Should Labor be Induced in Extra-Long Pregnancies?

Compared to normal-length pregnancies, pregnancies that go on too long carry a slightly greater risk of fetal death at or near the time of birth. For that reason, physicians sometimes recommend that labor be induced when a pregnancy has gone on longer than normal. But induction of labor may also entail a small risk, especially if there is no sign of impending spontaneous labor. Which is the lesser risk?

To find out, researchers combed all the available data from previous studies of inducing, or not inducing, labor after unusually long gestation (usually 41 weeks). In all, they reviewed 30 studies involving a total of over 12,000 women in 14 countries.

The results? Inducing labor after 41 weeks resulted in fewer infant deaths. It also resulted in fewer caesarean deliveries, though on the other hand it did result in more assisted (operative) vaginal births. All in all, induction of labor after 41 weeks of gestation appeared to be a good choice. However, it was not determined in this study whether there is an optimal time of induction - should it be at 41 weeks, or 42, or even 43?

Based on this analysis, women who experience an extra-long gestation can safely consider induction of labor as an option.

California's Death With Dignity Law is Declared Unconstitutional

In 2015, California became the fourth state to pass legislation designed to allow terminally ill patients to end their own life under certain prescribed conditions (see this blog, Sept 17, 2015). The law, called the End of Life Option Act, has always been somewhat controversial. And last week, opponents of the law won a battle in court when a Superior court judge declared the law unconstitutional, according to an article in the LA Times.

On what grounds is the law unconstitutional, you might ask? It turns out that the judge's decision had nothing to do with the law itself; his decision was based solely on the fact that the law was passed during a special session of the legislature devoted solely to health care issues. The judge declared that the law was not a health care issue, and so it was unconstitutional to pass it during the special legislative session.

Really? Not a health care issue when a terminally ill patient is in excruciating pain? California's Attorney General has already filed an appeal to the judge's ruling with the 4th District Court of Appeal. He's also asked that the law stay in place while the matter is under appeal.

The matter could end up with the Supreme Court. Or, the law might need to be considered all over again in a regular session of the legislature.

Keeping Human Organs Alive Longer Before Transplantation

One of the practical limitations to transplantation of organs from a recently-deceased donor to a recipient is the length of time that human organs remain viable outside a human body. Even if the organ is immediately cooled on ice, it's only a matter of hours before it is no longer considered healthy enough for transplantation. Sometimes it would take too long to transport the organ from where it is harvested to where it is needed, even if pilots and planes were standing by to transport it.

That may be about to change. Several companies (OrganOx and Transmedics) are working to extend the time during which human organs can be kept alive outside the body for up to a full day. This is being accomplished not by cooling the organ, but by keeping it warm and perfused with blood throughout storage and transport so that the organ's metabolic requirements are met and it can continue to function. The techniques require some expensive equipment (much more expensive than just a cooler of ice!), but if lives can be saved the extra cost may just be worth it.

And if we are allowed to dream, if the time of organ storage outside a human body could be extended to weeks or even months, it might be possible to establish human organ banks in some distant future!

Life Expectancy in the U.S. Continues to Decline

Life expectancy in the U.S. has fallen for the second year in a row, according to the CDC. 

Back in 2015 the World Health Organization (WHO) ranked the U.S. 31st out of 183 countries in terms of life expectancy; right between Cuba and Costa Rica.  And then things began to go downhill.  In 2015, life expectancy in the U.S. fell for the first time in a long time (see this blog, Dec. 9, 2016), and now the CDC reports that it has fallen again in 2016, the latest year for which there are complete data.

Although we can argue about whether or not two years in a row is the beginning of a long-term trend, surely this is not a good sign.  Developed and developing countries generally report increases in longevity nearly every year, reflecting better health care, more stringent safety standards, better environmental conditions, fewer wars, and so on.  That's what the U.S. did, at least until two years ago.

Among the top ten causes of death each year, three stand out as largely responsible for increased death rates over the past two years, according to a CNN report: unintentional injuries, Alzheimer's disease, and suicides.  Unintentional injuries include accidental drug overdose deaths, of which there were 63,000 in 2016!  The "war on drugs" isn't working, it seems.

Does a Frozen Embryo Have an Expiration Date?

How long can a frozen embryo be stored before it is implanted into its potential mother? Does a frozen embryo have an effective "use by" date, like most foods?

Recent evidence suggests that frozen embryos could be stored almost indefinitely, it seems. Case in point: a 25-year old woman recently gave birth to a child after receiving an embryo that was conceived and frozen 25 years ago. In other words, the embryo was conceived and frozen in the same year that its birth mother was born!

