Unintentional weight loss: Clinical characteristics and outcomes in a prospective cohort of 2677 patients.

Background Whereas there are numerous studies on unintentional weight loss (UWL), these have been limited by small sample sizes, short or variable follow‐up, and focus on older patients. Although some case series have revealed that malignancies escaping early detection and uncovered subsequently are exceptional, reported follow-ups have been too short or unspecified and necropsies seldom made. Our objective was to examine the etiologies, characteristics, and long-term outcome of UWL in a large cohort of outpatients. Methods We prospectively enrolled patients referred to an outpatient diagnosis unit for evaluation of UWL as a dominant or isolated feature of disease. Eligible patients underwent a standard baseline evaluation with laboratory tests and chest X-ray. Patients without identifiable causes 6 months after presentation underwent a systematic follow-up lasting for 60 further months. Subjects aged ≥65 years without initially recognizable causes underwent an oral cavity examination, a videofluoroscopy or swallowing study, and a depression and cognitive assessment. Results Overall, 2677 patients (mean age, 64.4 [14.7] years; 51% males) were included. Predominant etiologies were digestive organic disorders (nonmalignant in 17% and malignant in 16%). Psychosocial disorders explained 16% of cases. Oral disorders were second to nonhematologic malignancies as cause of UWL in patients aged ≥65 years. Although 375 (14%) patients were initially diagnosed with unexplained UWL, malignancies were detected in only 19 (5%) within the first 28 months after referral. Diagnosis was established at autopsy in 14 cases. Conclusion This investigation provides new information on the relevance of follow-up in the long-term clinical outcome of patients with unexplained UWL and on the role of age on this entity. Although unexplained UWL seldom constitutes a short-term medical alert, malignancies may be undetectable until death. Therefore, these patients should be followed up regularly (eg yearly visits) for longer than reported periods, and autopsies pursued when facing unsolved deaths

Time to diagnosis and associated costs of an outpatient vs inpatient setting in the diagnosis of lymphoma: a retrospective study of a large cohort of major lymphoma subtypes in Spain

Background: Mainly because of the diversity of clinical presentations, diagnostic delays in lymphoma can be excessive. The time spent in primary care before referral to the specialist may be relatively short compared with the interval between hospital appointment and diagnosis. Although studies have examined the diagnostic intervals and referral patterns of patients with lymphoma, the time to diagnosis of outpatient compared to inpatient settings and the costs incurred are unknown. Methods: We performed a retrospective study at two academic hospitals to evaluate the time to diagnosis and associated costs of hospital-based outpatient diagnostic clinics or conventional hospitalization in four representative lymphoma subtypes. The frequency, clinical and prognostic features of each lymphoma subtype and the activities of the two settings were analyzed. The costs incurred during the evaluation were compared by microcosting analysis. Results: A total of 1779 patients diagnosed between 2006 and 2016 with classical Hodgkin, large B-cell, follicular, and mature nodal peripheral T-cell lymphomas were identified. Clinically aggressive subtypes including large B-cell and peripheral T-cell lymphomas were more commonly diagnosed in inpatients than in outpatients (39.1 vs 31.2% and 18.9 vs 13.5%, respectively). For each lymphoma subtype, inpatients were older and more likely than outpatients to have systemic symptoms, worse performance status, more advanced Ann Arbor stages, and high-risk prognostic scores. The admission time for diagnosis (i.e. from admission to excisional biopsy) of inpatients was significantly shorter than the time to diagnosis of outpatients (12.3 [3.3] vs 16.2 [2.7] days; P < .001). Microcosting revealed a mean cost of (sic)4039.56 (513.02) per inpatient and of (sic)1408.48 (197.32) per outpatient, or a difference of (sic)2631.08 per patient. Conclusions: Although diagnosis of lymphoma was quicker with hospitalization, the outpatient approach seems to be cost-effective and not detrimental. Despite the considerable savings with the latter approach, there may be hospitalization-associated factors which may not be properly managed in an outpatient unit (e.g. aggressive lymphomas with severe symptoms) and the cost analysis did not account for this potentially added value. While outcomes were not analyzed in this study, the impact on patient outcome of an outpatient vs inpatient diagnostic setting may represent a challenging future research

