Instantaneous Wave-free Ratio versus Fractional Flow Reserve to Guide PCI.

BACKGROUND: The instantaneous wave-free ratio (iFR) is an index used to assess the severity of coronary-artery stenosis. The index has been tested against fractional flow reserve (FFR) in small trials, and the two measures have been found to have similar diagnostic accuracy. However, studies of clinical outcomes associated with the use of iFR are lacking. We aimed to evaluate whether iFR is noninferior to FFR with respect to the rate of subsequent major adverse cardiac events. METHODS: We conducted a multicenter, randomized, controlled, open-label clinical trial using the Swedish Coronary Angiography and Angioplasty Registry for enrollment. A total of 2037 participants with stable angina or an acute coronary syndrome who had an indication for physiologically guided assessment of coronary-artery stenosis were randomly assigned to undergo revascularization guided by either iFR or FFR. The primary end point was the rate of a composite of death from any cause, nonfatal myocardial infarction, or unplanned revascularization within 12 months after the procedure. RESULTS: A primary end-point event occurred in 68 of 1012 patients (6.7%) in the iFR group and in 61 of 1007 (6.1%) in the FFR group (difference in event rates, 0.7 percentage points; 95% confidence interval [CI], -1.5 to 2.8; P=0.007 for noninferiority; hazard ratio, 1.12; 95% CI, 0.79 to 1.58; P=0.53); the upper limit of the 95% confidence interval for the difference in event rates fell within the prespecified noninferiority margin of 3.2 percentage points. The results were similar among major subgroups. The rates of myocardial infarction, target-lesion revascularization, restenosis, and stent thrombosis did not differ significantly between the two groups. A significantly higher proportion of patients in the FFR group than in the iFR group reported chest discomfort during the procedure. CONCLUSIONS: Among patients with stable angina or an acute coronary syndrome, an iFR-guided revascularization strategy was noninferior to an FFR-guided revascularization strategy with respect to the rate of major adverse cardiac events at 12 months. (Funded by Philips Volcano; iFR SWEDEHEART ClinicalTrials.gov number, NCT02166736 .).

Ten-year Follow-up Study of Grenz Ray Treatment for Lentigo Maligna and Early Lentigo Maligna Melanoma.

Radiotherapy is often used to treat lentigo maligna. However, the long-term efficacy and safety of radiotherapy approaches have not been thoroughly evaluated. We aimed to evaluate the long-term efficacy and safety of ultrasoft X-ray/Grenz ray treatment in those patients. A total of 161 lesions from 159 patients received treatment with Grenz ray between 2005 and 2007. Follow-up of recurrence was performed 10 years after the final treatment. In the study setting, the cure rates were 97% for primary therapy with Grenz ray alone and 100% when Grenz ray was combined with partial or radical excision. The treatment is well tolerated, simple to perform, and has an excellent cosmetic outcome, with 94% of patients pleased with the results. Grenz ray is painless, effective, and safe for use when surgery is not feasible. Thus, Grenz ray can be considered as a standard treatment option for lentigo maligna.

Conventional and synthetic MRI in multiple sclerosis: a comparative study.

OBJECTIVES: To compare the assessment of patients with multiple sclerosis (MS) using synthetic and conventional MRI. MATERIALS AND METHODS: Synthetic and conventional axial images were prospectively acquired for 52 patients with diagnosed MS. Quantitative MRI (qMRI) was used for measuring proton density and relaxation times (T1, T2) and then, based on these parameters, synthetic T1W, T2W and FLAIR images were calculated. Image stacks were reviewed blindly, independently and in random order by two radiologists. The number and location for all lesions were documented and categorised. A combined report of lesion load and presence of contrast-enhancing lesions was compiled for each patient. Agreement was evaluated using kappa statistic. RESULTS: There was no significant difference in lesion detection using synthetic and conventional MRI in any anatomical region or for any of the three image types. Inter- and intra-observer agreements were mainly higher (p < 0.05) using conventional images but there was no significant difference in any specific region or for any image type. There was no significant difference in the outcome of the combined reports. CONCLUSION: Synthetic MR images show potential to be used in the assessment of MS dissemination in space (DIS) despite a slightly lower inter- and intra-observer agreement compared to conventional MRI. KEY POINTS: • Synthetic MR images may potentially be useful in the assessment of MS. • Examination times may be shortened. • Inter- and intra-observer agreement is generally higher using conventional MRI.

