March 7th, 2016

Interesting Developments in Understanding Miscarriage

AGAIN, just because I'm posting about something does not mean it has anything to do with me!

Anyway, I get MedPage Today updates, sort of by accident, but I never turned it off because there's some good links in there pretty consistently. Today's link of interest was a long form piece on Mosaic that was absolutely not worth my time. The Medpage Today link promised science, and the first half was first person narrative of agonizing emotional experience. Then the next bit was the same-old-same-old on there isn't much to do about multiple miscarriages except in rare circumstances. And then _finally_ a few short paragraphs on the actual science. An unfulfilling tease!

But it did give me names to google and THIS summary is worth reading.

The basic idea is that we've recently discovered that nearly all fetuses have some kind of genetic "abnormality". So ... maybe it's not the fetus. Brosens and Quenby (those are some awesome names right there!!!) went looking at the lining, and discovered that women who have multiple miscarriages have uterine lining that is very receptive to implantation. Maybe a little _too_ receptive to implantation.

"Put differently, to be successful, the lining of the womb (endometrium) must be ‘receptive’ to implanting embryo but also ‘selective’. In RPL women, the lining of the womb appears excessively receptive (‘super-receptivity’) but insufficiently selective. Hence, many of our patients report that they find it very easy to become pregnant (‘super-fertile’) but then fail to hold onto the pregnancy."

So far, so good -- matches one of the folk theories of miscarriage okay.

"we showed that IL-33/ST2 activation is both prolonged and disordered in endometrial cells from RPL patient. As aforementioned, exposure of mice uteri to these signals prolonged the implantation window in these animals, allowing out-of-phase implantation and resulting in early pregnancy loss."

So they've identified some of the biochemistry of the dance of implantation, and identified at least one major issue with it in women who have repeated miscarriages. AND THEY CAN DO THIS TEST BEFORE YOU EVER GET PREGNANT AT ALL. Which is pretty amazing, right there. " it is possible to develop tests that predict prior to conception the likelihood of pregnancy complications."

The future holds wonderful prospects! They are hoping their work on the womb's side of the pregnancy developmental process might also lead to insights into fetal growth restriction and preeclampsia. That might be a little optimistic, but I'm so happy that smart people are tackling another component of this complicated and super important area of research.

Improving the ER for people on the spectrum

Kaiser Health News article at MedPage Today about changing emergency rooms to better serve people with autism -- children AND adults. Part of this is driven by doctors who have children with diagnoses, part by the fact that people on the spectrum generally have other medical needs at higher rates than the general population, and partly to improve medical care. There's a little better customer service = better business going on, too.

""People on the [autism] spectrum utilize the healthcare system more often. They disproportionately are using our services," said Edward Jauch, director of emergency medicine at the Medical University of South Carolina. From a cost standpoint alone, he said, it makes sense to figure out how to care for them effectively and efficiently."

He would know.

"Jauch's 21 year-old son has autism and frequently required emergency care as a child. So Jauch would often speak to emergency departments about the disorder. He has for years brought his son into work, so his residents can learn how to interact with someone with autism, and "not when they're in a moment of crisis.""

"Of autistic children who use the emergency department, almost one in four are sedated or restrained to keep calm. But if giving a squishy toy achieves the same effect, hospitals can drive down the cost of care, patients don't need to be medicated and they might be more receptive to treatment."

I'm very happy to see this development. My sense is that medical care -- at least in the places where I have lived -- has improved in this sense over the course of my lifetime, because of changes demanded by, well, everyone. More women in healthcare at all levels, more awareness of the kinds of things that drive litigation and changes in medical training have all added up to a lot more compassion today than in decades past (and that's been a long-standing trend -- much longer than I've been alive). But it is nice to know that people on the spectrum aren't going to be completely left out forever.

"Put another way: If she had a child with autism, "I would probably drive a further distance" if it meant going to a hospital with better-suited care, said Cara Harwell, the nurse practitioner at Nemours who launched their program." Given what women routinely do in the course of picking a hospital for their births, and given that women who use a hospital for a birth tend to return to that hospital for any future family needs for hospital treatment, this does actually seem like a no-brainer -- there are few other differentiators between hospitals that are apparent to patients.

Penicillin allergies and skin testing

I don't actually have any idea if I have a penicillin allergy. However, when asked if I have any allergies to medications, I do mention that I have always had horrendous GI effects from taking *cillins, and for whatever reason, it winds up on my chart as an allergy. I just won't take *cillins which are prescribed to me (sort of a moot point these days, because I've reduced the going-to-the-doctor to the point where no one has a chance to prescribe me anything. Huge improvement all around and much cheaper, too) anyway. I do have _lots_ of other allergies, however, including a shellfish allergy (not all shellfish: crab, prawns, lobster, shrimp, etc.) that leads to hives and monster migraines and GI problems; milk products cause GI and respiratory problems and a list of other things that I try to avoid because they seem to trigger respiratory problems and really, why go there?

Anyway. My husband sent me something recently asserting that penicillin allergy was over reported, and I was skeptical, however, here is an interesting development. Someone did a bunch of skin testing!

Initial N = 225. People who had a health record stating they were allergic to penicillin.

"Patients on antihistamines and beta-blockers were excluded from the trial."

This got them down to 206. They skin tested them. 201 did not have reactions to the skin test.

"A cohort deemed likely to benefit from penicillin therapy was prioritized for inpatient testing. In patients who were nonreactive to both tests, a penicillin G test with 500 mg of oral amoxicillin challenge was administered."

The size of this cohort is not stated in this summary (is it the 206? Or something else?). Of this group, one person reacted to saline (!). 10 people had a negative histamine test (what does that mean anyway?) and were removed.

Overall, out of the 206 that survived from the original 225, only 5 had positive reactions to skin testing. Everyone else got the label taken off their chart and could be prescribed *cillins. The idea is NOT just to save money -- some of those other abx have really disturbing side effects (altho not as bad as dying from a penicillin allergy, presumably).

I am, however, a bit flummoxed. On the one hand, I'm sort of tempted to go in for skin testing now. On the other hand, I'd have to completely go off allergy meds to do so. So. Hrm. Maybe during one of those months when I'm super ambitious and am not reacting to anything at all.

ETA: Here is an explanation of the saline and negative histamine test results and what they mean when doing allergy testing. Basically, the people who did this study did the study according to current best practice skin testing practice.

And let me tell you, back in the 1980s, they didn't do it this way, and I suspect that's why I knew a couple people who were allergic to everything (even things they said didn't bother them, but which skin tests showed they were allergic to). Nice to know they're getting this all sorted out!