Weight loss resident survival guide: Difference between revisions
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==Diagnosis and Management== | ==Diagnosis and Management== | ||
Shown below is an algorithm summarizing the diagnosis of [[weight loss]].<ref name="pmid8919685">{{cite journal |vauthors=Guigoz Y, Vellas B, Garry PJ |title=Assessing the nutritional status of the elderly: The Mini Nutritional Assessment as part of the geriatric evaluation |journal=Nutr. Rev. |volume=54 |issue=1 Pt 2 |pages=S59–65 |date=January 1996 |pmid=8919685 |doi=10.1111/j.1753-4887.1996.tb03793.x |url=}}</ref><ref name="pmid31330781">{{cite journal |vauthors=Reber E, Gomes F, Vasiloglou MF, Schuetz P, Stanga Z |title=Nutritional Risk Screening and Assessment |journal=J Clin Med |volume=8 |issue=7 |pages= |date=July 2019 |pmid=31330781 |pmc=6679209 |doi=10.3390/jcm8071065 |url=}}</ref><ref name="pmid12880610">{{cite journal |vauthors=Kondrup J, Allison SP, Elia M, Vellas B, Plauth M |title=ESPEN guidelines for nutrition screening 2002 |journal=Clin Nutr |volume=22 |issue=4 |pages=415–21 |date=August 2003 |pmid=12880610 |doi=10.1016/s0261-5614(03)00098-0 |url=}}</ref><ref name="pmid9673603">{{cite journal |vauthors=Gazewood JD, Mehr DR |title=Diagnosis and management of weight loss in the elderly |journal=J Fam Pract |volume=47 |issue=1 |pages=19–25 |date=July 1998 |pmid=9673603 |doi= |url=}}</ref><ref name="pmid23115205">{{cite journal |vauthors=Hu J, Van Valckenborgh E, Menu E, De Bruyne E, Vanderkerken K |title=Understanding the hypoxic niche of multiple myeloma: therapeutic implications and contributions of mouse models |journal=Dis Model Mech |volume=5 |issue=6 |pages=763–71 |date=November 2012 |pmid=23115205 |pmc=3484859 |doi=10.1242/dmm.008961 |url=}}</ref><ref name="pmid6380395">{{cite journal |vauthors=Biemer JJ |title=Hepatic manifestations of lymphomas |journal=Ann. Clin. Lab. Sci. |volume=14 |issue=4 |pages=252–60 |date=1984 |pmid=6380395 |doi= |url=}}</ref><ref name="pmid24784334">{{cite journal |vauthors=Gaddey HL, Holder K |title=Unintentional weight loss in older adults |journal=Am Fam Physician |volume=89 |issue=9 |pages=718–22 |date=May 2014 |pmid=24784334 |doi= |url=}}</ref> | Shown below is an algorithm summarizing the diagnosis of [[weight loss]].<ref name="pmid8919685">{{cite journal |vauthors=Guigoz Y, Vellas B, Garry PJ |title=Assessing the nutritional status of the elderly: The Mini Nutritional Assessment as part of the geriatric evaluation |journal=Nutr. Rev. |volume=54 |issue=1 Pt 2 |pages=S59–65 |date=January 1996 |pmid=8919685 |doi=10.1111/j.1753-4887.1996.tb03793.x |url=}}</ref><ref name="pmid31330781">{{cite journal |vauthors=Reber E, Gomes F, Vasiloglou MF, Schuetz P, Stanga Z |title=Nutritional Risk Screening and Assessment |journal=J Clin Med |volume=8 |issue=7 |pages= |date=July 2019 |pmid=31330781 |pmc=6679209 |doi=10.3390/jcm8071065 |url=}}</ref><ref name="pmid12880610">{{cite journal |vauthors=Kondrup J, Allison SP, Elia M, Vellas B, Plauth M |title=ESPEN guidelines for nutrition screening 2002 |journal=Clin Nutr |volume=22 |issue=4 |pages=415–21 |date=August 2003 |pmid=12880610 |doi=10.1016/s0261-5614(03)00098-0 |url=}}</ref><ref name="pmid9673603">{{cite journal |vauthors=Gazewood