Prognostic factors and disease-specific survival among immigrants diagnosed with cutaneous malignant melanoma in Sweden.

Little is known about cutaneous malignant melanoma (CMM) among immigrants in Europe. We aimed to investigate clinical characteristics and disease-specific survival among first- and second-generation immigrants in Sweden. This nationwide population-based study included 27,235 patients from the Swedish Melanoma Register diagnosed with primary invasive CMM, 1990-2007. Data were linked to nationwide, population-based registers followed up through 2013. Logistic regression and Cox regression models were used to determine the association between immigrant status, stage and CMM prognosis, respectively. After adjustments for confounders, first generation immigrants from Southern Europe were associated with significantly more advanced stages of disease compared to Swedish-born patients [Stage II vs. I: Odds ratio (OR) = 2.37, 95% CI = 1.61-3.50. Stage III-IV vs I: OR = 2.40, 95% CI = 1.08-5.37]. The ORs of stage II-IV versus stage I disease were increased among men (OR = 1.9; 95% CI = 1.1-3.3; p = 0.020), and women (OR = 4.8; 95% CI = 2.6-9.1; p < 0.001) in a subgroup of immigrants from former Yugoslavia compared to Swedish-born patients. The CMM-specific survival was significantly decreased among women from former Yugoslavia versus Swedish-born women [hazard ratio (HR)=2.2; 95% CI = 1.1-4.2; p = 0.043]. After additional adjustments including stage, the survival difference was no longer significant. No survival difference between the second generation immigrant group and Swedish-born patients were observed. In conclusion, a worse CMM-specific survival in women from former Yugoslavia was associated with more advanced stages of CMM at diagnosis. Secondary prevention efforts focusing on specific groups may be needed to further improve the CMM prognosis.

Complement Activation Correlates With Disease Severity and Contributes to Cytokine Responses in Plasmodium falciparum Malaria.

The impact of complement activation and its possible relation to cytokine responses during malaria pathology was investigated in plasma samples from patients with confirmed Plasmodium falciparum malaria and in human whole-blood specimens stimulated with malaria-relevant agents ex vivo. Complement was significantly activated in the malaria cohort, compared with healthy controls, and was positively correlated with disease severity and with certain cytokines, in particular interleukin 8 (IL-8)/CXCL8. This was confirmed in ex vivo-stimulated blood specimens, in which complement inhibition significantly reduced IL-8/CXCL8 release. P. falciparum malaria is associated with systemic complement activation and complement-dependent release of inflammatory cytokines, of which IL-8/CXCL8 is particularly prominent.

Interobserver variability of histopathological prognostic parameters in cutaneous malignant melanoma: impact on patient management.

Clinical management of primary cutaneous melanomas is based on histopathological staging of the tumour. The aim of this study was to investigate, in a non-selected population in clinical practice, the agreement rate between general pathologists and pathologists experienced in melanoma in terms of the evaluation of histopathological prognostic parameters in cutaneous malignant melanomas, and to what extent the putative variability affected clinical management. A total of 234 cases of invasive cutaneous malignant melanoma were included in the study from the Stockholm-Gotland Healthcare Region in Sweden. Overall interobserver variability between a general pathologist and an expert review was 68.8-84.8%. Approximately 15.5% of melanomas ≤1 mm were re-classified either as melanoma in situ or melanomas >1 mm after review. In conclusion, review by a pathologist experienced in melanoma resulted in a change in recommendations about surgical excision margins and/or sentinel node biopsy in subgroups of T1 melanomas.

Electrical impedance spectroscopy as a potential adjunct diagnostic tool for cutaneous melanoma.

