Unintended Weight Loss Research Articles

Statin Use and Incident Frailty in Women Aged 65 Years or Older: Prospective Findings From the Women's Health Initiative Observational Study

Inflammatory biomarkers have shown consistent associations with disability and frailty in older adults. Statin medications may reduce the incidence the frailty because of their anti-inflammatory effects. This study examines associations between current use, duration, and potency of statin medications and incident frailty in initially nonfrail women 65 years old or older. The authors conducted a prospective analysis of data from the Women's Health Initiative Observational Study (WHI-OS) conducted at 40 clinical centers in the United States. Eligible women were nonfrail and 65-79 years old at baseline (n = 25,378). Current statin use at baseline was ascertained through direct inspection of medicine containers during clinic visits. Frailty was ascertained through self-reported indicators and physical measurements at baseline and 3-year clinic contacts. Components of frailty included self-reported low physical function, exhaustion, low physical activity, and unintended weight loss. Multinomial logistic regression models were used to adjust for covariates predicting incident frailty. Among the 25,378 eligible women, 3453 (13.6%) developed frailty by the 3-year follow-up contact. Current statin use had no association with incident frailty (multivariate-adjusted odds ratio [OR] = 1.00; 95% confidence interval [CI], 0.85-1.16). Duration and potency of statin use were also not significantly associated with incident frailty. Among low potency statin users, longer duration of use was associated with reduced risk of frailty (p for trend =.02). A similar pattern of results was observed when frailty was studied in the absence of intervening, incident cardiovascular events. Overall, incidence of frailty was similar in current statin users and nonusers.

Unintended Weight Loss in Older Persons

Unintended weight loss has a profound effect on morbidity and mortality in older persons. A therapeutic approach to unintended weight loss in older persons depends on correct classification. A careful differential diagnostic approach is mandatory, combined with nutritional and often pharmacological interventions. While starvation due to protein-energy undernutrition is widely regarded as the primary cause of loss of fat and fat-free mass in older persons, a failure to improve with nutritional replacement should trigger a consideration of other causes. Both sarcopenia and cachexia are resistant to hypercaloric feeding. Cachexia may be amenable to suppression of proinflammatory cytokines in known inflammatory disease states.

A prospective study on malnutrition and quality of life in patients with head and neck cancer

The objective of this observational prospective study in patients with squamous cell carcinoma (SCC) of the oral, oropharyngeal and hypopharyngeal cavity was to look into the relation between malnutrition (>or=10% unintended weight loss within 6 months) and specific quality of life (QoL) parameters longitudinally. Bodyweight and QoL were monitored in 47 patients with SCC at diagnosis, end of treatment and six months after treatment. EORTC QoLQ-C30 and H&N 35 questionnaires were used to assess QoL. Significantly lower scores on the global QoL during treatment (p=0.01) and revalidation (p=0.02) were found for patients who had lost >or=10% compared to patients with <10% loss of weight within 6 month. Patients with radiotherapy and a treatment modality of radiotherapy with surgery or chemotherapy kept their unintended weight loss until the end of treatment. Patients with head and neck cancer treated with radiotherapy are specifically susceptible to malnutrition during treatment with no improvement in body weight or QoL. Professional preventive nutritional support is therefore already required on diagnoses.

Unintended weight loss in the elderly living at home: the aged in Home Care Project (AdHOC).

