Integrating PROs in clinical practice has the potential to enhance patient-centered care. The online version of the User's Guide will be updated periodically.

IMPORTANCEThe expected duration of menopausal vasomotor symptoms (VMS) is important to women making decisions about possible treatments.OBJECTIVES To determine total duration of frequent VMS (Ն6 days in the previous 2 weeks) (hereafter total VMS duration) during the menopausal transition, to quantify how long frequent VMS persist after the final menstrual period (FMP) (hereafter post-FMP persistence), and to identify risk factors for longer total VMS duration and longer post-FMP persistence. DESIGN, SETTING, AND PARTICIPANTSThe Study of Women's Health Across the Nation (SWAN) is a multiracial/multiethnic observational study of the menopausal transition among 3302 women enrolled at 7 US sites. From February 1996 through April 2013, women completed a median of 13 visits. Analyses included 1449 women with frequent VMS. MAIN OUTCOMES AND MEASURESTotal VMS duration (in years) (hot flashes or night sweats) and post-FMP persistence (in years) into postmenopause. RESULTSThe median total VMS duration was 7.4 years. Among 881 women who experienced an observable FMP, the median post-FMP persistence was 4.5 years. Women who were premenopausal or early perimenopausal when they first reported frequent VMS had the longest total VMS duration (median, >11.8 years) and post-FMP persistence (median, 9.4 years). Women who were postmenopausal at the onset of VMS had the shortest total VMS duration (median, 3.4 years). Compared with women of other racial/ethnic groups, African American women reported the longest total VMS duration (median, 10.1 years). Additional factors related to longer duration of VMS (total VMS duration or post-FMP persistence) were younger age, lower educational level, greater perceived stress and symptom sensitivity, and higher depressive symptoms and anxiety at first report of VMS.CONCLUSIONS AND RELEVANCE Frequent VMS lasted more than 7 years during the menopausal transition for more than half of the women and persisted for 4.5 years after the FMP. Individual characteristics (eg, being premenopausal and having greater negative affective factors when first experiencing VMS) were related to longer-lasting VMS. Health care professionals should counsel women to expect that frequent VMS could last more than 7 years, and they may last longer for African American women.

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OBJECTIVE:Tamoxifen reduces the risk of developing breast cancer but also affects the risks of certain vascular and neoplastic events. Our purpose was to estimate the effects of tamoxifen on potentially life-threatening vascular and neoplastic outcomes. DESIGN:Random effects meta-analysis of published randomized controlled trials. PATIENTS:Participants in all trials in which a treatment arm that included tamoxifen was compared to a similar control arm. Breast cancer risk reduction and treatment trials were included. T amoxifen, a selective estrogen receptor modulator with both estrogen agonist and antagonistic properties, is among the most widely prescribed breast cancer reduction therapies. INTERVENTIONS: Tamoxifen at variable dose and duration. MEASUREMENTS AND MAIN RESULTS:1 It is the only agent currently approved by the U.S. Food and Drug Administration (FDA) for the reduction of breast cancer risk in women at increased risk for this disease, and may be considered for women with a 15-year projected breast cancer risk of ≥ 1.66%. 2As a mixed estrogen agonist and antagonist, tamoxifen affects a variety of clinical conditions in addition to breast cancer. Tamoxifen is generally well tolerated but is infrequently associated with life-threatening events including development of endometrial cancer and pulmonary emboli. Precise estimation of the magnitude of the risk of lifethreatening conditions which may be associated with tamoxifen use are of special significance when considering its use for breast cancer risk reduction. The only published meta-analyses of adverse outcomes with tamoxifen were performed by the Early Breast Cancer Trialists' Collaborative Group.4 They did not examine the incidence of many outcomes of possible significance such as stroke and myocardial infarction, and their analyses only included patients receiving tamoxifen for breast cancer treatment. Furthermore, they have not conducted analyses of potentially higher risk groups such as postmenopausal women. The purpose of the present study was to estimate the effects of tamoxifen on potentially life-threatening vascular and neoplastic outcomes by conducting a meta-analysis of data from all published randomized controlled trials involving its use. We analyze results separately for patients receiving tamoxifen for different indications and for different patient subgroups. We did not include results for raloxifene, another estrogen receptor, because the data supporting its efficacy for breast cancer risk reduction are still preliminary.

