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

Amnesia global transitoria y consumo de tóxicos que motivan la consulta al servicio de urgencias

Objetivo: Conocer la epidemiología de las consultas en urgencias por amnesia global transitoria (AGT), ya sea pura, asociada al consumo de tóxicos o en el contexto de una agresión sexual. Metodo: Estudio retrospectivo de enero a diciembre de 2018. Se revisaron las AGT atendidas en intoxicados (AGTtox), en víctimas de agresiones sexuales (AGTsex) y las amnesias puras (AGTpur), evaluando la presencia de tóxicos. Resultados: Se identificaron 287 AGT: 169 AGTsex (58,9%), 62 AGTpur (21,6%) y 56 AGTtox (19,5%). De ellas, 218 (76%) fueron mujeres y la edad osciló entre 16 y 90 años (60,6% menores de 30 años). Reconocieron consumo de alcohol 201 casos (72,8%), con etanolemia positiva en 105 (49,1%) (media de 0,74 g/l y máxima de 3,9 g/l). Admitieron consumo de cannabis 20 pacientes (7,1%), con analítica positiva en 39 casos (17,3%); cocaína 14 (4,9%), con analítica positiva en 28 (12,4%), y anfetaminas 5 (1,7%), con analítica positiva en 20 (8,8%). Presentaron síntomas de intoxicación 58 casos (20,1%). Cuatro pacientes ingresaron en coma. Se realizó una tomografía computarizada (TC) craneal a 66 pacientes (23%), se hospitalizaron 7 y no hubo ningún fallecimiento. Conclusiones: La prevalencia de AGT es mayor si se incluyen los intoxicados y las agresiones sexuales, modificando la determinación de tóxicos la epidemiología de la AGT en urgencias

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

Primary care referrals of patients with potentially serious diseases to the emergency department or a quick diagnosis unit: a cross-sectional retrospective study.

BACKGROUND: In Spain, primary healthcare (PHC) referrals for diagnostic procedures are subject to long waiting-times, and physicians and patients often use the emergency department (ED) as a shortcut. We aimed to determine whether patients evaluated at a hospital outpatient quick diagnosis unit (QDU) who were referred to ED from 12 PHC centers could have been directly referred to QDU, thus avoiding ED visits. As a secondary objective, we determined the proportion of QDU patients who might have been evaluated in a less rapid, non-QDU setting. METHODS: We carried out a cross-sectional retrospective cohort study of patients with potentially serious conditions attended by the QDU from December 2007 to December 2012. We established 2 groups of patients: 1) patients referred from PHC to QDU (PHC-QDU group) and 2) patients referred from PHC to ED, then to QDU (PHC-ED-QDU group). Two observers assessed the appropriateness/inappropriateness of each referral using a scoring system. The interobserver agreement was assessed by calculating the kappa index. Multivariate logistic regression analysis was performed to identify the factors associated with the dependent variable 'ED referral'. RESULTS: We evaluated 1186 PHC-QDU and 1004 PHC-ED-QDU patients and estimated that 93.1% of PHC-ED-QDU patients might have been directly referred to QDU. In contrast, 96% of PHC-QDU patients were found to be appropriately referred to QDU first. The agreement for PHC-QDU referrals (PHC-QDU group) was rated as excellent (ϰ=0.81), while it was rated as good for PHC-ED referrals (PHC-ED-QDU group) (ϰ=0.75). The mean waiting-time for the first QDU visit was longer in PHC-QDU (4.8 days) than in PHC-ED-QDU (2.6 days) patients (P=.001). On multivariate analysis, anemia (OR 2.87, 95% CI 1.49-4.55, P<.001), rectorrhagia (OR 2.18, 95% CI 1.10-3.77, P=.01) and febrile syndrome (OR 2.53, 95% CI 1.33-4.12, P=.002) were independent factors associated with ED referral. Nearly one-fifth of all QDU patients were found who might have been evaluated in a less rapid, non-QDU setting. CONCLUSIONS: Most PHC-ED-QDU patients might have been directly referred to QDU from PHC, avoiding the inconvenience of the ED visit. A stricter definition of QDU evaluation criteria may be needed to improve and hasten PHC referrals