To describe associations between unintended weight loss (UWL) and characteristics of nutritional status. A comparative cross-sectional assessment study at 11 sites in Europe. The target population was a stratified random sample of 4,455 recipients of home care (405 in each random sample from 11 urban areas) aged 65 years and older. the Resident Assessment Instrument for Home Care, version 2.0. Epidemiological and medical characteristics of clients and service utilisation were recorded in a standardized, comparative manner. UWL was defined as information of 5% or more weight loss in the last 30 days (or 10% or more in the last 180 days). The final sample consisted of 4,010 persons; 74% were female. The mean ages were 80.9 +/- 7.5 years (males) and 82.8 +/- 7.3 years (females). No associations were found between single diagnoses and UWL, except for cancer. Cancer patients were excluded from further analyses. Persons with a Cognitive Performance Scale value (CPS) superior 3 (impaired) had increased risk of UWL (OR = 2.0) compared with those scoring inferior or egal 3 (less impaired). Only in the oldest group did we find a significant association between UWL and reduction in ADL and IADL functions, comparing those who scored 3 or less with those who scored more than 3 (disabled). A binary logistic regression model explained 26% of UWL: less than one meal/day, reduced appetite, malnutrition, reduced social activity, experiencing a flare-up of a recurrent or chronic problem, and hospitalisation were important indicators. We recommend a regular comprehensive assessment in home care to identify clients with potential risk factors for weight loss and malnutrition, in particular those discharged from hospital, and those with physical dependency or cognitive problems. This study may provide incentives to create tailored preventive strategies.

Urinary Incontinence: A Neglected Geriatric Syndrome in Nursing Facilities

Urinary incontinence (UI) is common but inadequately assessed and treated in nursing facility (NF) residents. The purpose of this study is two-fold: (1) to determine perceptions about the importance of UI and its management in the NF setting compared with other geriatric syndromes and (2) to compare barriers to UI care as perceived by physicians, geriatric nurse practitioners (GNPs), directors of nursing and other nurses in administrative positions (DONs), and nursing assistants (NAs). Computer-based surveys of physicians and DONs and a hard copy survey of NAs at their national meetings; an online survey of GNPs. Responses included 395 physicians (31% response rate), 152 DONs (34%), 118 GNPs (23%), and 277 NAs (60%). Physicians, GNPs, and DONs evaluated and managed UI significantly less often than 5 other geriatric syndromes (behavioral symptoms of dementia, falls, unintended weight loss, pain, and delirium). In contrast, NAs were more likely to be involved in UI care than in care provided for residents with any of the other 5 syndromes. All 4 groups agreed that UI has less effect on clinical outcomes than the other 5 syndromes. However, DONs rated UI first with respect to cost of care; NAs third behind falls and pain; and physicians and GNPs rated UI fourth behind falls, behavioral symptoms, and delirium. With respect to quality of life effects, physicians and GNPs rated UI fifth and fourth respectively and DONs fourth. In contrast, NAs rated UI second only to pain with respect to its effect on quality of life. Perceived barriers differ among the 4 groups with physicians relatively more concerned that drug treatment alone is ineffective (P = .002); GNPs relatively more concerned with lack of effective nondrug interventions (P = .001); and DONs relatively more concerned about sufficient time to assess and manage UI (P = .001). NA respondents rated concern about anticholinergic drug effects lower than did respondents in the other 3 groups (P = .001). Physicians, GNPs, and DONs are more likely to be involved in evaluating and managing behavioral symptoms of dementia, pain, falls, delirium, and unintended weight loss than UI in the NF setting. This leaves NAs as first-line managers for a condition that they perceive to have an important impact on quality of life. Perceived barriers to improving UI care differ among the 4 groups suggesting that approaches to overcoming the barriers should be multi-faceted.

An unusual case of high alpha-fetoprotein level and liver masses

A 60-year-old man was admitted to our institution because of abdominal ultrasound and CT scan evidence of several solid liver masses (Fig. 1, abdominal CT scan) associated with significantly increased alpha-fetoprotein level (1800ng/ml; normal value <15). Unintended weight loss, anorexia and weakness occurred in the previous 4 months. He denied alcohol abuse and liver diseases. His medical history was unremarkable except for duodenal ulcer diagnosed by barium enema 15 years before and treated with H-2 antagonists.

