The combined effect of pravastatin and aspirin on clinical cardiovascular events

The 3-hydroxy-3methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, or statins, can achieve significant reductions in plasma low-density lipoprotein (LDL)-cholesterol levels. Experimental and clinical evidence now shows that some statins interfere with formation of atherosclerotic lesions independent of their hypolipidemic properties. Vulnerable plaque rupture can result in thrombus formation and artery occlusion; this plaque deterioration is responsible for most acute coronary syndromes, including myocardial infarction (MI), unstable angina, and coronary death, as well as coronary heart diseaseequivalent non-hemorrhagic stroke. Inhibition of HMG-CoA reductase has potential pleiotropic effects other than lipid-lowering, as statins block mevalonic acid production, a precursor to cholesterol and numerous other metabolites. Statins' beneficial effects on clinical events may also thus involve nonlipid-related mechanisms that modify endothelial function, inflammatory responses, plaque stability, and thrombus formation. Aspirin, routinely prescribed to post-MI patients as adjunct therapy, may potentiate statins beneficial effects, as aspirin does not compete metabolically with statins but acts similarly on atherosclerotic lesions. Common functions of both medications include inhibition of platelet activity and aggregation, reduction in atherosclerotic plaque macrophage cell count, and prevention of atherosclerotic vessel endothelial dysfunction. The Cholesterol and Recurrent Events (CARE) trial provides an ideal population in which to examine the combined effects of pravastatin and aspirin. Lipid levels, intermediate outcomes, are examined by pravastatin and aspirin status, and differences between the two pravastatin groups are found. A modified Cox proportional-hazards model with aspirin as a time-dependent covariate was used to determine the effect of aspirin and pravastatin on the clinical cardiovascular composite endpoint of coronary heart disease death, recurrent MI or stroke. Among those assigned to pravastatin, use of aspirin reduced the composite primary endpoint by 35%; this result was similar by gender, race, and diabetic status. Older patients demonstrated a nonsignificant 21% reduction in the primary outcome, whereas the younger had a significant reduction of 43% in the composite primary outcome. Secondary outcomes examined include coronary artery bypass graft (38% reduction), nonsurgical bypass, peripheral vascular disease, and unstable angina. Pravastatin and aspirin in a post-MI population was found to be a beneficial combination that seems to work through lipid and nonlipid, anti-inflammatory mechanisms. ^

The role of cardiovascular comorbidities in ovarian cancer survival

Objective. One facet of cancer care that often goes ignored is comorbidities, or diseases that exist in concert with cancer. Comorbid conditions may affect survival by influencing treatment decisions and prognosis. The purpose of this secondary data analysis was to identify whether a history of cardiovascular comorbidities among ovarian cancer patients influenced survival time at the University of Texas M. D. Anderson Cancer Center. The parent study, Project Peace, has a longitudinal design with an embedded randomized efficacy study which seeks to improve detection of depressive disorders in ovarian, peritoneal, and fallopian tube cancers. ^ Methods. Survival time was calculated for the 249 ovarian cancer patients abstracted by Project Peace staff. Cardiovascular comorbidities were documented as present, based upon information from medical records in addition to self reported comorbidities in a baseline study questionnaire. Kaplan-Meier survival curves were used to compare survival time among patients with a presence or absence of particular cardiovascular comorbidities. Cox Regression proportional models accounted for multivariable factors such as age, staging, family history of cardiovascular comorbidities, and treatment. ^ Results. Among our patient population, there was a statistically significant relationship between shorter survival time and a history of thrombosis, pericardial disease/tamponade, or COPD/pulmonary hypertension. Ovarian cancer patients with a history of thrombosis lived approximately half as long as patients without thrombosis (58.06 months vs. 121.55 months; p=.001). In addition, patients who suffered from pericardial disease/tamponade had poorer survival than those without a history of pericardial disease/tamponade (48 months vs. 80.07 months; p=.002). Ovarian cancer patients with a history of COPD or pulmonary hypertension had a median survival of 60.2 months, while the median survival for patients without these comorbidities was 80.2 months (p=.014). ^ Conclusion. Especially because of its relatively lower survival rate, greater emphasis needs to be placed on the potential influence of cardiovascular comorbid conditions in ovarian cancer.^

