Dilating the vagina to prevent damage from radiotherapy: systematic review of the literature.

BACKGROUND: UK guidelines recommend routine vaginal dilation during and after pelvic radiotherapy to prevent stenosis. OBJECTIVE: To examine critically the evidence behind this guideline. SEARCH STRATEGY: Cochrane-style systematic review of the data and literature relevant to vaginal dilation and stenosis attributable to radiotherapy. SELECTION CRITERIA: Any and every measure of vaginal or sexual function after radiotherapy. DATA COLLECTION AND ANALYSIS: Numerous papers gave recommendations on dilation during or immediately after radiotherapy, but only seven contained relevant data. Case reports describe vaginal fistulas or psychological morbidity. Two trials showed that encouraging dilation increased compliance, but the first trial found no difference in sexual function scores. One comparative unmatched trial showed no advantage from inserting mitomycin C. A report of five women implied that stenosis can be treated by dilation many years after radiotherapy. One uncontrolled observational report involving 89 women showed that the median vaginal length 6-10 weeks after therapy was measured at 6 cm, but women tolerated a 9-cm measurer after 4 months of dilation experience. One retrospective report implied that dilation lowered stenosis rates, but the control group is not comparable. MAIN RESULTS: Dilation during or immediately after radiotherapy can cause damage, and there is no evidence that it prevents stenosis. Dilation might stretch the vagina if commenced after the inflammatory phase. AUTHOR'S CONCLUSIONS: Dilation might help treat the late effects of radiotherapy, but it must not be assumed that this applies to the acute toxicity phase. Routine dilation during treatment is not supported by good evidence.

Urinary incontinence in elderly women: findings from the Health, Aging, and Body Composition Study.

OBJECTIVE: To estimate the prevalence of and risk factors for stress and urge incontinence in a biracial sample of well-functioning older women. METHODS: We performed a cross-sectional analysis of 1,584 white and black women, aged 70-79 years, enrolled in a longitudinal cohort study. Participants were asked about incontinence, medical problems, and demographic and reproductive characteristics and underwent physical measurements. Using multivariable logistic regression, we compared women reporting at least weekly incontinence with those without incontinence. RESULTS: Overall, 21% reported incontinence at least weekly. Of these, 42% reported predominantly urge incontinence, and 40% reported stress. Nearly twice as many white women as black women reported weekly incontinence (27% versus 14%, P <.001). Factors associated with urge incontinence included white race (odds ratio [OR] 3.1, 95% confidence interval [CI] 2.0-4.8), diabetes treated with insulin (OR 3.5, 95% CI 1.6-7.9), depressive symptoms (OR 2.7, 95% CI 1.4-5.3), current oral estrogen use (OR 1.7, 95% CI 1.1-2.6), arthritis (OR 1.7, 95% CI 1.1-2.6), and decreased physical performance (OR 1.6 per point on 0-4 scale, 95% CI 1.1-2.3). Factors associated with stress incontinence were chronic obstructive pulmonary disease (OR 5.6, 95% CI 1.3-23.2), white race (OR 4.1, 95% CI 2.5-6.7), current oral estrogen use (OR 2.0, 95% CI 1.3-3.1), arthritis (OR 1.6, 95% CI 1.0-2.4), and high body mass index (OR 1.3 per 5 kg/m2, 95% CI 1.1-1.6). CONCLUSION: Urinary incontinence is highly prevalent, even in well-functioning older women, whites in particular. Many risk factors differ for stress and urge incontinence, suggesting differing etiologies and prevention strategies.

New-onset incontinence and markers of frailty: data from the Hispanic Established Populations for Epidemiologic Studies of the Elderly.

BACKGROUND: Urinary incontinence in older adults has many distinct etiologies and is associated with lower self-reported health. However, it is unclear whether the new onset of urinary incontinence marks newly emergent frailty. METHODS: Using a longitudinal population-based survey of older Mexican Americans (N = 2660) across five south-western states, this study compared the strength of association between markers of physical frailty such as activities of daily living (ADLs), instrumental activities of daily living (IADLs), and performance (timed walk, timed chair rise, and tandem balance) with baseline incontinence (prevalent disease) and new-onset incontinence (incident disease). RESULTS: We found that 14.1% of the participants (n = 329) were incontinent at baseline (prevalent cases) and 11.6% (n = 208) were newly incontinent 2 years later (incident cases). Controlling for other covariates, prevalent incontinence was only associated with a 60% increased risk of having difficulty walking 8 ft. Incident incontinence was associated with a twofold increased risk of impairment in ADLs and IADLs, and poor performance on all three physical measures. CONCLUSIONS: Incident incontinence is associated with an increased risk of more global functional impairment. Thus, incident disease may be an important early marker for signaling the onset of frailty among persons who become incontinent after the age of 65 years.