Chewing Problems and Mortality in Older Adults in Home Care: Results from the Aged in Home Care Study

To assess the association between chewing problems and risk of mortality in an older population receiving home care in Europe. Retrospective cohort study. Eleven European countries. Two thousand seven hundred fifty-five older adults (mean age+/-standard deviation 82.2+/-7.2) in home care. Data were collected using the Minimum Data Set for Home Care. Study personnel recorded chewing problems (inability to chew food easily and without pain or difficulties, regardless of cause) that presented in the last 3 days before baseline assessment. Data on mortality were collected over a 1-year period. Three hundred ninety-five participants (14.3%) presented with chewing problems. One-year mortality differed significantly according to presence of chewing problems; 303 of 2,361 (12.8%) without chewing problems (crude incident rate per person-year (p-y)=0.15) and 80 of 394 (20.3%) participants with chewing problems (crude incident rate per p-y=0.24) died during follow-up. After adjusting for potential confounders, the risk of death was significantly higher for participants with chewing problems (adjusted hazard ratio (HR)=1.45, 95% confidence intervals (CI)=1.05-1.99). This association remained after exclusion of participants with cognitive impairment (adjusted HR=1.50, 95% CI=1.03-2.20) and those with unintended weight loss (adjusted HR=1.62, 95% CI=1.12-2.34). In older adults in home care in Europe, chewing problems are associated with greater risk of mortality.

Endoscopic Mucosal Resection of H. Pylori Negative Esophageal MALT Lymphoma

Introduction: MALT lymphoma is a cancer of gastrointestinal mucosa associated with H. Pylori infection. Less than 1% of MALT lymphoma occur in the esophagus. Esophageal MALT lymphoma has previously been treated with radiation therapy. We describe a case of Endoscopic Mucosal Resection as therapy for the treatment of esophageal MALT lymphoma confined to the mucosa. Case: A 38 year old female presented with 3 months of GERD symptoms despite treatment with a variety of medications. She denied hematemesis, melena, hematochezia or unintended weight loss. She denied alcohol or tobacco use. Her family history is significant for a father with colon polyps. Physical exam was unremarkable. Laboratory analysis: WBC 8, HCT 43, Plts 275, K 4.0, Cr 0.7, LFT normal. H. Pylori IgG Negative. An EGD was performed that demonstrated a 4.4 mm*1.8 mm nodule 4 cm above the GE junction. Biopsies of the nodule demonstrated lymphoma. Gastric biopsies demonstrated no evidence of H. Pylori or malignancy. EUS demonstrated a hypoechoic lesion with 2 mm of depth localized to the mucosa. CT scan showed no evidence of lymphadenopathy or other disease. The nodule was removed with an EMR technique. It was first raised with 10 cc of normal saline. An oblique 16 mm hard EMR cap was attached to a single channel therapeutic endoscope and the nodule was removed using a snare. Histopathology showed extranodal monoclonal kappa restricted marginal cell lymphoma with normal surrounding mucosa. Immunohistochemistry demonstrated: LCA+/CD20+/CD79a+ Bcle-2 staining demonstrated residual reactive germinal center. Discussion: Extranodal MALT lymphomas arise in mucosal organs of the gastrointestinal tract, usually in the stomach and colon. H. Pylori infection is the usual underlying etiology of MALT lymphoma in the stomach and eradication of H. Pylori is the initial treatment of choice for gastric MALT lymphoma. This patient demonstrated no evidence of H. Pylori infection on either gastric biopsy or serology. MALT lymphoma in the esophagus is very rare. MALT lymphomas are confined to the primary site and tend to disseminate slowly. There have been two previously documented cases of MALT lymphoma arising in the esophagus. In these reports EMR has been demonstrated to be an effective technique to remove MALT lymphoma that has not invaded the muscularis. Complete removal of esophageal MALT lymphoma with EMR precludes further treatment with radiation therapy.