Antibiotic susceptibility and resistance among bacterial enteropathogens isolated from international travelers to Mexico, Guatemala, and India, 2006--2008

The incidence rates of travelers' diarrhea (TD) have remained unchanged for the last fifty years. More recently, there have been increasing recommendations for self-initiated therapy and even prophylactic therapy for TD. There is no recent data on the in vitro activities of commonly used antibiotics for TD therapy and whether there have been any changes in susceptibilities over the last ten years. 456 enteropathogens were isolated from adult travelers to Mexico, India, and Guatemala between the years 2006 to 2008. MICs were determined for 10 different antimicrobials by the agar dilution method. Traditional antibiotics such as ampicillin, trimethoprim/sulfamethoxazole, and doxycycline continue to show high levels of resistance. Current first line antibiotic agents including fluoroquinolones and azithromycin had significantly higher MICs when compared to 10 years ago and MIC90 levels were beyond the CSLI cutoffs for resistance. There were significant geographical differences in resistance patterns when comparing Central America with India. Entertoxigenic Escherichia coli (ETEC) isolates were more resistant to ciprofloxacin (p=0.023), and levofloxacin (p=0.0078) in India; whereas, enteroaggregative Escherichia coli (EAEC) isolates from Central America showed more resistance. When compared to MICs of isolates 10 years prior, there was a four to ten-fold increase in MIC90s for ceftriaxone, ciprofloxacin, levofloxacin and azithromycin for both ETEC and EAEC. There were no significant changes in rifaximin MICs over the last ten years, which makes it a promising agent for TD. Rising MICs over time implicate the need for continuous surveillance of susceptibility patterns worldwide and for geography specific recommendations in TD therapy.^

Psychosocial predictors of HIV testing behaviors among high risk heterosexuals

Though a lot of progress has been made in the treatment, prevention, and in increasing the knowledge and awareness of HIV/AIDS, the CDC reports that over 21% of the people infected with HIV are unaware of their HIV serostatus. Thirty-one percent of people infected with HIV are diagnosed late in the disease progression, often too late to prevent the transmission or the progression of HIV to AIDS. CDC has set a goal to increase by the year 2010, the number of people aware of the HIV serostatus by 5%. ^ This study examined the association between decision-making and risk-taking (assessed using the decision-making confidence and risk-taking scales of the Texas Christian University Self Rating Form) and HIV testing behaviors within a population of heterosexuals at risk for HIV infections living in Harris County, Texas (N=923). Data used in the study was obtained during the first cycle of the National HIV Behavioral Surveillance among heterosexuals at risk for HIV infection (NHBS-HET1), conducted from October, 2006 to June, 2007. Eighty percent of the study population reported testing for HIV at some point in their lives. The results showed that individuals who scored high (>3.3) on the decision-making confidence scale of the TCU/SRF were more likely to be tested for HIV when compared to those who scored low on the scale (OR= 2.02, 95% CI= 1.44–2.84), and that individuals who score low on the risk-taking scale of the TCU/SRF were more likely to have been tested for HIV when compared to those who scored high on the scale (OR= 1.65, 95% CI= 1.2–2.31). Several demographic factors were also assessed for their association with HIV testing behaviors. Only sex was found to be associated with HIV testing. ^ The findings suggest that risk-taking and decision-making are predictors of HIV testing behaviors such as prior HIV testing within heterosexuals living in high-risk areas of Houston, Texas, and that intervention designed to improve the risk-taking and decision-making attributes of this population might improve HIV testing within this population.^

Spatial analysis of water body distance and West Nile Virus human cases in Houston, TX

