Deanna K. Martin

Health Outcomes Associated with Polypharmacy in Community‐Dwelling Older Adults: A Systematic Review

To summarize evidence regarding the health outcomes associated with polypharmacy, defined as number of prescribed medications, in older community‐dwelling persons.

The association between urinary and fecal incontinence and social isolation in older women

OBJECTIVE To describe the association between social isolation and urinary incontinence and fecal incontinence in older women. METHODS We conducted a secondary database analysis of the National Social Life, Health and Aging Project for women aged 57 to 85 years old. Our primary outcome was self-report of often feeling isolated. We explored self-report of daily urinary incontinence and weekly fecal incontinence. Two logistic regression analyses were performed to assess the association between often feeling isolated and (1) daily urinary incontinence and (2) weekly fecal incontinence. RESULTS A total of 1412 women were included in our analysis. Daily urinary incontinence was reported by 12.5% (177/1412) of community-dwelling older women. More women with daily urinary incontinence reported often feeling isolated (6.6%; 95% confidence interval [CI], 1.3-11.9 vs 2.6%; 95% CI, 1.7-3.5; P = .04) compared with women without daily urinary incontinence. Women with daily urinary incontinence had 3.0 (95% CI, 1.1-7.6) increased odds of often feeling isolated after adjusting for depressive symptoms, age, race, education, and overall health. Weekly fecal incontinence was reported by 2.9% (41/1412) of women. Weekly fecal incontinence and often feeling isolated were associated on univariable analysis (crude odds ratio, 4.6; 95% CI, 1.4-15.1). However, after adjusting for depressive symptoms, age, race, education, and overall health the association between weekly fecal incontinence and often feeling isolated was not significant (adjusted odds ratio, 0.65; 95% CI, 0.1-5.3; P = .65). CONCLUSION After adjusting for confounders, daily urinary incontinence was significantly associated with often feeling isolated. Weekly fecal incontinence was not found to be associated with often feeling isolated on multivariable logistic regression.

Surgical site infection after hysterectomy.

OBJECTIVE Our objective was to estimate the occurrence of surgical site infections (SSI) after hysterectomy and the associated risk factors. STUDY DESIGN We conducted a cross-sectional analysis of the 2005-2009 American College of Surgeons National Surgical Quality Improvement Program participant use data files to analyze hysterectomies. Different routes of hysterectomy were compared. The primary outcome was to identify the occurrence of 30-day superficial SSI (cellulitis) after hysterectomy. Secondary outcomes were the occurrence of deep and organ-space SSI after hysterectomy. Logistic regression models were conducted to further explore the associations of risks factors with SSI after hysterectomy. RESULTS A total of 13,822 women were included in our final analysis. The occurrence of postoperative cellulitis after hysterectomy was 1.6% (n = 221 women). Risk factors that were associated with cellulitis were route of hysterectomy with an adjusted odds ratio (AOR) of 3.74 (95% confidence interval [CI], 2.26-6.22) for laparotomy compared with the vaginal approach, operative time >75th percentile (AOR, 1.84; 95% CI, 1.40-2.44), American Society of Anesthesia class ≥ 3 (AOR, 1.79; 95% CI, 1.31-2.43), body mass index ≥40 kg/m(2) (AOR, 2.65; 95% CI, 1.85-3.80), and diabetes mellitus (AOR, 1.54; 95% CI, 1.06-2.24) The occurrence of deep and organ-space SSI was 1.1% (n = 154 women) after hysterectomy. CONCLUSION Our finding of the decreased occurrence of superficial SSI after the vaginal approach for hysterectomy reaffirms the role for vaginal hysterectomy as the route of choice for hysterectomy.

Oophorectomy: the debate between ovarian conservation and elective oophorectomy

AbstractOvarian cancer remains the fifth deadliest cancer among women because of its early asymptomatic nature and lack of efficacious screening methods, leading to frequent late-stage diagnosis. Elective oophorectomy is an option for women undergoing benign hysterectomy as a means of reducing their ovarian cancer risk. Benefits also include reduced risk of repeat surgical operation due to adnexal masses and reduced anxiety related to perceived risk of ovarian and breast cancer. The potential negative side effects of elective oophorectomy, such as decreased cognition and sexual function and increased risk of osteoporosis and cardiac mortality, offer support for ovarian conservation. The implications of this elective procedure and the possible consequences without it require physicians to review the pros and cons with patients in light of the patient’s individual circumstances and ovarian cancer risk.

The Vulvovaginal Symptoms Questionnaire: a questionnaire for measuring vulvovaginal symptoms in postmenopausal women.