There are no official databases of when embryos are frozen and subsequently used, and so there's no way of knowing if this is a record of some sort. The couple chose the embryo after reviewing its biological parents' profiles, because they were interested in a child that would look somewhat like themselves. Only later were they made aware of the embryo's age. The embryo came from a faith-based fertility clinic that focuses on saving, not destroying, embryos.

Reproductive scientists are not surprised that embryos remain viable after long-term storage, although there have been no scientific studies carried out to find that out. The available evidence suggests that embryos are at the greatest risk of damage by the thawing procedure, and not by the length of frozen storage.

Baby Sickened Because Mother Eats Placenta

The Centers for Disease Control and Prevention (CDC) reports that a baby in Oregon was treated for Group B streptococcus infections - twice in a week! - apparently because its mother was ingesting improperly prepared placental pills.

Although the CDC does not recommend placenta consumption, it's a fad in some circles that just won't go away. According to CNN News, devotees include Kim Kardashian and Alicia Silverstone. There is even a group called the Association of Placenta Preparation Arts that claims to have "placenta preparation specialists" who know how to prepare the placenta properly for ingestion. As if there actually is a "proper" method for preparing the placenta for ingestion. Members of the group believe that placenta consumption has benefits including preventing postpartum depression and increasing milk production.

Pardon me, but there is no evidence that these people know what they are doing (see this blog July 19, 2007 and June 13, 2015). Feel free to check out their website, compare it to the CDC report and any available scientific evidence, and make up your own mind if you wish.

Advance Directives, and Suing for "Wrongful Life"

When it comes to their last moments, some medical patients would prefer to die gently without having their chest opened, their heart shocked, or their breathing taken over by a pump, especially if their chances of a meaningful recovery are low. To that end, many patients sign advance directives that are intended to provide a clear statement of their wishes. Hospitals often encourage patients to sign an advance directive because it can provide guidance to the medical team when (or if) patients can no longer speak for themselves.

But what happens when the medical team doesn't honor a patient's advance directive? This is not as far-fetched as it might seem. Physicians are trained to save lives, and it's difficult for them to watch a patient die when they know that a procedure might keep the patient alive, if even only for a while. If a patient is kept alive by medical measures specifically not wanted as documented by their advance directive, should damages be awarded for "wrongful life"? It all boils down to whether an advance directive should be viewed as only advisory, or whether it should be considered similar to a legal document.

This is a legal grey zone that is now being tested by several "wrongful-life" lawsuits. Traditionally, courts have been reluctant to punish doctors who aggressively work to save their patients. But recent court decisions suggest that the tide may be turning to favor the patient, according to an article in The New York Times. Time will tell.

Do you have an advance directive? You'll probably be asked that question the next time you visit an emergency room or are admitted to a hospital. The question is; even if you do, will it be honored?

An artificial Womb

A baby that is born at 23 weeks of gestation (about halfway through the normal gestation period) has only about a 50% chance of surviving. The main problem for babies born prematurely ("preemies") is that they struggle to breathe, for their lungs are not yet fully developed. Their underdeveloped hearts, too, have a hard time pumping all of the blood that the baby requires outside of the womb. In the womb, the baby's still-developing lungs are filled with amniotic fluid, and so the baby doesn't breathe at all. Oxygen is delivered to the baby (and CO2 is removed) by the blood circulating between mother and baby via the umbilical cord.

In an effort to increase the chances of survival of very premature preemies, scientists are now working to develop an artificial womb. So far, the artificial womb has only been tried with premature lambs in an experimental setting, but the early results look promising. The artificial womb looks a bit like a large re-sealable bag. Upon delivery, a premature lamb is put into the bag, and the bag is then filled with artificial amniotic fluid and sealed to prevent infections. Ports provide access to the umbilical cord and allow for exchange of amniotic fluid. The umbilical artery and vein are cannulated so that blood can be exchanged with the lamb, just as it would be in the womb. Premature lambs have been kept alive in the artificial womb for four weeks; long enough to dramatically increase their chances of survival outside the womb.

It may be awhile before you'll see artificial wombs for human use. But perhaps some day, you'll have a grandchild that was delivered at 19 weeks of gestation then grown for four weeks or more in a plastic bag!

Supreme Court Nominee Gorsuch Opposes Death With Dignity Laws

Judge Neil Gorsuch, president Trump's nominee to the U.S. Supreme Court, is not a supporter of death with dignity (also called medical aid in dying) laws. In his 2009 book entitled The Future of Assisted Suicide and Euthanasia he defends his position, writing "...all human beings are intrinsically valuable and the intentional taking of human life by private persons is always wrong."