Cambios en la etiología, incidencia y pronóstico de la infección respiratoria aguda de vías bajas en pacientes infectados por el virus de la inmunodeficiencia humana

Aim To describe the, incidence, the changes in the etiology and the prognosis of lower respiratory tract infection (LRTI) in HIV infected patients, presenting by the first time to the Emergency Department (ED), during years 2000-2010. Study design Prospective collection of data. Metbods Data were collected on the first visit of HIV-infected patients at our ED due to a LRTI, (defined according to the criteria of the European Respiratory Society), between 1/1/2000 and 31/12/2010. A series of epidemiological and laboratory variables as well as the need for admission to the intensive care unit (ICU). LRTI etiology were also collected. The influence ofthe mentioned variables on 30-day mortality were analyzed. Results One hundred thirty one patients were included. LRTI represented 27% of visits to the ED by HIV-infected patients. Mean age was 39±9 years. 72% of patients were males. 18% required admission to the ICU. The most frequent LRTI was pneumonia by P. jiroveci in 35 cases, bacterial penumonia in 27 and pulmonary tuberculosis in 20. LRTI incidence gradually reduced significantly over time from 6.13 × 1000 patients/year in year 2000 to 0.23 × 1000 patients/year in 2010 (p<0.05). Overall mortality was 14%. Logistic regression analysis showed that admission to ICU (p<0.004) and viral load (p<0.029) were independent variables predicting mortality. Conclusion LRTI is a pathology with a decreasing incidence, probably related to the widespread utilization increased of HAART regimens. lts etiology has also been changing, but with a non negligible mortality, mostly when ICU admission was required.Objetivo Describir la incidencia, la etiología y el pronóstico de la infección de las vías espiratorias bajas (IVRB) en los pacientes VIH, que acudieron a un Servicio de Urgencias (SU), durante el período del 2000–2010. Diseño del estudio Estudio prospectivo de 10 años de evolución. Métodos Se recogió únicamente el primer episodio del paciente que acude al SU por IRVB (definida según la European Respiratory Society). Se analizaron una serie de variables epidemiológicas y de laboratorio, así como la necesidad de ingreso en una unidad de cuidados intensivos (UCI). Se estudió la etiología de la IRVB y la incidencia. Finalmente se analizaron la influencia de las variables con la mortalidad a 30 días. Resultados Se incluyeron un total de 131 pacientes. La edad media fue de 39 ± 9 años. El 72% de los pacientes eran varones y el 18% de los pacientes requirieron ingreso en la UCI. La IRVB más frecuente fue la neumonía por P. jirovecci, seguida de la neumonía bacteriana en 27 y la tuberculosis pulmonar en 20. La incidencia de IRVB se ha ido reduciendo gradualmente de forma significativa, 6,13 × 1.000 pacientes/año en 2000 a 0,23 × 1.000 pacientes/año en 2010 (p < 0,05). El análisis de regresión logística mostró que la única variable que predijo mortalidad fue el ingreso en UCI (p < 0,05; OR: 73,01). Conclusión La IRVB es una enfermedad cuya incidencia y etiología han ido disminuyendo y cambiando respectivamente, probablemente en relación con la utilización generalizada del TAR. Sin embargo, todavía presenta una mortalidad nada despreciable, que es mayor cuando el paciente requiere ingreso en la UCI

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

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

Characteristics of 19 patients diagnosed with cancer during follow-up.

<p>Characteristics of 19 patients diagnosed with cancer during follow-up.</p

Eighteen months’ outcomes of patient groups.

<p>Eighteen months’ outcomes of patient groups.</p