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Menopause occurs at a critical juncture in life when preventative health care can have a major impact. However, recommendations for immunizations are often neglected, leading to unnecessary morbidity and mortality in aging women. The aim of this review is to highlight the importance of immunization checkpoints at menopause to optimize the quality of care and health maintenance in older women and to provide an overview of the impact of immunizations on women's health.This is an opinion article based on the current US and Canadian guidelines. A review of various guidelines from the Centers for Disease Control and Prevention and National Advisory Committee on Immunizations were conducted for each vaccine.Disease prevention benefits are well established for several diseases, such as hepatitis A, hepatitis B, tetanus, human papillomavirus, streptococcus pneumonia, shingles, and COVID-19. During clinical encounters, a needs assessment regarding vaccinations should be conducted. However, barriers to adult vaccination including lack of patient and provider knowledge about the need for vaccination, lack of priority for preventive services, and concerns regarding costs, insurance coverage, and reimbursement all contribute to the adult immunization gap. Given the importance of immunization and the need to decrease vaccine-preventable diseases, it is the obligation of healthcare practitioners to recommend vaccines and provide education on vaccination guidelines and associated risks. As women often seek medical attention at menopause because of changes in their physiology that require attention, it is the ideal time to discuss the importance of immunization.

National standards for immunizations are set by the Advisory Committee on Immunization Practices in the United States and the National Advisory Committee on Immunizations in Canada. In Mexico, the National Immunization Technical Advisory Group sets standards for infants and adolescents but not for adults. In this Practice Pearl, guidelines for some adult immunizations in women and the recent and potential upcoming changes in vaccines are reviewed.

OBJECTIVE: To describe the burden of pneumococcal disease and associated risk factors in the Canadian adult population, delineate available pneumococcal vaccines and associated efficacy and effectiveness data, and review current pneumococcal vaccine recommendations and community-acquired pneumonia (CAP) prevention strategies in Canada. QUALITY OF EVIDENCE: Pneumococcal vaccination guidelines from the Canadian National Advisory Committee on Immunization in 2013 and 2016 constitute level III evidence for CAP prevention in the Canadian adult population. MAIN MESSAGE: It is recommended that immunosuppressed adults of all ages receive the 13-valent pneumococcal conjugate vaccine (PCV13) (grades A and B recommendations). In 2016, the National Advisory Committee on Immunization also recommended that all adults aged 65 years and older receive PCV13 (grade A recommendation) on an individual basis, followed by the 23-valent pneumococcal polysaccharide vaccine (grade B recommendation). This update is based on a large clinical study that demonstrated PCV13 efficacy against vaccine-type CAP in this population. CONCLUSION: Physicians should focus on improving pneumococcal vaccination rates among adults, which remain low. Vaccination with PCV13 should also be considered for adults with chronic conditions, whose baseline risk is often higher than that for healthy individuals aged 65 years and older.

Background The secondary fracture prevention gap in the osteoporosis field has been previously described as a ‘crisis’. Closing this gap is increasingly important in the context of accumulating evidence showing that an incident fragility fracture is associated with an increased risk of subsequent fracture within 1–2 years, known as imminent fracture risk. The objective of this study was to use health services data to characterize the time between index fragility fractures occurring at different osteoporotic sites and subsequent fractures. Methods This retrospective observational study used de-identified health services data from the publicly funded healthcare system in Ontario, the largest province of Canada. Patients aged > 65 with an index fragility fracture occurring between 2011 and 2015 were identified from the ICES Data Repository using International Classification of Diseases (ICD)-10 codes. We examined median time to subsequent fragility fractures for osteoporotic fracture sites until the end of follow-up (2017). BMD assessment and use of osteoporosis therapies following index fracture were also characterized. Results Among 115,776 patients with an index fragility fracture, 17.8% incurred a second fragility fracture. Median time between index and second fracture occurring at any site was 555 days (interquartile range: 236–955). For each index fracture site examined, median time from index to second fracture was 3 years post index fracture. Conclusions This cohort of Canadian patients aged > 65 years who experienced a fragility fracture at any site are at imminent risk of experiencing subsequent fracture within the next 2 years and should be proactively assessed and treated.