Five states (Oregon, Washington, Vermont, Colorado, and California) currently have death with dignity laws, and several others are considering them. In general these laws allow a person to terminate his/her own life under certain very narrow circumstances, which generally include the presence of a terminal illness, adequate counseling, and the consent of a physician. The Supreme Court has not yet considered a case involving these laws, so for now the states can make their own decisions.

Not every state is likely to pass death with dignity laws; indeed, some state's legislatures or legal counsels actively oppose them. The deputy solicitor general of the state of Wisconsin, for one, is already thinking about strategies for opposing death with dignity laws, should one ever be challenged in the federal courts.

The first challenge to a death with dignity law in the Supreme Court is likely to have a friend in Justice Gorsuch, should he be confirmed by the U.S. Senate. Just sayin'.

Do Women Make Better Physicians Than Men?

A new study published in JAMA Internal Medicine raises the very real possibility that in some undefined way, women may be better physicians than men. The authors of the study examined the records of more than a million and a half Medicare patients 65 and older admitted to a hospital, using 30-day mortality and readmission rates as their measured endpoints. They found that the 30-day death rate for patients treated by women physicians was lower than for patients treated by men physicians (11.07% vs. 11.49%). Patient readmission rates, too, were lower for women physicians. The differences were statistically significant and independent of medical condition or severity of illness.

To control for how patients were assigned to doctors, the authors focused on patients whose admissions were non-elective at hospitals and where the assignment of physician depended only on the physician's work schedule, and not on choice. Finally, to eliminate differences in physician specialty as a factor, the study focused only on physicians who were general internists.

The difference between 11.07% vs. 11.49% deaths would translate to four fewer deaths for every thousand patients treated by women physicians. Given that more than 10 million Medicare patients are admitted to hospitals every year, tens of thousands of lives might be saved if we could learn exactly how women physicians are different. One theory is that women physicians are more likely to stick to evidence-based protocols and medical practice guidelines, but that would need to be tested.

Life expectancy declines in the U.S.

Life expectancy is defined as the number of years a person born in any given year can expect to live, on average.  It's commonly used to as a comparative measure of the health of a population over time, or to compare different populations.

In the past, life expectancy in the U.S. generally rose year-over-year as health care improved and the U.S. became more safety-conscious (the requirement that we use seat belts while driving, for example).  But now the Centers for Disease Control & Prevention (CDC) reports that life expectancy actually declined in 2015. A person born in 2015 can expect to live 78.8 years, on average - down from 78.9 years in 2014.

A decline of only 0.1 years doesn't sound like much, and indeed it isn't.  But life expectancy in the U.S. has risen steadily and consistently for over 45 years, so 2015 represents a noticeable change.  The only other year in those 45 years that life expectancy declined was 1993, at the height of the HIV/AIDS epidemic.

This time around, there doesn't seem to be just one obvious cause.  In 2015, eight of the ten top causes of death (including suicides and accidents, as well as chronic diseases such as heart disease and diabetes) showed an increase in death rates.  If life expectancy continues to decline in future years, health officials will have to dig deeper to try to discern the cause.  For now, a wait-and-see approach seems most appropriate.

An Increase in Suicides Among Young Adolescents

From 2007 to 2014 (the last year for which data are available) the suicide rate among young adolescents aged 10 to 14 doubled, according to the Centers for Disease Control and Prevention (CDC). In 2014 there were 425 deaths from suicide in this age group. And for the first time, the number of deaths by suicide among young adolescents exceeded the number of deaths from auto accidents, which has been declining in recent years.

The trend is disturbing, but for now a cause (or causes) has not been identified. Officials speculate that one factor may be the rise of social networking, which enables bullying to be witnessed not just by a close group of friends or classmates, but the whole school and even the wider community, magnifying the shame and unhappiness of the victim. And with 24-hour access to the social networking, bullying does not necessarily end after school.

It's something to think about. Is there anything we might do to reverse this trend?

New Infant Safe-Sleep Recommendations to Prevent SIDS

Every year in the U.S., approximately 3,500 seemingly healthy infants die suddenly during their sleep.  A few deaths are clearly due to strangulation or suffocation, but most are lumped under the ill-defined heading of sudden infant death syndrome (SIDS).  The actual causes of many of these SIDS deaths are never identified clearly, though it is suspected that certain body positions and the type of bedding may contribute to many of the cases.  The highest risk is to infants between 1 and 4 months of age.