Unintentional onset of anorexia nervosa

The purpose of this article is to report a series of patients with an onset of anorexia nervosa precipitated by unintended weight loss rather than the more typical onset following intentional dieting, or the occasional iatrogenic beginning. Retrospectively, case notes of 66 consecutive outpatient evaluations at an eating disorder diagnostic clinic between 2002 and 2006 were reviewed. Five cases, 7.6%, of inadvertent onset anorexia nervosa were identified. Causes of the inadvertent weight loss were varied: the mourning of a death, a parasitic infection, medication side effects and surgery. None had intended to lose weight. We postulate that inadvertent weight loss may be as powerful a trigger as intentional dieting to initiating anorexia nervosa in predisposed individuals; self-induced weight loss may not be a necessary precursor to anorexia nervosa.

Phase I Study of Radical Thoracic Radiation, Weekly Irinotecan, and Cisplatin in Locally Advanced Non-small Cell Lung Carcinoma

Irinotecan and cisplatin individually are active in non-small cell lung carcinoma (NSCLC). Each is synergistic with radiation. Dosages of 65 mg/m2 of irinotecan and 30 mg/m2 of cisplatin Q weekly times four every 6 weeks yielded a 36% response rate and median survival of 11.6 months in advanced NSCLC (Jagasia et al.; Clinical Cancer Research 7: 68, 2001). A weekly schedule for each agent (versus less frequent doses) limits toxicity and increases the opportunity for radiosensitization. We initiated a phase I study of weekly irinotecan and cisplatin during radical thoracic radiation (TRT). Cisplatin was fixed at 25 mg/m2 Q weekly times seven. Irinotecan was dosed initially at 30 mg/m2 per week for 7 weeks and was increased by 10 mg/m2 per week in three- to six-patient cohorts. TRT was administered in 34 single daily fractions to 63 Gy. Eligibility stipulated locally advanced NSCLC; Eastern Cooperative Oncology Group performance status 0 to 1; < or = 10% unintended weight loss; and adequate physiologic indices. Fifteen patients were accrued: nine were stage IIIB, five were stage IIIA, and one had isolated mediastinal node recurrence after prior surgery. Median age was 65 years (range, 47-77). Seven patients received irinotecan at a dose of 30 mg/m2 per week; (dose level 1). Seven other patients received irinotecan at a dose of 40 mg/m2 per week; (dose level 2). The one other patient received irinotecan in doses of 50 mg/m2 per week; (dose level 3). Neutropenic fever occurred in one patient each at dose levels 1 and 2. Grade 4 neutropenia occurred in three patients at each dose level. Transient grade 3 diarrhea occurred in one patient at dose level 1. Esophagitis of grade 3 or higher occurred in one patient each at dose levels 2 and 3. There was one late grade 3 pneumonitis at dose level 2. Delivered irinotecan dose intensity for dose level 1 was 27 mg/m2 per week; for dose level 2, it was 31.4 mg/m2 per week. Nine of 13 evaluable patients (69%) responded. At median potential follow-up of 5 years, 14 have progressed, and 11 have died. Projected median survival is 28 months; one patient who was treated for mediastinal node recurrence remains free from progression at 6 years. Weekly irinotecan and cisplatin combined with radical TRT (63 Gy) is active and fairly well tolerated in locally advanced NSCLC. In combination with fixed-dose cisplatin (25 mg/m2 per week), the maximum-tolerated dose of irinotecan is 30 mg/m2 per week.

A pilot study comparing megestrol acetate concentrated suspension (MA-CS) and megestrol acetate oral suspension (MA-OS) on weight gain in patients with HIV-associated unintended weight loss (UWL)

A pilot study comparing megestrol acetate concentrated suspension (MA-CS) and megestrol acetate oral suspension (MA-OS) on weight gain in patients with HIV-associated unintended weight loss (UWL)

Hypothalamic Dysfunction and Neuroendocrine and Metabolic Alterations in Huntington Disease: Clinical Consequences and Therapeutic Implications

