Cardiovascular Health, Race, and Decline in Cognitive Function in Midlife Women: The Study of Women's Health Across the Nation.

BACKGROUND: Cognitive decline may progress for decades before dementia onset. Better cardiovascular health (CVH) has been related to less cognitive decline, but it is unclear whether this begins early, for all racial subgroups, and all domains of cognitive function. The purpose of this study was to determine the impact of CVH on decline in the 2 domains of cognition that decline first in White and Black women at midlife. METHODS AND RESULTS: Subjects were 363 Black and 402 White women, similar in baseline age (mean±SD, 46.6±3.0 years) and education (15.7±2.0 years), from the Chicago site of the Study of Women's Health Across the Nation. Cognition, measured as processing speed and working memory, was assessed annually or biennially over a maximum of 20 years (mean±SD, 9.8±6.7 years). CVH was measured as Life's Essential 8 (blood pressure, body mass index, glucose, non-high-density lipoprotein cholesterol, smoking, physical activity, diet, sleep). Hierarchical linear mixed models identified predictors of cognitive decline with progressive levels of adjustment. There was a decline in processing speed that was explained by race, age, and the 3-way interaction of race, CVH, and time (F1,4308=8.8, P=0.003). CVH was unrelated to decline in White women but in Black women poorer CVH was associated with greater decline. Working memory did not decline in the total cohort, by race, or by CVH. CONCLUSIONS: In midlife Black women, CVH promotion may be a target for preventing the beginnings of cognitive decline, thereby enhancing independent living with aging.

The independent associations of anti-Müllerian hormone and estradiol levels over the menopause transition with lipids/lipoproteins: The Study of Women's health Across the Nation.

BACKGROUND: The menopause transition (MT) is linked to adverse changes in lipids/lipoproteins. However, the related contributions of anti-Müllerian hormone (AMH) and estradiol (E2) are not clear. OBJECTIVE: To evaluate the independent associations of premenopausal AMH and E2 levels and their changes with lipids/lipoproteins levels [total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), apolipoprotein B (apoB) and apolipoprotein A-1 (apoA-1)] over the MT. METHODS: SWAN participants who transitioned to menopause without exogenous hormone use, hysterectomy, or bilateral oophorectomy with data available on both exposure and outcomes when they were premenopausal until the 1st visit postmenopausal were studied. RESULTS: The study included 1,440 women (baseline-age:mean±SD=47.4±2.6) with data available from up to 9 visits (1997-2013). Lower premenopausal levels and greater declines in AMH were independently associated with greater TC and HDL-C, whereas lower premenopausal levels and greater declines in E2 were independently associated with greater TG and apo B and lower HDL-C. Greater declines in AMH were independently associated with greater apoA-1, and greater declines in E2 were independently associated with greater TC and LDL-C. CONCLUSIONS: AMH and E2 and their changes over the MT relate differently to lipids/lipoproteins profile in women during midlife. Lower premenopausal and/or greater declines in E2 over the MT were associated with an atherogenic lipid/lipoprotein profile. On the other hand, lower premenopausal AMH and/or greater declines in AMH over the MT were linked to higher apo A-1 and HDL-C; the later found previously to be related to a greater atherosclerotic risk after menopause.

Infertility, recurrent pregnancy loss, and risk of stroke: pooled analysis of individual patient data of 618 851 women.

