Breast cancer chemoprevention: An update on current practice and opportunities for primary care physicians.

Several risk assessment models have been validated for the estimation of risk of breast cancer in women. Chemoprevention through hormonal therapy is an effective way to reduce the incidence of breast cancer in women with high risk. Selective estrogen receptor modulators, tamoxifen and raloxifene, are approved for this indication by the United States Food and Drug Administration, and aromatase inhibitors have also shown promise in recent studies. These medications are generally well tolerated, except for reported increased rates of fractures and venous thromboembolic events. Despite strong recommendations from several regulatory bodies, advocacy for chemoprevention has been inadequate in practice, more so among the primary care physicians. Studies have identified several barriers in physicians, patients, and the system, contributing to this problem. Lack of knowledge about risk assessment models and chemoprevention options preclude physicians from prescribing these medications with confidence. Fear of potential adverse events, confusion regarding the purpose of the therapy, and need for continued adherence for five years are among the principal reasons for reduced chemoprevention uptake and early discontinuation among patients. Multifaceted interventions directed at education and training of health care professionals, proper counseling of women at high risk, and promotion of the development of improved medications might help ensure better chemoprevention uptake in the target population.

The Association Between the Mechanical Ventilator Pressures and Outcomes in a Cohort of Patients with Acute Respiratory Failure.

BACKGROUND: Pressures measured during mechanical ventilation provide important information about the respiratory system mechanics and can help predict outcomes. METHODS: The electronic medical records of patients hospitalized between 2010 and 2016 with sepsis who required mechanical ventilation were reviewed to collect demographic information, clinical information, management requirements, and outcomes, such as mortality, ICU length of stay, and hospital length of stay. Mechanical ventilation pressures were recorded on the second full day of hospitalization. RESULTS: This study included 312 adult patients. The mean age is 59.1 ± 16.3 years; 57.4% were men. The mean BMI was 29.3 ± 10.7. Some patients had pulmonary infections (46.2%), and some patients had extrapulmonary infections (34.9%). The overall mortality was 42.6%. In a multi-variable model that included age, gender, number of comorbidities, APACHE 2 score, and PaO2/FiO2 ratio, peak pressure, plateau pressure, driving pressure, and PEEP all predicted mortality when entered into the model separately. There was an increase in peak pressure, plateau pressure, and driving pressure across BMI categories ranging from underweight to obese. CONCLUSIONS: This study demonstrates that ventilator pressure measurements made early during the management of patients with acute respiratory failure requiring mechanical ventilation provide prognostic information regarding outcomes, including mortality. Patients with high mechanical ventilator pressures during the early course of their acute respiratory failure require more attention to identify reversible disease processes when possible. In addition, increased BMIs are associated with increased ventilator pressures, and this increases the complexity of the clinical evaluation in the management of obese patients.

Unfavorable Socioeconomic Factors Underlie High Rates of Hospitalization for Complicated Thyrotoxicosis in Some Regions of the United States.

OBJECTIVE: The authors' institution-a safety net, university, and tertiary-care hospital located in West Texas-has a high number of hospital admissions for complicated thyrotoxicosis. It was hypothesized that unfavorable socioeconomic conditions result in increased risk of poor outcomes in hyperthyroid patients, and increased rates of hospitalization for thyrotoxicosis in West Texas. The primary aim of this study was to identify factors associated with admission for complicated thyrotoxicosis in patients living in the Panhandle and Llano Estacado of Texas. METHOD: A retrospective chart review of patients aged ≥18 years with a diagnosis of thyrotoxicosis evaluated at the authors' institution from January 2011 to January 2017. Patients were divided into two groups: a hospitalized group, consisting of patients who required hospitalization for complicated thyrotoxicosis, and an outpatient group. Demographics, clinical, and biochemical data were reviewed to identify factors associated with hospitalization for complicated thyrotoxicosis. RESULTS: The hospitalized group consisted of 80 patients, and the outpatient group consisted of 294 patients. Thyrotoxicosis accounted for 0.05% of all-cause hospital admissions during the study period. Patients with thyrotoxicosis and a lack of health insurance had 12 times higher odds of being hospitalized for complicated thyrotoxicosis compared to patients with commercial insurance. Conversely, the odds of hospitalization for complicated thyrotoxicosis were reduced by 63% in patients with a higher median income, and by 33% in those with college or university studies versus high school studies. Thirty-two percent of patients hospitalized for complicated thyrotoxicosis presented with thyroid storm, and this accounted for 7% of the studied cohort. CONCLUSION: Socioeconomic conditions are the main factors associated with the odds of being admitted to a hospital in West Texas for complicated thyrotoxicosis, including thyroid storm. Patients without healthcare insurance have higher odds of admission, while patients with higher education and living in areas of higher income have lower odds of hospital admission due to thyrotoxicosis.

Primary esophageal diffuse large B cell lymphoma presenting with tracheoesophageal fistula: A rare case and review.

Primary non-Hodgkin lymphomas in the esophagus are rare. Tracheoesophageal fistulas mainly arise from solid esophageal carcinoma or mediastinal malignancies. Our patient presented with cough, dysphagia and weight loss, and upon initial computed tomography imaging and esophagogastroduodenoscopy, a malignant mass in the middle third of esophagus with tracheoesophageal fistula was found. The location of the mass and presence of malignant tracheoesophageal fistula were strongly suggestive of squamous cell carcinoma. However, tumor biopsy revealed diffuse large B-cell lymphoma. This case report details a rare incident of a primary diffuse large B-cell lymphoma presented as tracheoesophageal fistula and reviews previous literature.