special clothes that are permeated with permethrin. Personally, I have never seen such clothes for sale, but this is what the CDC says to do. I suppose if you can get Permethrin, you can spray your own clothes with it.<br />
-Use highly effective insect repellent. DEET seems to be the best, in my opinion. Use it on all exposed skin, and even on your clothes. And use it even if pregnant. Use it copiously.<br />
-Don't go outside when mosquitoes are active and present.<br />
-Remove all standing water from the land. This is where mosquitoes breed.<br />
-Treat standing water with insecticide or some other effective treatment.<br />
-Use insect foggers outside, on a personal or municipal basis.<br />
<br />
And finally, as a society, we need to control the Aedes Aegypti mosquitoes.<br />
https://en.wikipedia.org/wiki/Aedes_aegypti.<br />
This is not the only nasty virus or disease transmitted by this mosquito.<br />
<br />
There are some biological control mechanisms to control this mosquito. But we will have to get over our natural inclination to protect species. It is rare for humans to conduct deliberate annihilation of a species, but it has been done before. Smallpox has been destroyed. Some agricultural pests have been destroyed. Other infectious diseases are on their way out. If we can vaccinate everybody we can stop more infectious diseases. But vaccinating everyone requires some force, as there will always be selfish individuals who wish to take advantage of the herd immunity we provide them, while not simultaneously helping to provide that immunity. These individuals will need to be either convinced or coerced. Somehow. My personal politics preclude the use of force on people, but I would support some kind of strong coercion for this. Like keeping unvaccinated kids out of schools.<br />
<br />
Worldwide, 140,000 people die of measles every year:<br />
http://www.usatoday.com/story/news/2015/07/02/measles-death-washington-state/29624385/<br />
These deaths are preventable with the vaccine. Everyone who declines the vaccine is part of the problem, not the solution. We all must accept the risk of the vaccine in order to benefit from the vaccine. And the risk of the vaccine is very very low. My children have been vaccinated as per the normal schedule. There was no doubt in my mind that it was a good idea. And now my kids cannot kill anyone by transmitting measles to someone. This, to me, is profoundly beneficial. And sensible.<br />
<br />
So this Zika virus is going to infect a lot more people.<br />
<br />
We can control it in the USA because we have measures to control mosquitoes that other nations don't have. Of note, living in a cold climate is not a protection. As anyone who has fished in Canada or Alaska knows, in the summer, there are tons of mosquitoes. And the mosquitoes come back every year. They survive the winter.<br />
<br />
We have been down this road before. West Nile Virus was a similar kind of event. Ebola had a very high mortality, but was controlled with really heroic efforts by some people who deserve a Nobel Prize, like Doctors Without Borders. There are significant new epidemics every year or two.<br />
<br />
And in fiction, I have read several doomsday novels about killer viruses. Mostly man made viruses.<br />
<br />
Steven King wrote "The Stand". There is a very good movie as well.<br />
More recently, Russel Blake wrote "Upon a Pale Horse". <br />
Both are good books.<br />
<br />
Here is a list of books about epidemics:<br />
<br />
http://www.goodreads.com/list/show/19535.Best_Fiction_Books_About_Diseases_or_Viruses<br />
<br />
Please use the links above. I hope to be able to give better answers in the future.<br />
<br />
Thanks<br />
Dr Marcus<br />
Blog is at doctorjohnmarcus.blogspot.com<br />
<br />
89 North Maple Ave<br />
Ridgewood NJ USA 07450 </div>
Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com0tag:blogger.com,1999:blog-5044073699235306403.post-61794750522625050192015-04-09T14:53:00.001-04:002015-04-09T15:28:50.501-04:00Hummus Food Recalls and ListeriaFood Recalls and Listeria<br />
<br />
As part of my job as an Obstetrician I like to follow the news.<br />
<br />
One thing that is frequently in the news is Food Recalls.<br />
<br />
Not too uncommonly there will be news that the various Departments of Health will recall a particular type of food because there is some food-born illness lurking in that food. Sometimes companies will recall food on their own.<br />
<br />
It is always something different.<br />
<br />
Sometimes, the spinach farm is next to the pork farm, and there is heavy rain, and the pork "droppings" run into the spinach. So the spinach might be found to harbor E Coli bacteria.<br />
<br />
Sometimes the barn that grows eggs is found to have bird droppings on the eggs, because the wrong kind of bird has flown into the barn. And those bird droppings carry bird borne infections. Egg farmers have been shut down for this.<br />
<br />
A few years ago it was Melons. Before that it was brussel sprouts.<br />
<br />
And recently a peanut butter company executive was charged with a crime because he didn't do enough to make sure the peanut butter was uninfected. I don't know the outcome of that trial.<br />
<br />
Sometimes the recall is very specific. Like frozen food from a specific shift of a factory.<br />
<br />
A few weeks ago a pregnant women informed me that she had a mild flu like illness. Then she informed me that she ate food that was subject to recall for listeria.<br />
<br />
Listeria is dangerous to fetuses. It does unspeakable damage to them, or they die. I have seen these babies. Listeria hides because the maternal illness is very mild or nothing, but the fetal illness is extreme.<br />
<br />
If we know of the exposure we can monitor and treat the mother and fetus with antibiotics. Ampicillin can be effective, but it takes a high dose. So high a dose that the pharmacist calls to ask if I am sure. Ampicillin is very safe, and Listeria is very dangerous, so I will treat preventatively if possible.<br />
<br />
Most of the time we don't know of the exposure. And the baby and family pays the price. It is rare, but it really does happen. And most Obs have seen the terrible end results.<br />
<br />
The latest recall is from a popular brand of Hummus. It was found to contain Listeria.<br />
<br />
Do a google search for Hummus Listeria Recall and you will find the brand. It is called Sabra.<br />
<br />
Here is the CNN link:<br />
<br />
http://www.cnn.com/2015/04/09/us/sabra-hummus-recall/index.html<br />
<br />
Please, if you have Hummus in your fridge, check the recall and throw out the Hummus. It is just not worth it.<br />
<br />
I have put a poster up in my office as this particular Hummus is really good and it is really popular around here. It is my favorite brand.<br />
<br />
So watch the news for food recalls. Especially if you are pregnant.<br />
<br />
Thank you very much.<br />
<br />
Dr John Marcus<br />
doctorjohnmarcus.blogspot.com<br />
<br />
89 North Maple Ave<br />
Ridgewood NJ 07481<br />
<br />
<br />
<br />Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com0tag:blogger.com,1999:blog-5044073699235306403.post-17968991038433650902015-03-27T22:15:00.001-04:002015-03-27T22:15:12.983-04:00Friday Night Hi Everybody.<br />
<br />
It is Friday7 about 8 pm and I just got back from rounds. I signed out for the weekend to my friend Dr Damien-Coleman. She is a very nice person and a great doctor. For my goals this weekend I am looking at about 8 hours of work going through my lab results and reports from other doctors. I will restart on this tomorrow as I have been working 12 hour days since Monday. I will get my lab results interpreted and my opinions out to my patients. I hope to use my "patient portal" for most of my results. More about that later in this post.<br />
<br />
Today's belated blog is about the future. The future is here, and it is bringing tremendous changes to our culture and society. A hundred years ago calling on someone meant going to their door and knocking. It was like that for thousands of years. But since 100 years ago or so calling on someone meant dialing your phone. At first, 80 years ago, it was picking up the phone and asking the operator to plug your phone line into someone else's line. 50 years ago, the operator was replaced with equipment. Every person's phone had a ring with holes to actually spin to dial. Kids nowadays have no idea what that means. The next change, when I was young, a person could pay a few dollars a month to push buttons instead of turn the dial. Nowadays, I doubt if a dial phone would even work any more. Only push buttons with tones remains. Then, when I was in high school, the cell phones came. Now, people are dropping their home "land line" phones like hot potatoes. People are just using their cells. But there are two further changes that have come up unexpectedly.<br />
<br />
The first: most people don't even answer the phone anymore. Most people don't even use the phone anymore. People have moved to cell texts to move information around. Some people still call others. But most don't. And the kids, forget it. A phone call? They don't want it. It is much too slow. In the time of one call, then could have made 20 texts. Now we are also losing email.<br />
<br />
The second change: kids have abandoned email. The kids now are no longer filling in the email spot on application forms. They don't want email. It is too slow, cumbersome, and polluted with spam. It still has business uses. But for rapid personal connections, email is dead. Everyone is using texts and micro-blogging sites.<br />
<br />
Why am I wasting time on a gynecology blog to say this?<br />
<br />
Because today I received about 10 phone calls from patients asking for some information or advice. I called every one of them back before I closed up the day. And only one answered the phone. There are now 9 calls into me that are just completely unanswered. I feel awful about it.<br />
<br />
The phone, as a reliable form of communication, is completely useless. Nobody uses it reliably any more.<br />
<br />
But I have a solution to this awful and vexing problem.<br />
<br />
But first, let me explain the technology changes in my office. We of Lifeline have moved our EMR software to a much bigger package called NextGen. We have been doing this for months now. Those of you who have read my blog in the past will realize the huge difficulties of moving from paper to EMR. I have described how hard it is here on this blog.<br />
<br />
But now, the original software package was not fulfilling our needs. So we, as a group, moved ourselves, our practices, and our Electronic Medical Records, to a new software package called NextGen. The move to NextGen EMR software was just as big and just as traumatic as our move to our original EMR. But NextGen has some much more powerful functions.<br />
<br />
One of the more powerful functions is called the "Patient Portal". The patient portal is a website. The patients can log on to this encrypted and secured website and access a ton of functions related to their health care on the portal. They can review whatever <u>medications</u> the computer thinks they are taking. They can ask for, get, and review their <u>appointments</u>. They can read their "<u>patient plans</u>". This is the end of the medical note that is created for them when they are in for their appointment. The <u>patient plan</u> function is still being rolled out so don't expect it there every time. But it is nice to see. In the patient plan people can see their "<u>problem list</u>". The problem list is generated by myself by the conduct of general medical practices. The problem list has already generated questions to me about something they don't understand. So the resolution of their lack of understanding is... wait for it... <u><b>Their Understanding.</b></u> And that is a <u>Good Thing</u>. And if there is a <u>Mistake</u> in their records (theoretically that might be possible), then there can once again be a correction, and then an... <u><b>Understanding</b></u> (an understanding that goes the other way, patient to doctor). And any correction to the medical records is a <u><b>Good Thing</b></u>.<br />
<br />
It goes without saying that I am starting to love the patient portal.<br />
<br />
But the biggest lesson here is that of <u><b>Communication</b></u>.<br />
<br />
Today, on Friday afternoon, I made 10 phone calls and only one phone call was actually answered. I left no protected health information on any answering machine. At the very same time, I made about 15 protected email responses, some with multiple round trips both ways. And each and every one of them was at least potentially received and read by patients. And the information was received and understood in a completely secure and confidential manner. There is no way that a nosy neighbor, a jealous husband, or a worried mother, can read or hear the information in that secure portal controlled email. Remember the email never went out on a normal email server. It is only fake as an email. The email is really only served by an encrypted web site. That only one person can read. The person who holds the password for that email.<br />
<br />
So today I made 10 phone calls, 9 of which went nowhere with no results, as I cannot leave any substantially private information on an answering machine, and 15 secure portal messages, all of which went through, and many of which were started by patients themselves. All of which contained highly valuable personally important information.<br />
<br />
How secure is this information? I can tell you that it is as secure as NextGen can make it. NextGen is based on some very advanced encryption. It satisfies the requirements of HIPAA. It satisfies the Feds. If HIPAA is violated without due care, there is a potential for a fifty thousand dollar <u><b>per incident</b></u> fine. So you can be sure that I am keeping my passwords secure.<br />
<br />
The hardest part of making the portal work is getting the patients actually started on it. Starting a portal account requires some hard work making sure that patients actually get secure access. So the account is set up with some very personal communications of passwords, followed by a round trip of emails to a pre-existing email account.<br />
<br />
This set up process is actually too much of a hurdle for some people. There are many people out there who either will not or cannot go through this process of creating a secure account on the portal. But for those who do, there is a connection with really fast and secure access to communication between them and myself.<br />
<br />
And that connection can do a lot to help people. I promise to do my best.<br />
<br />
But I'll tell you what. 90 percent failed phone calls vs 100 percent successful secured emails tells a story.<br />
<br />
I'll take the successful communications vs the failed ones any day of the week.<br />
<br />
....<br />
<br />
I haven't posted a blog here in some time. It has been much too long. Perhaps I need an editor who can give me assignments and deadlines. Like I've said before I have not abandoned this blog. I have been working very hard. One of the things that has been keeping me busy has the process of moving my EMR over to NextGen. NextGen is a much more complicated piece of software. It requires a tremendous amount of work to make it go. I am working and succeeding at it. <br />
<br />
I just reviewed my side of this blogspot site. I have sort of the "back" side of the site. I have about 20 blog posts that have been started and are at some stage of completion. There is never enough time to write and complete these posts but I do enjoy writing them. And it has been very popular. I haven't looked at it in awhile but there are still thousands who find these blog posts and read them, from all over the world. I have more readers from worldwide than from the USA. There are many readers from Germany, from Africa, from Russia, and of course from Canada. Here near NY City I am only a few hours driving time from Canada. But the readership continues, even when I am not actively blogging. Thank you all for reading this. It is really rewarding.<br />
<br />
...<br />
<br />
<b><u>Now for something new</u></b>.<br />
<br />
I have a problem that I have been thinking about for a long time.<br />
<br />
This really should be a new blog post but I want to start it now.<br />
<br />
One of my jobs as a Gyne is that of dealing with the problem of Breast Cancer. The problem is that about one in 8 women are destined to get breast cancer. That means if you personally know 100 women, you know that 12 of them will get breast cancer.<br />
<br />
The good news is that breast cancer is treatable. It is something that can be removed. People can be saved. Lives saved. Wives, mothers, sisters, can be saved.<br />
<br />
But the key is diagnosing it early.<br />
<br />
There are three ways to diagnose it early, before it becomes an obvious and deadly problem. The first is by routine Gyne checkups. This is basic good medical care, and all women need a Gyne checkup once a year, without fail. A Gyne checkup can get a history and examine the breasts and pelvic parts of women. It is important and it is my job. <br />
<br />
The second early diagnosis is mammograms. Mammograms have gone through a process of technical improvements through the years. They are constantly evolving. There are more improvements than you can count. Sterotactic, 3D, computer enhanced, tomographic, focal, compressed, and on and on. Then there are other imaging techniques, like ultrasound, sonograms, CT, MRI, thermography, etc. All of these may have their uses. But they have challenges too, like expenses, scheduling hassles, radiation exposure, lack of scientific proof, lack of financial resources, coverage limits, etc.<br />
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But the final and cheapest early warning system for breast cancer is "<u><b>Self Breast Examinations</b></u>". For the last 25 years I have been asking women to examine their own breasts for lumps. There seems to be good science that says that SBE works for women. And it can easily save lives. Once women get over the shock of finding a lump, they can get down to the hard work of diagnosing it. And they can get down to the hard work of protecting their own children's mother, who is a very important person. An irreplaceable person. Or, if they have no kids, then they can get down to the hard work of protecting their mothers daughter. Who is also very important.<br />
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There is an overwhelming problem with Self Breast Examination.(SBE). Most women recognize this problem. And they complain about this problem to me a dozen times a day.<br />
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The problem is women examining their breasts are <b>not experienced enough to know what they are finding</b>.<br />
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I explain to them a hundred times a day that all women go through this same problem. There aren't any women with a tremendous amount of experience doing SBE. All women who do SBE are beginners with an experience level of one and only one set of breasts to examine.<br />
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I have a solution.<br />
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It is radical and will be roundly criticized. And it will be viciously criticized.<br />
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But I believe that it will save a lot of lives. <br />
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If what I am going to propose comes to fruition, the problem of SBE might be solved.<br />
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I will propose to form an organization organized around the principle of generating a group of people dedicated to one thing and one thing only. The examination of each others breasts.<br />
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This will take the "<b>Self</b>" out of "<b>Self Breast Examination</b>s". And it will replace it with "<b>Shared Breast Examination</b>". I am not proposing that a women expose her breasts to the world. But that she come together with other women who have a similar goal in life, and train each other in the principles of breast examination.<br />
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I think that woman can learn how to examine breasts. And by sharing and teaching and learning, the knowledge can expand.<br />
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Women can learn how to feel the difference of glands, ducts, cysts, and tumors.<br />
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In my office I used to buy breast lump models. These were artificial breasts that had artificial lumps. They were pretty cool teaching aids but they got grungy really fast and fell apart in a matter of weeks.<br />
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But imagine instead that I had Real Breasts to show women. Well, this is what I am going to propose.<br />
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I would propose that this organization become real. With a mission statement. And a website. And all that goes with it. And some means of protecting women's privacy and rights as well.<br />
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I am in the early stages of thinking about this proposal. I have not come up with any insurmountable problems<br />
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For instance, the first probem: One needs a medical licence to examine someones breast. Solution: we are teaching women to examine their own breasts. And using many real breasts as examples. And besides, these are consenting adults. They can examine each others breasts as they need to without hassles from outsiders.<br />