Objective This study aims to develop a Vulvovaginal Symptoms Questionnaire (VSQ) to determine the symptoms, emotions, life impact, and sexual impact of vulvovaginal symptoms on postmenopausal women. Methods We developed a questionnaire that focuses on vulvovaginal symptoms based on modifications to Skindex-16, a validated questionnaire for measuring the impact of skin disease. We recruited postmenopausal women seeking routine gynecologic care to test the psychometric properties of the VSQ. Test-retest reliability was assessed 2 to 4 weeks after their initial recruitment and measured using intraclass coefficients. Four distinct a priori scales of the VSQ were developed: symptoms, emotions, life impact, and sexual impact. Confirmatory factor analysis was performed to verify the four a priori scales by evaluating the goodness of fit of a final confirmatory factor analysis model. The internal consistency of the scales was assessed by calculating Cronbach’s &agr; coefficients. Results The VSQ is a 21-item written questionnaire with four scales: symptoms, emotions, life impact, and sexual impact. One hundred twenty postmenopausal women participated in the psychometric validation of the VSQ. The test-retest reliability measured by intraclass coefficients was 0.75, 0.60, 0.55, and 0.65 for the symptoms, emotions, life impact, and sexual impact scales, respectively. The goodness of fit of the confirmatory factor response model was confirmed. The Cronbach’s &agr; coefficients were 0.76, 0.87, 0.83, and 0.82 for the respective scales. Conclusions The VSQ is a reliable and internally consistent instrument for measuring vulvovaginal symptoms in postmenopausal women.

The effects of comorbidity on the benefits and harms of treatment for chronic disease: a systematic review.

Background There are concerns about the potential for unintentional harms when clinical practice guidelines are applied to patients with multimorbidity. The objective was to summarize the evidence regarding the effect(s) of comorbidity on the outcomes of medication for an index chronic condition. Methods A systematic review was conducted of studies published in MEDLINE and Cochrane Trials before May 2012. The search strategy was constructed to identify articles indexed with “comorbidity” or a related term or by a given condition and one or more additional specified comorbid conditions. The search yielded 3252 articles, of which 37 passed the title/abstract screening process, and 22 were included after full-text review. An additional 23 articles were identified by screening the reference lists for included articles. Information was extracted on study design; population; therapy; comparison groups; outcome(s); main findings. Findings Indexing of articles was inconsistent, with no term for “multimorbidity,” and rare use of “comorbidity”. Only one article examined the effects of comorbidity per se, finding no benefit of tight control of DM among persons with high comorbidity, defined using a comorbidity index. The remainder examined pairs of conditions, the majority of which were post-hoc analyses of randomized controlled trials and which found no difference in outcomes according to whether a comorbid condition was present. Several demonstrated no difference or an increased risk of adverse outcome among persons with DM and tight control of HTN as compared to usual control. Several demonstrated lack of benefit of statins among persons with end-stage renal disease. Conclusions There is limited evidence regarding the effects of multiple comorbidities on treatment outcomes. The majority of studies demonstrated no effect of a single comorbid condition on outcomes. Additional studies examining a broad range of comorbidity are required, along with clear and consistent indexing to allow for improved synthesis of the evidence.

Vulvovaginal symptoms prevalence in postmenopausal women and relationship to other menopausal symptoms and pelvic floor disorders.

Objective:The primary objective of this study was to use the Vulvovaginal Symptom Questionnaire (VSQ) to estimate the prevalence and examine the emotional, lifestyle, and sexual impact of vulvovaginal symptoms in postmenopausal women. Methods:We administered the VSQ, a previous validated instrument to 358 postmenopausal women recruited from primary care physician offices and local senior centers. The first seven questions of the VSQ comprise the symptom subscale (itching, burning, hurting, irritation, dryness, discharge, and odor). Women who answered “Yes” to any of the first seven symptom questions were considered to have vulvovaginal symptoms. Results:Two hundred seventy-nine women were recruited from primary care offices and 79 women were recruited from senior centers. One hundred eighty-three postmenopausal women (51.1%; 95% CI 45.9%, 56.3%) reported at least one vulvovaginal symptom. The most common symptom was being dry 35.8% (n/N = 128/358). Ten percent of women (n/N = 38/358) reported five or more symptoms and 6% of women reported all seven symptoms in the last week. For women reporting one or more vulvovaginal symptoms, 40.4% (n/N = 74/183) reported emotional impact (Yes to ≥1 out of 4 emotional impact subscale items) and 32.8% (n/N = 60/183) reported lifestyle impact (Yes to ≥1 out of 5 lifestyle impact subscale items) from these symptoms. For sexually active women reporting vulvovaginal symptoms, 75.3% (n/N = 67/89) reported sexual impact (Yes to ≥1 out of 4 sexual impact subscale items). Vulvovaginal symptoms were associated with increased co-occurrence of specific pelvic floor disorders, including pelvic organ prolapse (P = 0.001), anal incontinence to solid stool (P = 0.001), urinary frequency (P = 0.02), urgency urinary incontinence (P = 0.001), and dysuria (P < 0.001). Conclusions:Vulvovaginal symptoms are common and present in over 50% of postmenopausal women. Sizeable proportions of women with vulvovaginal symptoms report emotional, lifestyle, and sexual impact from these symptoms.