OBJECTIVE: To examine the associations of infertility, recurrent miscarriage, and stillbirth with the risk of first non-fatal and fatal stroke, further stratified by stroke subtypes. DESIGN: Individual participant pooled analysis of eight prospective cohort studies. SETTING: Cohort studies across seven countries (Australia, China, Japan, Netherlands, Sweden, the United Kingdom, and the United States) participating in the InterLACE (International Collaboration for a Life Course Approach to Reproductive Health and Chronic Disease Events) consortium, which was established in June 2012. PARTICIPANTS: 618 851 women aged 32.0-73.0 years at baseline with data on infertility, miscarriage, or stillbirth, at least one outcome event (non-fatal or fatal stroke), and information on covariates were included; 93 119 women were excluded. Of the participants, 275 863 had data on non-fatal and fatal stroke, 54 716 only had data on non-fatal stroke, and 288 272 only had data on fatal stroke. MAIN OUTCOME AND MEASURES: Non-fatal strokes were identified through self-reported questionnaires, linked hospital data, or national patient registers. Fatal strokes were identified through death registry data. RESULTS: The median follow-up for non-fatal stroke and fatal stroke was 13.0 years (interquartile range 12.0-14.0) and 9.4 years (7.6-13.0), respectively. A first non-fatal stroke was experienced by 9265 (2.8%) women and 4003 (0.7%) experienced a fatal stroke. Hazard ratios for non-fatal or fatal stroke were stratified by hypertension and adjusted for race or ethnicity, body mass index, smoking status, education level, and study. Infertility was associated with an increased risk of non-fatal stroke (hazard ratio 1.14, 95% confidence interval 1.08 to 1.20). Recurrent miscarriage (at least three) was associated with higher risk of non-fatal and fatal stroke (1.35, 1.27 to 1.44, and 1.82, 1.58 to 2.10, respectively). Women with stillbirth were at 31% higher risk of non-fatal stroke (1.31, 1.10 to 1.57) and women with recurrent stillbirth were at 26% higher risk of fatal stroke (1.26, 1.15 to 1.39). The increased risk of stroke (non-fatal or fatal) associated with infertility or recurrent stillbirths was mainly driven by a single stroke subtype (non-fatal ischaemic stroke and fatal haemorrhagic stroke), while the increased risk of stroke (non-fatal or fatal) associated with recurrent miscarriages was driven by both subtypes. CONCLUSION: A history of recurrent miscarriages and death or loss of a baby before or during birth could be considered a female specific risk factor for stroke, with differences in risk according to stroke subtypes. These findings could contribute to improved monitoring and stroke prevention for women with such a history.

Psychosocial Well-Being and Progression of Coronary Artery Calcification in Midlife Women.

Background Prevention of cardiovascular disease (CVD) is a public health priority. The combination of physical activity, a healthy diet, and abstaining from tobacco plays an important role in prevention whereas aspects of psychosocial well-being have largely been examined separately with conflicting results. This study evaluated whether the combination of indices of psychosocial well-being was associated with less progression of coronary artery calcium (CAC). Methods and Results Participants were 312 women (mean age 50.8) from the SWAN (Study of Women's Health Across the Nation) ancillary Heart Study, free of clinical CVD at baseline. A composite psychosocial well-being score was created from 6 validated psychosocial questionnaires assessing optimism, vitality, life engagement, life satisfaction, rewarding multiple roles, and positive affect. Subclinical CAC progression was defined as an increase of ≥10 Agatston units over 2.3 years measured using electron beam tomography. Relative risk (RR) regression models examined the effect of well-being on CAC progression, progressively adjusting for sociodemographic factors, depression, healthy lifestyle behaviors, and standard CVD risk factors. At baseline, 42.9% had a CAC score >0, and progression was observed in 17.6%. Well-being was associated with less progression (RR, 0.909; 95% CI, 0.843-0.979; P=0.012), which remained significant with adjustment for potential confounders, depression, and health behaviors. Further adjustment for standard CVD risk factors weakened the association for the total sample (RR, 0.943; 95% CI, 0.871-1.020; P=0.142) but remained significant for the 134 women with baseline CAC>0 (RR, 0.921; 95% CI, 0.852-0.995; P=0.037). Conclusions Optimum early prevention of CVD in women may result from including the mind side of the mind-heart-body continuum.

Adipokines and Subclinical Cardiovascular Disease in Post-Menopausal Women: Study of Women's Health Across the Nation.