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Another problem: There is no scientific proof this will work. Answer: we will not know unless we try. <br />
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Problem: woman may be harmed by anxiety and unnecessary biopsies. Solution: there is tremendous anxiety now, and lack of skill as well. And biopsies can be minimized by using needles and fine needle aspiration instead of open procedures.<br />
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I would ask the reader and the community to think about the meaning of breasts to the world. Breasts are perceived as beautiful. Boys fantasize. Girls compare. Babies love and feed. Women have surgery to make them bigger, smaller, and firmer. Breasts are part of birth. Breasts feed life to babies. Breasts are much visible to world, appreciated, and loved by everyone. But they are also one of the biggest sources of fear. Most women fear breast cancer more than a heart attack. And heart attacks are more than 15 times more likely to strike a woman dead, as her breasts. All breasts are beautiful, no matter the shape nor size. But the fear surrounding their health is so out of proportion that it is unreasonable. I don't think there is any subject in the world that has such a dramatic juxtaposition of beauty, love, fear, and danger, as human breasts.<br />
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It is time we started helping women get over their fear of SBE and bringing reason back to the subject of early diagnosis of breast cancer.<br />
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I hope to be part of the solution.<br />
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I realize this is a big dream.<br />
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But it might be possible to do better than we are doing now.<br />
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Thank you for reading.<br />
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Please pass the link to this blog on to others.<br />
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Thank you sincerely,<br />
<br />
Dr John Marcus<br />
doctorjohnmarcus.blogspot.com<br />
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Member of Lifeline Medical Associates<br />
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89 North Maple Ave<br />
Ridgewood NJ 07450<br />
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Comments are of course welcome. Please post comments.Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com1tag:blogger.com,1999:blog-5044073699235306403.post-67754234436525669762014-04-21T20:15:00.001-04:002014-04-21T20:15:04.391-04:00Delivering physicians as patients.<br />
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Yesterday I delivered a fellow physician. A 37 year old cardiologist at 40 weeks.<br />
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She started her labor naturally, a few hours after breaking her water. The labor progressed well, naturally and on it's own. She arrived in the hospital at a very appropriate 3-4 centimeters dilation, and progressed at better than 1 centimeter per hour (this is the standard rate for the first baby).<br />
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She received her epidural at 5 cm, as she didn't want to continue with the natural discomforts. She still felt some pressures and a bit of pain with the contractions, but I assured her that feeling some of the contractions is a good thing. She certainly did not appear to be in any distress from the pain.<br />
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This physician was medically healthy and was planning a normal labor. And she and her husband were really nice to be around.<br />
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The thing about physicians, nurses, and pretty much any other licensed professional, is that their life may be bit more stressful than, for instance, a hairdresser, a truck driver, or a chef, for instance. And undue stress makes any pregnancy high risk.<br />
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Because of the requirements of being a licensed professional, I consider a licensed professional to be a high risk pregnancy. This is my opinion. I don't know if the textbooks or medical journals would confirm this or not. High risk pregnancies would of course include lawyers.<br />
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Malpractice attorneys are even higher risk. Most physicians hate taking care of malpractice attorneys. I don't. They are people too. They require very good care. I provide that for sure. Most physicians think that malpractice attorneys are lying evil bastards. The attorneys don't think of themselves like that, but as defenders of the weak, downtrodden, and injured. The attorneys believe that they are seeking the truth for justice sake. Most physicians believe contrarily that they are liars one and all. Physicians call them "Trial Liars", which is a play on the name the lawyers call themselves, "Trial Lawyers". In any case, they are also high risk pregnancies. It is clear that the trial lawyers have an unbelievably stressful life. And you can see it in their eyes when they are not working.<br />
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There is a big disagreement on the meaning of "truth" between doctors and lawyers. The lawyers engage in what they call "truth seeking" behaviors in courtrooms and pretrial activities. The physicians see those same courtroom activities as remotely disconnected from the truth. Physicians see trials as complete shams, as nothing but highway robbery by brigands and liars. With briefcases instead of guns. Why such a discrepancy in the belief in truth? Physicians see truth scientifically. Especially if it has been experimentally established, as is done in medical science. Lawyers see truth as a culmination of belief, by whatever method makes it believable. The lawyers believe that truth is whatever the Judge and Jury believe it to be.<br />
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Personally, I believe that truths exists in the space of ideas. There are real, absolute truths, as Plato would have described them. They are not physical things. You cannot weigh a truth with a scale. This is similar to a human soul, and mathematical theorems. These truths are real, but you cannot hold them in your hand. Only in your head, and written down on paper. So, physicians and lawyers will never agree on what the truth really is. Physicians ignore this reality of truth at their own peril, when a skillful attorney rips them apart as part of a trial strategy.<br />
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Anyway physicians are not immune to the stresses of being a professional. Therefore physicians have a high risk pregnancy. I think this risk is manifested in several ways.<br />
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One, they work ungodly hours. Pregnant women are supposed to be off their feet once every three hours, resting for 15 minutes. This will let the natural adrenaline of a normal day fade down a bit. These are work rules that are enforced by the federal government for everyone. But most physicians will not stop working after three hours. Especially if there are sick patients that need their attention, and they are behind schedule. All physicians are behind schedule, because there are people with unpredictable needs. And no one wants to say to someone, I think you have a tumor, but we will talk about it next week. So, we do our best to comfort the patient in front of us, and then get behind schedule a bit.<br />
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Two, physicians know about pathology personally. They see it on a daily basis. And if they do not see it in themselves, they will be hard pressed to believe that it is there. So many physicians will ignore indications of serious trouble.<br />
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Three, physicians still get "medical students disease". This disease is an inappropriate belief that some pathology affects them. To mix a metaphor, they are in a forest but cannot see the forest because they can only see the trees. Physicians make poor doctors to themselves, and have a fool for a doctor, and a fool for a patient. These are old sayings in medicine. Every doctor should have a good therapeutic alliance with another good doctor, to keep these anxieties in check. And the doctor for the doctor should have a calm demeanor, and a lot experience. This will prevent medical students disease by proxy.<br />
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Anyway, this particular patient was doing beautifully in labor. She was physically strong, and a very good pusher when it was time to push. But, as a physician, we need to consider this is a high risk patient, and we need to be ready for complications.<br />
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So, after pushing for an hour, the babies heart beat starts going much faster than normal. I discussed with her and husband the reasons why this might be the case. A common reason might be infection. Another reason might be the babies head getting squished in the birth canal. Ultimately this was the cause for her. But no one wants to leave the baby in a stressed out condition, so I decide to help the baby come out a bit sooner. Before the baby really gets stressed from the rapid heart beat. She obviously agrees.<br />
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When the baby was on the "outlet" of the vagina, I decided to use the vacuum forceps. This will help the baby be born a bit sooner. And there are many studies which show that "outlet forceps" have as good a prognosis as natural labor, or better.<br />
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So I used the vacuum. True to form, the high risk factors start coming in to play.<br />
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First of all, there was a loose nuchal cord.<br />
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Then, there was a "shoulder dystocia". This means the baby is stuck with it's head out, and the shoulders are holding the baby in. Shoulder Dystocia is a bad thing to happen. Babies can get injured or worse by the difficulties associated with delivery past the stuck shoulders. I have an entire blog post already written about shoulder dystocia. I still need to edit it some before it becomes good enough for publication on this blog, but that blog post is coming.<br />
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So, we wind up doing two basic maneuvers to relieve the shoulder dystocia. We did a McRoberts, and suprapubic pressure by a very skilled nurse. The shoulder dystocia was then released and did not cause any harm to the baby, thank God.<br />
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Then we had the third stage of labor. The placenta came out. And then she had a postpartum hemorrhage.<br />
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In a normal pregnant woman, the baby gets about half of the mothers cardiac output of blood, directly to the underside of the placenta. The uterus gets it's blood supply from the mom via very very large blood vessels. They may be as thick as your thumb. What stops the blood flow normally is that the uterus contracts down tightly. These uterine muscles, which just finished pushing the baby and placenta out, need to continue to contract, and get very tight, to close the placental blood flow. Without the placenta blocking it, and if the uterus doesn't contract, the blood flows out of the mother like a river. It literally pours out like a thick waterfall. In the presence of postpartum hemorrhage, a woman can bleed to death in minutes. Postpartum hemorrhage is the number one cause of maternal death in advance countries. The last I looked, about a hundred women a year die from postpartum hemorrhage in our country alone.<br />
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So here we are with a high risk pregnancy, a fellow physician, and we have already dealt with a shoulder dystocia. Now we have blood pouring out like a faucet. What to do?<br />
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The first thing is to get the uterus to contract. We literally compress it with our hands. One had in the vagina, and one hand on the top of the uterus. At the same time we compress the uterine vessels with our vaginal hand, and give the new mom some medicines that will further tighten the uterus. We not only compress it, but we massage it. That seems to work better than just squeezing it. A hemorrhaging uterus can be more or less controlled by physical pressure. In fact, all bleeding, from anywhere, responds to pressure, if there is a way to press on either the bleeding place or the blood vessels feeding the bleeding. In this case we can do both. Just remember that pressure stops all bleeding, no matter where it comes from. Anyone can save a life by remembering that bleeding stops with pressure. That is the point of a tourniquet that all boy scouts learn about.<br />
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So then I stopped the bleeding with pressure, massage, and medicines. Thankfully she had an epidural. Without the epidural these pressures are very uncomfortable, to say the lease. I even had our anesthesiologist come and boost her epidural quite a bit. This worked to keep her comfortable.<br />
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After the pediatric physician checked the baby, and declared the baby healthy, our new mom got her new baby while I finished up the vaginal repairs. <br />
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The next day on rounds, she and the baby looked wonderful. She was walking around with a big smile.<br />
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So, we have to be ready for pathologies like Shoulder Dystocia and post partum hemorrhage at any time.<br />
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A good obstetrician will review the protocols many times in their career, and stay up to date, and ready, willing, able, and confident, to manage these things on a moments notice. For that matter, midwives need to stay on top of these things as well.<br />
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Thanks for reading my blog. Comments are encourage.<br />
<br />
Available at doctorjohnmarcus.blogspot.com<br />
<br />
Doctor John W Marcus MD FACOG PC<br />
89 North Maple Ave<br />
Ridgewood, NJ, 07481<br />
<br />
Phone 201-447-0077<br />
Fax 201-447-3560<br />
<br />
Thanks for reading.Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com1tag:blogger.com,1999:blog-5044073699235306403.post-21333240581733986262013-11-28T01:02:00.000-05:002013-11-28T01:02:13.539-05:00<h2>
<b><u>People you would like to know:</u></b></h2>
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It is now just after midnight on the beginning of Thanksgiving day. I am trying to catch up on my labs and reports for patients. </div>
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I am looking at a report from a Neurologist consultation for a 26 year old nurse who has terrible migraines and some painful disk disease in her back. So I am thinking of her personality and her character strengths. I know her well. </div>
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She also has two small children that I have delivered for her. She is in the late stages of nursing her second baby now. </div>
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Despite having these medical and life challenges, this is a person that I think that you would be glad to know her acquaintance. </div>
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Think of her lifestyle: She is a nurse. This means she is dedicated to the proposition that other people need hands on care to improve their well being. She also has two small children, who obviously need her time. In addition to this, she has back and neck pain, and frequent migraines. </div>
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Despite all of this, this person is never in a mood to be mean. She seems to always be in an uplifting mood. Her husband is the executive chef for a large corporation. He is a big guy, tall and substantial in size. He is similarly in a good mood. They are both busy in their life, but they get along very well, and their kids are doing well. </div>
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It is people like this that make the world a better place. Both of them, the new mom and her husband, are the kind of people that anyone with any sense would like to surround themselves with. </div>
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In my role as her personal physician, I am dedicated to helping her optimize her life. But for my sake, I am glad to be able to be there and do my best. I feel myself lucky to be able to be a big part of the life of people who give so much value to the world. </div>
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I try to live my life in a way that is an example for other people. I try to do good deeds, because they come back 10 fold. I try to have good karma, because that reflects back on me as well. </div>
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I think that many if not most people are really good for the world. The good people of the world, which is most of them, make the world a much better place for all the rest of us. I hope I am numbered among those of us who enrich the lives of others. I think I do. But ultimately others will need to judge me. And then I, like all the rest of us, will face my judgement day. </div>
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Upon further reflection, I find that most of my patients are very good people in their hearts. Everyone has challenges, but most people enrich the world more than they take from it. </div>
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So that is my Thanksgiving message on this Thanksgiving day. Among all of the turkey feasts, and pumpkin pie, I give thanks that there are so many good people in the world that enrich my life, and that allow me a position of honor to enrich their lives. </div>
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Thanks for reading my blog </div>
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Dr John W Marcus MD FACOG </div>
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Obstetrics and Gynecology </div>
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89 North Maple Ave </div>
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Ridgewood, NJ, 07481 </div>
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Phone 201-447-3560 </div>
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Fax 201-447-3560 </div>
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Blog is at doctorjohnmarcus.blogspot.com </div>
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Comments are welcome </div>
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Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com1tag:blogger.com,1999:blog-5044073699235306403.post-77484118689553138602013-11-25T21:09:00.000-05:002013-11-25T21:23:01.584-05:00<b><u>International Medicine, </u></b><b><u>British-isms, and </u></b><b><u>"Melting Pot" medicine</u></b><br />
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I just did a checkup for a 35 year old woman who had a very nice cockney accent. This means she is from a central neighborhood of London. I think that means she grew up within listening distance of a certain cathedral's bells. Or maybe Big Ben. I am not sure which cathedral, but it is a somewhat small area. The cockney accent is unique in the English language. Once you understand what it sounds like, you probably won't forget it. I delivered her baby about two years ago. Having a nice conversation with her was really fun. I like to provide my care in a culturally aware manner and I did no different for her. Knowing peoples backgrounds is not only fun for me, but it allows me to fine tune my conversation and words in a manner that enhances communication and maybe makes them a little less uncomfortable in the office.<br />
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Either that or I make myself into a culturally clumsy buffoon <sigh>. But I try and it is fun.<br />
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Here in Ridgewood, in Northern New Jersey, 20 minutes from the George Washington Bridge, I get customers from all over the world. I have many patients from all over Europe, especially Germany (BMW is close by). I have patients that work in Embassies, and in the United Nations. Many of my patients hail from all of the big countries of Europe. Many from Eastern Europe. I have learned a little bit of Russian from my Russian patients. I would like to say Bolshoi Spasibo to my new Russian mommies. One of which is leaving The Valley Hospital with her new 7 pound 10 oz baby tomorrow. There is a ton of South Americans here. Brazil is well represented because it is a giant country with a lot of corporate connections. I have decided that my favorite Cesarean Section music is called "Brazilian Soul". Think of the "Girl from Ipanema". It is beautiful and peaceful music, and I started that music with a super nice couple from Brazil.<br />
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Check this out <a href="http://www.youtube.com/watch?v=kDGUZeZWKZo">http://www.youtube.com/watch?v=kDGUZeZWKZo</a><br />
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This is a song from the musical genre called Bossa Nova, from Brazil. It is mostly in Portugese. Not that song itself, but the Bossa Nova.<br />
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But I have patients from most of the South American countries and cities, Buenos Airies to Caracas, even Havana. These folks are so lucky because their winter vacations brings them to <b>summertime</b> when they go back home. Some of them stay there for a month, and avoid our winter snows.<br />