West Nile Virus (WNV) is an arboviral disease that has affected hundreds of residents in Harris County, Texas since its introduction in 2002. Persistent infection, lingering sequelae and other long-term symptoms of patients reaffirm the need for prevention of this important vector-borne disease. This study aimed to determine if living within 400m of a water body increases one’s odds of infection with WNV. Additionally, we wanted to determine if one’s proximity to a particular water type or water body source increased one’s odds of infection with WNV.^ 145 cases’ addresses were abstracted from the initial interview and consent records from a cohort of patients (Epidemiology of Arboviral Encephalitis in Houston study, HSC-SPH-03-039). After applying inclusion criteria, 140 cases were identified for analysis. 140 controls were selected for analysis using a population proportionate to size model and US Census Bureau data. MapMarker USA v14 was used to geocode the cases’ addresses. Both cases’ and controls’ coordinates were uploaded onto a Harris County water shapefile in MapInfo Professional v9.5.1. Distance in meters to the closest water source, closest water source type, and closest water source name were recorded.^ Analysis of Variance (p=0.329, R2 = 0.0034) indicated no association between water body distance and risk of WNV disease. Living near a creek (x2 = 11.79, p < 0.001), or the combined group of creek and gully (x 2 = 14.02, p < 0.001) were found to be strongly associated with infection of WNV. Living near Cypress Creek and its feeders (x2 = 15.2, p < 0.001) was found to be strongly associated with WNV infection. We found that creek and gully habitats, particularly Cypress Creek, were preferential for the local disease transmitting Culex quinquefasciatus and reservoir avian population.^

Enlarged tracheoesophageal puncture: A systematic review and retrospective analysis

Background. An enlarged tracheoesophageal puncture (TEP) results in aspiration around the voice prosthesis (VP) and may lead to pneumonia. The aims of this research were: (1) to conduct a systematic review and meta-analysis on enlarged TEP; (2) to analyze preoperative, perioperative, and postoperative risk factors for enlarged TEP; and (3) to evaluate control of leakage around the VP using conservative treatments and adverse events in patients with enlarged TEP.^ Methods. A systematic review was conducted (1978-2008). A summary risk estimate was calculated using a random-effects meta-analysis model. A retrospective cohort study was completed. Patients who underwent total laryngectomy and TEP at The University of Texas M. D. Anderson Cancer Center (MDACC) were included. Multiple logistic regression methods were used to assess risk factors for enlargement. Descriptive and bivariate statistics were calculated to evaluate outcomes and adverse events. Results: Twenty-seven manuscripts were included in the systematic review. The summary risk estimate of enlarged TEP/leakage around the VP was 7.2% (95% CI: 4.8%-9.6%). Temporary VP removal and TEP-site injections were the most commonly reported treatments. Neither prosthetic diameter (p=0.076) nor timing of TEP (p=0.297) significantly increased risk of enlargement per stratified analyses of published outcomes. The cumulative incidence of enlarged TEP was 18.6% (36/194, 95% CI: 13.0%-24.1%) in the MDACC cohort. Enlarged TEP occurred exclusively in irradiated patients. Adjusting for length of follow-up and timing of TEP, advanced nodal disease (ORadjusted: 4.3, 95% CI: 1.0-19.1), stricture (ORadjusted : 3.2, 95% CI: 1.2-8.6), and locoregional recurrence/distant metastasis after laryngectomy (ORadjusted: 6.2, 95% CI: 2.3-16.4) increased risk of enlarged TEP. At last follow-up, conservative methods controlled leakage around the VP in 81% (29/36) of patients. Unresolved leakage was associated with recurrent cancer (p=0.081) and TEP-site irregularity (p=0.003). Relative to those without enlargement, enlarged TEP patients had significantly higher risk of pneumonia (RR: 3.4, 95% CI: 1.9-6.2).^ Conclusions. These data establish that enlarged TEP poses serious health risks, and provide insight into medical and oncologic factors that may contribute to development of this complication. In addition, this research supports the use of conservative treatments to address leakage after enlarged TEP in lieu of complete TEP closure.^

Clinical and economic outcomes of serious postoperative infections following resection of common respiratory and gastrointestinal solid tumors