Huntington's disease (HD) is a hereditary neurodegenerative disorder characterized by cognitive, psychiatric, behavioural and motor disturbances. Although the course of HD is also frequently complicated by unintended weight loss, sleep disturbances and autonomic nervous system dysfunction, the aetiology of these signs and symptoms remains largely unknown. In recent years, many novel findings from both animal and human studies have emerged that indicate considerable hypothalamic, endocrine and metabolic alterations in HD. However, a comprehensive overview of these findings is lacking and their precise clinical significance is far from clear. Therefore, in this review we attempt to put these recent developments in the field into perspective by integrating them with previous findings in a comprehensible manner, and by discussing their clinical relevance, with a special focus on body weight, sleep and autonomic functions in HD, which will also allow for the identification of future lines of research in this area.

Lessons Learned from an Old Acquaintance

Lessons Learned from an Old Acquaintance

The Safety of Megestrol Acetate Concentrated Suspension (MA-CS) and Megestrol Acetate Oral Suspension (MA-OS) in a Pilot Study in Patients with HIV-Associated Unintended Weight Loss (UWL).

Weight loss remains a common complication of HIV. MA-CS is a NanoCrystal® formulation of megestrol acetate that is bioavailable in the fasted state, which provides benefit in the treatment of UWL in HIV patients. 121 patients with HIV-associated UWL were screened and 63 patients (sites: South Africa, India, US) were randomized to MA-CS (575 mg/5 mL, n=32) or MA-OS (800 mg/20 mL, n=31) qAM in an open-label, multi-center, 12-week pilot study. Eligibility for study entry required basal cortisol levels > 10 mcg/dL and ACTH stimulated cortisol levels > 18 mcg/dL within 1 hour (time of day not specified). The standard reference ranges for cortisol are 5–25 mcg/dL at 8 am and 3–12 mcg/dL at 4 pm. Patients had Day 3 and weekly weight measurements. Safety assessments included adverse events, laboratory measures, and vital signs. Abnormal laboratory values, including cortisol levels, were considered adverse events. Demographics were comparable between the groups. Overall mean weight change relative to baseline favored MA-CS 11.9 lbs (10% increase) vs. MA-OS 7.7 lbs (6% increase) as did the time course of weight gain. The most frequently reported adverse events (AEs) and serious adverse events, equally divided between both groups, were related to the adrenal axis. Only 1 patient, of the 5 who discontinued therapy, had cortisol abnormalities. There were few isolated clinical laboratory abnormalities, with the exception of cortisol levels, and no other laboratory trends were identified. Of the 121 patients screened for this study 35 patients (29%) were not eligible for the study due to cortisol abnormalities, as defined by the protocol. Following treatment, mean basal cortisol levels: dropped approximately 70% in both treatment groups, were below 10 mcg/dL in ~ 80% of the patients in each group, and were below 5 mcg/dL in 18 (64%) and 23 (72%) of MA-CS and MA-OS patients, respectively. Following treatment and stimulation with ACTH, a 2-fold increase in cortisol levels occurred within 1 hour in 24/32 MA-CS and 25/28 MA-OS patients, and levels > 18 mcg/dL were seen in 6 MA-CS and 7 MA-OS patients. The majority of patients with lowered basal cortisol levels returned to > 10 mcg/dL within one month after discontinuation of treatment. There were no clinically significant mean changes for hemoglobin A1C and fasting glucose in either group. One patient (MA-OS) discontinued due to elevated glucose. One death occurred on MA-OS and was considered unrelated to the study drug. Megestrol acetate is an effective intervention for HIV-associated weight loss. The study examined the safety profile of MA-CS and MA-OS. The findings were predictable and in line with current labeling for both products. While the glucocorticoid effects noted were consistent with adrenal suppression, the gland continued to be responsive, patients remained asymptomatic and levels returned to normal within one month of discontinuation of treatment in the majority of patients. As with similar agents, when patients are stressed or appear symptomatic while receiving megestrol acetate, administration of replacement corticosteroids should be considered. The changes in glucose metabolism were usually minimal.