BACKGROUND: Previous studies have shown statistically significant differences in electrical impedance between various cutaneous lesions. Electrical impedance spectroscopy (EIS) may therefore be able to aid clinicians in differentiating between benign and malignant skin lesions. OBJECTIVES: The aim of the study was to develop a classification algorithm to distinguish between melanoma and benign lesions of the skin with a sensitivity of at least 98% and a specificity approximately 20 per cent higher than the diagnostic accuracy of dermatologists. PATIENTS/METHODS: A total of 1300 lesions were collected in a multicentre, prospective, non-randomized clinical trial from 19 centres around Europe. All lesions were excised and subsequently evaluated independently by a panel of three expert dermatopathologists. From the data two classification algorithms were developed and verified. RESULTS: For the first classification algorithm, approximately 40% of the data were used for calibration and 60% for testing. The observed sensitivity for melanoma was 98.1% (101/103), non-melanoma skin cancer 100% (25/25) and dysplastic nevus with severe atypia 84.2% (32/38). The overall observed specificity was 23.6% (66/280). For the second classification algorithm, approximately 55% of the data were used for calibration. The observed sensitivity for melanoma was 99.4% (161/162), for non-melanoma skin cancer was 98.0% (49/50) and dysplastic nevus with severe atypia was 93.8% (60/64). The overall observed specificity was 24.5% (116/474). CONCLUSION: EIS has the potential to be an adjunct diagnostic tool to help clinicians differentiate between benign and malignant (melanocytic and non-melanocytic) skin lesions. Further studies are needed to confirm the validity of the automatic assessment algorithm.

Non-functioning pituitary microadenoma in children and adolescents: Is follow-up with diagnostic imaging necessary?

PURPOSE: No consensus exists regarding follow-up recommendations for suspected pituitary microadenoma in children. To address this knowledge gap, we investigated the growth potential of pituitary solid and cystic lesions <10 mm in children and evaluated the accuracy of magnetic resonance imaging (MRI) measurements. METHODS: The children included were <18 years at first pituitary MRI and radiologically diagnosed with a non-functioning microadenoma or cyst <10 mm. Lesion size at first and latest MRI as well as all individual MRI examinations were re-evaluated. RESULTS: In total, 74 children, median age 12 years (range 3-17), had a non-functioning microadenoma, probable microadenoma, or cyst. Of these, 55 underwent repeated MRI (median 3, range 2-7) with a median follow-up of 37 months (range 4-189). None of the pituitary lesions without hormonal disturbances increased significantly during follow-up. Two radiologists agreed that no lesion could be identified in 38/269 (14%) MRI examinations, and in 51/231 (22%) they disagreed about lesion location. In 34/460 (7%) MRI measurements size differed >2 mm, which had been considered significant progression. CONCLUSION: Non-functioning pituitary microadenoma in children has small size variations, often below the spatial resolution of the scanners. We suggest lesions <4 mm only for clinical follow-up, lesions 4-6 mm for MRI after 2 years and ≥7 mm MRI after 1 and 3 years, with clinical follow-up in between. If no progression, further MRI should only be performed after new clinical symptoms or hormonal disturbances.

[Conditions for performing CT and MRI scans in pregnant and lactating patients]. / Att tänka på vid neuroradiologisk diagnostik av gravida och ammande.

Many women are pregnant during several percent of their lives. Occasionally, there is a need for neuroradiological examinations during pregnancy or lactation. In our clinical work, we regularly see that female patients are being withheld relevant diagnostic scans during pregnancy, due to insufficient knowledge or an unbalanced comparison between benefits and risks. This article describes the current knowledge regarding conditions for performing CT and MRI scans in pregnant and lactating patients, including the use of contrast media. PET scans and reactions to contrast media are briefly mentioned, but interventional radiology is not discussed.

Female urinary incontinence: patient-reported outcomes 1 year after midurethral sling operations.

INTRODUCTION AND HYPOTHESIS: Although midurethral slings have become standard surgical methods to treat stress urinary incontinence (SUI), little is known about women who still have urinary incontinence (UI) after surgery. This study assesses and compares the patient-reported outcome 12 months after tension-free vaginal tape (TVT), tension-free vaginal tape-obturator (TVT-O), and transobturator tape (TOT), with a special focus on women who still have urinary leakage postoperatively. METHODS: This study analyzed preoperative and 12-month postoperative data from 3,334 women registered in the Swedish National Quality Register for Gynecological Surgery. RESULTS: Among the women operated with TVT (n = 2,059), TVT-O (n = 797), and TOT (n = 478), 67 %, 62 %, and 61 %, respectively, were very satisfied with the result at the 1-year follow-up. There was a significantly higher chance of becoming continent after TVT compared with TOT. In total, 977 women (29 %) still had some form of urinary leakage postoperatively. Among the postoperatively incontinent women who expressed a negative impact of UI on family, social, work, and sexual life preoperatively, considerably fewer reported a negative impact in all domains after surgery. Of those in the postoperatively incontinent group who had coital incontinence preoperatively, 63 % reported a cure of coital incontinence. CONCLUSIONS: The proportion of women very satisfied with the result of the operation did not differ between the three groups. TVT had a higher SUI cure rate than did TOT. Despite urinary leakage 1-year postoperatively, half of the women were satisfied with the result of the operation.