Unlike infections occurring during periods of chemotherapy-induced neutropenia, postoperative infections in patients with solid malignancy remain largely understudied. The purpose of this population-based study was to evaluate the clinical and economic burden, as well as the relationship of hospital surgical volume and outcomes associated with serious postoperative infection (SPI) – i.e., bacteremia/sepsis, pneumonia, and wound infection – following resection of common solid tumors.^ From the Texas Discharge Data Research File, we identified all Texas residents who underwent resection of cancer of the lung, esophagus, stomach, pancreas, colon, or rectum between 2002 and 2006. From their billing records, we identified ICD-9 codes indicating SPI and also subsequent SPI-related readmissions occurring within 30 days of surgery. Random-effects logistic regression was used to calculate the impact of SPI on mortality, as well as the association between surgical volume and SPI, adjusting for case-mix, hospital characteristics, and clustering of multiple surgical admissions within the same patient and patients within the same hospital. Excess bed days and costs were calculated by subtracting values for patients without infections from those with infections computed using multilevel mixed-effects generalized linear model by fitting a gamma distribution to the data using log link.^ Serious postoperative infection occurred following 9.4% of the 37,582 eligible tumor resections and was independently associated with an 11-fold increase in the odds of in-hospital mortality (95% Confidence Interval [95% CI], 6.7-18.5, P < 0.001). Patients with SPI required 6.3 additional hospital days (95% CI, 6.1 - 6.5) at an incremental cost of $16,396 (95% CI, $15,927–$16,875). There was a significant trend toward lower overall rates of SPI with higher surgical volume (P=0.037). ^ Due to the substantial morbidity, mortality, and excess costs associated with SPI following solid tumor resections and given that, under current reimbursement practices, most of this heavy burden is borne by acute care providers, it is imperative for hospitals to identify more effective prophylactic measures, so that these potentially preventable infections and their associated expenditures can be averted. Additional volume-outcomes research is also needed to identify infection prevention processes that can be transferred from higher- to lower-volume providers.^

Impact of maternal Tdap vaccination on pertussis infection in young infants

Undiagnosed infected mothers often are the source of pertussis illness in young infants. The Centers for Disease Control and Prevention (CDC) recommends Tdap vaccine for post-partum women before hospital discharge. This intervention has been implemented at Ben Taub General Hospital (BTGH) in Houston, TX since January 2008. Our objective was to compare the proportion of infants born at BTGH and developing pertussis to the total number of pertussis cases before and after the intervention. Methods. We conducted a cross-sectional comparative study between the pre-intervention (7/2000 to 12/2007) and post-intervention (1/2008 to 5/2009) periods. Information on pertussis diagnosis was determined using ICD-9 codes, infection control records, and molecular microbiology reports from Texas Children's Hospital (TCH) and BTGH. Only patients ≤ 6 months of age with laboratory-confirmed B. pertussis infection were included in the study. Results. 481 infants had pertussis illness; 353 (73.3%) during pre-intervention and 128 (26.6%) during post-intervention years. The groups were comparable in all measures including age (median 73 vs. 62.5 days; p=0.08), gender (males 54.2%; p=0.47), length of hospitalization (median 9.8 vs. 4 9.5 days; p=0.5), outcomes (2 deaths in each period; p=0.28) and pertussis illness at TCH (95.2% vs. 95.3%; p=0.9). The proportion of pertussis patients born at BTGH, and thus amenable to protection by the intervention, was not statically different between the two periods after adjusting for age, gender and ethnicity (7.3% vs. 9.3%; an OR=1.05, 95% CI 0.5-2.1, p=0.88). Conclusions. Vaccinating only mothers with Tdap in the post-partum period does not reduce the proportion of pertussis in infants age ≤ 6 months. Efforts should be directed at Tdap immunization of not only mothers, but also all household and key contacts of newborns to protect them against pertussis illness before the primary DTaP series is completed.^

Automated soldier medical readiness: Prevalence of " medically not ready" using data from the electronic soldier readiness processing system (ESRP)