Background The menopausal transition is characterized by increased cardiovascular risk, weight gain, and increased adiposity for many women. The adipose-derived secretory proteins adiponectin and leptin are associated with insulin resistance, metabolic syndrome, and cardiovascular disease but their role in subclinical atherosclerotic disease is unclear. This cross-sectional study evaluated the associations of adiponectin and leptin with carotid artery intima-media thickness, adventitial diameter, presence of carotid plaques, and brachial-ankle pulse wave velocity (baPWV) in women aged 54 to 65 years. Methods and Results Participants were 1399 women from SWAN (Study of Women's Health Across the Nation), a community-based study of women transitioning through menopause. Carotid ultrasound and baPWV measures were obtained at SWAN follow-up visits 12 or 13, when 97% of participants were post-menopausal. Adipokines were assayed from serum specimens obtained concurrently at these visits. Linear and logistic regression models were used to evaluate adiponectin or leptin, both log-transformed attributable to skewness, in relationship to carotid artery intima-media thickness, adventitial diameter, baPWV, and presence of carotid plaque. Covariates included age, race, study site, smoking, alcohol use, obesity, cardiovascular disease risk factors, and menopausal status. Lower levels of adiponectin were related to greater carotid artery intima-media thickness, wider adventitial diameter, and faster baPWV; associations were attenuated after adjusting for cardiovascular disease risk factors. Higher levels of leptin were associated with greater carotid artery intima-media thickness and wider adventitial diameter in minimally and fully adjusted models, and contrary to expectation, with slower baPWV, particularly among women with diabetes mellitus or obesity. Conclusions Adiponectin and leptin are 2 important inflammatory pathways that may contribute to adverse subclinical cardiovascular disease risk profiles in women at midlife.

High-density lipoprotein cholesterol and arterial calcification in midlife women: the contribution of estradiol and C-reactive protein.

OBJECTIVE: Studies suggest a reversal in the protective association of high-density lipoprotein cholesterol (HDL-C) and cardiovascular disease in women traversing menopause. Decreasing estrogen levels during the transition, as well as inflammation, may explain this reversal. We tested whether either estradiol or C-reactive protein (CRP) concentrations modified the association of HDL-C with aortic (AC) or coronary artery calcification (CAC). METHODS: A total of 478 participants between ages 46 to 59 from the Study of Women's Health Across the Nation Heart baseline visit were included. AC and CAC presence were defined as Agatston score of 100 or higher and 10 or higher, respectively. Logistic regression was used for analysis. RESULTS: A total of 112 (23.53%) participants had AC 100 or higher and 104 (21.76%) had CAC 10 or higher. In unadjusted models, a 1-mg/dL higher in HDL-C was associated with 3% lower odds of AC (95% CI: 0.95-0.99) and 4% lower odds of CAC (95% CI: 0.95-0.98). In adjusted models, a significant interaction between HDL-C and estradiol with respect to AC but not CAC was detected, such that higher HDL-C level was protective at the highest estradiol quartile (odds ratio: 0.91, 95% CI: 0.84-0.99 per 1 mg/dL higher HDL-C, P = 0.03) but tended to associate with greater risk at the lowest quartile (odds ratio: 1.04, 95% CI: 0.98-1.10 per 1 mg/dL higher HDL-C, P = 0.16). CRP did not modify any association. CONCLUSIONS: The protective cardiovascular association of higher HDL-C levels on AC was modified by estradiol but not CRP concentrations. The pathways through which estradiol might influence this association should be further investigated.

Video Summary:http://links.lww.com/MENO/A689.

Identifying women who share patterns of reproductive hormones, vasomotor symptoms, and sleep maintenance problems across the menopause transition: group-based multi-trajectory modeling in the Study of Women's Health Across the Nation.