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Of course no city on the planet doesn't have a lot of Chinese, and we are no exception. Mandarin, Cantonese, Taiwan, Hong Kong, etc. They are <b>all </b>here.<br />
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There are so many ethnic Asian Indians that I think of them as locals now. No matter what city they come from, Mumbai to Calcutta to the small towns, they seem more local than foreign. Many of them speak their uniquely accented English.<br />
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There are many Japanese folks. Konichiwa my friends.<br />
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There are a good amount of families here that hail from Turkey. Many of them speak German, American English, some speak Aramaic, (The language of Jesus Christ), Swedish, etc.<br />
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Lebanese? Of course. They have a most beautiful French sound to their accent. I try to say Bon Jour to them when I arrive in their room. Comment Alei Voux, mon ami? I really don't know how to spell in French. And I certainly don't know how to write the special characters. Other Arabic countries as well. Then there are many Persians, from Iran. No middle east list would be complete without all of the different kinds of people from Israel.<br />
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And there are a number of Australians of course, not to mention New Zealand. G'day, mate.<br />
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As I sit here now I realize that my customer base is from all over the world. And I find that I like it. It is really fun. My own ethnic heritage is very very mixed. I am northern European, but I don't think I can claim any one ethnicity as my own, other than maybe Chicagoan. (From Chicago, Illinois). My mom is Canadian, and that makes me a Canadian Citizen as well. Canada is very easy on their foreign based citizens. They have never asked me to pay taxes, or even to report a single form to them. Nevertheless, I carry an American Passport. I am certainly an American, born here in the Chicago area.<br />
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When I was a child back in Chicago we were taught that the USA was a "melting pot" of ethnic heritages. This was the preferred terminology. This means that the American Culture has melted and formed out of all of the cultures of the peoples that came here before us. This even included the Native Americans obviously.<br />
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But tonight I was having my conversation with a fluent Cockney speaker so I decided to use my little bit of British knowledge. I was mostly having fun.<br />
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How does that go? Well, they know pharmacists as "Chemists". Emergency Rooms there are called "Casualty". The word Vitamins uses a soft i, like the word Bit, not like the word Bite. Vacations are "Holidays". There are a lot of other changes. When saying the letter Z, it does not rhyme with "Tea" or "Tee", but is Zed.<br />
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Now try to sing your ABC's with Zed instead of Zee.<br />
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I have found an ABC song on youtube. It is very interesting in that the child bear has a mild cockney accent, sings the zee as the zed, but the daddy bear speaks like he is from Philadelphia. Here it is.<br />
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<a href="http://www.youtube.com/watch?v=TGHidmEKU44">http://www.youtube.com/watch?v=TGHidmEKU44</a><br />
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So, right there, is a little bit of the melting pot.<br />
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Thanks for reading my blog<br />
<br />
I have a lot of other blog posts partially written.<br />
<br />
Comments are welcome.<br />
<br />
Doctor John Marcus MD<br />
89 North Maple Ave<br />
Ridgewood NJ 07450<br />
USA<br />
<br />
phone number 201-447-0077<br />
fax 201-447-3560<br />
<br />
blog is at http://doctorjohnmarcus.blogspot.com <br />
<br />
Comments are welcome.Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com0tag:blogger.com,1999:blog-5044073699235306403.post-52188704703087675032013-11-02T19:00:00.000-04:002013-11-02T19:00:17.600-04:00<h2>
AntiMullerian Hormone (or Mullerian Inhibiting Factor) </h2>
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I would like a share a story about the perils of believing that all that is new and modern is better. </div>
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I have a patient who is about 42 years old. She had one child about 4 years old and she desperately wanted another. I took her through the basic infertility workup that I have described on these pages and we found that she had nearly run out of her supply of eggs. So try as she might, and push fertility meds as far as she can (Follistim, Perganol, Menotropin, Menopur, Repronex, urofollitropin, Gonal-F, Fertinex, and many more), she could not make her own good eggs or embryos. </div>
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So for a woman such as her, all hope is not lost. Nowadays, she can still have a baby or babies. The problem becomes how does one get good eggs? What she frequently does, is she <u>borrows them</u>! What she does is, she finds an <u>Egg Donor</u>. The egg donor is usually a younger woman, who is willing to share her eggs with the other woman, the one who no longer has enough good ones of her own. Lets call this one the patient. Once the donor is selected and screened for an appropriate family history, and infections like HIV are ruled out, the donor is put into an IVF cycle. But the donor will not use her own eggs, she will give them away to the patient. The donor is usually paid for her time and effort, and risk, but I think the ethics of the transaction have to be that the eggs are not the purchased item. The eggs are given freely. </div>
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The IVF specialist doctor will then give fertility medications to the donor, to deliberately hyper-stimulate (to a moderate degree), and make 10-25 eggs or so. Then the IVF specialist will retrieve the eggs from the donor. This involves some anesthesia, a sterile operating room, a sonogram to find the follicles, and a longish needle to aspirate the eggs. One egg from each follicle. A follicle is about 2.5 cm, a little less than an inch. But the egg is much smaller than a period at the end of a sentence. Then the IVF specialist will hand the eggs over to a specialist called an <u>Embryologist</u>, who will mix the egg with sperm from the patients husband (or whoever is selected to be the genetic father. Sometimes sperm donors are used as well). If the eggs cannot be penetrated by the sperm, the embryologist can force a sperm into the egg with a tiny needle. This is called Intracytoplasmic Sperm Injection, or ICSI. ICSI is very common nowadays. It is used, for instance, if the husband/father has only a few sperm to work with. Or if the sperm are weak. </div>
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ICSI is well established, it works, and the babies seem to be fine. I have delivered a lot of ICSI babies, no problem. For awhile, the MFMs were worried about chromosomal damage, heart problems, growth problems, etc. The MFMs were scanning these babies up down and sideways, doing invasive amnios or amniocentesis to see the chromosomes, and ordering all of these babies to have cardiac echocardiograms. I guess that is what MFMs do. MFMs will reach to the ends of the earth to find ways to make sure that everything is ok. And if they don't know, they will order every test under the sun. I don't say this because I begrudge their skill, and they are a very valuable service. But sometimes their need to analyze really piles up to uncomfortable levels. I think part of my job as a compassionate physician and counselor is to explain to my patients what the odds are in any given set of stressful circumstances. This way, people can take control of their own risks and plans and hopes. Sometimes we just have to say no and stop the testing. And sometimes we just have to say that not knowing the science is different from knowing the science shows risk. </div>
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In my practice all of the ICSI babies have seemed normal to me. </div>
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Anyway, this 42 year old I was telling you about was really really careful and picked her egg donor from clear across the country. This way many things matched up just right. (height, color, eyes, intelligence, ethnicity, etc). The egg donor was an otherwise healthy 27 year old. She was going to fly to New Jersey when her follicles were just about ready to be aspirated for the eggs. </div>
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But, there was a sudden fly in the ointment. Just before she started the egg stimulation cycle, it was found that her AMH was a bit low. Her Anti Mullerian Hormone. This implies that the donor was short of her own eggs. If the donor couldn't make eggs then the whole plan would fall apart, including the patients own hormonal preparations to accept the embryos in a few weeks. Since I don't do IVF, but I do counsel my patients to the best of my ability, my patient called my up in a seriously stressed out condition. She still was thinking clearly. But to cancel her preparations up to this point would have delayed her family another 4 to 6 months. And she would have to do all of this hard work all over again. </div>
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Mind you, this patient is an extremely intelligent executive for a large successful corporation. She knew as much as anyone would about her entire story. She did not suffer from any kind of character flaws. She was psychologically very strong. </div>
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So I reviewed the entire history with her. We knew that the young donor had no gynecological problems. By all the evidence other than AMH she was able to make normal eggs, and normal menstrual cycles. </div>
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And when I looked at the scientific literature of various sorts around the value of the AMH test, it was said that the AMH test should not be used in an isolated manner, because it was not 100 percent reliable. </div>
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But, wait a minute, they say that about all tests. No tests are 100 percent about anything. In something as complicated as human biology, there are no certainties about anything. (except maybe death and taxes). But I thought about it for awhile. </div>
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Her IVF docs told her to cancel the cycle, as they don't like IVF failures. Why? Anything that throws their stats off will make the IVF docs look like buffoons when potential patients look up the ever present <u>success rates</u> that are published all over the place. Everyone, every potential patient, wants to go to the best IVF doctors, so they look up success rates and wants to get an appointment at the best place. If someone else is zero point eight percent lower in the success rates, then they are going to take their business to the best place. Which is elsewhere. </div>
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So IVF docs hate failures, and hate anything that might affect their success rates. If any IVF docs have a tiny bit higher success rate than anyone else, and they are getting a lot of patients because of it, those IVF doctors are not going to advise any marginal cases to go forward with IVF. In other words, they will give IVF mostly to the people who need it the least, and avoid given IVF to the patients who need it the most. </div>
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This leaves some patients dejected. And many marginal cases that have some hope for IVF are turned away. </div>
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This is, I suppose, an extension of the law of unintended consequences. When the powers that be forced the statistics out into the open, then the statistics became more important than the patients. And then some docs who provide IVF only to the easy cases, even to those who didn't even need it, became really busy. They formed giant clinics. The docs who did IVF only on young heathy women, whe were nearly guaranteed a good result every time, had the best published statistics. </div>
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There are some statistical methods that can tease out the success rates of the difficult cases from the easy ones, but the law of unintended consequences still holds. </div>
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So anyway, I advised my patient to go ahead and continue the cycle with the young donor with the poor AMH. I figured the biggest loss would only be the money and the time if the one cycle failed. This would at most be a month. But...think about it... the gain would be a family maybe 5 months sooner that a cancelled cycle. And an isolated AMH doesn't mean that much anyway. I figured that statistics were 5 to 1 in my patients favor that the cycle would work, even with the low AMH. How could a healthy 27 year old donor suddenly run out of quality eggs? The statistics did not favor failure, even with the IVF clinic telling her to quit. </div>
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Then a most beautiful thing happened...</div>
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She got pregnant with twins...</div>
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The pregancy was very eventful, with placenta previa, some bleeding, hypertension, some working bedrest, some hospitalizions, some bit of temporary gestational diabetes (due to steroids given to help the babies when they were threatening to come early), some meds to quiet the uterus, lots of MFM consultations (and using their excellent information with proper discretion to keep it real and simple), and big babies. </div>
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Then... <u style="font-weight: bold;">38 week healthy full term, nice and big, twins.</u> Born via a repeat C-Section, in an OR with big smiles, nice soul music playing, and a big team of very experienced support staff. </div>
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I shared a story about the perils of believing that all that is new is better. </div>
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What is the moral of the story? </div>
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Don't let an isolated antimullerian hormone test wreck your life. Two beautiful living babies are proof of that. In fact, don't let any isolated test result wreck your life. </div>
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And think about the young egg donor. She now has proven her eggs, and the worth of her ovaries. If the cycle was cancelled, she might have thrown away contraception, had an unwanted pregnancy, lost her life's partner for possible infertility, gone into a depressive spiral, or worse. Now she knows she is good and healthy. AMH be damned. </div>
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Another even more important moral is that <u>Statistics are Abused</u>. Because the IVF programs are forced to divulge their stats, they become slave to the stats. And they will cancel cycles if there is even a 20 percent reduction in possible success for one woman. They live and die by the statistics numbers. Everyone does. If my patient did not call me, those babies would not have been born. </div>
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Pretty soon Obstetricians are going to have their stats published. CS rates, mortality rates, etc. But since every obstetrician does things a little bit differently, they will be punished in what may be completely unexpected manners. And maybe rewarded unfairly. By the statistics that are misused. </div>
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I would like my patients to retain freedom of choice. Freedom of C-Section or vaginal birth, for instance, who can take that away from them? I would not want to. I will do everything I can to make sure their decision is not only proper for them, and that they have thought about all the alternatives to what they have chosen, but I will also do what I can to support them to believe that their choice is valid, proper, and comfortable. </div>
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So after an 18 hour labor and pushing a baby out, and a women is laying there with beautiful new baby on her chest, and she is all sweaty, and the nurses are cleaning up last nights dinner from her gown, and the floor is getting mopped up, and her vagina is sore from stitching, she will have the biggest smile of victory she has ever had. And the baby is in that comfortable spot that they love on top of her mom. Then, she will have known that it was all worth it. And she will have a megawatt smile and a beautiful relief. </div>
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But, if she elected to have the baby the other way, because her own mother's life is wrecked by urinary incontinence and sexual disability, or her brother was strangled in labor and she can't bear the thought of it, and no one offered her mother a C-Section, or maybe she just didn't want to stretch her vagina out, then she can be confident that she will have her baby just the same. And she can be confident that her wishes were honored in a safe and caring manner. </div>
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Who would take her ability to choose away? I would not willingly take that choice away. </div>
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The statistics may be misinterpreted and the bean counters will get involved, and the politically active ones will get involved and make a ton of misinterpretations, and the world will change. </div>
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I will do my part to keep it real, and honest, and proper. </div>
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By the way, I have once again been elected to the position of Associate Director of my Department of Ob/Gyn. It is my second stint in this position. </div>
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In the past I have been elected or assigned to be the Associate Director, the Chairman of the Department, the Director of Education, the Director of the Oncology Committee, the department secretary, the treasurer, and who knows what else. I have also been the director of the Bergen County Medical Society. </div>
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One of these days I will post my full CV. </div>
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Thanks for reading. </div>
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My blog is at http://doctorjohnmarcus.blogspot.com </div>
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John W Marcus MD Ob/Gyn FACOG </div>
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Obstetrics and Gynecology </div>
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89 North Maple Ave </div>
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Ridgewood NJ 07450 </div>
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Phone 201-447-0077 </div>
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Fax 201-447-3560 </div>
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Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com0tag:blogger.com,1999:blog-5044073699235306403.post-30617242917777670122013-09-30T20:03:00.001-04:002013-09-30T20:47:49.236-04:00<h2>
<span style="font-weight: normal;"><u>I had a Light Schedule Today, and Pre Conception Counselling</u></span></h2>
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I had a light schedule today. It was a real treat for me. My usual Monday hours are 1 pm to 8 pm. Lately I have been very busy and I need to work hard to keep up with the work. I book a checkup or Ob visit every 15 minutes, with time off for lunch, and I schedule a new patient for 45 minutes. I think that should be plenty of time, but obviously if I discover a major problem, or if the patient really needs some help with some problem, that won't be enough time. Lately my hours have been very full. </div>
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But today, there was plenty of time to speak to most of my patients. What that means is that I had more time to discuss things that are important to me. I had a new preconceptional patient and that was a lot of fun, talking about how to keep her and the baby safe during the pregnancy, and about the spiritual values of attempting a conception. As readers of my blog know, many people never get to experience the spiritual happiness and value of attempting a conception. Most people miss this opportunity because of inadequate contraception. All of their pregnancies are unplanned. The kids are still loved just as much, though, of course.<br />
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Today, one preconceptional patient was a vegetarian, and she is trying to work her way up to being a vegan. We discussed the challenges of being a vegan while pregnant. It is certainly safe and possible to be pregnant and have a happy outcome as a vegan. I stress that the new moms must take particular care to eat from all of the food groups every day. Proteins she can get from beans, nuts, and lentils. She will get an extensive amount of vitamins, minerals, and fiber from the healthy vegetables. She should also try get some natural fats, such as olive oil or canola oil. She should never consume synthetic fats, such as margarine or shortening. And she should never consume saturated fats. Fortunately there aren't any vegetarian saturated fats, unless you count synthetic ones like margarine.<br />