Polymorphisms in the serotonin transporter gene of patients with atopic dermatitis-association with personality traits related to high level of anxiety.

CONTEXT: The symptoms of atopic dermatitis (AD) are often aggravated by anxiety, and the serotonin transporter (5-HTT) has been shown to be of importance in this context. Three polymorphisms affecting transcription of this gene are known: a repetitive element, in the promoter region (5HTTLPR), a variable number tandem repeats (VNTR) within intron 2 referred to as STin2, and a single-nucleotide (A/G) polymorphism (SNP) located within the 5-HTTLPR. OBJECTIVE: To examine for possible relationships between these polymorphisms and aggravation of AD by stress. MATERIALS AND METHODS: Thirty-three patients with a history of such aggravation, together with 33 age- and gendermatched healthy control subjects, were recruited. The Karolinska Scales of Personality questionnaire was employed to evaluate anxiety-related personality traits and genomic DNA was extracted from blood samples and analyzed using the polymerase chain reaction. RESULTS: Although the prevalence of the short and long alleles of 5-HTTLPR did not differ between the patients and healthy controls, there was a tendency towards high prevalence of the short (10-copy) variant of STin2 among the patients. When the study population was further analysed by subdivision into subgroups all AD patients with high- anxiety traits carried the short variant of STin2. In the corresponding healthy control group, the prevalences of the 10-and 12-copy variants were 62% and 38%, respectively (P < 0.01). CONCLUSION: These findings indicate a possible association between the 10-copy variant of STin2 and aggravation of AD by anxiety.

Mohs micrographic surgery revisited: A multidisciplinary, collaborative approach for the treatment of aggressive and recurrent basal cell carcinoma on the head and neck.

Mohs micrographic surgery is the preferred surgical option for high-risk basal cell carcinomas. In our institution, the method is exclusively used for the treatment of aggressive and recurrent facial tumours selected via multidisciplinary team meetings and consistently managed using a multidisciplinary approach. The aim of this retrospective patient-record study was to examine the outcomes for basal cell carcinomas managed with Mohs micrographic surgery and to present our experience from multidisciplinary team meetings and interdisciplinary collaborations. All patients treated between September 2009 and March 2019 at Karolinska University hospital were included. In a total of 143 facial basal cell carcinomas in 138 patients, 86 primary and 57 recurrent, the recurrence rate was 4.9% after a median follow-up of 24 months. In regions, where highly specialised Mohs surgeons performing all the steps of the procedure are limited, interdisciplinary collaboration can be an effective strategy for appropriate patient selection and for performing all steps of Mohs surgery with dermatosurgeons eradicating the tumour, pathologists evaluating the histopathology, followed by reconstructive surgery by plastic surgeons. The approach we present here provides a robust and functioning Mohs surgical service during the build-up of the organisation, while providing the opportunity to train new surgeons. Once the clinic has been set up, the multidisciplinary approach should always be considered and applied when dealing with complex cases.

Impact of female urinary incontinence and urgency on women's and their partners' sexual life.

AIMS: To assess the impact of female urinary incontinence (UI) and urgency on women's and their partners' sexual life in sexually active couples and to elucidate the concordance of answers within couples. METHODS: Women aged 18-74 years with UI and/or urgency (n = 206) were consecutively recruited from four outpatient clinics. Those with a partner (n = 170) completed a questionnaire regarding relationship and sexual life and gave a similar questionnaire to him. The present paper focuses on 99 couples with an active sexual life. RESULTS: Twenty-two percent of the men and 43% of the women stated that the female urinary symptoms impaired their sexual life. Forty-nine percent of the women expressed worries about having urinary leakage during sexual activity, but most of their men, 94%, did not. Twenty-three percent of the men and 39% of the women responded that the woman leaked urine during sexual activity. The majority, 84%, of women considered this a problem, but 65% of their partners did not. Except for this disparity, the rest of the answers were significant concordant within the couples. CONCLUSIONS: Female UI and urgency negatively affected sexual life in almost half of the women and in every fifth partner. A need for information and advice concerning sexual issues due to the woman's urinary disorder was found in one fifth of the couples. The majority of women with urinary leakage during sexual activities considered this as a problem, but most of their partners did not. Overall, the concordance of the answers within the couples was high.