Identifying accurate numbers of soldiers determined to be medically not ready after completing soldier readiness processing may help inform Army leadership about ongoing pressures on the military involved in long conflict with regular deployment. In Army soldiers screened using the SRP checklist for deployment, what is the prevalence of soldiers determined to be medically not ready? Study group. 15,289 soldiers screened at all 25 Army deployment platform sites with the eSRP checklist over a 4-month period (June 20, 2009 to October 20, 2009). The data included for analysis included age, rank, component, gender and final deployment medical readiness status from MEDPROS database. Methods.^ This information was compiled and univariate analysis using chi-square was conducted for each of the key variables by medical readiness status. Results. Descriptive epidemiology Of the total sample 1548 (9.7%) were female and 14319 (90.2%) were male. Enlisted soldiers made up 13,543 (88.6%) of the sample and officers 1,746 (11.4%). In the sample, 1533 (10.0%) were soldiers over the age of 40 and 13756 (90.0%) were age 18-40. Reserve, National Guard and Active Duty made up 1,931 (12.6%), 2,942 (19.2%) and 10,416 (68.1%) respectively. Univariate analysis. Overall 1226 (8.0%) of the soldiers screened were determined to be medically not ready for deployment. Biggest predictive factor was female gender OR (2.8; 2.57-3.28) p<0.001. Followed by enlisted rank OR (2.01; 1.60-2.53) p<0.001. Reserve component OR (1.33; 1.16-1.53) p<0.001 and Guard OR (0.37; 0.30-0.46) p<0.001. For age > 40 demonstrated OR (1.2; 1.09-1.50) p<0.003. Overall the results underscore there may be key demographic groups relating to medical readiness that can be targeted with programs and funding to improve overall military medical readiness.^

Identfying predictors of St. Louis encephalitis activity in Houston Texas

Generalized linear Poisson and logistic regression models were utilized to examine the relationship between temperature and precipitation and cases of Saint Louis encephalitis virus spread in the Houston metropolitan area. The models were investigated with and without repeated measures, with a first order autoregressive (AR1) correlation structure used for the repeated measures model. The two types of Poisson regression models, with and without correlation structure, showed that a unit increase in temperature measured in degrees Fahrenheit increases the occurrence of the virus 1.7 times and a unit increase in precipitation measured in inches increases the occurrence of the virus 1.5 times. Logistic regression did not show these covariates to be significant as predictors for encephalitis activity in Houston for either correlation structure. This discrepancy for the logistic model could be attributed to the small data set.^ Keywords: Saint Louis Encephalitis; Generalized Linear Model; Poisson; Logistic; First Order Autoregressive; Temperature; Precipitation. ^

Prevalence of methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization among dental professionals

Background. MRSA (methicillin-resistant Staphylococcus aureus) is a multi-drug resistant bacterium that is quite prevalent in social environments where close person-to-person contact and crowding are an issue. In dental settings, the likelihood of transmission of MRSA may be higher than among other healthcare practitioners because of the close proximity between a patient's nose (where MRSA colonizes) and the field of procedure (the mouth) to the dental professional. Objective. To estimate the prevalence of MRSA nasal colonization among dental professionals (dentists and dental hygienists) in the Greater Houston Metropolitan Area, Texas, and analyze its associations with demographic, professional and personal protective equipment-related variables. Methods. 800 dental professionals (400 dentists and 400 dental hygienists) were randomly selected in the Greater Houston Metropolitan Area. Multiple waves of nasal swab kits and a self-administered questionnaire were mailed to increase the response rate of the study population. The swabs were cultured on chromagenic agar growth medium and bacterial growth results were evaluated after 18 hours. Positively selected bacterial colonies were confirmed as MRSA by further culturing these isolated bacteria on blood agar plates. Associations between positive nasal swabs and self-reported professional practice patterns, personal protective equipment use and demographics were analyzed using multiple logistic regression. Main Results. Completed questionnaires and nasal swabs were received from 496 study participants (68%). Fourteen cultures were positive for MRSA (4.2% among dentists and 1.6% among dental hygienists, p=0.07). After adjusting for gender, dental hygienists had a significantly lower prevalence of nasal colonization of MRSA as compared to dentists (OR: 0.20, 95% CI: 0.05–0.75). No other significant associations or interactions were found. Conclusion. The prevalence of nasal colonization with MRSA among dentists is similar to that reported for health care workers in general, whereas prevalence among dental hygienists is only slightly above that of the general population (1%). Differences in practice patterns and use of personal protective equipment did not explain this difference in this study, and was possibly due either to residual confounding or unexplored risk factors. Increased prevalence of MRSA among dentists warrants further investigation as to the reason for the increased rate and to allow implementation of measures to avoid transmission and progression to disease. ^

Prevalence of gastro esophageal reflux disease following the Montreal Consensus and its association with Helicobacter pylori infection and obesity in a random sample of adults of Ciudad Juarez, Mexico, 2004.