OBJECTIVE: To identify groups of women who share levels and patterns of change in follicle-stimulating hormone (FSH), self-reported sleep maintenance problems, and frequent vasomotor symptoms (VMS) up to 10 years before and after their final menstrual period and to evaluate their premenopausal characteristics. METHOD: Group-based multi-trajectory modeling grouped 1,407 women from the Study of Women's Health Across the Nation who had an observed natural menopause and did not use hormone therapy, based on repeated measures of FSH, sleep maintenance problems, and frequent VMS relative to final menstrual period. Multivariable analyses assessed race/ethnicity, body mass index, smoking, and depressive symptoms as predictors of group membership. RESULTS: Women formed five distinct groups: (1) low symptoms (low VMS/sleep problems)/high FSH rise (N = 552; 39.2%); (2) moderate VMS and sleep problems/low FSH rise (N = 169; 12.0%); (3) dominant sleep problems (lower VMS/high sleep problems)/high FSH rise (N = 203; 14.4%); (4) dominant VMS (high VMS/lower sleep problems)/high FSH rise (N = 297; 21.1%)); and (5) high symptoms (high VMS/high sleep problems)/intermediate FSH rise (N = 186; 13.2%)). Multivariate analyses showed that race/ethnicity, premenopausal body mass index and depressive symptoms, and increasing depressive symptoms during the early phase of the transition predicted group membership. CONCLUSIONS: Women can be classified based on shared levels and patterns of FSH, sleep maintenance problems, and frequent VMS across the menopause transition. Either VMS or sleep maintenance problems can be dominant in the face of high FSH. Experiencing one menopause-related symptom or hormone profile does not automatically imply that another is also being experienced.

Contribution of common chronic conditions to midlife physical function decline: The Study of Women's Health Across the Nation.

BACKGROUND: Chronic conditions are associated with worse physical function and commonly develop during midlife. We tested whether the presence of 8 chronic conditions, or the development of these conditions, is associated with declines in physical function among midlife women as they transition into early late life. METHODS: Participants (N = 2283) were from the Study of Women's Health Across the Nation. Physical function was assessed at 8 visits starting at the study's fourth clinic visit in 2000/2001 through follow-up visit 15 (2015/2017) using the Short Form-36 Physical Function subscale. Chronic conditions included diabetes, hypertension, osteoarthritis, osteoporosis, stroke, heart disease, cancer, and depressive symptoms. Repeated-measures Poisson regression modeled associations between 1) prevalent chronic conditions at analytic baseline (visit 4) and longitudinal physical function, and 2) change in physical function associated with developing a new condition. Models were adjusted with the total number of other chronic conditions at visit 4. RESULTS: In separate fully-adjusted longitudinal models, prevalent heart disease and osteoporosis were associated with 18% (IRR = 0.815, 95% confidence interval [CI]: 0.755-0.876) and 12% (IRR = 0.876, 95% CI: 0.825-0.927) worse initial physical function, respectively. Prevalent osteoarthritis was associated with approximately 6% (IRR = 0.936, 95% CI: 0.913-0.958) worse initial physical function, and a slight additional worsening over time (IRR = 0.995, 95% CI: 0.994-0.996). A 12% (IRR = 0.878, 95% CI: 0.813-0.950) decrease in physical function concurrent with stroke development was evident, as was accelerated decline in physical function concurrent with heart disease development (IRR = 0.991, 95% CI: 0.988-0.995). CONCLUSIONS: Initial prevalent conditions related to the musculoskeletal system were associated with worse initial physical function, with some evidence of accelerated decline in physical function with osteoarthritis. Stroke and heart disease are less common than osteoarthritis in this age group, but the severe effects of these conditions on physical function shows the need for a greater focus on cardiovascular health during midlife. Women who develop chronic conditions during midlife may be at particular risk for poor physical function as they age, warranting disability prevention efforts focused on this population.

Trajectory analysis of sleep maintenance problems in midlife women before and after surgical menopause: the Study of Women's Health Across the Nation (SWAN).

OBJECTIVE: Investigate temporal patterns of sleep maintenance problems in women who became surgically menopausal (hysterectomy with bilateral oophorectomy) before their final menstrual period and examine whether presurgery trajectories of sleep maintenance problems are related to problems staying asleep postsurgery. METHODS: Longitudinal analysis of sleep self-reports collected every 1 to 2 years from 1996 to 2013 from 176 surgically menopausal women in the Study of Women's Health Across the Nation, a seven-site community-based, multiethnic/multiracial, cohort study. Median follow-up was 15.3 years (4.2 years presurgery, 10.2 years postsurgery). Group-based trajectory modeling was used to identify patterns of problems staying asleep, and the presurgery trajectories were used to predict similar postsurgery sleep problems. RESULTS: Four trajectory patterns of sleep maintenance problems were identified: low (33.5% of women), moderate (33.0%), increasing during presurgery (19.9%), and high (13.6%). One-fifth of women reported a presurgery increase in these problems. Postsurgically, problems staying asleep remained associated with similar levels of presurgical problems, even after adjusting for postsurgical early morning awakening, frequent vasomotor symptoms, and bodily pain score (ßlow = -1.716, ßmoderate = -1.144, ßincreasing = -0.957, ßhigh = -1.021; all P values <0.01). CONCLUSIONS: Sleep maintenance problems were relatively stable across time postsurgery. These data are remarkably consistent with our trajectory results across the natural menopause, suggesting that presurgical assessment of sleep concerns could help guide women's expectations postsurgically. Although reassuring that sleep complaints do not worsen postsurgically for most surgically menopausal women, referral to a sleep specialist should be considered if sleep symptoms persist or worsen after surgery.