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There will be two particular challenges do deal with as a pregnant vegan mom. One, she will need to get DHA. DHA is an essential (which means it must be consumed orally) fatty acid. It is one of the common omega 3 fatty acids. DHA makes human brains and eyes. Most women and humans get their DHA from fish or fish oil. A vegan obviously cannot. Fortunately, nature provides an answer for these new moms. DHA is available in algae. So pregnant women can get "vegan fish oil". It is marketed like that by the companies that provide it. Unfortunately, algae oil can get a bit expensive. It can cost 20 dollars a month, or much more if consumers are not careful where they get it. I usually recommend "Expecta" algae oil. It is made by one of the largest baby formula providers, Johnson and Johnson, a large and successful corporation with worldwide operations. The price for algae oil varies between 10 dollars and 200 dollars a month. The usual price seems to be about 16 dollars a month.<br />
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The second challenge that a vegan will have is getting her Probiotics. Probiotics are living bacterial cultures that are necessary to consume to keep a human in a healthy state of commensual life with the bacteria that live upon us. Bacteria actually outnumber our human cells by millions to one. This is because that bacteria are enormously smaller than human cells. Human cells are very large compared to the bacterial cells that live in our intestinal system and on our skin. There is no such thing as a sterile human, and a human would certainly not survive if he or she tried. The bacteria in and upon us are an important part of our immune system, our digestion, and our cleanliness. A person needs to get a sufficient amount of Probiotics in her diet in order to replace the ones that are lost inside of us due to natural loss, chemicals in our food, and antibiotics that we have to live around to maintain a normal state of sanitation. There are antibiotics in and on our food, in our toothpaste, and in and on our environment due to cleaning chemicals. We certainly cannot live without modern sanitation, so in cleaning up our environment aggressively, we are also altering our probiotic bacterial environment. This is just a natural consequence of our modern life. We need to consume probiotics to replace what it missing.<br />
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Most people get their probiotics with Yogurt and communal living. Newborns get it from the mother and father, via the skin of the mothers nipples, and just being held and fed. Nobody really gets enough probiotics. We also get some from fresh uncooked vegetables, which are certainly not sterilized before we eat them.<br />
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I encourage my patients to get some yogurt, or, better yet, try a bit of Keffir every day. Keffir is a drinkable smoothie yogurt that originated in Russia. And it has been a tremendous improvement to the western diet. Vegans may object to the dairy source of Keffir. That is why I try to ask a vegan if they will allow a bit of dairy. And this hinges on why they are vegan to begin with. If they are vegan because they object to the treatment of dairy animals, then they cannot consume yogurt. If they are vegan because they are afraid of the cholesterol, then maybe I can try to get them to have some low-fat Keffir in their diet. Keffir is really yummy. I like the blueberry smoothie. It is about 3 dollars a quart. And it is a super probiotic. The ones that I buy, like Lifeway, claim to have 12 or more strains of acidophilus, or other probiotic organisms. It only takes a little bit to colonize our intestines. We don't have to drink the whole bottle every day. But if we did, the whole bottle is only 600 calories. So that is not so bad, if we had an attack of a Keffir binge. That would be infinitely preferable to a 32 ounce soda, or a big ice cream smoothie, which would have thousands of calories from the sugar and fat.<br />
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I also seen a woman, a surgical operating room nurse, come in with the dreaded postmenopausal bloating and cramping. There were tears in her eyes. On exam, the bloating and cramping came from her uterus and not her ovaries, which should be a tremendous relief for her. I ordered her a vaginal sonogram, an abdominal CT scan, an ovarian cancer screening test called an "OVA-1", and an Gastrointestinal specialist consult. The OVA-1 test is easily found on Google, for those interested in looking it up. It is far more advanced than the old CA125 test. My ordering of the OVA-1 test is slightly off label, because it is approved for the pre-operative workup of ovarian cysts. I warned her that false positives are common, and that I did not think she had any ovarian tumors, cysts, or problems. But her tears turned into a smile, knowing that the workup is well under way, and that her ovaries are likely ok. Since she works at a local hospital, she won't be charged anything to get the tests done. I think she is going to be fine.<br />
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Altogether it was a great day.<br />
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Everyone should be fine.<br />
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Thank you sincerely,<br />
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John W Marcus MD FACOG<br />
Obstetrics and Gynecology<br />
89 North Maple Ave<br />
Ridgewood, NJ 07450<br />
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Phone number 201-447-0077<br />
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Blog at doctorjohnmarcus.blogspot.com<br />
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Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com0tag:blogger.com,1999:blog-5044073699235306403.post-26119517162217887752013-08-03T11:54:00.000-04:002013-08-03T12:14:48.022-04:00<h2>
<b><u>VBAC, and Bonding of new Dads</u></b></h2>
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It is now Saturday morning, about 10:30 AM. I just finished doing a repeat Cesarean Section of a 38 year old woman at 39 weeks. Her last baby was born by a different Ob. For her first baby she labored for days, eventually the labor obstructed, and she even got a fever. Then she got a section. That kind of a labor, with obstruction, and eventually infection, really stresses the mother and her baby. The risks to the mother and the baby increases over time. If those risks are not mediated and managed, then eventually there will be a catastrophic outcome. In those situations, the Cesarean is lifesaving for both her and her baby. And, it will likely save the baby from terrible brain damage or something awful if the infection is unchecked. If the labor obstructs beyond reason, then she would have had what we call a "neglected labor". These are deadly. Neglected labors still happen around the globe. We must all work towards a just and compassionate world where every human being is allowed a safe birth. Fortunately, around here, neglected labors are rare. They show up once in a while though. Usually it is a women who makes an ill advised attempt at a home birth, using incompetent assistants. This might might be an untrained or unlicensed midwife. Or, someone who has no midwife at all. Last year I met a mom of a quadriplegic baby who attempted an unsuccessful and ultimately traumatic home birth. It was tragic. This happened in the next town over.<br />
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My patient this morning recovered from her prior labor and section just fine. Even though she was quite tired. I believe that her prior care was provided in a competent and timely manner, she received her antibiotics, and everyone was happy in the end. The problem was that the labor obstructed. One will never know if a labor is destined to obstruct, unless one tries to labor. Sometimes a malpresentation can make the obstruction obvious even before the labor begins, such as a transverse or sideways baby.<br />
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So at the beginning of this pregnancy, we had a discussion about the possibility of attempting another labor. I discussed with her the possibilities, and under what conditions it might be safe enough to try for a Vaginal Birth After Cesarean, a VBAC. VBACs are still allowed by the medical establishment. The risks are well known. About one in 300 uteri will actually rupture open in labor, through the old CS incision. This can permanently injure or kill that baby, and/or the new mom. VBACs can only be conducted by a hospital and medical team that is available for "Immediate" surgical intervention. With immediate intervention, most of these new moms and their babies can be saved from a uterine rupture. VBACs can only be conducted if the labor seems medically "easy". That means there is no sign of obstruction, the labor starts naturally, and it progresses well. Without that, the new mom must have a repeat CS.<br />
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Our hospital and my practice does provide this level of care. To maintain this level of care, we need an obstetrician on the OB unit, at all times ready to go. I personally volunteer to take my shifts on the OB unit to provide this care. We also need an operating room open and usable at all times. We need an anesthesia provider always available. We need nursing staff ready, able, competent, and confident enough to intervene at a moments notice when the signs of uterine rupture are present. Many, if not most, hospitals, do not have such depth of resources. And, even more importantly, the skill set of all the involved personnel must stay fresh. A hospital that delivers one baby a day may see a uterine rupture once a decade. Or never, if VBACs are not allowed. A hospital that delivers 10 babies a day, with a big high risk population, will see it routinely. I have personally saved more than a few babies from abrupted placentas, uterine ruptures, knotted umbilical cords, and other various catastrophes. It feels really really good to save a life. I have a wonderfully rewarding life and I am very very glad to be here doing what I do.<br />
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Anyway, this morning, we had a 39 week mom, of advanced maternal age, with no sign of labor, and some risks if she did. The baby was biggish, in the 8 pound range, close to 4 kilograms, and the baby remained very high out of the pelvis. We both chose to repeat the CS and get the baby out while the baby is good. Other women might want to keep trying for a vaginal birth, to give it a few more days or weeks. If she understood the risks then of course we would honor her request for more time. If she understood and wanted her baby out now, by CS, then of course we can do that too.<br />
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Typically I don't provide a "take it or leave it" approach. I tell the woman and husband what I think. I give them my recommendations, and my thoughts, and my estimate of odds, and I let them come to the conclusion that is best for them. Almost always, people are happy to think these thoughts. Sometimes, they really ask penetrating questions about what I think they really should do. If they ask like that, I go back and review what I think might make them the happiest, I might review the risks either way, and tell them what I think. Sometimes it is a section, sometimes it is to wait. But the time crunch is always a problem. Usually, I wish I had more time to do these things. I do my best to allocate enough time. There is never enough time.<br />
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So I was doing a CS about 8:45 this morning and everything is going well, and we are listening to nice music, and the baby seems really happy, and the mom is smiling while we are working. I noticed that the new Father is really bonding well with his new baby. He is holding the baby close, talking to her, getting to know her really well, and looks super comfortable. I had him hold the baby up to the mom for a kiss. All together, it took about 30 minutes to do the whole delivery.<br />
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What struck me was that the new Father was the big winner here. Here he is, holding his baby nicely, and getting a whole lot of new baby time, even before the mother gets the baby. In a vaginal birth, the mom gets the baby. We do "skin to skin" now, so the baby gets delivered right onto the mom. She holds the baby. We hope to give them an hour of bonding. It seems to me that the babies like it a lot more. The babies seem much more peaceful with their mom. The babies know that dinner is but one mouthful away, in the beautiful way that babies find the nipple and nurse. But in a Section delivery, the new Daddy gets most of the baby time. I asked him to remember this moment and this day. Because I still remember my babies in my arms when they were born. That is how I think of my babies, really little, in my arms. In most C-Sections, the new Daddy gets to hold the baby for a prolonged period of time. <br />
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I am certain that this is a positive and wholesome experience for the new Daddy and his baby. He loves his baby with Agape, which means unconditionally and forever. And that bond is unusually strengthened to a great degree when he can hold his new baby like this.<br />
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It is really beautiful to watch that bond strengthen in the delivery room.<br />
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Thank you sincerely,<br />
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<b>Dr John W Marcus MD </b><br />
<b>Board Certified Obstetrics and Gynecology </b><br />
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89 North Maple Ave<br />
Ridgewood NJ 07450<br />
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Phone 201-447-0077<br />
Fax 201-447-3560<br />
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Blog at https://doctorjohnmarcus.blogspot.com/<br />
<br />Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com2tag:blogger.com,1999:blog-5044073699235306403.post-38456838234919952342013-02-25T23:03:00.001-05:002013-02-25T23:03:23.752-05:00<h2>
<i><u>Human Genetics Analysis</u></i></h2>
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Every day in the office I deal with the issues involved in human genetics. Making a human baby involves the union of the genetics of a mother and a father. A man and a women. Benjamin Franklin (one of the American Founding Fathers) used to like to say that only two things in life are certain. They were, in order of importance, Death and Taxes. Americans repeat that phrase often. We usually say it fast without any pause in between. I would add that there are a few other certain things in life. At the beginning of life, there is Birth. One cannot have a death without having a birth. There is a Franklindian certainty (of the Death and Taxes type) that a human being must have one genetic mother, to be born. One mother must provide the genetics. Every person who is born has one genetic mother.</div>
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Similarly, every human that is born has a genetic father. </div>
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What are genes? They are the information storage system of all known life. The DNA system is astonishingly the same for all known life. The Scientists Watson and Crick received a Nobel prize for discovering that the genes live on a helical molecule called DNA. Deoxyribonucleic Acid. They discovered it in the 1950's. A normal structure of the DNA molecules in a living human cell is for each of these molecules to be coiled up into Chromosomes. An uncoiled DNA molecule is several meters long. Coiled up, 46 of them fit into the nucleus of a cell, and the chromosomes are millions of times shorter. Chromosomes are easily visible under a microscope. I see pictures of actual human baby chromosomes all the time. This is the end result of a genetic amniocentesis. A normal cell has exactly 46 chromosomes. 23 chromosomes come from the mother, via her egg, and 23 from the father, via his sperm. The woman always contributes 23 chromosomes. Since every women (and human) has 23 pairs, or 46 total, every egg has to choose one of the pair of each 23 pairs. This has some astonishing statistical implications. For instance, each woman can make 2 to the 23rd power different kinds of human eggs. No more, and no less (unless there is chromosomal "pathology"). 2 to the 23rd is 8,388,608 different kinds of human eggs for each woman. Each human woman is born with about 300,000 human eggs. They are created before she is born, and she will create no more during her life. Statistically speaking, every one of those 300,000 eggs is completely different, genetically and chromosomally unique. The odds of any two eggs having the same chromosomal material is about one in 8.4 million. The odds of there being two identical eggs in a woman, out of her whole complement of 300,000, is about one in 28. This is 8.4 million divided by 300,000. </div>
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The statistics for sperm are exactly the same, but for the fact that men make trillions of sperm throughout their life. But they can only make 8,388,608 different kinds of sperm. </div>
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How many different kinds of human siblings can a specific man and women make? This is an easy statistic. It is, choose one of the different kinds of eggs, and choose one of the different kinds of sperm. The math is 8,388,608 times 8,388,608. Equivalently, 8,388,608 squared. This equals 70,368,744,177,664. Not one more or one less. Lets just call it 70 trillion. So a couple would have to have about 35 trillion children before they had a 50 percent chance of having genetically identical children. Obviously identical twins are much more common than that. The reason there are more identical twins is because the human embryo sometimes splits into two or more, before the third day of conceptional life. </div>
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Therefore, chromosomally speaking, it is vanishingly unlikely that any two humans have anywhere near the same identical chromosomes, unless they are identical twins. </div>
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And unrelated humans have even less likelihood of having common DNA. </div>
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If a single family can make 70 trillion different kinds of offspring, then how many genetically different kinds of humans can be made? It boggles the mind. </div>
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There are a lot more interesting genetic facts and conclusions. </div>
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Lets get started with some more interesting analysis. </div>
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Everyone has two of the first chromosome, called chromosome number one. It is the largest chromosome, so it contributes a lot of genetic material. Everyone gets one from their father, and one from their mother. The one they got from their mother is a genetic identical copy of her mother's. And the other is an identical copy of their father's first chromosome. Her mother got one from her mother. And her mother got a perfect copy from her mother. And so on and so on. The only changes that exist are "mutations". Mutations are spontaneous changes in genetic material that happen when a child gets a different chromosome that their parent had. Mutations happen because of an error in the copying mechanism that creates cell division. They might happen, for instance, when a gamma ray hits the chromosome and changes it. Or when the wrong biological molecule gets stuck in the copying machine. </div>
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Mutations happen at a statistically predictable rate. Most mutations are "bad", but some are favorable. Mutations are important because they are one source of genetic evolution. The other, more important source, is simply which chromosomal rearrangements of the 70 trillion possible, are "better"? Which one makes a human smarter, bigger, stronger, more resistant to disease, etc? Which one will survive, and therefore survive long enough to make even better children? </div>
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Because we know how many mutations there seem to be, we can extrapolate backwards in time to a genetic "Adam and Eve", that was the first set of humans. Genetics professors have done this, and have decided that the first human tribe consisted of about 40 human females, or "Eves", and they existed about 200,000 to 250,000 years ago. Most likely this tribe was in North Africa, and spread out from there. Since then the human species has grown in number. Most of the growth is recent. There have been about 120,000,000,000 humans born since then. 120 billion. The reason I say Eves and not Adams, is that it is easier to do these statistics with women, because of some genetic implications of the mitochondrial DNA, which is a different set of DNA, and only comes from the mother. </div>
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A similar analysis has been done with the "Y" chromosome, that only comes from fathers, and the fathers father, and his father, and so one. </div>
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The fossil record, and anthropology, is consistent with the human species being this old. All of recorded history begins about 8000 years ago. But we know that modern human culture, with words, art, tribe hunting, of large and dangerous game, and oral histories, began at least 50,000 years ago. </div>