Prevalence, incidence, and risk factors associated with hip fractures in community-dwelling older Mexican Americans: results of the Hispanic EPESE study. Establish Population for the Epidemiologic Study for the Elderly.

OBJECTIVES: To determine the rates and risk factors associated with hip fractures in the community-dwelling older Mexican-American population. DESIGN: A prospective survey of a regional probability sample of older Mexican Americans aged 65 and over. SETTING: The 1993-1996 Hispanic Established Population for the Epidemiologic Study of the Elderly (H-EPESE), a probability sample of noninstitutionalized Mexican Americans, aged 65 and over, living in the Southwestern states of Texas, New Mexico, Colorado, Arizona, and California. PARTICIPANTS: In 1993-1994 and in 1995-1996, 2895 persons, aged 65 and over, considered Mexican American, were selected at baseline as a weighted probability sample. Sample weights were used to extrapolate to the estimated 498,176 older Mexican Americans residing in the Southwest US. MEASUREMENTS: Self-reported hip fracture and functional measures by in home interviews. RESULTS: Hip fracture prevalence was 4.0% at baseline. The overall incidence of hip fractures for women was 9.1 fractures/1000 person-years. The incidence rate for men was 4.8 fractures/1000 person-years. Extrapolation from these data to the entire older Mexican American population indicated that approximately 5162 new fractures occurred in the population during the 2 year study period. In women, hip fractures were associated independently with advanced age, not being married/living alone, having had a stroke, limitations with activities of daily living and instrumental activities of daily living. In men, only the latter limitations were associated independently with hip fracture. CONCLUSIONS: This study indicates that older Mexican American people may have hip fracture incidence rates that place them at highest risk among the Hispanic subgroups. In light of a sparse literature on this population, the fracture estimates derived from this work contributes to our understanding of the true fracture estimates in this population. Based on the extrapolated population rates, hip fracture in this population is a significant public health problem. Adequate preventive measures need to be implemented in this growing US population.

Patterns of prescription drug utilization in elder Mexican Americans: results from the Hispanic EPESE Study. Established Population for the Epidemiologic Study of the Elderly.

The objective of this study was to determine the patterns of prescription medication usage among community-dwelling Mexican-American elders. This was a cross-sectional survey of a regional probability sample of 2,895 community-dwelling Mexican Americans, aged 65 and over. Of the sample, 58.1% used at least one prescribed medication within the two weeks prior to their participation in the study. Women were significantly more likely than men to use analgesics, non-steroidal anti-inflammatory agents, prescription nutritional supplements, and other central nervous system and endocrine medications. Subjects aged 75 and over were more likely to use cardiovascular medications, nutritional supplements, ophthalmic preparations and antihistamines, while those in the age groups 65-69 and 70-74 were more likely to use hypoglycemic and endocrine medications. Interestingly, there was a significantly decreased usage of hypoglycemic medications in the older age group (aged 75 and over) as compared with the younger age groups (65-69 and 69-74). This may indicate that Mexican American elders are dying at younger ages from complications related to diabetes mellitus and are not alive to use hypoglycemic medications at ages 75 and over. Also, men used more hypoglycemic medication than women (77% vs 70%). There was no relationship between use of medication and severity of diabetic illness.

Genetic and environmental influences on body fat distribution, fasting insulin levels and CVD: are the influences shared?

Central body fat distribution has been shown to be related to hyperinsulinemia, insulin resistance, hypertriglyceridemia, and atherosclerosis to a greater degree than general obesity. There are known to be both genetic and environmental effects on all components of this clustering. Whether these genetic effects are due to one set of genes in common to the components or whether genetic influences on insulin resistance and/or general/abdominal fatness 'turn on' other genes that affect other components of the syndrome is not clear. We analyzed data from the Swedish Adoption/Twin Study of Aging (60% female; monozygotic = 116, dizygotic = 202; average age 65 years) to determine whether there were genetic and/or environmental factors shared among general body fat distribution, abdominal body fat distribution, fasting insulin levels and cardiovascular disease. We found additive genetic effects in males to be significantly different from those in females with genetic effects accounting for variance in waist-hip ratio (males = 28%; females = 49%), body mass index (males = 58%; females = 73%), fasting insulin levels (FI) (males = 27%; females = 49%), and cardiovascular disease (CVD) (males = 18%; females = 37%). There were also shared genetic and environmental effects among all the variables except CVD, but a majority of the genetic variance for these measures was trait specific.

Genetic and environmental influences on waist-to-hip ratio and waist circumference in an older Swedish twin population.