Randomized, Double-blind, Placebo Controlled Phase III Trial of Oxymetholone for the Treatment of HIV Wasting and Lipodystrophy

Methods We analyzed the effects of oxymetholone [50 mg BII) and TII)] in a randomized (1:1:1), double-blind, placebo-controlled phase III study with 92 subjects (all on ART) experiencing unintended weight loss>10% of ideal weight according to Broca with special emphasis on body composition measurement 80 patients (69 men,11 women, mean age:38,8 years) completed the 16-week doubleblind study phase.

A Pilot Study Comparing Megestrol Acetate Concentrated Suspension (MA-CS) to Megestrol Acetate Oral Suspension (MA-OS) on Weight Gain and Body Composition in Patients with HIV-Associated Unintended Weight Loss (UWL).

BACKGROUND: MA-CS is a new NanoCrystal® technology formulation of megestrol acetate that is bioavailable in the fasted state, which may provide benefit in the treatment of UWL in HIV patients.METHODS: 63 patients with HIV-associated UWL (weight loss to 90% of the lower limit of ideal body weight) were recruited from South Africa, India and the US and then randomized to receive MA-CS (575 mg/5 mL) or MA-OS (800 mg/20 mL) once-daily for 12 weeks in a randomized, open-labeled, multi-center, pilot proof-of-principle study (sample size determined empirically). Patients had weight, body composition (bioimpedance analysis - BIA), and anthropometric measurements obtained at baseline and weekly thereafter, except BIA which was measured at 6 and 12 weeks. Weight changes were compared using the Wilcoxon Rank Sum test.RESULTS: The demographics were comparable between the two groups. The mean weight change from baseline to Week 12 for MA-CS was 5.4 kg (55.6 kg to 61 kg, 10% of baseline body weight). The mean weight change from baseline to Week 12 for MA-OS was 3.5 kg (54.4 kg to 57.9 kg, 6% of baseline body weight). Differences from baseline, in the mean changes in weight, were observed as early as Day 3 (p=0.024) for MA-CS, however no increase was noted until the second week for MA-OS. Similar between group differences were noted consistently at the weekly assessment intervals until week 12 (p= 0.024). Of these weight changes, lean body mass accounted for ~40% of the increase in both treatment groups (MA-CS was ~5% greater than MA-OS). Of the anthropometric measures, the mean triceps skin fold increased by ~36% at Week 12, relative to baseline, in both MA-CS and MA-OS treatment groups. Other anthropometric changes were all smaller (less than 7%) and comparable between treatments. The types and incidence rates of adverse events were similar between MA-CS and MA-OS.CONCLUSIONS: Both products were successful at increasing body weight. There was a greater and more rapid mean change from baseline in the weight gain for MA-CS than MA-OS. The observed weight changes reflected increases in both lean body mass and body fat. MA-CS had a greater change in lean body mass. This trial supports the principle that improved bioavailability of megestrol acetate in the fasted state with MA-CS may be associated with faster time to onset of changes in body weight.

Frailty: Emergence and Consequences in Women Aged 65 and Older in the Women's Health Initiative Observational Study