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Anyway, I was looking at a photograph of human chromosomes today, with a new patient to the practice, and she had a bunch of really interesting questions to ask. She had already had a genetic amnio, and this was the report on the baby. The baby had normal looking chromosomes. The baby had 23 pairs of human chromosomes, labelled 1 to 22. All of them looked normal. There were two X chromosomes, and no Y chromosomes, so we knew it was a girl. </div>
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One of the most common abnormalities of the amnio result is a triplication of the 21st chromosome. This is the second smallest chromosome. Somehow, when a sperm or egg is created, the chormosome sorting machinery goes awry. This means an egg or a sperm gets an extra chromosome This means that this human fetus would have trisomy 21, or Down's syndrome. Down's is quite common. It is not a mutation. A 35 year old women has a one in 300 chance of having a Down's baby. A 40 year old has about a one in 30 chance. It is much more common as a women gets older. </div>
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There are trisomies of all the chromosomes. Most are incompatible with human life, and never create pregnancies. Trisomy 21 is one exception in that these pregnancies create a human with Down's syndrome. Trisomy 13 and 18 do create pregnancies, but the fetuses never survive more than a few days of life, if they even get to full term. They are highly abnormal. On the other hand Trisomy of the X chromosome is much less abnormal. In a female with an extra X chromosome, she is completely normal. It will likely even never get diagnosed. Even her children will likely be normal. Men with an extra X are called Klinefelters. They are tall, they are tend to have weak muscles, they may have an emotionally tough puberty, and they don't make sperm. So they cannot have their own children. Trisomy of the Y is called XYY. These are normal males. The teaching used to be that these boys were troublemakers, had high testosterone, and wound up in prison a lot. More modern thinking is that they are about 3 inches taller than usual, and about 5 IQ points smarter than average. They are basically normal people, like the XXX females are normal. </div>
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Finally, I would like to say that that the scientific quantity of knowledge in the field of genetics is exploding. There is so much to know about genetics analysis of individuals, and their children, and the means of inheritance, that it is literally impossible to keep up with current knowledge, recommendations, and the science. I have spoken with our genetics consultants, and I am continually surprised by the new genetics testing that is possible. And these possibilities continue to expand. The geneticists themselves have to frequently hit the books to figure out any individual case. </div>
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Myself, I frequently refer to geneticists because there is just too much to know. </div>
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There are a couple of advancements to note, though: </div>
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About 1990, the US Federal Government funded the genetic sequencing of an individual. The cost to do this was about 3 billion dollars. The wikipedia page is here: http://en.wikipedia.org/wiki/Human_Genome_Project </div>
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The first draft of the genome was printed about the year 2001. </div>
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Now, the cost to do the sequencing continues to decrease. </div>
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There is a report of a company that can do an individual's sequencing using "system on a chip" technology borrowed from the computer industry. This company claims to be able to entirely sequence a human for about a thousand dollars. I reported about this in a prior blog post. </div>
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Right now it costs my patients, or their insurance companies, about 3 or 4 thousand dollars to test for a few breast cancer genes. Do the math and you will see that the cost of genetics analysis will continue to plummet over the next few years. </div>
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Also, the Genetic Amniocentesis may be going to way of the dodo bird. I mean, it may be going extinct. Or, it is going to become increasingly rare, and used only at the end stage of a diagnostic workup. Women hate doing the amnio because it pokes a needle very near their baby. And it has a miscarriage risk quoted to be somewhere between one in 300 and one in 1500. Nowadays, I can order a simple blood test that can tell me if the pregnancy has a trisomy 13, 18, or 21. These are the most useful trisomies to test for. The one that I do in my office is the Materna T-21 test. I recently ordered it for a pregnant women who was found to have a downs risk of about 1 in 350. In the past, this women would have faced a very difficult choice between risking the amnio, with it's inherent risks, or risking the Down's, with a risk of about one in 350. Technically, her Downs risk was completely normal, because we don't call it elevated risk until the risk is about one in 300 or more. But, in this day and age, where a common Down's syndrome risk assessment is one out of a quarter million, I don't see how couples are going to be happy living with a risk of Down's of one in 350 when I can do a noninvasive nearly risk free amnio alternative. </div>
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We can only hope that the insurance companies will pay for the noninvasive modern T21 style tests. I think they will ultimately come along and pay for it, but it will take some time and work to convince them. </div>
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Thank you for reading my blogs. Comments are very welcome. </div>
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Dr John W Marcus MD FACOG PC </div>
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89 North Maple Ave </div>
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Ridgewood, NJ 07450 </div>
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Phone 201-447-0077 </div>
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Fax 201-447-3560 </div>
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Blog at : Http://doctorjohnmarcus.blogspot.com/ </div>
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Please send your friends to read here as well. </div>
Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com1tag:blogger.com,1999:blog-5044073699235306403.post-54032896948723615932012-12-05T17:47:00.001-05:002012-12-05T17:47:16.982-05:00<h2>
<u>Hyperemesis Gravidarum, or super vomiting of pregnancy. </u></h2>
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Right now our beloved Princess Kate is hospitalized with Hyperemesis Gravidarum. </div>
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The royal spokesperson has said that she is less than 12 weeks pregnant, but has not given us her due date yet. We can assume that she is past 8 weeks or so, or the HG would not be at this stage. So she is between 8 and 12 weeks. That means she is due near July 1st 2013. </div>
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HG happens when the pregnant women is so nauseous that she vomits nearly continuously. </div>
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Nausea and Vomiting are completely normal parts of the first trimester of pregnancy. Most women will experience some of this. In fact, most women will lose some weight the first trimester of pregnancy, just because they cannot eat a lot of food. </div>
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But, when a women suddenly gets so sick that she cannot tolerate fluids, and what fluid she does have vomits back up, two bad things will happen. First, she will get severely dehydrated. And that will make her very very weak. Her blood pressure will be low, and she may not have the stamina to even get out of bed. The second bad thing that happens is that she will lose electrolytes, such as sodium, potassium, and chloride. Losing the electrolytes is worse than plain dehydration because it can make the heart beat irregular, or worse. </div>
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We can detect this severe dehydration by weighing the patient. If she loses 10 pounds over a few days, then she has certainly lost enough fluids to go to the hospital. There, we can replace the fluids and check the electrolytes. </div>
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Obstetricians don't really know what causes such a severe intestinal problem. We know that progesterone, which is a hormone that the ovary and placenta makes in abundance, can make people sick. Some women get really bad PMS from the natural progesterone of a normal menstrual cycle. The progesterone peaks about day 23 or so of a normal 28 day cycle. A lot of women feel awful from that peak of progesterone. It makes their breasts sore. It retains fluid. It makes them crabby. It makes them gain a few pounds of fluid. It makes their intestines fill with gas, and they get really bloated. They really hate it. The peak progesterone level of a normal cycle is about 12 or so, according to my lab. In pregnancy it may go up to several hundred, as the placenta makes a ton of it. The natural purpose of the progesterone seems to be to keep the uterus from having a menstrual period, and thereby pushing the baby out. The uterine muscle responds to the progesterone by getting very soft and dilated. Unfortunately, that same kind of muscle is in human intestines. Under the influence of that much progesterone the intestinal muscles seem to dilate and get soft. This prevents peristalsis and makes the women nauseous as the food backs up into the stomach and esophagus. </div>
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There is also a strong belief among some people that the nausea has an evolutionary purpose. </div>
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What I mean is that the vomiting may be a defense mechanism to protect the fetus from noxious foods and exposures. This is because the first trimester has an importance unlike any other time in human events. It is the phase of organogenesis. </div>
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The first trimester of pregnancy lasts from about 2 weeks of pregnancy (that is before the pregnancy is even known about) until about 13 weeks. The first trimester has an unbelievably important function for the fetus. It is the phase of "organogenesis". This means that the baby is actually forming it's own anatomy. The heart is being built into chambers, the kidneys are being made, all the tissue layers are folding into final position, the basic brain structure is starting up, and all of the events that create a human being are happening. After 14 weeks, all of this complicated tissue construction is done. The only thing left is to grow and fine tune the functions of the organs. </div>
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What is the last organ to be completed? I like to tell my patients it is the brain. That is done, in some people, around the 40th year of life or so. There is a bit of humor and a bit of truth in that statement. It is my belief that the human brain never stops developing. Since we can all learn new things, and do new activities, it seems to me that the brain never stops growing. For this reason I believe in lifelong "effortful" learning. Effortful is the opposite of Effortless. For this reason, I like to say that people should push to learn and do and experience new things all the time. For me, my recent activities include learning to play the guitar, learning languages, and learning new computer processes. Such as learning how to write a blog on Google, learning the Java programming language, expanding my knowledge of Pascal, keeping up with the latest Basic compiler from Microsoft, and things like that. </div>
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And to grow the brain we have to nourish it. That is why I recommend everyone including myself to take DHA omega three supplements. This is an essential fatty acid component of human brains, that no one gets enough of, that cannot be created inside of a human. I take and recommend 300 mg a day of DHA. </div>
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Probably the second to last organ to be finished is the lungs. I don't know why, but the human lung has a lot of trouble oxygenating a human being until about 36 weeks of pregnancy or so. There are multiple issues with the function of an immature human lung, but one of the last factors to be created is Surfactant. The NICU now uses artificial surfactant and that helps the premees quite a bit. It helps them breath. </div>
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But, until all of this complicated organogenesis is done, there is a very delicate fetus. If there is some unfortunate exposure to a toxin of any sort, it may have a disastrous effect on the organogenesis. The heart may not form right. The cover over the spine may fail to fuse, causing anything from a spina bifida to anencephaly. There may be entire limbs missing. There may be a tiny imperfection, like a cleft lip. There may be a huge central failure, like syrinomelia, where the legs are fused. This is why most physicians are loath to prescribe any medicines in the first trimester. We will, if possible, defer any medical treatments to the second trimester. Sometimes, we will defer treatments of minor infections. We will push hard to defer X-rays, if possible. We will certainly advise against smoking, drinking, and illegal drugs. We do not advise refraining from exercise or sex, unless there is a specific reason to do so. </div>
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So, some people believe that Hyperemesis is Mother Natures way of protecting the fetus from noxious exposures. Most pregnant women will run away from any noxious fumes, because it makes them extremely nauseous. This serves a very important purpose of keeping those toxic fumes away from the baby. </div>
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As an obstetrician, my job is to keep the baby safe. Keeping the baby safe means keeping the mother comfortable. </div>
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If a pregnant women has more vomiting than is safe for the baby, then we need to take action. The first thing to do is to see if dietary modifications will help. I will ask the women to start taking a tiny sip of Gatorade every 20 minutes. This will replace the electrolytes and the fluid slowly, and prevent there from being too much fluid in the stomach as to make her vomit it back up. I will ask her to stop all spicy and greasy foods. I might ask her to have one salty cracker (called a saltine her in the USA) every twenty minutes. Sometimes the saltines and Gatorade diet does the trick. </div>
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Sometimes we try the BRAT diet. This is bananas, rice, apples, and toast. This diet is explained on Wikipedia page here: http://en.wikipedia.org/wiki/BRAT_diet. </div>
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If the women needs medications to stay hydrated, then we usually start with phenergan and or odansetron (Zofran). If pills get vomited, then go to suppositories. Women don't like that of course. If that doesn't work, then go to IV or Subcutaneus pumps of these meds. Plenty of women are maintained on these meds, sometimes they need them for most of the pregnancy, if the situation is really bad. </div>
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If nothing else works, then the women needs both IV fluids and IV nutrition. These IV's can save both the mother and the fetus, and I have managed this many times. Most of the time I will ask for the help of a specialist in IV nutrition. Our hospital has several of these specialists available. I call them into the case, and their help is very much appreciated. </div>
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Sometimes, in bad cases, such as if the gallbladder goes bad at the same time as Hyperemesis, these women will need IV nutrition for the whole pregnancy. It is certainly possible. These women are really suffering, though. </div>
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If the vomiting is not managed well enough, then the stomach acids can inflame the esophagus This can get really painful, and needs to be managed as well. These stomach acids are really bad for the teeth, too. Just like in a bulimic patient. </div>
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Let's hope that Princess Kate doesn't need this kind of service, but if she does need it, I am sure that it can be provided. </div>
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Thanks once again for reading. </div>
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Dr John W Marcus MD FACOG </div>
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89 North Maple Ave </div>
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Ridgewood NJ 07450 </div>
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phone 201-447-0077 </div>
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fax 201-447-3560 </div>
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blog at doctorjohnmarcus.blogspot.com </div>
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comments below are very much appreciated. </div>
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Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com3tag:blogger.com,1999:blog-5044073699235306403.post-37383422571205284532012-12-05T16:40:00.001-05:002012-12-05T16:40:26.804-05:00Stem Cells<br />
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Everybody asks, <b><u>"Should I have my umbilical cord blood stem cells frozen and stored?"</u></b> Usually, by the time patient is asking me this question, she has been bombarded with advertisements from the stem cells storage companies. But, even if the patient doesn't ask me, I will ask the patient at about 20 weeks. In my practice, it is a prenatal care checklist item for 20 weeks, along with the 20 week genetic and anatomy sonogram. So, I will make sure that the patient has the information that she needs to make a good decision.<br />
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First of all, everybody should be aware that umbilical cord stem cell storage has not been endorsed by any professional group other than the stem cell companies themselves. My ACOG states that this procedure is unnecessary. Anything that is unnecessary is not going to be a covered benefit under the health insurance. So, anyone who does it is going to have to find a way to pay for it.<br />
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It costs anywhere from $1350 to $9000 or so to get the process started. The price varies from company to company. There is also variance on what exact services you have contracted for. There are some companies that will take the whole placenta and use it to get more of the stem cells. Other companies will take a short segment of the umbilical cord itself. All of these things are added cost.<br />
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Once the stem cells are frozen and kept under liquid nitrogen, the companies that do this work will charge you once a year to keep the cells frozen. The yearly charge is something on the order of 150 to 250 dollars a year. I suppose that if you don't pay, they would throw out the stem cells. Or maybe donate them to science, or a public stem cell bank.<br />
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<b><u>What is the benefit of doing this?</u></b><br />
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The stem cells that are retrieved from the umbilical cord, fetal blood, and placenta, are processed and examined by the cord blood storage companies. Then they are deep frozen under liquid nitrogen. This does not kill the cells. It preserves them for future use. If, in the future, this baby has some kind of medical problem that can be cured with an infusion of stem cells, then the stem cells are there for the baby to use. These problems are usually some kind of leukemia or cancer. In that case, the future oncologist has the option of removing this victims bone marrow cells, curing the cancer, then thawing out the stem cells, and then restoring the immune system with those stem cells. This is all only theoretical, because the successful cases done like this are rare.<br />
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The stem cell companies claim that about one out of 200 stored units are eventually put to use. I have not seen an independent validation of this claim. If this is so, then I think that everybody should do the stem cell storage. I think it is more likely that there is a small number of stem cell units that are used. The rest will stay frozen indefinitely.<br />
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There is a ton of ongoing research right now to see if stem cells can be used to treat a bunch of other conditions. There is some some studies being done for heart disease, and some even on autism. So the applications for stem cells seem to be widening. It may be that the future for stem cells is very wide indeed.<br />
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On the other hand, biotechnology marches on. It seems now, that many times, the biologists can get stem cells retrieved even from grown ups. If this is so, then there is no reason to store the fetal cells, as everyone has stem cells. We can use the adult stem cells to do the job of the fetal stem cells. If that is true, then no one needs to freeze the fetal stem cells, we have our adult cells and that will be good enough.<br />