Gastroesophageal reflux disease is a common condition affecting 25 to 40% of the population and causes significant morbidity in the U.S., accounting for at least 9 million office visits to physicians with estimated annual costs of $10 billion. Previous research has not clearly established whether infection with Helicobacter pylori, a known cause of peptic ulcer, atrophic gastritis and non cardia adenocarcinoma of the stomach, is associated with gastroesophageal reflux disease. This study is a secondary analysis of data collected in a cross-sectional study of a random sample of adult residents of Ciudad Juarez, Mexico, that was conducted in 2004 (Prevalence and Determinants of Chronic Atrophic Gastritis Study or CAG study, Dr. Victor M. Cardenas, Principal Investigator). In this study, the presence of gastroesophageal reflux disease was based on responses to the previously validated Spanish Language Dyspepsia Questionnaire. Responses to this questionnaire indicating the presence of gastroesophageal reflux symptoms and disease were compared with the presence of H. pylori infection as measured by culture, histology and rapid urease test, and with findings of upper endoscopy (i.e., hiatus hernia and erosive and atrophic esophagitis). The prevalence ratio was calculated using bivariate, stratified and multivariate negative binomial logistic regression analyses in order to assess the relation between active H. pylori infection and the prevalence of gastroesophageal reflux typical syndrome and disease, while controlling for known risk factors of gastroesophageal reflux disease such as obesity. In a random sample of 174 adults 48 (27.6%) of the study participants had typical reflux syndrome and only 5% (or 9/174) had gastroesophageal reflux disease per se according to the Montreal consensus, which defines reflux syndromes and disease based on whether the symptoms are perceived as troublesome by the subject. There was no association between H. pylori infection and typical reflux syndrome or gastroesophageal reflux disease. However, we found that in this Northern Mexican population, there was a moderate association (Prevalence Ratio=2.5; 95% CI=1.3, 4.7) between obesity (≥30 kg/m2) and typical reflux syndrome. Management and prevention of obesity will significantly curb the growing numbers of persons affected by gastroesophageal reflux symptoms and disease in Northern Mexico. ^

Usage of Urinary Antigen Test for Legionella on diagnosed community-acquired pneumonia in San Antonio hospitals

Purpose. To evaluate the use of the Legionella Urine Antigen Test as a cost effective method for diagnosing Legionnaires’ disease in five San Antonio Hospitals from January 2007 to December 2009. ^ Methods. The data reported by five San Antonio hospitals to the San Antonio Metropolitan Health District during a 3-year retrospective study (January 2007 to December 2009) were evaluated for the frequency of non-specific pneumonia infections, the number of Legionella Urine Antigen Tests performed, and the percentage of positive cases of Legionnaires’ disease diagnosed by the Legionella Urine Antigen Test.^ Results. There were a total of 7,087 cases of non-specific pneumonias reported across the five San Antonio hospitals studied from 2007 to 2009. A total of 5,371 Legionella Urine Antigen Tests were performed from January, 2007 to December, 2009 across the five San Antonio hospitals in the study. A total of 38 positive cases of Legionnaires’ disease were identified by the use of Legionella Urinary Antigen Test from 2007-2009.^ Conclusions. In spite of the limitations of this study in obtaining sufficient relevant data to evaluate the cost effectiveness of Legionella Urinary Antigen Test in diagnosing Legionnaires’ disease, the Legionella Urinary Antigen Test is simple, accurate, faster, as results can be obtained within minutes to hours; and convenient because it can be performed in emergency room department to any patient who presents with the clinical signs or symptoms of pneumonia. Over the long run, it remains to be shown if this test may decrease mortality, lower total medical costs by decreasing the number of broad-spectrum antibiotics prescribed, shorten patient wait time/hospital stay, and decrease the need for unnecessary ancillary testing, and improve overall patient outcomes.^