OBJECTIVE: To investigate the genetic and environmental influences on waist-to-hip ratio (WHR) and waist circumference (WC) measurements in males and females. DESIGN: Measurements taken from 1989-1991 as part of The Swedish Adoption/Twin Study of Aging (SATSA) were used for analysis. The SATSA sample contains both twins reared together as well as twins reared apart. SUBJECTS: 322 pairs of twins (50 identical, 82 fraternal male pairs and 67 identical, 123 fraternal female pairs); age range: 45-85y (average age, 65y). MEASUREMENTS: Waist-to-hip ratio (WHR), waist circumference (WC) and body mass index (BMI). RESULTS: In males, additive genetic effects were found to account for 28% of the variance in WHR and 46% of the variance in WC. In females, additive genetic effects were found to account for 48% of the variance in WHR and 66% of the variance in WC. The remaining variance in males was attributed to unique environmental effects (WHR, 72%; WC, 54%) and in females the remaining variance was attributed to unique environmental effects (WHR, 46%; WC, 34%) and age (WHR, 6%). When BMI was added into these models it accounted for a portion of the genetic and environmental variance in WHR, and over half of the genetic and environmental variance in WC. CONCLUSION: There are both genetic and environmental influences on WHR and WC, independent of BMI in both males and females, and the differences between the sexes are significantly different.

Psychological and behavioral predictors of body fat distribution: age and gender effects.

OBJECTIVE: Abdominal fat has been shown to be associated with several adverse outcomes including diabetes, cardiovascular disease, and hypertension. Risk factors for abdominal fatness include genetic effects, age, and gender. Most recently, it has been hypothesized that psychological factors, as well as behavioral factors, may play a part in where fat is distributed. The purpose of this study was to assess the longitudinal predictive power of psychological variables (cynicism, anger, anxiety, and depression) measured in 1987 on waist-hip ratio (WHR) measured from 1992 to 1994 among different age and gender groups, as well as to test if alcohol consumption or smoking (measured in 1990) would mediate any of the relationships found. RESEARCH METHODS AND PROCEDURES: Data from the Swedish Adoption/Twin Study of Aging (n = 1392; average age: 58 years for middle-aged group and 74 years for older group; 58% female) were analyzed using a maximum-likelihood regression model where age, gender, and age by gender effects were assessed. RESULTS: Cynicism and anxiety predicted WHR in middle-aged subjects regardless of gender. Cynicism explained 2.5% of the variance in WHR and anxiety explained 1.7% of the variance in WHR. Anger predicted WHR in males regardless of age, explaining 4.0% of the variance; depression predicted WHR only in middle-aged females, explaining 2.0% of the variance. All analyses adjusted for body mass index, and neither alcohol consumption or smoking status mediated the relationships. DISCUSSION: These findings are suggestive with regard to the hypotheses that certain psychological states and behaviors may be associated with increased abdominal fatness.

The effect of six months training on weight, body fatness and serum lipids in apparently healthy elderly Dutch men and women.

OBJECTIVE: To investigate the effect of a six-months training program on changes in body weight and lipid concentrations, and their interrelationship in elderly people. DESIGN: Intervention study. The elderly subjects were randomly assigned to a control group or one of two supervised aerobic training groups, either all round activities or ergometer cycling, both exercising 3-4 times a week for six months. SUBJECTS: 229 elderly men and women, aged 60-80 y. MEASUREMENTS: Various fatness parameters by anthropometry, serum lipids and peak power output. RESULTS: During the intervention, no significant changes were observed in weight or body fatness in subjects of the training groups. Serum high density lipoprotein (HDL), low density lipoprotein (LDL) and total cholesterol and triglycerides tended to change in a favourable direction in the elderly of the intervention groups, but only triglyceride concentration in women of the cycle ergometer group (mean difference with controls: -0.24 mmol/L, 95% confidence interval (CI): -0.45, -0.03) and total serum cholesterol and HDL-cholesterol concentrations in subjects of the all-round activity group, (-0.32mmol/L, 95% CI: -0.63, -0.01 and -0.15mmol/L, 95% CI -0.25, -0.05, respectively) were significantly reduced as compared to controls. Regression analysis showed that the intervention-control difference in change of all lipids was independent of changes in weight, body fat and previous engagement in sport activity. CONCLUSION: Regular physical exercise in an elderly population resulted in favourable changes in serum lipid concentrations that were not significant, but no change in body weight or fatness. Change in lipid concentration could not be attributed to change in weight or body fat.

World War I origins of the syphilis epidemic among 20th century black Americans: a biohistorical analysis.