Objective-To examine change in health-related quality of life (HRQL) during the menopausal transition, controlling for chronological aging, symptoms, and other covariates.Design-A prospective, longitudinal study of women aged 42-52 at baseline recruited at seven US sites (N=3302) in the multiethnic Study of Women's Health Across the Nation (SWAN). Cohort eligible women had an intact uterus, at least one ovary, were not currently using exogenous hormones, were either pre-or early perimenopausal, and self-identified as one of the study's designated racial/ ethnic groups. Data from the baseline interview and six annual follow-up visits are reported. HRQL was assessed with five subscales from the SF-36 with reduced functioning defined as being in the lowest 25% on a subscale. Covariates included symptoms, medical conditions, sociodemographics variables, physical activity, and psychological factors. Address Correspondence to: Nancy E. Avis, PhD, Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Piedmont Plaza II -2 nd floor, Winston-Salem, NC 27157-1063. Telephone: 336-716-6974, Facsimile: 336-716-7554, E-mail: navis@wfubmc.edu. Clinical Centers: University of Michigan, Ann Arbor -Dr. MaryFran Sowers, PI; Massachusetts General Hospital, Boston, MA -Dr. Robert Neer, PI 1994 Dr. Joel Finkelstein, PI 1999-present; Rush University, Rush University Medical Center, Chicago, ILDr. Lynda Powell, PI; University of California, Davis/Kaiser -Dr. Ellen Gold, PI; University of California, Los Angeles -Dr. Gail Greendale, PI; University of Medicine and Dentistry -New Jersey Medical School, Newark -Dr. Gerson Weiss, PI 1994-2004 Dr. Nanette Santoro, PI 2004 -present; and the University of Pittsburgh, Pittsburgh, PA -Dr. Karen Matthews, PI. (pre-pre, pre-peri, peri-peri, pre/peri-post, post-post) found that women who remained peri-menopausal at both time-points and women taking hormone therapy (HT) exhibited small, but significantly greater declines on the physical health domains than women who remained pre-menopausal. Despite this large sample, only a small percentage of women transitioned from pre or perimenopause to post menopause or remained postmenopausal at both time-points, due to the young age of the women at baseline and the short follow-up.Kumari et al. 23 studied the impact of the menopausal transition on SF-36 scores among 2,489 women followed through the Whitehall II study, with a particular focus on symptoms. Ageadjusted results showed no impact of the menopause transition on SF-36 scores, although women who reported vasomotor symptoms or depression experienced large and significant declines. However, this study was not designed to focus on the menopause transition and The present paper uses longitudinal data from the large multiethnic Study of Women's Health Across the Nation (SWAN) to examine changes in HRQL over the menopausal transition, controlling for symptoms and other covariates. All women were either pre or early perim...

Effective mentorship is likely one of the most important determinants of success in academic medicine and research. Many papers focus on mentoring from the mentor's perspective, but few give guidance to mentees forging these critically important relationships. The authors apply "managing up," a corporate concept, to academic medical settings both to promote effective, successful mentoring and to make a mentor's job easier. Managing up requires the mentee to take responsibility for his or her part in the collaborative alliance and to be the leader of the relationship by guiding and facilitating the mentor's efforts to create a satisfying and productive relationship for both parties. The authors review the initiation and cultivation of a mentoring relationship from the perspective of a mentee at any stage (student through junior faculty), and they propose specific strategies for mentee success.

Patient web portals (PWPs), defined as the integration of electronic medical records and patient health records, have been related to enhanced patient outcomes. A literature review was conducted to characterize the design and evaluation of PWPs to improve health care processes and outcomes in diabetes. A summary of 26 articles revealed the positive impact PWPs have on patient outcomes, patient-provider communication, disease management, and access to and patient satisfaction with health care. Innovative and useful approaches included the evaluation of specific components of the PWPs, assessing the impact of PWPs on mediators of health behaviors, such as patient distress, identification of barriers to use, and patient willingness to pay for access. Future research should focus on relevant processes that mediate patient and provider use, impact on health care utilization, and a patient-centered approach to the design and integration of educational opportunities afforded through PWPs.

The University of Pittsburgh Medical Center (UPMC) has implemented a personal health record grounded in the Chronic Care Model, UPMC HealthTrak, to assist patients with diabetes self-management. UPMC HealthTrak is based in the physician office and connects the patient, physician, and electronic medical record (EMR). Its functionalities include secure, electronic communication with the physician's office, along with preventive healthcare reminders, and disease-specific tools and information. In this paper, we describe challenges to office-based implementation of and initial patient reaction to the technology in the context of diabetes care. UPMC has deployed a secure Web-based patient portal, UPMC HealthTrak. We implemented UPMC HealthTrak in the ambulatory setting and assessed its impact on patient-practice communication. We conducted 10 90-minute focus groups (five pre- and five postimplementation) to assess patient reaction to UPMC HealthTrak. Focus groups were analyzed using grounded theory techniques. During the period September 2004-January 2007, there was no significant change in number of patient encounters or telephone calls received in our office, but the number of HealthTrak messages increased. Our 39 pre- and postimplementation focus group participants felt that the system would enhance communication with the office, and that the reminder system would be helpful. They also liked having access to laboratory tests remotely. They were frustrated when tests were not released and messages not answered. A Web-based patient portal can be integrated into a clinical office, although patients may not quickly change communication patterns. Patients are responsive to technology. Future work should focus on diabetes-related outcomes assessment and intensifying interventions.