How do urinary incontinence and urgency affect women's sexual life?

OBJECTIVE: To investigate the impact of urinary incontinence and urgency on women's sexual life and the prevalence of urinary leakage during sexual activity. A further aim was to explore factors affecting sexual desire and satisfaction with sexual life. DESIGN: A semi-structured questionnaire study. SETTING AND SAMPLE: Sexually active women (n=147) aged 18-74years with urinary incontinence and urgency were recruited from four outpatient clinics. METHODS: The women completed questionnaires concerning medical history, psychosocial situation, partner relationship and sexual life, and answered the Bristol Female Lower Urinary Tract Symptoms questionnaire. All underwent clinical evaluation. MAIN OUTCOME MEASURES: Prevalence of urinary leakage during sexual activity, factors affecting sexual desire and sexual satisfaction. RESULTS: The vast majority considered sexuality to be important in their lives. One-third of the women had urinary leakage during sexual activity. Half reported that sexual life was more or less spoiled due to their urinary incontinence or urgency and they were worried about having urinary leakage during intercourse, and almost two-thirds worried about odor and felt unattractive. The women's dissatisfaction with sexual life was strongly correlated to unsatisfying psychological health, orgasmic disability and worry about urinary leakage during intercourse. Insufficient vaginal lubrication, unsatisfying psychological health and their partners' ill health were significantly correlated with decreased sexual desire. CONCLUSIONS: Urinary incontinence and urgency have a negative impact on women's sexual life. Thus, a dialogue about sexual function in women with urinary symptoms should become an integral component in clinical management.

Correction: Differences in cutaneous melanoma treatment and patient satisfaction.

[This corrects the article DOI: 10.1371/journal.pone.0205517.].

Injury downregulates the expression of the human cathelicidin protein hCAP18/LL-37 in atopic dermatitis.

Reduced production of antimicrobial peptides was proposed to contribute to susceptibility for skin infections in atopic dermatitis (AD). Focusing on the human cathelicidin protein, hCAP18, the aim of the present study was to explore whether reduced hCAP18 expression is a constitutive trait in AD and if established inducers affect the expression of hCAP18 in the skin of AD. First, we compared levels of hCAP18 mRNA between lesional skin in AD and psoriasis and verified significantly lower expression of hCAP18 mRNA in AD. In non-lesional skin, however, there was no difference between AD, psoriasis and healthy, indicating that there is no constitutive defect in the production of hCAP18 in AD patients. In healthy skin, hCAP18 was reported to be rapidly induced following wounding and here we verified this pattern in healthy controls and in psoriasis. In AD lesions, however, the expression of hCAP18 mRNA was markedly suppressed following wounding. Obviously, the inflammation in AD lesions neutralizes the expected induction of hCAP18 and even induces suppression. Notably, the mechanism to upregulate hCAP18 following vitamin D treatment was functional in lesional as well as in non-lesional AD indicating that the CAMP gene is normally regulated in this respect. In addition, cultured primary keratinocytes from non-lesional skin of psoriasis, AD and healthy skin, upregulated hCAP18mRNA following treatment with vitamin D. Itching is a hallmark of AD and scratching inevitably injures the skin. Failure to upregulate hCAP18 in eczema following injury is likely to affect antimicrobial protection and tissue repair in AD.

Patients with cutaneous head and neck melanoma, particularly elderly with more advanced primary tumors, seem to benefit from initial CT staging before considering a sentinel lymph node biopsy.