To define frailty using simple indicators; to identify risk factors for frailty as targets for prevention; and to investigate the predictive validity of this frailty classification for death, hospitalization, hip fracture, and activity of daily living (ADL) disability. Prospective study, the Women's Health Initiative Observational Study. Forty U.S. clinical centers. Forty thousand six hundred fifty-seven women aged 65 to 79 at baseline. Components of frailty included self-reported muscle weakness/impaired walking, exhaustion, low physical activity, and unintended weight loss between baseline and 3 years of follow-up. Death, hip fractures, ADL disability, and hospitalizations were ascertained during an average of 5.9 years of follow-up. Baseline frailty was classified in 16.3% of participants, and incident frailty at 3-years was 14.8%. Older age, chronic conditions, smoking, and depressive symptom score were positively associated with incident frailty, whereas income, moderate alcohol use, living alone, and self-reported health were inversely associated. Being underweight, overweight, or obese all carried significantly higher risk of frailty than normal weight. Baseline frailty independently predicted risk of death (hazard ratio (HR)=1.71, 95% confidence interval (CI)=1.48-1.97), hip fracture (HR=1.57, 95% CI=1.11-2.20), ADL disability (odds ratio (OR)=3.15, 95% CI=2.47-4.02), and hospitalizations (OR=1.95, 95% CI=1.72-2.22) after adjustment for demographic characteristics, health behaviors, disability, and comorbid conditions. These results support the robustness of the concept of frailty as a geriatric syndrome that predicts several poor outcomes in older women. Underweight, obesity, smoking, and depressive symptoms are strongly associated with the development of frailty and represent important targets for prevention.

Fast and simple screening for nutritional status in hospitalized, elderly people

Undernutrition has been frequently reported among hospitalized elderly patients. The aim of this study was to evaluate the mini nutrition assessment (MNA) and a screening sheet for malnutrition (SSM) by full nutritional assessment (FNA) in elderly people, and to construct a shorter screening method by combining important questions from MNA and SSM. Having a screening tool as fast and simple as possible could increase its use in clinical routines. FNA, MNA and SSM were carried out on 60 hospitalized patients (>65 years). Sensitivity and specificity for MNA and SSM were calculated in comparison with FNA. In order to construct a short and simple screening tool, questions from the two screening tools, which differed significantly between mal- and well-nourished patients, were used in a multivariate, stepwise linear regression. The regression model was simplified to be suitable in clinical routines. Malnourishment was diagnosed by FNA in 58.3% of the elderly patients, with no gender difference. Body mass index, unintended weight loss, recent surgery and loss of appetite were predictors of malnutrition in the regression model (R(2) = 60.1%). The sensitivity and specificity of the simplified regression model were 89 and 88%, respectively, which was more precise than MNA (77 and 36%) and SSM (89 and 60%). According to FNA, malnutrition is frequent in elderly hospitalized patients. Four questions are sufficient to conduct precise nutritional screening for malnutrition in elderly hospitalized patients. This new screening tool should be verified in other samples.

Síndrome constitucional secundario a fluoxetina: a propósito de un caso

Unintended weight loss is a significant problem in elderly subjects, with a high prevalence and potential complications. This problem has multiple ethiologies: it is mostly due to organic disease, but drugs can be potential offenders. Fluoxetin has different gastrointestinal side effects, but only one previous study has described it’s relation with severe unintended weight loss. We present here an 80 years old woman with unintended weight loss due to the use of fluoxetine.

Seasonal Dyspnea

A 63-year-old white man with a history of coronary artery disease, hypertension, and diabetes mellitus was referred to the pulmonary clinic for persistent dry cough and shortness of breath. In May 2000, he began to have dry cough, malaise, and occasional chills. Previously, he had been able to walk for a mile without significant shortness of breath, but by the end of the summer months he was unable to walk 10 feet without significant dyspnea. He reported no fever or purulent sputum. He also denied hemoptysis, rhinorrhea or sinus congestion, chest pain, orthopnea, paroxysmal nocturnal dyspnea, or peripheral edema. He did report an unintended weight loss of eight pounds over the course of the summer. On further questioning, he admitted to having had similar symptoms during the previous three summers that resolved after the first frost in the autumn. His review of systems was significant for the absence of visual abnormalities, dermatitis, arthralgia, myalgia, or recurrent infection. He has a remote history of tobacco use, approximately 10 pack-years. He is a farmer who grows herbs and vegetables but not roses or flowers. He lives in an 80-year-old log home and does not have any pets. He denied significant exposure to asbestos or silica, but has had annual exposure to pesticides and fertilizers.