Recognizing that parenting is a new and potentially overwhelming experience for some parents, the American Academy of Pediatrics (AAP) has produced relatively easy-to-understand guidelines for parents that are designed to reduce the risk of SIDS.  Foremost among them; newborns should sleep in a crib or bassinet in the same room as their parents for at least six months, and preferably up to a year.  According to the AAP, room-sharing alone reduces the risk of SIDS by 50%.  The crib (or bassinet) should have a relatively firm, bare sleep surface that is free of toys, pillows, and, if possible, even blankets.  The newborn should be placed on his/her back.  If blankets are necessary for warmth, they should not restrict the baby's breathing or cause overheating.

For some reason, breastfeeding also apparently reduces the risk of SIDS, so it, too, is recommended. And it goes without saying that the infant should not be exposed to smoke, alcohol, or illicit drugs.

Simple, really.  Easy enough for even a new parent to understand, and that's the point. A little prevention goes a long way.

Is There a Natural Limit to Human's Lifespan?

For at least a century, human life expectancy (how long a person can expect to live) has been steadily increasing. Some of the increase in life expectancy has been due to advances in medicine and improvements in health care delivery. An increased awareness of safety has also had an effect. And yet, we can all expect to die sometime. Is there a natural upper limit to the human lifespan?

Better understanding of the process whereby cells age and die has led some scientists to propose that the aging process could someday be slowed, to the extent that humans could live a lot longer than they currently do. That may be possible in the distant future. But a new report in Nature seems to suggest that in the absence of successful intervention with the aging process, the "natural" limit to the human lifespan is about 115 years.

The evidence is intriguing. Using the death records of the International Database on Longevity, the authors plotted the age of the oldest person to die in each year from 1968 to 2006. The age of the oldest person to die in any given year rose from 111 years old in 1969 to about to 115 years old in 1995. But since that time it has risen no further. Only three persons have ever lived longer than 115 years (call them exceptions). So unless those scientists who are working on delaying the aging process achieve a breakthrough soon, you better plan on having your affairs in order by the time you reach 115 years old.

Caster Semenya Wins Gold at the Olympics

It has been a long and sometimes humiliating road for Caster Semenya, who won the women's 800-meter race at the 2016 Olympics. That's because Caster is thought to have an intersex condition characterized by ambiguous genitalia and quite possibly high testosterone levels - in other words, she may be a "tweener" in terms of gender. After she won the women's 800 meters race at the 2009 World Games, Caster was subjected to humiliating gender determination - by a committee, no less. Cleared to compete again in 2010, she won a silver medal in the 800 meters race at the 2012 Olympic Games (see this blog Aug. 16, 2012).

In an effort to establish a policy for female athletes that could be applied before competition, not after, in 2011 the International Association of Athletics Federations (IAAF) developed a policy based on testosterone levels. The first test case was a woman named Dutee Chand who was prevented from competing as a woman in 2014 because she had testosterone levels above the limit for females. Ms. Chand appealed the decision to the Court of Arbitration in Sport (CAS), based in Switzerland. In 2015 the CAS ruled in favor of Ms. Chand and suspended the IAAF's policy for two years. The CAS argued that there was insufficient evidence to conclude that women with high testosterone levels benefit from such a performance advantage that they should be excluded from competing as females. The court gave the IAAF two years to provide more persuasive evidence for its policy, if it could.

And that's where we stand today. Based on the CAS ruling, there was no way that a defensible policy defining femaleness for the purpose of athletic competition could have been developed for the 2016 Olympics, and so Caster Semenya was quietly allowed to compete again. In a brief statement, the International Olympic Committee said only that it encourages the IAAF to go back to the CAS "with arguments and evidence to support the reinstatement of it hyperandrogenism rules."

For the record, Caster Semenya has always identified herself as a woman. She wasn't looking for the controversy she caused in 2009, and she wasn't looking for it in 2016. She just wanted to compete. And that, after all, is the spirit of the Olympics.

Sex Reassignment and Olympic Competition

For the 2016 Olympics, the International Olympics Committee (IOC) established a clear and defensible policy regarding persons who have chosen to undergo sex reassignment, so that they may compete in Olympic sports. The new policy recognizes that gender identity should be a personal choice; that all athletes should have the opportunity to compete in the Olympics; and that Olympics competition should be fair.

With these three guiding principles in mind, the IOC has set forth the guidelines for persons who transition from male to female. A transgender woman who wants to compete in the Olympics must have identified herself as a woman for at least the past four years. After that, she need only prove that her testosterone levels have been below 10 nmol/l for 12 months before her first competition and remain at those levels throughout her period of eligibility. Testing to verify these levels may be required. A testosterone level of 10 nmol/l is below the level found in normal males. (Presumably there would be no athletic advantage for a transgender person who had transitioned from female to male, so such persons may compete as males without restriction.)