Full blood count values as a predictor of poor outcome of pneumonia among HIV-infected patients

Background To evaluate the predictive value of analytical markers of full blood count that can be assessed in the emergency department for HIV infected patients, with community-acquired pneumonia (CAP). Methods Prospective 3-year study including all HIV-infected patients that went to our emergency department with respiratory clinical infection, more than 24-h earlier they were diagnosed with CAP and required admission. We assessed the different values of the first blood count performed on the patient as follows; total white blood cells (WBC), neutrophils, lymphocytes (LYM), basophils, eosinophils (EOS), red blood cells (RBC), hemoglobin, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin concentration, mean corpuscular hemoglobin, red blood cell distribution width (RDW), platelets (PLT), mean platelet volume, and platelet distribution width (PDW). The primary outcome measure was 30-day mortality and the secondary, admission to an intensive care unit (ICU). The predictive power of the variables was determined by statistical calculation. Results One hundred sixty HIV-infected patients with pneumonia were identified. The mean age was 42 (11) years, 99 (62%) were male, 79 (49%) had ART. The main route of HIV transmission was through parenteral administration of drugs. Streptococcus pneumonia was the most frequently identified etiologic agent of CAP The univariate analysis showed that the values of PLT (p < 0.009), EOS (p < 0.033), RDW (p < 0.033) and PDW (p < 0.09) were predictor of mortality, but after the logistic regression analysis, no variable was shown as an independent predictor of mortality. On the other hand, higher RDW (OR = 1.2, 95% CI 1.1-1.4, p = 0.013) and a lower number of LYM (OR 2.2, 95% CI 1.1-2.2; p = 0.035) were revealed as independent predictors of admission to ICU. Conclusion Red blood cell distribution and lymphocytes were the most useful predictors of disease severity identifying HIV infected patients with CAP who required ICU admission. Electronic supplementary material The online version of this article (10.1186/s12879-018-3090-0) contains supplementary material, which is available to authorized users

Maneig de la sèpsia en un servei d'Urgències hospitalàries d'un centre de tercer nivell. Oportunitats de millora