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So, in the final decision making, a family needs to decide the odds of using these stem cells, versus the odds of not using them or not needing them because the body makes it's own. I also tell my patients that if they need the stem cells years later, and they didn't store them, they may be very sorry.<br />
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And then the decision is affected by how much you value the 2000 dollars or so you invest in it.<br />
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I tell a family, "if you have a lot of money, then you can spend a lot on the stem cell fees". On the other hand, "If you don't have a lot of money, and 2000 dollars will break the bank, then don't do it. Either way, I will help you both figure out the right thing to do is, and I will help you do it. You need to make your decision some time before the placenta comes out." I will then note in the chart that we had the discussion, and I will note whatever they seem to be deciding at the moment. We will revisit this discussion throughout the rest of the pregnancy and I will offer to help decision making.<br />
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The majority of the people in Bergen County will decide that they do not want to pay for it.<br />
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If they do, there are a couple of good choices available.<br />
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Viacord is the biggest company. They are based in Ohio. They will not let you visit your unit of blood. They generally will not negotiate with you. They will provide my office with 500 dollar coupons that people can use to lower the price from 2300 to 1700 dollars.<br />
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Neostem is the best local company. They are based in the next town, Allendale New Jersey. I personally have met some of the people, and I like them. They will let you visit your unit of blood. They have good prices. They will talk to you on the phone. They also have a coupon available in my office.<br />
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CBR is another big company.<br />
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There are a hundred others.<br />
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The local blood bank still does it as well. I don't know why more people don't use them. Maybe they are being out marketed by the commercial providers? I don't think the blood bank markets the service at all. They used to have an open donation program that was free to donors. I sent a lot of donors their way. The donor program is now closed due to lack of money. As you can imagine, the donor program was quite expensive to administer. If it ever opens again, I will send a lot of patients to the blood bank for stem cell donations. It was a very very popular program with my patients when it was still open.<br />
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Ultimately, the decision to store the stem cells is difficult for most people. It is an assessment of risks, potential benefits, and costs.<br />
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Sometimes, the grandparents have a very strong opinion, and take action. It's great watching them when they do this. It becomes a parent taking care of a child, but the parent is the new grandparent, and the child is the pregnant women and her husband. The grandparents say, "where doing this, that's all their is to say about it". They will allow no dissent. And then the stem cells are stored.<br />
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I don't know how the stem cell companies find the pregnant women to market to, but they seem to use some kind of internet magic. There was a story of a 17 year old girl who got pregnant, and did some looking around the internet on Google. Pretty soon, there were items in her mail box to help her with the pregnancy, and try to sell her things. This, despite nobody but her knowing about the pregnancy. Her Father read the mail, and found out she was pregnant. I don't know the outcome of that story. There is a strong lesson there, though. The lesson is, almost nothing one does is the modern world is completely private. I think, for the sake of safety, always assume there is a camera watching you, and there is someone who knows what you do on the internet. There are technical ways to block that snooping, but I am pretty sure they are not completely successful at blocking your trail.<br />
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I think the next post will be about Hyperemesis Gravidarum, as that is what our beloved princess Kate is hospitalized with right now.<br />
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Thank you sincerely,<br />
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John W Marcus MD FACOG<br />
89 North Maple Ave<br />
Ridgewood NJ 07450<br />
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phone 201-447-0077<br />
fax 201-447-3560<br />
blog at doctorjohnmarcus.blogspot.comAnonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com0tag:blogger.com,1999:blog-5044073699235306403.post-80893778443975825732012-11-13T22:51:00.000-05:002012-11-13T22:51:15.367-05:00<h2>
<u>Pre-eclampsia or Toxemia</u></h2>
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<u><b>Toxemia is a big problem.</b></u></div>
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Toxemia strikes about one in twenty pregnant women. It is usually mild, but sometimes is severe. Occasionally it will become life threatening. When it gets really bad, it develops into eclampsia (instead of pre-eclampsia). When it is super bad, it leads to a failure of the blood systems, then we call it HELLP syndrome. HELLP is an acronym for "Hemolysis, Elevated Liver Functions, and Low Platelets". About one out of 75,000 pregnant women will get toxemia so bad that they die of it. </div>
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The professors of Ob all call this pre-eclampsia. The old folks will likely call it toxemia. Personally, I like to call it toxemia. I think the name toxemia better reflects an understanding of what the disease process is. The old latin name of pre-eclampsia just doesn't create any useful meaning to me. In any case, all physicians know both meanings. </div>
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To put the mortality rate into perspective, there are about 5000 hospitals in the USA. This means that about 1 in 15 hospitals can be expected to lose a patient to toxemia in one year. And about one in 20 Obstetricians will lose one patient in his or her's entire career. This is assuming an Ob career involves about 5000 babies. Personally, I have already delivered more than 5000 babies, but I believe I have more experience than most. </div>
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Some hospitals have more high risk cases. Those high risk hospitals will obviously have a much higher count of the risky cases. </div>
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My hospital, The Valley Hospital in Ridgewood NJ, attracts these extremely high risk cases. We have one of the best Neonatal Intensive Care Units in existence. Our chief neonatologist is Dr Frank Manginello. He is a noted author of one of the best NICU reference books in existence. His best selling book is called <u>Your Premature Baby.</u> The book is available on Amazon. Here is the Amazon link: <span style="background-color: white; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 13px;">http://amzn.com/0471239968 . </span></div>
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We also have a superb IVF program, and a wonderful Maternal Fetal Medicine team, not to mention a medical staff in the thousands, most of which were trained in New York City. Many of them maintain privileges at University hospitals. </div>
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For instance, my favorite fetal cardiologist is Dr Zvi Maran. He has privileges at both Valley and at Columbia University. Columbia is about 20 minutes away just over the George Washington Bridge. Dr. Maran took care of my daughter when she had a very frightening cardiac arrhythmia. He and his excellent partners got her through this and eventually her heart healed itself. </div>
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So, hospitals with a higher risk population is going to see a lot more of the riskier cases, and their experience is going to be higher than just the numbers will show. </div>
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<b>What is Toxemia</b>? </div>
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Nobody really knows for sure. But, even though we aren't sure what it is, we do know an awful lot about what it does. The body of the pregnant women is behaving as if there were a really bad toxin in the blood stream. No toxin has ever been found. But all of the organs start to fail. First, the blood pressure starts going up. This is due to the arteries feeding these organs squeezing down on the blood flow, leading to less flow to these organs. Early on, the kidneys start to malfunction. The kidneys start making less urine. This leads to fluid retention and severe swelling, and usually 10 pounds or more of fluid is retained all throughout the body. The kidneys start to "spill" protein into the urine. There is usually no protein in urine because the kidneys are good at making clear urine and keeping the valuable protein in the body. In toxemia the protein spills out. </div>
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So a lot of prenatal care is designed to check for these things. In a prenatal visit, the blood pressure will be checked, the patient will be weighed to see if there is this sudden severe fluid retention, and the urine will be checked for protein. All of these checks are to test for the signs of toxemia. </div>
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Officially, the diagnosis of toxemia requires an elevated blood pressure, and some protein in the urine. </div>
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The brain will eventually be affected. Some of the signs of toxemia affecting the brain are: a bad headache, visual changes including dark spots, sparkles, blurry vision, loss of vision, or more rarely, personality changes. </div>
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The liver will be affected some times. This will lead to an elevation of the "liver enzymes" on a comprehensive panel of blood tests. If the liver gets too swollen, it can cause pain in the liver area of the abdomen. This is considered the right upper quadrant of the abdomen, just under the lower edge of lowest rib. A very swollen liver can actually rupture. If this happens, the patient may die from the blood loss into her abdominal cavity. I have never seen a liver rupture, but I have seen many many painful tender livers, with elevations of the liver blood tests. This is all quite common if toxemia gets to the HELLP stage. </div>
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In the blood, the red cells can rupture. This can lead to severe anemia, and elevations of bilirubin in the blood on tests, and bilirubin in the urine as well. Also, in the blood, the platelets can get used up by the toxemia, leaving the platelet count perilously low. These women may need platelet transfusions. Platelet transfusions are easy to order from the blood bank, and can be lifesaving If the platelet count gets too low, a life threatening hemorhage becomes likely, especially at the time of delivery. At delivery a woman needs all the platelets she has to shut off the blood flow to the placenta. Without that, there will be a hemorrhage. </div>
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The blood flow to the heart muscle can be compromised, leading to heart failure, or a heart attack. </div>
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All of the organs can be compromised. </div>
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None of the toxemia directly affects the baby. Only to the extent that toxemia affects the mom or the placenta. </div>
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If the blood flow to the placenta is compromised, then the baby may become short on oxygen, or may be short on nutrition. The baby may stop growing. The babies blood pressure may become very low. </div>
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The placenta might even disconnect from the mother. If this disconnection is more than a mild case, then the baby will be distressed or even die. We call these placental disconnections <b><u>Abruptions</u></b>. Placental abruptions are much more common with hypertension, than will normal blood pressure. Abruptions can also happen from some kind of trauma to the pregnant uterus. Car accidents, falling over on ice or on the stairs, or physical assault on the fetus, can all cause the placenta to abrupt. A complete abruption when a woman is far away from the hospital will almost certainly end the babies life, and will very much risk the mothers as well. Sometime the blood just pours out of the vagina like a hose. If this happens there are only a few minutes, perhaps 10 but maybe up to 30 minutes, to try to save the baby and the mom. I have seen many abruptions. If it happens in the hospital it is almost certain that we can save the mom and the bay. If the private obstetrician is not there with the patient, then we have the on call ob. The "doc in box". In my years doing the on call, I have saved maybe 4 or 5 or more from a placental abruption. Mostly by doing a really fast C-Section. </div>
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After the baby is delivered the nurses will sometimes come up to me and say, "thank you for coming right away when I called you. You saved this baby". My answer to that is, "no, you saved the baby by being there, recognizing the problem, and calling me without delay. You saved the baby, I was just doing my job". In the end, doing our jobs requires a lot of teamwork. Everyone becomes a link in this chain of human events. And when it all works out, we can all be really proud of what we do. </div>
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But not all abruptions are complete. Many are partial. It is easier to save those babies. </div>
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<b><u>How to diagnose it? </u></b></div>
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If the blood pressure is elevated, then we know there is a problem. It might be "gestational hypertension", which used to be called PIH, or pregnancy induced hypertension. Or, it might be toxemia. We will look for protein in the urine, either on a urine dip strip or on a 24 hour urine collection. We will order blood tests to look for hemolysis, low platelets, and liver function tests. We will likely need to do these tests in the hospital. The patient may be formally admitted, or she may be kept as an outpatient for up to 24 hours. </div>
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We will ask her if she has a headache, or visual changes, or sudden fluid retention and swelling, We will ask her about nausea, and pain in the liver area. </div>
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We will weigh her, examine her lungs, heart, liver, and uterus. We will check the reflexes. If they are elevated, that is a sign of toxemia. </div>
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If the blood pressure is below 160/100, and there is no hemolysis and the platelets are normal, and there is no liver involvement, and no brain involvement, then we call it mild toxemia. Mild toxemia remote from full term can be observed, usually in the hospital, but sometimes at home. Mild toxemia at term should be delivered without delay. </div>
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Delivery cures toxemia 100 percent of the time. If the women has permanent damage to her kidneys, or heart, or anything else, as result of a terrible toxemia, then those problems can last forever. But the toxemia itself will be gone. usually it fades away from hours or days after delivery, and is completely gone in 6 weeks time after delivery of the baby. </div>
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A patient with severe toxemia will need to be delivered regardless of the gestational age. Even if it means losing the baby. We have to deliver the woman, even at 22 weeks, and sometimes deliver a non-viable baby. If we do not deliver the baby, then the mother may die or be permanently damaged from the multiple pathways of pathology I described above. We do not want to have a maternal mortality. </div>
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Even having said all of that, ACOG (American College of Ob/Gyn) has written a recommendation that some milder cases of severe preeclampsia, if they are remote from term, may be allowed to stay pregnant a little bit longer if it means the difference between life and death for the fetus. ACOG will only allow this protocol under certain circumstances. Among them are an experienced facility with very experienced Obstetricians, perhaps with Maternal Fetal Medicine specialists available. Our facility fulfills all of those criteria. Therefore I am comfortable managing a "moderately" preeclamptic patient without immediate delivery. But in most cases, immediate delivery is necessary. </div>
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<b><u>Who is at risk? </u></b></div>
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Some women are much more likely than others to get toxemia. Hypertensive patients, diabetics, older pregnant women, over stressed women, women who have had it before, women who use drugs like cocaine, women without prenatal care, women who suffer from poverty or who don't have a family or husband to help, women with anxiety disorder. </div>
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But even so, it can happen to anybody at any time. </div>
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<b><u>Prevention? </u></b></div>
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Many things have been tried to prevent toxemia. Nothing has worked. We can certainly prevent some of the risk factors, though. We can provide proper prenatal care, proper nutrition, prevention of diabetes, lower lifestyle stress issues, prevent drug abuse, and engage the family into a social support group. </div>
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Aspirin has been tried and it doesn't work. </div>
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Calcium, magnesium, vitamins, none of them work. </div>
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We usually advise some moderate bedrest to lower the blood pressure, but most Obs don't believe that bedrest will actually prevent it. And bedrest itself has a number of severe risks, especially including lethal embolisms from DVTs, but also including severe decondioning, which may require physical therapy to overcome. </div>
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Someday, someone may actually find the toxin of toxemia. If they do, there will surely be a Nobel prize to that individual. </div>
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Thanks for reading. </div>
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John Marcus MD Ob/Gyn </div>
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89 North Maple Ave </div>
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Ridgewood NJ 07450 </div>
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201-447-0077 </div>
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blog at doctorjohnmarcus.blogspot.com </div>
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Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com5tag:blogger.com,1999:blog-5044073699235306403.post-68162402044789194282012-11-10T15:31:00.001-05:002012-11-10T15:53:10.482-05:00<span style="font-size: large;"><b><u>Influenza after Hurricane Sandy</u></b></span><br />
<span style="font-size: large;"><b><u><br /></u></b></span>
It is now Saturday November 10th, and it's my first weekend off since Hurricane Sandy came through. When I woke up today I was struck by the thought that I haven't had any phone calls for influenza yet this season. We are well into flu season. Usually, by now, there are a ton of calls. I wondered "what was up with that?" Why no calls for influenza? So I did what I usually do with these kinds of influenza questions. I opened my iPhone and surfed over to Google's flu tracking tool at http://www.google.org/flutrends/ Immediately I discovered that the United States is having a bad flu year. Here is a screen shot of my iPhone page: (Hint: If you click on this picture, it gets much bigger and more readable):<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkWUX55b_ltAgEiuPp2n3QnbeU3zYfuO3rT65V4vcUEFCy1rGa3bsOWt0PzyxgItFlJxHEYSS1ueZoe4jIx5uKH20M7pdpVSa-QFqLElyIYoTEgXvWI46k2XENOjcJQ4_KHitG8JQuWSL6/s1600/IMG_0756.PNG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkWUX55b_ltAgEiuPp2n3QnbeU3zYfuO3rT65V4vcUEFCy1rGa3bsOWt0PzyxgItFlJxHEYSS1ueZoe4jIx5uKH20M7pdpVSa-QFqLElyIYoTEgXvWI46k2XENOjcJQ4_KHitG8JQuWSL6/s320/IMG_0756.PNG" width="213" /></a></div>
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<br />
The line for the present year is a darker blue than prior years. This years line ends at about November first, because that is the most current data. You can see that the present incidence of influenza is well into the moderate range, and it it well above prior years. This years line is above all prior years, with the exception of the really high H1N1 year. That tall peak was the year that H1N1 happened. Google's web service tracks influenza by analyzing search terms that people type into Google. Google's flu tracking technique is statistically validated, and their results are published in the scientific journals. It turns out that Google's technique gives us flu data about two weeks sooner than the old way. The old way was just collecting case results from emergency rooms, and things like that. <br />