Impact of Chronic Medical Condition Development on Longitudinal Physical Function from Mid- to Early Late-Life: The Study of Women's Health Across the Nation.

BACKGROUND: Chronic medical conditions (CMCs) often emerge and accumulate during the transition from mid- to late-life, and the resulting multimorbidity can greatly impact physical function. We assessed the association of CMC presence and incidence on trajectories of physical function from mid- to early late-life in the Study of Women's Health Across the Nation. METHODS: Physical function was assessed at eight clinic visits (average 14 years follow-up) using the physical function subscale of the Short Form-36. CMCs included osteoarthritis, diabetes, stroke, hypertension, heart disease, cancer, osteoporosis, and depressive symptomatology, and were considered cumulatively. Repeated-measures Poisson models estimated longitudinal change (expressed as percent difference) in physical function by chronic CMCs. Change-points assessed physical function change coincident with the development of a new condition. RESULTS: Women (N = 2,283) followed from age 50.0 ± 2.7 to 64.0 ± 3.7 years; 7.3% had zero CMCs through follow-up, 22.5% (N = 513) had no baseline CMCs but developed ≥1, 22.7% women had ≥1 baseline CMC but never developed another, and 47.6% had ≥1 baseline CMC and developed ≥1 more. Each additional baseline CMC was associated with 4.0% worse baseline physical function and annual decline of 0.20%/year. Women with more baseline CMCs had greater decline in physical function with a new CMC (-1.90% per condition); and annual decline when developing a new condition accelerated by -0.33%/year per condition. CONCLUSIONS: Self-reported physical function changes are evident from mid- to early late-life with the development of CMCs. Preventing or delaying CMCs may delay declines in physical function, and these potential pathways to disability warrant further research.

Greater Periaortic Fat Volume at Midlife Is Associated with Slower Gait Speed Later in Life in Women: The SWAN Cardiovascular Fat Ancillary Study.

BACKGROUND: Higher perivascular adipose tissue (PVAT) contributes to adverse physiologic alterations in the vascular wall, and thus could potentially limit normal physical function later in life. We hypothesize that higher PVAT volume at midlife is prospectively associated with slower gait speed later in life, independent of overall adiposity and other risk factors. METHODS: Participants from the Study of Women's Health Across the Nation (SWAN) cardiovascular fat ancillary study were included. PVAT volume around the descending aorta was quantified using existing computed tomography scans at midlife, while gait speed was measured after an average of 10.4 ± 0.7 years. RESULTS: Two hundred and seventy-six women (aged 51.3 ± 2.8 years at PVAT assessment) were included. Mean gait speed was 0.96 ± 0.21 m/s. Adjusting for study site, race, education level, menopausal status, and length of descending aorta at PVAT assessment, and age, body mass index, difficulty paying for basics, overall health and smoking status at gait speed assessment, a higher midlife PVAT volume was associated with a slower gait speed later in life (p = .03). With further adjustment for presence of any comorbid conditions by the time of gait speed assessment, the association persisted; every 1SD increase in log-PVAT was associated with 3.3% slower gait speed (95% confidence interval: 0.3-6.3%; p = .03). CONCLUSION: Greater PVAT in midlife women may contribute to poorer physical function in older age supporting a potential role of midlife PVAT in multiple domains of healthy aging. Additional research is needed to fully elucidate the physiologic changes associated with PVAT that may underlie the observed associations.