[cat] La sèpsia és una de les principals causes de mortalitat en el nostre medi. A Catalunya, la incidència de sèpsia en els últims anys ha estat de 213 casos per 100.000 habitants amb una mortalitat hospitalària del 21,6%. Si el quadre clínic és de xoc sèptic, la mortalitat és superior al 35%. La revisió del 2018 de la SSC i l'Intitute for Healthcare Improvement recomanen la implementació d'un conjunt de mesures durant la primera hora d'estada als serveis d'urgències hospitalàries (SUH) en els pacients amb sospita de sèpsia. El compliment d'aquestes mesures s'associa a un millor pronòstic 167. A pesar de l'eficàcia d'aquestes mesures ens trobem amb dues limitacions a l’hora d'optimitzar el maneig inicial d'aquests pacients: la dificultat per identificar els pacients amb sèpsia, a causa de la naturalesa ambigua de les manifestacions clíniques inicials, i l'adhesió heterogènia per part del personal sanitari a les guies de maneig de la sèpsia. El 1992 es van publicar per primera vegada les definicions de sèpsia, basades en els criteris de SIRS. Deu anys després, es van revisar els criteris i es van publicar les conclusions de la segona conferència del consens, que no va modificar substancialment aquestes definicions 23,168. Amb el pas dels anys, aquests criteris van mostrar algunes deficiències que van suscitar algunes crítiques per part de la comunitat científica. El SIRS va ser considerat poc sensible i inespecífic 169,170. Experts de diferents societats científiques van publicar la tercera definició de consens de la sèpsia i el xoc sèptic amb alguns canvis importants: es van eliminar els conceptes de SIRS i de sèpsia greu; la sèpsia es va definir com una disfunció orgànica potencialment mortal per una resposta de l’hoste desregulada a la infecció, i es va determinar com a criteri de sèpsia la variació, d'almenys, dos punts de l’indicador SOFA26. A més, van proposar l'indicador qSOFA per predir la mortalitat intrahospitalària fora de l’UCI27. Tot i la importància de la sèpsia quant a incidència, gravetat i costos, encara es detecten deficiències en la seva identificació i en el seu maneig terapèutic. Per aquests motius ens vam plantejar conèixer i analitzar com s’identifica i com es tracta la sèpsia en el nostre SUH i investigar com es podria millorar el circuit assistencial. Els estudis que componen la present tesi es van realitzar a l'Hospital Clínic de Barcelona. L'assistència del SUH està organitzada per nivells de gravetat segons el model de triatge establert MAT. En relació a l'atenció del pacient amb sèpsia o xoc sèptic cal dir que no existeix una detecció específica ni un circuit físic determinat. Per tal d'assolir els objectius es va dividir el treball en quatre estudis. El primer analitza com es realitza la prescripció d’antibiòtics en un SUH. El segon ens permet detectar les barreres amb les quals es troba el personal sanitari en la prescripció i l'administració dels antibiòtics en un SUH. El tercer descriu les característiques del maneig inicial de la sèpsia greu i el xoc sèptic. Finalment, el quart analitza el valor diagnòstic i pronòstic de l'indicador qSOFA en el triatge dels pacients que consulten en un SUH. Aquests estudis han permès identificar aspectes rellevants de la clínica, l'epidemiologia i el maneig dels pacients que consulten al nostre SUH per sèpsia. D'aquesta manera hem contribuït a identificar oportunitats de millora i així establir les bases pel disseny d'estratègies, tant en el diagnòstic com en el tractament d'aquesta patologia, que permetin avançar en la seguretat i qualitat assistencial d’aquests malalts. Les conclusions d’aquesta tesi ens ha permès dissenyar estratègies formatives i de prescripció electrònica que actualment estan implementant en el nostre SUH.[eng] Sepsis is one of the main causes of mortality in our environment. In Catalonia, the sepsis's incidence has been 213 cases per 100.000 inhabitants with a 21.6% hospital mortality in the last years. If the symptoms suggest septic shock, the mortality is greater than 35%. The 2018 SCC and Institute for Healthcare Improvement revision recommend the implementation of a set of measures in patients with suspected sepsis, during the first hour of stay in the emergency department (ED). The compliance with these measures is associated with a better prognosis 167. Despite the effectiveness of these measures we find two limitations when it comes to optimizing the patients’ initial treatment: the difficulty in identifying the patients with sepsis, due to the ambiguous nature of the initial clinical manifestations, and the health personnel heterogeneous adhesion to the sepsis guidelines. The researches that make up the present thesis were carried out at the Hospital Clínic of Barcelona. The ED assistance is organized by levels of gravity according to the established triage model MAT. In relation to the patient's attention with sepsis or septic shock, it must be said that there is no specific detection, neither a defined physical circuit. In order to achieve the objectives, the project was divided into four studies. The first one analyzes how the antibiotics prescription is performed in a ED. The second allows us to detect the barriers that can hampered the antibiotics prescription and administration in a ED by the health personnel. The third one describes the characteristics of the initial management of severe sepsis and septic shock. Finally, the fourth analyzes the diagnostic and prognostic value of the qSOFA indicator in the patients selection who consult in a ED. These researches have helped to identify relevant aspects of the clinic, epidemiology and management of patients who consult for sepsis in our ED. In this sense, we have contributed to identify opportunities for improvement and thus to lay the foundations for the design of strategies, both in the diagnosis as well as the treatment of this pathology, which allow us to make improvements in the safety and the quality care of these patients. The thesis conclusions have allowed us to design the training strategies and electronic prescription that are currently being implemented in our ED