Background Recent studies are lacking reports on mortality after non-hip fractures in adults aged > 65. Methods This retrospective, matched-cohort study used de-identified health services data from the publicly funded healthcare system in Ontario, Canada, contained in the ICES Data Repository. Patients aged 66 years and older with an index fragility fracture occurring at any osteoporotic site between 2011 and 2015 were identified from acute hospital admissions, emergency and ambulatory care using International Classification of Diseases (ICD)-10 codes and data were analyzed until 2017. Thus, follow-up ranged from 2 years to 6 years. Patients were excluded if they presented with an index fracture occurring at a non-osteoporotic fracture site, their index fracture was associated with a trauma code, or they experienced a previous fracture within 5 years prior to their index fracture. This fracture cohort was matched 1:1 to controls within a non-fracture cohort by date, sex, age, geography and comorbidities. All-cause mortality risk was assessed. Results The survival probability for up to 6 years post-fracture was significantly reduced for the fracture cohort vs matched non-fracture controls (p n = 101,773 per cohort), with the sharpest decline occurring within the first-year post-fracture. Crude relative risk of mortality (95% confidence interval) within 1-year post-fracture was 2.47 (2.38–2.56) in women and 3.22 (3.06–3.40) in men. In the fracture vs non-fracture cohort, the absolute mortality risk within one year after a fragility fracture occurring at any site was 12.5% vs 5.1% in women and 19.5% vs 6.0% in men. The absolute mortality risk within one year after a fragility fracture occurring at a non-hip vs hip site was 9.4% vs 21.5% in women and 14.4% vs 32.3% in men. Conclusions In this real-world cohort aged > 65 years, a fragility fracture occurring at any site was associated with reduced survival for up to 6 years post-fracture. The greatest reduction in survival occurred within the first-year post-fracture, where mortality risk more than doubled and deaths were observed in 1 in 11 women and 1 in 7 men following a non-hip fracture and in 1 in 5 women and 1 in 3 men following a hip fracture.

Sexual problems are common in women of all ages. Despite their frequency and impact, female sexual dysfunctions (FSDs)are often unrecognized and untreated in clinical settings. In response, the International Society for the Study of Women's Sexual Health convened a multidisciplinary, international expert panel to develop a process of care (POC)that outlines recommendations for identification of sexual problems in women. This POC describes core and advanced competencies in FSD for clinicians who are not sexual medicine specialists and serve as caregivers of women and, therefore, is useful for clinicians with any level of competence in sexual medicine. The POC begins with the expectation of universal screening for sexual concerns, proceeds with a 4-step model (eliciting the story, naming/reframing attention to the problem, empathic witnessing of the patient's distress and the problem's impact, and referral or assessment and treatment)that accommodates all levels of engagement, and delineates a process for referral when patients' needs exceed clinician expertise. Distressing problems related to desire, arousal, and orgasm affect 12% of women across the lifespan. Low desire is the most common sexual problem, but sexual pain and other less common disorders of arousal and orgasm are also seen in clinical practice. Screening is best initiated by a ubiquity statement that assures the patient that sexual concerns are common and can be revealed. Patient-centered communication skills facilitate and optimize the discussion. The goal of the POC is to provide guidance to clinicians regarding screening, education, management, and referral for women with sexual problems.

Background The aim of the present study was to explore features associated with glycemic control in type 2 diabetes (T2D) patients undergoing care by specialist clinics. Methods Literature searches identified diabetes registries whose databases recorded outcomes of specialist care. The LMC Diabetes Registry database (n = 58 280; LMC) was queried to identify patients with T2D who had been seen in a defined 14-month period. Logistic regression modeling was used to identify predictors of glycemic control in these patients. Poor glycemic control was defined as HbA1c ≥9.0% (75 mmol/mol) despite specialist care for ≥1 year. Results Few published registry-based studies have discussed glycemic control and outcomes of specialist care for T2D. Among 10 590 LMC patients with T2D, mean HbA1c was 7.6% (60 mmol/mol), with 38% of patients meeting the Canadian Diabetes Association target of ≤7.0% (53 mmol/mol). Overall, 15% showed poor glycemic control with persistent HbA1c ≥9.0% (75 mmol/mol); among insulin-treated patients (n = 3856), 28% met this criterion. Patient characteristics independently associated with poor glycemic control included early age of onset, the number of diabetes education program visits, the number of oral therapies, and insulin use. Conclusions Type 2 diabetes patients with poor glycemic control are found disproportionately in referral specialist care clinics. These functionally refractory patients demonstrate features that may assist in predicting their potential outcome, and may represent a group with specific barriers to care. Specialist patient registries, such as the LMC Diabetes Registry, may provide critical information regarding this cohort.