Some might argue that having undergone development as a male until after puberty might confer a competitive advantage and thus be unfair to other female athletes. But barring male-to-female transgender athletes from the Olympics altogether would violate both the first and second principles; that gender identity is personal and that there be a way for all athletes to compete. Unless the new rules unleash a flood of male athletes transgendering to female just to compete in the Olympics (and no one expects that), the IOC has done the right thing. Good for them!

The U.S. Death Rate Increased in 2015

The death rate per 100,000 people in the U.S., also called the mortality rate, increased in 2015 for the first time in years, even when adjusted for age. The increase was slight but unusual; in a healthy society, death rates generally decline as a result of better nutrition and health care. So what happened in 2015?

For years, there has been a slow upward trend in the death rate among middle-aged whites, due to increases in drug- and alcohol-related deaths (see this blog, Dec. 13, 2015). Suicides have also been on the rise. In the past, these increases in deaths were more than offset by declines in deaths from specific diseases, such as heart disease and some cancers. But in 2015 the death rate from heart disease stopped declining. As a result, for the first time in a long time the overall death rate in the U.S. increased in 2015.

It would be unusual if this were the start of a new long-term trend in the U.S., for most developed and developing nations are still reporting annual declines in mortality. A long-term trend toward increases in mortality in the U.S. would be a worrying sign of a decline in overall societal health. Perhaps it will focus our attention on the rising death rate due drugs, alcohol, and suicides. Might many of these deaths be preventable?

The Supreme Court Strikes Down a Texas Abortion Law

In a surprise ruling today, the U.S. Supreme Court struck down a Texas abortion access law (see this blog March 2, 2016) that severely restricted access to abortions in that state. The decision was a surprise because the court currently has only eight members, and it was widely believed that the court would be deadlocked on the issue until a ninth justice could be appointed after the presidential election.

Ever since Roe v. Wade, anti-abortionists have introduced legislation in many states designed to restrict access to abortion or make it more difficult. By striking down Texas's law, the court is signaling the states that they cannot restrict access to abortion simply by putting unnecessary obstacles in the way. In the majority opinion, Justice Breyer wrote, "We agree with the District Court that the surgical-center requirement, like the admitting-privileges requirement, provides few, if any, health benefits to women, poses a substantial obstacle to women seeking abortions, and constitutes an "undue burden" on their constitutional right to do so."

This new Supreme Court sets a fairly high bar for anti-abortion legislation; it must not introduce an "undue burden" on what is clearly a constitutional right.

California's End-Of-Life Law Takes Effect

Last Fall the California legislature passed a bill called the End-Of-Life Option Act (see this blog, Sept. 17, 2015). Following the signature of governor Jerry Brown in October, the new law went into full effect on June 9th. The new law gives terminally ill patients the option of terminating their lives at a time and place of their own choosing. The law was inspired by the plight of Brittany Maynard, a terminally ill young Californian who chose to move to Oregon in 2014 to take advantage of a similar law already in effect there.

The new law is not "assisted suicide". Patients who might choose to take advantage of the law will die soon anyway. The new law simply allows them to choose a more gentle way of dying, at a time and place of their choosing. The preferred term is "death with dignity" or "aid in dying".

In order to request a prescription for life-ending medication in California, the patient must be a California resident at least 18 years of age who is mentally capable of making an informed decision and who has been diagnosed by at least two physicians with a disease that will result in their death within six months. In addition, there's a long list of requirements that must be met before a prescription for life-ending medications is approved, as well as certain restrictions on how the drugs can be used (the patient must self-administer the drugs, for example). The experience of the only other states with similar laws (Washington, Oregon, and Vermont) is that only about half of all patients who are issued prescriptions for life-ending medications actually use them.

CDC Recommends No Alcohol Without Birth Control

The U.S. Centers for Disease Control and Prevention (CDC) is now recommending that women of reproductive age (roughly 15-44) who are not on birth control should not drink ANY alcohol, ever. That may be a tough sell. Many women of reproductive age do not have easy access to birth control; in most states it is available only by a doctor's prescription.

The new recommendation is based on the knowledge that no amount of alcohol is safe for the fetus; alcohol can cause several types of permanent damage to the fetus, collectively called fetal alcohol spectrum disorders (FASD). Many pregnancies are unplanned, and the woman may not know she is pregnant for 4-6 weeks. These 4-6 weeks are critical when it comes to the possible damage done by alcohol.

Waiting to stop drinking until you know you are pregnant is just asking for trouble. If you want to drink and don't want to take a chance of damaging your future child, get on birth control until you're ready to give up alcohol for nine months.

For more, review the CDC web page on the subject.