Healthy Lifestyle During the Midlife Is Prospectively Associated With Less Subclinical Carotid Atherosclerosis: The Study of Women's Health Across the Nation.

Background Measures of subclinical atherosclerosis are predictors of future cardiovascular outcomes as well as of physical and cognitive functioning. The menopausal transition is associated with accelerated progression of atherosclerosis in women. The prospective association between a healthy lifestyle during the midlife and subclinical atherosclerosis is unclear. Methods and Results Self-reported data on smoking, diet, and physical activity from 1143 women in the Study of Women's Health Across the Nation were used to construct a 10-year average Healthy Lifestyle Score ( HLS ) during the midlife. Markers of subclinical atherosclerosis were measured 14 years after baseline and included common carotid artery intima-media thickness ( CCA - IMT ), adventitial diameter ( CCA - AD ), and carotid plaque. The associations of average HLS with CCA - IMT and CCA - AD were estimated using linear models; the association of average HLS with carotid plaque was estimated using cumulative logit models. Average HLS was associated with smaller CCA - IMT and CCA - AD in the fully adjusted models ( P=0.0031 and <0.001, respectively). Compared with participants in the lowest HLS level, those in the highest level had 0.024 mm smaller CCA - IMT (95% confidence interval: -0.048, 0.000), which equals 17% of the SD of CCA - IMT , and 0.16 mm smaller CCA - AD (95% confidence interval: -0.27, -0.04), which equals 24% of the SD of CCA - AD . Among the 3 components of the HLS , abstinence from smoking had the strongest association with subclinical atherosclerosis. Conclusions Healthy lifestyle during the menopausal transition is associated with less subclinical atherosclerosis, highlighting the growing recognition that the midlife is a critical window for cardiovascular prevention in women.

Race/ethnic comparisons of waist-to-height ratio for cardiometabolic screening: The study of women's health across the nation.

OBJECTIVE: To compare the performance of waist-to-height ratio as a screening tool for cardiometabolic conditions - hypertension, prediabetes/diabetes, dyslipidemia, and subclinical inflammation - in 5 race/ethnic groups of mid-life women. METHODS: Waist-to-height ratio and 4 cardiometabolic conditions were assessed in 3033 premenopausal midlife women (249 Hispanic, 226 Chinese, 262 Japanese, 1435 European-American, and 861 African American). The areas under the receiver operating characteristic curve (AUROC) were compared across the five race/ethnic groups using waist-to-height ratio to determine the likelihood of the four cardiometabolic conditions. RESULTS: The performance of waist-to-height ratio to detect one or more cardiometabolic conditions was comparable among all race/ethnic groups (AUROC > 0.60, p = 0.252), and was good/fair (AUROC > 0.60) when hypertension, prediabetes/diabetes, dyslipidemia, or subclinical inflammation were analyzed separately. The performance of waist-to-height ratio of 0.50 was skewed towards higher specificity among groups with low prevalence of cardiometabolic conditions and lower median waist-to-height ratio, and towards higher sensitivity among groups with high prevalence of cardiometabolic conditions and higher median waist-to-height ratio. CONCLUSIONS: Waist-to-height ratio can be used for community-based screening of mid-life women who may need secondary prevention for cardiometabolic conditions. A simple public health message: "Keep your waist to less than half of your height" applies to midlife women.

Relation of Persistent Depressive Symptoms to Coronary Artery Calcification in Women Aged 46 to 59 Years.