Sexual function in older women after oophorectomy

OBJECTIVE: To compare the sexual function of older women who had bilateral oophorectomy with that of older women who had retained their ovaries. METHODS: This cross-sectional study involved analysis of 1,352 women aged 57 to 85 years from the National Social Life, Health, and Aging Project. Women with previous bilateral oophorectomy were compared with women who retained their ovaries. The primary outcome of interest was self-report of sexual ideation, chosen because having thoughts about sexual experiences is not prohibited by either a partner or a womans own physical limitations. RESULTS: Three hundred fifty-six (25.8%) women reported previous bilateral oophorectomy. Our analysis achieved 90% power to detect a difference of 10% in sexual ideation. No significant difference in the report of sexual ideation was found between women with previous bilateral oophorectomy and women who retained their ovaries (54.5% and 95% confidence interval [CI] 48.1–61.0 compared with 49.9% and 95% CI 45.3–54.5, P=.230), even after adjusting for current hormone therapy, age, education, and race (adjusted odds ratio 1.32, 95% CI 0.96–1.80). CONCLUSION: Bilateral oophorectomy may not play a pivotal role in sexual ideation and function among older women. LEVEL OF EVIDENCE: II

Over-the-counter treatments and perineal hygiene in postmenopausal women.

ObjectiveThe objective of this descriptive study was to quantify the personal hygiene habits/practices of, as well as the over-the-counter (OTC) products used by, postmenopausal women. Specifically, we were interested in any product that would contact the vulva or vagina. MethodsWe performed a cross-sectional study of postmenopausal women seeking routine gynecologic care. We developed a questionnaire on their personal hygiene habits/practices and the OTC products that they use that would contact the vulva or vagina. We recruited postmenopausal women seeking gynecologic care from two separate gynecology practices. Descriptive statistics were performed as appropriate to characterize the frequency of reported treatments and practices. ResultsThe questionnaire on OTC treatments and perineal hygiene was completed by 114 postmenopausal women. Fifty-eight women (50.9%) reported using at least one OTC vulvovaginal treatment in the last 3 months, including barrier treatments, topical anesthetics, powders, and antifungals. Women often used more than one OTC product. Thirty-seven women (32.5%) reported the use of two or more OTC products. Powders were used by 34 women (29.8%). Talcum powder was the most commonly used powder (26 of 34; 76.5%). Nine postmenopausal women (7.9%) reported douching in the last 3 months. ConclusionsWe found that more than half of postmenopausal women seeking gynecologic care have used an OTC product for vulvovaginal symptoms in the last 3 months and that one third of women use two or more products. Because the use of OTC products is very common, our study highlights the need for a detailed history inquiry about OTC product use and perineal hygiene practices.

Major postoperative complications after benign gynecologic surgery: a clinical prediction tool.

Objective The objective of this study was to create a clinical prediction tool to differentiate women at risk for postoperative complications after benign gynecologic surgery. Methods We utilized the 2005 to 2009 American College of Surgeons National Surgical Quality Improvement Program participant use data files to perform a secondary data-set analysis of women older than 16 years who underwent benign gynecologic procedures. We then temporally divided women into 2 similar cohorts. Our derivation cohort included all women undergoing benign gynecologic procedures in 2005 to 2008. Our validation cohort included all women undergoing benign gynecologic procedures in 2009. The primary outcome, composite 30-day major postoperative complications, was analyzed as a dichotomous variable. A prediction tool was then constructed to predict the occurrence of postoperative complications built from the logistic regression model by rounding the value of each estimated &bgr; coefficient to the nearest integer. An individual’s risk score was then computed by summing the number of points based on her preoperative characteristics. This risk score was then used to categorize women into low-, medium-, and high-risk groups. Results A prediction tool for benign gynecologic procedures identified women at low (2.7% and 2.4%), medium (6.3% and 6.8%), and high (29.5% and 23.8%) risk of complications in the derivation and validation cohorts, respectively. Conclusions A prediction tool can differentiate women at risk for postoperative complications after benign gynecologic surgery.