Background: The role of CT scanning at the time of diagnosis for patients with primary cutaneous head and neck melanoma (cHNM) clinically asymptomatic for metastatic disease remains unclear.Aim: To determine the positive yield of initial CT scanning before considering sentinel lymph node biopsy (SLNB) staging.Materials and methods: A retrospective review was performed on 170 consecutive patients with cHNM referred to a tertiary head and neck academic center for SLNBs from 2014 through 2018.Results: Initial CTs identified occult melanoma metastases in 7.1% and other advanced malignancies in 4.7%. The overall CT yield for patients >65 years (n = 115) was 13.9%, and 5.5% for patients <65 (only occult melanoma metastases). The SLNB yield did not differ between older (11.5%) and younger patients (10.2%). Patients with more advanced primary tumors were upstaged more often by both staging procedures. Multivariate analysis indicated a true-positive CT finding as the strongest prognostic factor for OS (p<.001).Conclusions and significance: The CT yield was >11% and higher for older than for younger patients. The findings suggest that CT imaging may be considered before SLNB staging, potentially identifying metastatic melanoma disease as well as other occult malignancies, enabling especially older patients to bypass the SLNB procedure.

"Taken by surprise" - Women's experiences of the first eight weeks after a second degree perineal tear at childbirth.

OBJECTIVE: This study explores women's experience of having a second degree perineal tear and related consequences to daily life during the first eight weeks after childbirth. METHOD: Written responses to open-ended questions in a questionnaire distributed about eight weeks postpartum and completed by 1,007 women with second degree perineal tears were excerpted from the national quality register, Perineal Laceration Register. Inductive qualitative content analysis was applied to the data. RESULT: The theme Taken by surprise illustrates women's experience of the first two months after having a second degree perineal tear at childbirth. Women were not prepared for the inconveniences and expressed concerns about their bodies. Further, they expressed distress about their physical and psychological recovery as well as how to return to a pre-childbirth condition. CONCLUSIONS: Although many women recovered fairly well the first months after a second degree perineal tear at childbirth, it was evident that a substantial number of women were unprepared for the pain and discomfort they experienced. It is apparent that also women with the "minor" perineal tears at childbirth need improved postpartum care with tailored analgesia and improved information, but also check-ups and reassurance of recovery from healthcare professionals. Health care professionals need to identify women with persisting problems so that they can be referred to inpatient care for additional assessments of the injury.

Forest-linked livelihoods in a globalized world.

Forests have re-taken centre stage in global conversations about sustainability, climate and biodiversity. Here, we use a horizon scanning approach to identify five large-scale trends that are likely to have substantial medium- and long-term effects on forests and forest livelihoods: forest megadisturbances; changing rural demographics; the rise of the middle-class in low- and middle-income countries; increased availability, access and use of digital technologies; and large-scale infrastructure development. These trends represent human and environmental processes that are exceptionally large in geographical extent and magnitude, and difficult to reverse. They are creating new agricultural and urban frontiers, changing existing rural landscapes and practices, opening spaces for novel conservation priorities and facilitating an unprecedented development of monitoring and evaluation platforms that can be used by local communities, civil society organizations, governments and international donors. Understanding these larger-scale dynamics is key to support not only the critical role of forests in meeting livelihood aspirations locally, but also a range of other sustainability challenges more globally. We argue that a better understanding of these trends and the identification of levers for change requires that the research community not only continue to build on case studies that have dominated research efforts so far, but place a greater emphasis on causality and causal mechanisms, and generate a deeper understanding of how local, national and international geographical scales interact.

The impact of female urinary incontinence and urgency on quality of life and partner relationship.

AIMS: To examine the impact of female urinary incontinence, urgency and frequency on quality of life, and partner relationship in women (18-74 years) and their partners, and make comparisons with the corresponding age groups in a Swedish population-based study. METHODS: Women with urinary incontinence, urgency and frequency (n = 206) completed specific questionnaires concerning medical history and the Bristol Female Lower Urinary Tract Symptoms questionnaire. Women who had a stable relationship (n = 170) also answered a questionnaire regarding psychosocial situation, partner relationship and sexual life, and were asked to give a similar questionnaire to their partner. Totally, 109 partners participated. RESULTS: The vast majority of the women considered that their urinary problems affected their physical activities negatively and almost half reported negative consequences for social life and joint activities. One third of both women and men experienced a negative impact on their relationship and about every fifth felt it had a harmful influence on physical proximity, intimacy, affection, and warmth. Compared to the older women, the younger were less satisfied with their psychological health, sexual life, leisure and financial situation, and compared to the younger men, the young women were less content with their somatic health. Overall, women with urinary problems and their partners were less satisfied with their somatic health than the corresponding age groups in the national population-based study. CONCLUSIONS: Female urinary incontinence, urgency and frequency significantly impair the quality of life in both younger and older women, and also have negative effects on the partner relationship and the partner's life.