Depressive disorders have been associated with cardiovascular disease (CVD), but the impact of depression on early atherogenesis has not been well described, particularly in women and minorities. The relation between repeated episodes of high depressive symptoms and coronary calcium (CAC) is unknown in women at midlife when depression is common. Participants in the Study of Women's Health Across the Nation Heart study were assessed annually for depressive symptoms (Center for Epidemiological Studies Depression Scale [CES-D scale]) over 5 years before CAC assessment and classified as high (CES-D ≥16) or not. CAC, measured by computed tomography, was analyzed as a categorical variable using cumulative logit partial proportional odds models. In these middle-aged women free of CVD and diabetes (194 black, 334 white), high depressive symptoms over 5 years were common; 19% had 1, 9% had 2, and 11% experienced ≥3 episodes. CAC was low; 54% had no CAC, 25% had scores from 0 to 10, and 21% had CAC ≥10 Agatston score. After adjusting for CVD risk factors, women with ≥3 episodes were twice as likely to have significant CAC (≥10 Agatston units) than women with no depressive episodes (odds ratio 2.20, 95% confidence interval 1.13 to 4.28, p = 0.020) with no difference by race. Women with 1 or 2 episodes did not differ from women with no episodes. In conclusion, in healthy women aged 46 to 59 years without clinical CVD or diabetes, persistent depressive symptoms were significantly associated with elevated CAC scores, suggesting that they are more likely to have pathophysiological and behavioral effects on the development of subclinical CVD than does a single episode of elevated depressive symptoms.

Primary Anastomosis versus Ostomy after Colon Resection during Debulking of Ovarian Carcinomatosis: A NSQIP Analysis.

Ovarian carcinomatosis poses a dilemma for the surgeon. When resecting colon for tumor invasion, one must decide between diversion and primary anastomosis (PA). We examined the National Surgical Quality Improvement Program to determine whether PA associated with more complications than ostomy. The National Surgical Quality Improvement Program dataset was queried for patients with ovarian carcinomatosis between 2007 and 2012. Current Procedural Terminology codes were used to further identify patients undergoing colectomy with PA or ostomy. Logistic regression was used to evaluate 30-day morbidity and mortality. The 1013 ovarian carcinomatosis patients who underwent elective colon surgery were divided into primary repair (n = 453, 43.5%) or ostomy (n = 586, 56.5%) groups. Preoperative demographics were similar; however, ostomy patients had more severe preoperative laboratory derangements. The 30-day mortality and postoperative transfusion requirements were higher in the ostomy group. On multivariate analysis controlling for confounders, the differences were no longer significant. In conclusion, 30-day mortality and postoperative complications were increased in the ostomy group. Given the laboratory derangements in this group, this may reflect tendency to allocate ostomies to more ill patients. Primary repair in a selected population does not worsen outcomes. Prospective evaluation would help determine the impact of PA in the ovarian carcinomatosis population.

The use of an essay examination in evaluating medical students during the surgical clerkship.

BACKGROUND: Third-year medical students are graded according to subjective performance evaluations and standardized tests written by the National Board of Medical Examiners (NBME). Many "poor" standardized test takers believe the heavily weighted NBME does not evaluate their true fund of knowledge and would prefer a more open-ended forum to display their individualized learning experiences. Our study examined the use of an essay examination as part of the surgical clerkship evaluation. METHODS: We retrospectively examined the final surgical clerkship grades of 781 consecutive medical students enrolled in a large urban academic medical center from 2005 to 2011. We examined final grades with and without the inclusion of the essay examination for all students using a paired t test and then sought any relationship between the essay and NBME using Pearson correlations. RESULTS: Final average with and without the essay examination was 72.2% vs 71.3% (P < .001), with the essay examination increasing average scores by .4, 1.8, and 2.5 for those receiving high pass, pass, and fail, respectively. The essay decreased the average score for those earning an honors by .4. Essay scores were found to overall positively correlate with the NBME (r = .32, P < .001). CONCLUSIONS: The inclusion of an essay examination as part of the third-year surgical core clerkship final did increase the final grade a modest degree, especially for those with lower scores who may identify themselves as "poor" standardized test takers. A more open-ended forum may allow these students an opportunity to overcome this deficiency and reveal their true fund of surgical knowledge.

The utility of mock oral examinations in preparation for the American Board of Surgery certifying examination.