The chronobiology of the menstrual life sequence of American women

Seasonal variation in menarche, menstrual cycle length and menopause was investigated using Tremin Trust data. Too, self-reported hot flash data for women with natural and surgically-induced menopause were analyzed for rhythms.^ Menarche data from approximately 600 U.S. women born between 1940 and 1970 revealed a 6-month rhythm (first acrophase in January, double amplitude of 58%M). A notable shift from a December-January peak in menarche for those born in the 1940s and 1950s to an August-September peak for those born in the 1960s was observed. Groups of girls 8-14 and 15-17 yr old at menarche exhibited a seasonal difference in the pattern of menarche occurrence of about 6 months in relation to each other. Girls experiencing menarche during August-October were statistically significantly younger than those experiencing it at other times. Season of birth was not associated with season of menarche.^ The lengths of approximately 150,000 menstrual intervals of U.S. women were analyzed for seasonality. Menstrual intervals possibly disturbed by natural (e.g., childbirth) or other events (e.g., surgery, medication) were excluded. No 6- or 12-month rhythmicities were found for specific interval lengths (14-24, 25-31 and 32-56 days) or ages in relation to menstrual interval (9-11, 12-13, 15-19, 20-24, 25-39, 40-44 and 44 yr old and older).^ Hot flash data of 14 women experiencing natural menopause (NM) and 11 experiencing surgically-induced menopause (SIM) did not differ in frequency of hot flashes. Hot flashes in NM women exhibited 12- and 8-hr, but not 24-hr rhythmicities. Hot flashes in SIM women exhibited 24- and 12-hr, but not 8-hr, rhythmicities. Regardless of type of menopause, women with a peak frequency in hot flashes during the morning (0400 through 0950) were distinguishable from those with such in the evening (1600 through 2159).^ Data from approximately 200 U.S. women revealed a 6-month rhythm in menopause with first peak in May. No significant 12-month variation in menopause was detected by Cosinor analysis. Season of birth and age at menopause were not associated with season of menopause. Age at menopause declined significantly over the years for women born between 1907 and 1926, inclusive. ^

The incidence of necrotizing changes in adults with pneumococcal pneumonia

Background. Necrotizing pneumonia is generally considered a rare complication of pneumococcal pneumonia in adults. We systematically studied the incidence of necrotizing changes in adult patients with pneumococcal pneumonia, and examined the severity of infection, the role of causative serotype and the association with bacteremia. ^ Methods. We used a data base of all pneumococcal infections identified at our medical center between 2000 and 2010. Original readings of chest X-rays (CXR) and computerized tomography (CT) were noted. All images were then reread independently by 2 radiologists. The severity of disease was assessed using the SMART-COP scoring system. ^ Results. There were 351 cases of pneumococcal pneumonia. Necrosis was reported in no original CXR readings and 6 of 136 (4.4%) CTs. With re-reading, 8 of 351 (2.3%) CXR and 15 of 136 (11.0%) CT had necrotizing changes. Overall, these changes were found in 23 of 351 (6.6%, 95% CI 4.0 - 9.1) patients. The incidence of bacteremia and the admitting SMART-COP scores were similar in patients with and without necrosis (P=1.00 and P=0.32, respectively). Type 3 pneumococcus was more commonly isolated from patients with than from patients without necrotizing pneumonia (P=0.05), but a total of 10 serotypes were identified among 16 cases in which the organism was available for typing. ^ Conclusions. Necrotizing changes in the lungs were seen in 6.6% (95% CI 4.0 - 9.1) of a large series of adults with pneumococcal pneumonia. Patients with necrosis were not more likely to have bacteremia or more severe disease. Type 3 pneumococcus was commonly implicated, but 9 other serotypes were also identified.^