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So, if the US is having a bad flu year, why am I getting no calls? I decided to look at New Jersey's results. When I clicked on New Jersey on the map, I got this:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0D_5f5r95d7PvdJecLoY_giFMVIjPZ7A7r4dKFWcw1pm1EmFA1lL5EjWdKqXVF2U-Evbb_sS0M6GjAuovVBublACGzE6aR62ezCrZTxgKQ2jFO826XymTgJ-EQjSRTkAfBH2NZ5qo9O-b/s1600/IMG_0755.PNG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0D_5f5r95d7PvdJecLoY_giFMVIjPZ7A7r4dKFWcw1pm1EmFA1lL5EjWdKqXVF2U-Evbb_sS0M6GjAuovVBublACGzE6aR62ezCrZTxgKQ2jFO826XymTgJ-EQjSRTkAfBH2NZ5qo9O-b/s320/IMG_0755.PNG" width="213" /></a></div>
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You can see that New Jersey's incidence is not only low, but has dropped off quite a bit over the last week. So Google's flu tracker seems to confirm my suspicion that we are having an anomalously mild flu season. Either that, or people with influenza are neither calling me about it, nor are they searching Google for answers. It seems to me that we are actually having a mild year.<br />
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Could it be hurricane related? Maybe so. There was no bus or train service for a very long time. Maybe no one is spreading flu on the bus, so the incidence is very low and dropping. It could be that no one was going to work, and therefore not spreading the flu at work. Or, a big factor might be that the kids are out of school for more than a week. If the kids cannot spread influenza at school, that might be enough to lower the incidence of influenza. Are there any other factors? Maybe all of the houses without heat were inhospitable to the influenza virus.<br />
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So, you heard it here first. This is headline news. Catastrophic Hurricanes during flu season causes a reduction in influenza incidence. The evidence is the strong dip in the dark blue line on the second screen shot above. This is a tiny silver lining in the cloud over our heads. If no one has noticed this effect before, maybe I can get the hurricane effect named after me, :). The Marcus effect, maybe? If it hasn't been named before?<br />
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If this reduction is real, then I would like all of you to consider the lethal nature of influenza. Every year, 25 to 50 thousand Americans die of influenza. Please compare that number to the 200 or so people who died in Hurricane Sandy. Maybe the silver lining isn't so small after all. If these statistics hold true, it may be that Hurricane Sandy saved more people from influenza than died from the storm. If you look at the yellow picture of the United States in the above two web pages, you can clearly see that the northeast states have a much lighter shade of yellow, compared to, say, the south from Florida to Texas. The northeast may have been affected by the hurricane, whereas the south is having a normal flu season. Maybe someone can compare this with prior years to see if the effect is real.<br />
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In my office I try to immunize all of my pregnant patients against influenza. All of the professional groups, such as the American Congress of Obstetrics and Gynecology, recommend that pregnant women get a flu shot ASAP. In fact, pregnant women should be first on the list if there is a shortage of vaccine. When H1N1 happened a few years ago, there was a severe shortage of that vaccine. Who was offered the vaccine first? Those most at risk were offered first. And that meant pregnant women were offered the vaccine first.<br />
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When the power went out in my office I took my boxes of vaccines home. I did that so I could keep them in a fridge at home, and keep them safe in the power outage. But I missed a box in the dark office. It warmed up and I had to throw out the whole box. That was a shame because I had the single dose vials. These have no preservatives and are better for pregnant women.<br />
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Back in 2009 I was a speaker at an influenza symposium given by our hospital, The Valley Hospital. At that time, influenza type H1N1 was running it's course. H1N1 is unbelievably evil. There were two giant epidemics last century that each killed millions of people. H1N1 came back again in the year 2009, and there were worries that we would once again have millions of people die. Well, that didn't happen. Our public health measures were very successful at averting the mortality rate of prior pandemics.<br />
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What is influenza? It is a virus that infects humans via microscopic airborne droplets. It doesn't just infect the lungs though, it gets loose into the blood stream as well. The major signs that one has influenza is high fevers and muscle aches. There is usually profound fatigue, some respirator illness such as a sore throat and cough, and maybe some intestinal discomforts.<br />
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Whenever a person has high fevers and muscle aches, we call that illness an Influenza Like Illness, or ILI. An ILI does not require a visit to the doctor or the emergency room, but a phone call to the doctor would be a great idea. The doctor can phone in a prescription for an antiviral medicine. One such medicine is called Tamiflu. Pregnant women with an ILI really should take the Tamiflu. In my experience the Tamiflu sometimes stops the virus in it's tracks. A persons energy then pops right back. The Tamiflu really avoids the prolonged fatigue that one gets while recovering from this nasty virus. Also, when one is recovering from an ILI, one should be resting and drinking plenty of fluids. This is especially true of pregnant women. Pregnant women simply don't have the reserve energy that non-pregnant adults do. Some of them cannot possibly recover from the profound fatigue unless they take the time to rest.<br />
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So the lesson for influenza is this:<br />
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Get vaccinated to prevent it.<br />
If you get an ILI, then push fluids, rest, and maybe take Tamiflu.<br />
If you are pregnant, then you must stop working, rest, push fluids, and take Tamiflu.<br />
Call your doctor.<br />
You won't need to go to the doctor unless there are other complications.<br />
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Once again, thanks very much for reading my blog. Please post links to my blog. It is really great to see all the people who are reading this from all over the world.<br />
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Sincerely,<br />
<br />
Doctor John Marcus MD<br />
89 North Maple Ave<br />
Ridgewood NJ, 07450<br />
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phone 201-447-0077<br />
fax 201-447-3560<br />
blog at doctorjohnmarcus.blogspot.com<br />
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I am soon to start twitter as well, as it was one of the only services that actually worked during the height of the storm. I do have an account, I just never really used it. I am still not sure if I tweet to other people, or if they tweet to me. In any case I just tweeted that I have a new blog post up. Where that tweet goes, I have no idea.Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com0tag:blogger.com,1999:blog-5044073699235306403.post-12111187928153439102012-11-05T23:24:00.001-05:002012-11-10T13:07:08.151-05:00<b>Hurricane Sandy Recovery, and more yeast infections. Some photos of tree damage in my town. </b><br />
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Today is Monday November 5th. Hurricane Sandy came through here exactly one week ago. Power came back at my house about 36 hours ago, and electrical power came to my office about 24 hours ago. This morning we went in to the office and restarted our business equipment. The phone system has completely lost it's mind. The programming is gone. This means that every phone in the office rings for every call. My staff was extremely busy all day taking phone calls and arranging new schedules. And they did it with our malfunctioning phone system. It sounds funny, but the fax machine started to answer every call. I am sure that was frustrating to callers who were answered by a fax tone. We unplugged the fax and forwarded those calls to a Lifeline fax server. And when we tried to send faxes, the receiving fax machine was putting our fax machine on hold, complete with music. Our fax machine does not need, or even like, music, so that obviously blew up our communications systems. Once, when I got tired of the phones ringing nonstop in the exam room, I pulled the phone off the wall and unplugged it. I think I moved much too fast. Besides alarming my patient, I banged my head into the corner of the cabinet by the phone. Ouch. That hurt. But I had a good laugh about it. Probably everyone's phone and fax system is deprogrammed by now. If it wasn't so serious it would be funny. Today, I had a women who needed to know a vaginal biopsy report to decide if she was going to have a C Section or not. But the lab couldn't get the test done, so now we have to decide without that information. That's kind of stressful. We will take good care of her anyway, and I think she will be satisfied with what we have done.<br />
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I think Halloween is cancelled now. It was rescheduled by Governor Christie, if you can believe that. First to Saturday, then to today, Monday. This, despite Halloween not being any kind of official holiday. But, since the streets are full of fallen trees, fallen power lines, piles of leaves, and piles of branches, there is just nowhere safe for the kids to go around trick or treating.<br />
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Most of my town is still without power, and the gas lines are still very long. Most of the gas stations are closed due to either running out of gas, or no electric. I called the Governor myself and was utterly surprised when a women answered the phone. I asked her to relay a message to the Governor that I thought the gas stations should get generators. Now, everyone must realize that Generators are dangerous machines. Our military has a spate of soldiers who died in war zones because of improperly wired generators. The press uses the term "faulty wiring". Faulty wiring means that electricity flows were it doesn't belong. Generators are only safe if they are operated within codes. That means that "electrical ground" is grounded, and "electrical neutral" is "bonded". If that is so, and connections are secure, than there is no danger. So, I asked the Governor to make sure that every local code official inspects the gas station generators, but not deny it due to permits. The other generator safety factor is that the generator must not "backfeed" into the power mains. If it does that, then there will be dangerous electricity where the power company thinks there isn't, and power line workers can get hurt, or worse. Worse, when the electrical mains come back, the generator cannot fight the strength of the power company, and the generator burns up in a ball of fire, especially including the gas tank on top of the generator. In an emergency, the best way to safely prevent backfeeding, is to pull the electrical meter. This completely prevents backfeeding. But, pulling the meter is illegal. I urged Governor Christie to explicity alllow pulling the meter at gas stations, by qualified electricians, so generators can be hooked up safely. Pulling the meter reduces the electricians job to just a few minutes. We know that generators are scary dangerous. We in Jersey know that. But, here in New Jersey, we are facing a killing freeze tonight, and many folks have no power. And many folks cannot get gas due to the lines (lines are called queues in other countries). Something has to be done. It is my belief that the legal electrical codes need to be modified to suit the emergency. Pulling the meter is a no brainer, and allows safe electrical supply to Gas Stations. The Gas Stations need to get electricity, and to start pumping gas. If generators are properly operated, then they do their function very safely. The electrical code officials are the best troops on the front lines of getting everyone the gas they need.<br />
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I don't see any gas stations on generators around here, with the one exception being the gas station that is owned by the mayor. That one has a nice generator hooked up, and at least our town can get gas there. But, there is still a giant line of waiting people queued up. I am sure that the mayor had no problem with proper hookup, or with the towns electrical inspector.<br />
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So, it is my opinion that getting the gas stations on generators is a priority. Moreover it is an easy job for an electrician. It will save lives and prevent misery over the next few days.<br />
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Unbelievably, we have a Nor'Easter coming in two days. These storms are "winter hurricanes" centered out over the Atlantic Ocean, which blow strong winds and rain inland. Usually there is a lot of wind damage and power lines down. We only get one every few years. It will only add to the misery, especially to those without power. I hope no more lives are lost.<br />
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I have lent my generator out to a local family without power. I hope it helps them, and it keeps their pipes from freezing.<br />
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What was the most common Gyne problem I saw in the office today? Yeast Infections. True to form, on Halloween and Easter, there were a ton of yeast infections. I carried my bottle of diflucan around in the office. And handed them out. I think the yeasts were worse than usual today. It is possible that the stress of the hurricane is worsening the situation, but it seems to me there is something more. My theory is that all of the veggies were gone from the grocery store and the peoples fridges, so people were compensating with lower quality food, with more carbos. Obviously that would include Halloween candy. But it would also include donuts, chips, and other junk food. Personally, I bought a box of donuts and brought it home, and no one at home complained there were too many donuts. How could I resist? The store had them out at the front. And everyone was stressed. The donuts were great.<br />
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I have a stack of photos of the tree damage done a week ago. There were trees snapped off at the trunk, and uprooted, some onto cars and houses. I have heard of no one in my town getting directly hurt by the hurricane.<br />
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Here are some of my photos. They are all within a two minute drive of my house:<br />
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The above tree snapped off at the main trunk.<br />
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This tree was uprooted and fell over next to a stop sign. The stop sign was turned upside down by the winds. That root ball is 7 feet tall.<br />
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This big healthy tree was snapped off. </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiO0-XMgc6SJ02S0_EtNw_xneQTmtHL9z3nthxh1wfV0wc70_jh4yYHZoomAbeFADsOhb53NOr_hIay0v8qnGNo4lNYoT5Fvr5rOM3vwz0X4pdg9kU6w0kBd1LGreTVJgYLnfLrfUPkn_Vu/s1600/IMG_0700.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiO0-XMgc6SJ02S0_EtNw_xneQTmtHL9z3nthxh1wfV0wc70_jh4yYHZoomAbeFADsOhb53NOr_hIay0v8qnGNo4lNYoT5Fvr5rOM3vwz0X4pdg9kU6w0kBd1LGreTVJgYLnfLrfUPkn_Vu/s320/IMG_0700.JPG" width="320" /></a></div>
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This tree was uprooted and landed on the car in the background. The car has a tarp on it. </div>
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These folks got a car smashed, and their house. </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8MvguEHsj1Nl5iUrxGj5GFmiln0nukdF5H4A0eKhi5hgeTPWCGlBRUy6L5g_VuSKxdnWjvZAl5WlXokEr0elak5Uh1lCdm3ZA_WyWHaAnXD2jS7nUrEEO81tlyCRTg3TJKgpSKQreiO1n/s1600/IMG_0705.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8MvguEHsj1Nl5iUrxGj5GFmiln0nukdF5H4A0eKhi5hgeTPWCGlBRUy6L5g_VuSKxdnWjvZAl5WlXokEr0elak5Uh1lCdm3ZA_WyWHaAnXD2jS7nUrEEO81tlyCRTg3TJKgpSKQreiO1n/s320/IMG_0705.JPG" width="320" /></a></div>
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1, A power line in the foreground 2. A Gen running in the garage! They are lucky to outlive this severe generator error. I informed a fireman around the corner, but he said he could do nothing. This is a lethal error. Never run a combustion engine inside, ever. </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQggBdSgGIwTzxjZyRq1_ChK_Rlvnig8yUyxnW717nO5cCZyG8mPevOvDtDUPyLPKQbpr0JEe_yeQfDzrCGyaxoXJ1Fw210s6XpWIVD4iR2EI-ETV7RAZ6aoIaHgQzQ6MGlfX9Pbe7BOHz/s1600/IMG_0706.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQggBdSgGIwTzxjZyRq1_ChK_Rlvnig8yUyxnW717nO5cCZyG8mPevOvDtDUPyLPKQbpr0JEe_yeQfDzrCGyaxoXJ1Fw210s6XpWIVD4iR2EI-ETV7RAZ6aoIaHgQzQ6MGlfX9Pbe7BOHz/s320/IMG_0706.JPG" width="320" /></a></div>
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This is a nice Honda Accord smashed by a tree. Obviously the driver would have died if it hit with him in it. </div>
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This uprooted tree barely missed the house. </div>
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This area was spared, but look at the power lines. Buried power lines look better and are safer. </div>
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A different view of an undamaged lot. </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTGbRV71MR4GhqLkImZ8ZGRuOOcWxggCQ9UFgDeqxB1wlOSmw4SdJpIakmVLLjzqm63dp0RaGkQ6b3HLDZKSbN8ZtyptRWISdeNZr9qCa2EHjA1ZWf7npb3-TPOqwOdzM3C34G-1uj-q-8/s1600/IMG_0717.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTGbRV71MR4GhqLkImZ8ZGRuOOcWxggCQ9UFgDeqxB1wlOSmw4SdJpIakmVLLjzqm63dp0RaGkQ6b3HLDZKSbN8ZtyptRWISdeNZr9qCa2EHjA1ZWf7npb3-TPOqwOdzM3C34G-1uj-q-8/s320/IMG_0717.JPG" width="320" /></a></div>
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Another undamaged Wyckoff lot? look in the back yard. A tree is down there. </div>
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This nice Mercedes Benz sacrificed itself to save the driveway. Obviously passengers in that car would have been killed. Look at the size of that tree trunk. It is as wide as the Mercedes. Only a part of the tree fell. it was a twin oak, or maybe a triplet oak. </div>
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This is a short 30 minute line just for gas cans, for generators. Notice the police keeping the peace? They all did a really great job. They came around, asking questions, and making sure everyone was ok. The guy behind me in this line had a tree branch come through his roof. The branch penetrated his bed where his legs would have been, had he been sleeping there. Thankfully, he wasn't in bed. But if he was in bed, he was ignoring the towns advice to stay on lower floors. To my knowledge, no one in my town got hurt in an upstairs room of their house. And there were no floods. </div>
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That's it for today, </div>
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Thanks, </div>
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Doctor John Marcus </div>
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Ob/Gyn </div>
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Ridgewood NJ 07450 </div>
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Office number 201-447-0077 </div>
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Blog is at doctorjohnmarcus.blogspot.com </div>
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I corrected a few typos on November 10th. My editor must have been taking a break. </div>
Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com0tag:blogger.com,1999:blog-5044073699235306403.post-69469428531339606322012-11-01T12:57:00.001-04:002012-11-01T15:00:27.275-04:00<b><u>Hurricane Sandy</u></b><br />
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The hurricane passed us last Monday. Today is Thursday. It was a historical storm, doing things that have never been done before. The radar and satellite images of Sandy at the time it hit southern New Jersey stretched from the arctic circle to South Carolina. The eye hit New Jersey, and that means that the storm surge on the right side of the storm, hit northern New Jersey and New York. This is where I live. Right at about 11 PM the remains of the eye of the hurricane passed just to the south and west of where I live and work, near Ridgewood New Jersey. Actually this hurricane briefly had a double wall, and it was the outer wall that hit us. Since then the power has been out, the phones were out, the cells were out, and the phone texts were delayed by hours. I am right now running on a generator at home. That is keeping some of the lights and the heat on. The TV's are working and the internet is back now. The answering service that I use is based at the hospital, and they are swamped. If you need to call me via the service just wait on the line and call back if necessary.<br />