BACKGROUND: Determine the utility of mock oral examinations in preparation for the American Board of Surgery certifying examination (ABS CE). METHODS: Between 2002 and 2012, blinded data were collected on 63 general surgery residents: 4th and 5th-year mock oral examination scores, first-time pass rates on ABS CE, and an online survey. RESULTS: Fifty-seven residents took the 4th-year mock oral examination: 30 (52.6%) passed and 27 (47.4%) failed, with first-time ABS CE pass rates 93.3% and 81.5% (P = .238). Fifty-nine residents took the 5th-year mock oral examination: 28 (47.5%) passed and 31 (52.5%) failed, with first-time ABS CE pass rates 82.1% and 93.5% (P = .240). Thirty-eight responded to the online survey, 77.1% ranked mock oral examinations as very or extremely helpful with ABS CE preparation. CONCLUSIONS: Although mock oral examinations and ABS CE passing rates do not directly correlate, residents perceive the mock oral examinations to be helpful.

A NSQIP Analysis of MELD and Perioperative Outcomes in General Surgery.

It is well known that liver disease has an adverse effect on postoperative outcomes. However, what is still unknown is how to appropriately risk stratify this patient population based on the degree of liver failure. Because data are limited, specifically in general surgery practice, we analyzed the model of end-stage liver disease (MELD) in terms of predicting postoperative complications after one of three general surgery operations: inguinal hernia repair (IHR), umbilical hernia repair (UHR), and colon resection (CRXN). National Surgical Quality Improvement Program data on 17,812 total patients undergoing one of three general surgery operations from 2008 to 2012 were analyzed retrospectively. There were 7402 patients undergoing IHR; 5014 patients undergoing UHR; 5396 patients undergoing CRXN. MELD score was calculated using international normalized ratio, total bilirubin, and creatinine. The primary end point was any postoperative complication. The statistical method used was logistic regression. For IHR, UHR, and CRXN, the overall complication rates were 3.4, 6.4, and 45.9 per cent, respectively. The mean MELD scores were 8.6, 8.5, and 8.5, respectively. For every 1-point increase greater than the mean MELD score, there was a 7.8, 13.8, and 11.6 per cent increase in any postoperative complication. The overall 30-day mortality rate was 0.9 per cent. In conclusion, the MELD score continuum adequately predicts patients' increased risk of postoperative complications after IHR, UHR, and CRXN. Therefore, MELD could be used for preoperative risk stratification and guide clinical decision making for general surgery in the cirrhotic patient.

Cardiovascular Fat, Menopause, and Sex Hormones in Women: The SWAN Cardiovascular Fat Ancillary Study.

CONTEXT: Cardiovascular risk increases in women after menopause. Mounting evidence demonstrates a role of cardiovascular fat (CF) in the pathogenesis of coronary heart disease, but no research has examined CF in relation to sex hormones or menopausal status in women. OBJECTIVE: The objective was to determine the relationship between CF depots, menopausal status, and endogenous sex hormones. DESIGN: Cross-sectional and longitudinal study designs were used. SETTING: The setting included the Study of Women's Health Across the Nation (SWAN) Heart and Cardiovascular Fat Ancillary Study. PARTICIPANTS: A total of 456 women (mean age, 50.75 y); 62% premenopausal/early perimenopausal, and 38% late peri-/postmenopausal. INTERVENTION: Menopausal status, endogenous sex hormones measured simultaneously with CF volumes, and circulating estradiol available 4.80 years (median) before CF measures. MAIN OUTCOME MEASURES: Volumes of CF (epicardial adipose tissue [EAT], paracardial adipose tissue [PAT], total heart adipose tissue [TAT = EAT + PAT], and aortic perivascular adipose tissue [PVAT]). RESULTS: In final models, late peri-/postmenopausal women had 9.88% more EAT, 20.72% more PAT, and 11.69% more TAT volumes than pre-/early perimenopausal women (P < .05). PVAT was not associated with menopausal status. In final models, lower estradiol concentrations were associated with greater volumes of PAT and TAT (P < .05). Women with the greatest reduction in estradiol since baseline had greater volumes of PAT compared to women with the least reduction (P = .02). CONCLUSIONS: Late peri-/postmenopausal women have greater volumes of heart fat compared with pre-/early perimenopausal women independent of age, obesity, and other covariates. Endogenous sex hormones are associated with CF. Perhaps CF plays a role in the higher risk of coronary heart disease reported in women after menopause.