This study aims to determine the emotional and physical impact of vaginal atrophy on North American postmenopausal women and their male partners.A weighted sample of 1,000 married or cohabiting North American postmenopausal women aged 55 to 65 years with vaginal discomfort and 1,000 male partners of postmenopausal women aged 55 to 65 years who experienced vaginal discomfort participated in the Clarifying Vaginal Atrophy's Impact on Sex and Relationships (CLOSER) online survey to determine the impact of vaginal discomfort and local estrogen therapy on intimacy, relationships, and women's self-esteem.Vaginal discomfort caused most surveyed North American women to avoid intimacy (58%), experience loss of libido (64%), and experience pain associated with sex (64%). Most surveyed North American men also believed that vaginal discomfort caused their partners to avoid intimacy (78%), experience loss of libido (52%), and find sex painful (59%). Approximately 30% of North American women and men cited vaginal discomfort as the reason they ceased having sex altogether. North American women who used local estrogen therapy to treat their vaginal discomfort reported less painful sex (56%), more satisfying sex (41%), and improved sex life (29%). Most men reported looking forward to having sex (57%) because of their partner's use of local estrogen therapy.Local estrogen therapy ameliorates the negative impact of vaginal atrophy on the intimate relationships of North American postmenopausal women and their male partners. Additional education and awareness efforts about the symptoms of and available treatments for vaginal atrophy may be of further benefit to North American partners.

Background Seasonal vaccination against influenza is the most important public health strategy to prevent influenza morbidity and mortality in children 6–23 months of age. However, influenza immunization uptake in this population remains sub-optimal. While parents look to healthcare professionals (HCPs) for guidance, HCPs may be neither aware of the burden of influenza disease in infants nor familiar with ways to address parental influenza vaccine hesitancy. The objective of this research was to describe the impact of an Information—Motivation—Behavioral Skills model (IMB)-based, accredited, online Continuing Medical Education (CME) program on seasonal influenza vaccination in children 6–23 months of age in Ontario, Canada during the 2016/2017 influenza season. Methods A multi-center, randomized, controlled trial was conducted whereby HCPs were randomized to either an accredited IMB-based CME or to routine practice (no CME). The CME addressed influenza burden in young children and identified parental barriers (hesitancy) to influenza vaccination, designed to inform, motivate, and upskill HCPs. All vaccine options were reviewed, including the adjuvanted, trivalent, inactive, influenza vaccine (aTIV). Immunization rates were compared between groups using Pearson’s chi-squared and a logistic regression model adjusting for socioeconomic status at the clinic-level. Results A total of 68 HCPs were recruited: 33 randomized to the CME group and 35 to routine practice. HCP interactions with parents were evaluated during 628 visits: 292 visits by HCPs in the CME group and 336 by HCPs in the routine practice group. Parents seen by HCPs in the CME group were ~30% more likely to agree to immunize their child with seasonal influenza vaccination compared with parents seen by HCPs in the control group (P = 0.007). The adjusted odds of influenza immunization were 1.5 times higher in the CME group compared with the control group. Children in the CME group were ~20% more likely to receive aTIV compared with children in the control group (P < 0.001). Conclusion HCP education with a tailored health behavior uptake model based CME addressing the burden of influenza disease in young children and influenza vaccine hesitancy was associated with a significant increase in influenza immunization. Disclosures W. Fisher, Seqirus: Consultant and Investigator, Consulting fee and Speaker honorarium. J. Yaremko, Seqirus: Collaborator and Investigator, Speaker honorarium. V. Brown, Seqirus: Investigator, Speaker honorarium. H. Garfield, Seqirus: Investigator, Speaker honorarium. E. Rampakakis, Seqirus: Independent Contractor, Consulting fee. C. Boikos, Seqirus: Employee, Salary. J. A. Mansi, Seqirus: Employee and Shareholder, Salary.