Syphilis outbreaks and differentials have been an ongoing issue in modern preventive medicine and public health. Since the early 20th Century, a variety of approaches has been employed to explain demographic and temporal variations in the prevalence of syphilis in the U.S. Public health experts and physicians have tended to rely on case-by-case approaches to explain group-specific patterns. This study, however, shows that population-level disease dynamics cannot be ascertained from these individual-level studies. We offer a biohistorical methodology to study syphilis prevalence differentials in U.S. populations. Using historical health data, this study suggests that the social disruption brought on by World War I was the critical and unique environmental condition which ignited an epidemic of syphilis among black Americans. By establishing this beginning point for the epidemic, this study further shows the persistence of the epidemic for the next 40 years and its decline. This biohistorical methodology could be applied to the analysis of STD epidemics in other populations and regions experiencing mass exposure events.

Health indices as predictors of cognition among older African Americans: MacArthur studies of successful aging.

Using cross-sectional and longitudinal data from the MacArthur Successful Aging Study, this paper examines associations between cognition and indices of health in 224 elderly African Americans 70 to 79 years of age at initial interview. The results indicated that greater average peak expiratory flow was predictive of better cognitive performance at the first interview. One longitudinal analysis showed that gender was the only significant predictor of change (change as a continuous variable) with women tending to slightly improve their cognitive performance over time. When change was treated as a dichotomous variable (e.g., a decline of 6 or more points), lower levels of average peak expiratory flow and education were predictive of decline, and positive self-ratings of current health and changes in health in the past year were important factors in the improvement of cognitive performance. The results indicate that, in addition to education, health is an important predictor of the status and course of cognitive functioning in older African Americans.

Population-based, genetically informative sample for studies of physical frailty and aging: black elderly twin study.

In this article 1 describe efforts to build a genetically informative, population-based sample of black twins to study physical frailty and aging in the United States. This project involves the use of governmental registries combined with sampling techniques developed to overcome limitations in the registry data. Two analytical approaches to measures of disability are included to illustrate the types of questions that can be addressed with this sample. These results suggest that physical disability in late life has both genetic and environmental determinants. Only with a genetically informative sample can evidence be collected indicating that frailty may be driven by fixed processes (i.e., disability resulting from activation of senescence genes), fluid processes (i.e., disability resulting from changes in the features of the environment), or a combination of both.

Participation of African Americans in clinical research.

Researchers throughout the United States have developed an increased interest in recruiting minority groups into studies. Such increased interests have been encouraged by the federal agencies that have mandated diversity in study populations. This editorial attempts to explore salient issues pertinent to the recruitment and retention of African Americans and cites culturally specific recruitment strategies that have been successfully applied by investigators. African Americans may have special concerns that may have to be addressed by the investigators prior to initiation of the study. Concerns may include the fear of being treated as a 'guinea pig' and the need for psychosocial programs. Such concerns require culturally sensitive strategies which may include trust-building and the provision of ancillary services. Although specific strategies are required to recruit and retain this special population in clinical studies, there are no guarantees that enrollment will be successful even with the inclusion of culturally sensitive mechanisms.

Identification of a cohort of male and female twins aged 65 years or more in the United States.

In this paper, a method with which to identify a national cohort of elderly twins is proposed. Record linkage algorithms were developed and applied to the > 30 million records contained in the Medicare beneficiary file. The matching algorithm for male/male pairs used race (black or white), last name, date of birth, and state of issuance of the Social Security number. Female/female and male/female pairs were selected with matching on race, date of birth, and the first seven digits of the Social Security number to compensate for the absence of maiden names. A stratified random sample of same-sex and opposite-sex white and black pairs (six groups) were selected and surveyed for determination of the actual prevalence of twins. On the basis of these results, the authors conclude that this method could identify an estimated 18,308 male/male, 7,544 female/female, and 204 male/female pairs of twins aged 65 years or more. This would be the largest sample of older twins ever assembled in the United States and represents a significant new resource for epidemiologic studies of the aging population.

Applying the realized probability of dying to cancer survival.

Age comparisons of survival in cancer cohorts generally utilize relative survival rates, which are based on indicators of the probability of survival for a given number of years after diagnosis. Cancer relative survival rates for the same number of years tend to decline as age at diagnosis increases. However, the same number of years of survival reflects higher relative longevity at older ages than at younger ages. The realized probability of dying (RPD) is a survival measure that expresses individual survival time after diagnosis relative to the survival distribution of an age-, race-, and sex-specific reference population, in effect weighing individual survival time more heavily as age at diagnosis increases. The purpose of this study was to apply the RPD as a survival measure in cancer epidemiology. Two cohorts of cancer patients, white males with prostate cancer and white females with breast cancer, aged 55 years and over at diagnosis, were followed for 15 years. Although older subjects survived less time after diagnosis than younger subjects, they achieved more favorable RPD values. We present survival analysis methods for analyzing the RPD in this population, an approach not previously used with this measure. The implications for use of the RPD in cancer epidemiology are discussed.