I like to tell my patients that if they cannot get me on the phone, and they may be in labor, or the baby is not moving well, or they have some emergency, then they should just go to the hospital. We always have an Obstetrician physically present in the hospital, 24/7. We call that the Valley On Call Ob Service, or informally, we call it the Doc in Box. We do 12 or 24 hour shifts. It is voluntary for us Ob's to be part of that service. Personally, I am part of that service. I have been since the start. We only allow experienced Obs to do the On Call Ob service. The hospital pays us for this service, but it is not enough to cover the business expenses, especially the malpractice insurance costs, of providing the service. I do it because it is great to stay part of the system, it is really great to save lives, and the money is welcome. Right now there is about 14 of us that share in that service.<br />
I was on duty for Hurricane Irene last year. It was a busy shift. Many of the Obs could not make it in to the hospital, so I covered their needs while they were away. I was on duty when the power went out in the great power outage a few years ago. We made do with various generators, and backups to generators. We kept everyone safe, and the power came back eventually. We definitely deferred some elective procedures, such as labor inductions and C-Sections. Our hospital now has really giant generators, the kind that are built on Semi Truck trailers. They are permanently installed. When the power goes out now, there is just a brief flash of the lights, and everything seems perfectly normal. We still try to defer elective cases while on the generators, though.<br />
Around my town, and in all of northern New Jersey, there are trees down. Some came down on houses. There are about 30 houses smashed by trees in my town. Many cars are smashed. Many of the trees came down on power lines. Many of the trees were uprooted and toppled. A lot of the trees just broke off on the main trunk. During the hurricane we could hear trees cracking all over town. It makes an unbelievable sound. Usually there are about 3 or 4 cracks over a few seconds, and then the tree falls. When the power lines fall, the transformers near the fall are overloaded and explode, creating a huge flash. If the transformer doesn't explode, then the power lines that make it to the ground start sparking an electrical fire. The brightness and the colors of those fires are amazing. At 11 pm there were giant sparks of these fires all over town. It went on for hours like that. It was a like a lightening storm with continuous flashes all over town. The fire department and police just didn't stop working keeping everyone safe. They cordoned off the wires, used heavy equipment and chain saws to keep some of the roads open, and rushed all over the place. They told the entire town with a reverse 911 call to stay out of the upstairs of the houses. Personally, I saw a tree lifted up into the air about twice it's height, spinning around, leaves and dirt flying everywhere, the air so dense with debris I couldn't see through it, and then the tree was ripped apart and the branches dropped about a hundred feet (30 meters) in front of my car. That was a sight I will never forget. It was like slow motion watching it in my mind.<br />
During the storm I sometimes would stand at my front door. The wind was not steady, but gusty. I could hear the wind, but then would come a really loud gust just howling out of the north. It would really roar. Then the trees would start cracking and falling. My town has millions of trees. I think if it wasn't for the trees, the houses would have lost many of their roofs.<br />
Oddly, my town never got a lot of rain. I was watching the rain bands on radar, and the rain just skipped us most of the time. We never got it heavy. This storm was really wide. There were rain bands up to Toronto, and down to South Carolina, and it mostly skipped us. Then, the mountains west of us got several feet of snow, and the ski resorts had their earliest opening ever.<br />
It is now Thursday. There is no power in my office yet. The power is restored within a few blocks of my building, but not up to my building yet. So, I cannot see my patients. Originally, when we cancelled Mondays hours, we scheduled a lot of them for Wednesday. But Wednesday came and went without power, and still barely with phones. So we have been trying to communicate with them via my phone calling service. But that is really problematic. For instance, the phone calling service called all of my Mondays patients to remind them of their appointment, but they also got a message that the hours were cancelled. The reminder was automatic, and we didn't stop the automatic reminders. I can't blame people for being confused. I just hope they aren't too upset. My phone calling service is called SecureReach, and they are based in Ohio. During the emergency, it was difficult to get everything perfectly right.<br />
Most of the people around here are taking these problems in a good mood. I have seen these situations before, when everyone comes together to help each other out, and everyone tries to do all the right things. That especially happened after 9/11. But sometimes trying too hard to be nice backfires.<br />
There are lines for gasoline throughout New Jersey. The lines are hours long. The stations that have power to pump gas run out of that gas in a matter of hours, and the stations that have no electricity have their gas locked up underground. Last night I waited for Gas at a Hess station. One guy was done pumping, but couldn't get out and make room for the next guy, because he was blocked by another car. So we tried to help guide him out so other people could get their gas, but he wouldn't move. People started yelling at him, people who already had their gas. They wanted to help the people behind. Nobody from behind came up to yell; they were being patient. Eventually, the guy blocking him moved and everything got back to normal. So, the only stress there was that everyone was trying to help each other, but one guy didn't want to help enough by moving out of the way. So he got yelled at.<br />
My power company has about 1700 workers on the power line repairs, and some more tree workers to move the fallen trees. Even so, there are millions of trees down and it will take weeks to get it all fixed. Usually, with a natural disaster, neighboring states will send their power line workers to help. After last years freak October blizzard brought down a bunch of trees (because the leaves were still on), the crew that fixed my neighborhood was from North Carolina. They were prowling around in a pack of about 10 large trucks just looking for the problems and fixing them as they went. This time, the damage covers such a wide area, that if the North Carolina workers are not working in North Carolina, they will be in Maryland or Delaware, where they need just as much help. This time, the news reports that crews are coming in from as far as Texas and California. That would mean that the entire country has mobilized to help repair from the storm. I don't think this has happened before, except maybe with Katrina. But the width of destruction this time goes from Canada to Cuba. So the mobilization will have to be very very wide.<br />
Meanwhile, my patients will need to just go to the hospital if they cannot get me on the phone. And there is a good chance they cannot, as the cell service is very weak. And the phone lines are dependent on fickle generators. The phone company has a generator running right now, but who knows how long their gas will last. When they run out, if they do, there will be no internet for me to post a blog.<br />
The food stores are mostly open, but they are completely out of perishables. Most of the perishables were thrown away, because there was no power to keep them cold. And many people, especially the ones without a generator, have lost all of their perishable food.<br />
Me and my family are doing fine. I wish you all well. Send your prayers for the more than two hundred people that have died, from Canada to Cuba. People have died from drowning in floods, from being washed away in rushing water, from live electrical wires, and by being trapped by falling trees.<br />
On a lighter note, there will be a baby boom in 9 months. There certainly was one 9 months after last years freak blizzard. All the local hospitals Ob units were quite busy. So, look for lots of new babies next summer.<br />
Once again, thanks for reading my blog.<br />
<br />
Dr John Marcus<br />
Ridgewood NJ 07450. <br />
Phone 201-447-0077<br />
blog at http://doctorjohnmarcus.blogspot.com<br />
<br />Anonymoushttp://www.blogger.com/profile/13199036997360124154noreply@blogger.com0tag:blogger.com,1999:blog-5044073699235306403.post-2444522801800514622012-10-18T21:07:00.000-04:002012-10-20T14:54:14.376-04:00<h2>
Yeast Infections: </h2>
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I see yeast infections every day in my office. Most women have at least some experience with this problem. Yeast is a huge problem on a global scale. I am going to spend quite a bit of time discussing it here because there are women who really suffer. Until the problem is resolved, it wrecks their life.<br />
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The symptoms could include vaginal or vulvar itching, some kind of discharge, maybe some swelling, sometimes there is burning to various degrees, and sometimes there is discomfort with sex. Sometimes the skin becomes so soft from inflammation that the skin actually cracks open from the minimal stress on it from daily activities, such as sitting or walking. When it gets that inflamed, the burning can become mind bending in severity. Usually, women won't let it get that bad. But sometimes, they have no choice and it becomes severe before they can do anything to fix it. Then, if the skin gets cracked, there can be bacterial infections on top of the yeast infections. Then, we need to get really serious about it and do everything we can, including admit patients to the hospital or even the ICU. I have seen all of this.<br />
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But sometimes, there are no symptoms at all. If a women has no symptoms but she clearly has a small or moderate amount of yeast in the vagina, we may choose to not call it an infection. We would only do this if there was no inflammation and no other problems.<br />
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Sometimes, the infection looks exactly like a jock itch that men get. Jock itch is a yeast infection that men get around their genitals, on their skin. Women can get the very same infection around their own genitals, even if it is not in the vagina, and the treatment may be the same as men. Jock itch is treated with jock itch spray that one can buy at the local pharmacy. If a women has a jock itch, then vaginal treatments will be mostly unhelpful. If a woman tries a vaginal treatment, she will certainly wonder why the itch is not getting better. Technically, a jock itch in a women is not a vaginitis at all, but a vulvitis. Either way, many times they wind up in my office for consultation and advice and treatment options.<br />
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Interestingly, there are yeast infections that people get on other areas of the body. If a yeast germ somehow gets under the skin it will start growing in an expanding ring. The center might clear a bit. This ring is called, believe it or not, a "<b>ringworm"</b>. It is most certainly not a worm. Ringworm is just like a jock itch, but in other areas of the body. In my practice I see ringworm type rings, centered on the vagina, sometimes going around the front all the way past the rectum. This infection is a yeast, not a worm. At this point, the infection could be called a "yeast infection", a "ringworm", or a "jock itch". All of them point to the same process. And the treatment is the same. It will be some oral meds, usually Diflucan, and some topical treatment including antifungals and antinflammatories.<br />
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Yeast organisms live in our environment. They are a natural and important part of our ecosystem. It is not possible to completely eliminate them from our environment. What we can do, though, is help our bodies defend ourselves from an attack by these germs. How do we defend ourselves?<br />
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First of all, stay healthy. A healthy body will have a healthy immune system, and that will help to fight off these germs. Healthy means eating a simple, safe, and balance diet, with minimal unnatural chemicals. In my mind, unnatural chemicals include preservatives, fake sugars, fake fats (like margarine or shortening), or overly processed carbohydrates. Too much sugar is bad for a human. What does it do? High blood sugars only feed the yeasts. Yeasts love the sugar and go nuts. So diabetics, who have naturally high blood sugars, are much more likely to get yeast infections. But you don't have to be a diabetic to get a high blood sugar level if you eat a whole pecan pie, or have a 32 ounce soda. In my practice, we always see an abundance of yeast infections after Halloween and Easter. These two holidays usually include lots of candy in the revelry, and women get yeast infections quite a bit when they eat too much candy.<br />
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Try to lose weight. I know that sounds like empty advice when a person simply cannot lose weight no matter how they try. Believe me, I know. I am not skinny myself. But, I have to say it, because it might work.<br />
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Take your vitamins. In my opinion, a person cannot eat such a perfectly balanced diet that one would get all of the essential nutrients every single day. It is just not technically possible. My personal vitamin D level was very low, despite having evidence of too much sun on my skin. So, now I will have to supplement D for the rest of my life. I try to take my vitamins every day, but remembering it is a challenge. Try to leave the vitamins out, on the counter. They are much easier to remember that way.<br />
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Another important nutrient is Probiotics. These are the healthy bacteria that need to live in a human to assist them in living a normal life. There are thousands of bacteria that a human needs to live. This would include for instance staph epi (epidermidis), and acidophilus, and thousands of other types. Our hospital now has a standing order to give our patients probiotics under certain circumstances. This would include antibiotic treatment. Bacterial antibiotic treatment is completely indiscriminate in its mission. It kills many of the good bacteria, while it is working to kill the bad ones. The end result of antibiotic treatment is, in may cases, not only a severe diarrhea, but an awful yeast infection. This is because the antibiotics have killed off the healthy bacteria that live in a normal vagina. Mainly, the healthy vaginal bacteria is acidophilus. A good acidiphilus will keep a vagina healthy by crowding out the yeasts, attacking the yeasts, creating the acid that keeps the vaginal pH very low, and actually making hydrogen peroxide. This kills all the invading germs. A woman that loses her vaginal acidophilus may be in for quite a lot of vaginal discomforts, until we can get her recolonized or at the very least replace the function of the acidophilus. If acidophilus just won't grow no matter what, then we can replace most of it's function with <b>Boric Acid.</b> Boric Acid has just the right pH for a vagina, and can make a woman comfortable, but it is a long term treatment, and it is not a cure. Most of the "compounding" pharmacies around here are very skillful at making vaginal boric acid suppositories. They do it all the time for my patients. If a women is somewhat technical, she may be able to help herself with this. She has to remember to not take it orally. It will not help.<br />
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I have a microscope in my office and very frequently I will look at the vaginal fluids. It is easy to see acidophilus. They are non motile gently curved rods. If there are none, that is a problem. If the bacteria move, there is a problem. Of course, the yeasts are thick walled clumps, buds, or strands. they are easy to see. Bacteria stuck all over the epithelial cells are called "clue" cells. I don't have a clue why anyone named them that. But if they are there, that is a problem. A women should have at least 80 percent of her epithelial cells clear of "clue" bacteria. Trichomonas are sometimes easy to see. That is a separate problem. They have a "flagella" that whips around really fast, and moves the Trich all over the place.<br />
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I also check vaginal pH. It should be very acidic, around 2-4. Any higher than that, and the abnormal uncomfortable germs can have a field day. We see elevated Ph's all the time. Sometimes, when nothing else works, it is time to get the Boric Acid to get the pH down. <br />
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A vagina should also be free of a certain kind of odor. For the sake of decency, I don't want to get too graphical with my metaphors. But, there are some odors that don't belong.<br />
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A pure yeast infection will mostly be free of bad odors. But, if there is a yeast odor, it may smell like beer, or fresh bread, from the obvious uses that humans have for the yeasts in our world.<br />
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There was an interesting study done about 10 years ago. What the investigators did was set up an exam room very near a pharmacies check out counter. When they saw a women buying a yeast treatment product, they asked the women if she wanted a professional exam. The exam was free, and she was told it was an investigational study. Most of the women agreed to have the exam. About a third of the women did not have a yeast infection at all. Many had a vaginitis, but of a different type such a bacterial, or trichomonas. Some had other very serious problems. There were even a few ectopic pregnancies, or appendicitis. These can be life threatening. There were some ovarian cysts, too. These are common, and only rarely a severe problem.<br />
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The bottom line is, if you are in any way unsure if it is a yeast infection, don't treat it without a professional opinion first. Or, if you do treat it with over the counter meds, and you don't get better in a day or two, you better come in for an exam. If it is the weekend, then strongly consider doing a pregnancy test. Even if you are menstruating right this very minute, it does not mean that you are not pregnant. Many pregnancies, and especially ectopics, have bleeding that is indistinguishable from a normal period. And ectopics are doubly risky if the mentruation is not like a typical period. And pregnancies can occur despite almost any kind of contraception. I like to tell my patients that even abstinence and virginity cannot totally prevent pregnancy. [I deleted a crummy Virgin Mary joke here, on the advice of someone I trust]. But, the reality is, plans for abstinence sometimes go awry. And some women even forget that they have had intercourse. Or, are reluctant to admit it to themselves or their family. So a pregnancy test should be strongly considered if there is any doubt.<br />
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What do I do in my office? I keep a bottle of Fluconazole oral yeast treatment in my office. If it looks like a simple yeast infection I might just give her a single dose out of my office stock. I buy it in bulk and it is much cheaper. I give it away as a free sample. One dose can cure. The drug companies obviously don't give free samples of a drug that works in one dose, but there is no reason that I cannot give it away. If the yeast comes back, I will ask her to try some Monistat over the counter meds. If that is not enough. I will need to rule out other problems, like a lost acidophilus. I think the best monistat is the single day treatment. It has the most ingredients and it will likely work in one dose. There is no reason to use a vaginal cream for days on end. Women dislike the extended courses. It is uncomfortable and messy.<br />
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I also might ask their husbands to use some jock itch spray on their relevant body parts. This can help the woman if it is going back and forth. It might help the man a bit too. At least I don't think it would hurt him.<br />
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In the old days, the Gynecologists would paint the vagina with some "gentian blue". I have never done that. But I understand that it would really stain everything in sight a bright blue. I don't think women would like that.<br />
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This post is just the beginning of the microbiology of the vagina. What would you guys think of a series of photos of vaginal microscopy? Post below if anyone thinks it might be interesting, or if it is unneccessary and too icky.<br />
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More posts are coming. I have a ton of ideas. I have a number of requests for Toxemia, so that will come soon. 1 in 20 pregnant women get Toxemia. I will try to make some sense of it.<br />
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Thanks sincerely.<br />
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Please don't copy this article without my consent.<br />
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But links to here are appreciated. <br />
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Sincerely,<br />
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John Marcus MD FACOG<br />
blog at doctorjohnmarcus.blogspot.com<br />
89 North Maple Ave<br />
Ridgewood NJ, 07450<br />
Phone number 201-447-0077.<br />
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