OBJECTIVETo highlight the utility of a large patient registry to identify functionally refractory patients (persistent HbA1c ≥75 mmol/mol [9.0%]) with type 2 diabetes, identify their barriers to glycemic control, and implement barrier-specific care path strategies to improve glycemic control.RESEARCH DESIGN AND METHODSA working group developed a structured tool to optimize the collection of information on barriers to glycemic control and designed structured care paths to address each barrier. Participants were identified from a large Canadian registry and were assigned to a certified diabetes educator (CDE) as their case manager for a 12-month period to coordinate assessment of their barriers and to implement appropriate care path strategies. The primary outcome measure was the mean change in HbA1c from baseline at 12 months.RESULTSOverall, 3,662 refractory patients were initially identified of whom 1,379 were eligible for inclusion and 155 enrolled. The most common barrier categories participants identified were psychological/support (93%), socioeconomic (87%), and accessibility (82%), with high concordance (75–94%) between participant and CDE. No specific barriers were predictive of hyperglycemia. After implementation of barrier-specific care paths, the mean reduction in HbA1c at 12 months was 17 mmol/mol (1.5%; P < 0.01 vs. baseline) versus only 5 mmol/mol (0.5%) in the source cohort (n = 966) who continued with standard care. The incidence of severe hypoglycemia did not change significantly during the study.CONCLUSIONSIn registry-identified hyperglycemic patients with type 2 diabetes, the use of barrier-specific care paths significantly improved glycemic control in otherwise refractory patients with persistently elevated HbA1c. Further studies using this strategy in other practice settings are warranted.

The dosing, schedules, and other aspects of combined oral contraceptive (COC) design have evolved in recent years to address a variety of issues including short- and long-term safety, bleeding profiles, and contraceptive efficacy. In particular, several newer formulations have altered the length of the hormone-free interval (HFI), in order to minimize two key undesired effects that occur during this time: hormone-withdrawal-associated symptoms (HWaS) and follicular development.This primer reviews our current understanding of the key biological processes that occur during the HFI and how this understanding has led to changes in the dosing and schedule of newer COC formulations.In brief, HWaS are common, underappreciated, and a likely contributor to COC discontinuation; because of this, shortening the HFI and/or supplementing with estrogen during the progestin-free interval may provide relief from these symptoms and improve adherence. A short HFI (with or without estrogen supplementation) may also help maintain effective follicular suppression and contraceptive efficacy, even when the overall dose of estrogen throughout the cycle is low.Taken together, the available data about HWaS and follicular activity during the HFI support the rationale for recent COC designs that use a low estrogen dose and a short HFI. The availability of a variety of COC regimens gives physicians a range of choices when selecting the most appropriate COC for each woman's particular priorities and needs.

Oral health is critical to overall good health and it also serves as a surrogate marker in critical disease. We commend Kelsall and O’Keefe[1][1] for highlighting the need to eliminate barriers to dental care for some of our most vulnerable patients. Oropharyngeal cancers are among the most

The aim of the present study was to explore features associated with glycemic control in type 2 diabetes (T2D) patients undergoing care by specialist clinics.Literature searches identified diabetes registries whose databases recorded outcomes of specialist care. The LMC Diabetes Registry database (n = 58 280; LMC) was queried to identify patients with T2D who had been seen in a defined 14-month period. Logistic regression modeling was used to identify predictors of glycemic control in these patients. Poor glycemic control was defined as HbA1c ≥9.0% (75 mmol/mol) despite specialist care for ≥1 year.Few published registry-based studies have discussed glycemic control and outcomes of specialist care for T2D. Among 10 590 LMC patients with T2D, mean HbA1c was 7.6% (60 mmol/mol), with 38% of patients meeting the Canadian Diabetes Association target of ≤7.0% (53 mmol/mol). Overall, 15% showed poor glycemic control with persistent HbA1c ≥9.0% (75 mmol/mol); among insulin-treated patients (n = 3856), 28% met this criterion. Patient characteristics independently associated with poor glycemic control included early age of onset, the number of diabetes education program visits, the number of oral therapies, and insulin use.Type 2 diabetes patients with poor glycemic control are found disproportionately in referral specialist care clinics. These functionally refractory patients demonstrate features that may assist in predicting their potential outcome, and may represent a group with specific barriers to care. Specialist patient registries, such as the LMC Diabetes Registry, may provide critical information regarding this cohort.