JD, Mehr DR |title=Diagnosis and management of weight loss in the elderly |journal=J Fam Pract |volume=47 |issue=1 |pages=19–25 |date=July 1998 |pmid=9673603 |doi= |url=}}</ref><ref name="pmid23115205">{{cite journal |vauthors=Hu J, Van Valckenborgh E, Menu E, De Bruyne E, Vanderkerken K |title=Understanding the hypoxic niche of multiple myeloma: therapeutic implications and contributions of mouse models |journal=Dis Model Mech |volume=5 |issue=6 |pages=763–71 |date=November 2012 |pmid=23115205 |pmc=3484859 |doi=10.1242/dmm.008961 |url=}}</ref><ref name="pmid6380395">{{cite journal |vauthors=Biemer JJ |title=Hepatic manifestations of lymphomas |journal=Ann. Clin. Lab. Sci. |volume=14 |issue=4 |pages=252–60 |date=1984 |pmid=6380395 |doi= |url=}}</ref><ref name="pmid24784334">{{cite journal |vauthors=Gaddey HL, Holder K |title=Unintentional weight loss in older adults |journal=Am Fam Physician |volume=89 |issue=9 |pages=718–22 |date=May 2014 |pmid=24784334 |doi= |url=}}</ref><ref name="Alibhai2005">{{cite journal|last1=Alibhai|first1=S. M.H.|title=An approach to the management of unintentional weight loss in elderly people|journal=Canadian Medical Association Journal|volume=172|issue=6|year=2005|pages=773–780|issn=0820-3946|doi=10.1503/cmaj.1031527}}</ref> | ||
{{familytree/start |summary=Weight loss Diagnostic Algorithm.}} | {{familytree/start |summary=Weight loss Diagnostic Algorithm.}} | ||
{{familytree | | | | | | | | | | A01 | | | | | | |A01=[[Patient]] presents with [[weight loss]]/ incidental finding }} | {{familytree | | | | | | | | | | A01 | | | | | | |A01=[[Patient]] presents with [[weight loss]]/ incidental finding }} | ||
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:❑ Assess the mental and functional status of the [[patient]].<br> | :❑ Assess the mental and functional status of the [[patient]].<br> | ||
:❑ Psychiatric illness screening. Geriatric Depression Scale may be utilized to assess for [[depression]] among elderly.<br> | :❑ Psychiatric illness screening. Geriatric Depression Scale may be utilized to assess for [[depression]] among elderly.<br> | ||
❑ '''Systemic review''':<br> | ❑ '''Systemic review''':<br> [[Cardiovascular system|Cardiovascular]], [[respiratory system|respiratory]], [[renal system|renal]], [[liver|hepatic]], [[Rheumatology|rheumatologic]], and [[Gastrointestinal system|GI]] exam. | ||
:❑ [[Gastrointestinal system|GI]]: Indigestion, [[early satiety]], altered stool pattern, [[abdominal pain]] may demonstrate [[GERD]], [[peptic ulcer]],[[cholecystitis]], and [[gastrointestinal system|GI]] [[malignancy]]<br> | |||
❑ '''Past medical history''':<br> Helps assess the nutritional status. May suggest of [[immunodeficiency]] (recurrent [[infections]]), diagnosed [[malignancy]], [[malabsorption]] (chronic [[diarrhea]]), [[HF]], [[dyspepsia]]. <br> | ❑ '''Past medical history''':<br> Helps assess the nutritional status. May suggest of [[immunodeficiency]] (recurrent [[infections]]), diagnosed [[malignancy]], [[malabsorption]] (chronic [[diarrhea]]), [[HF]], [[dyspepsia]]. <br> | ||
❑ '''Past surgical history''':<br> Helps assess nutritional status.<br> | ❑ '''Past surgical history''':<br> Helps assess nutritional status.<br> | ||
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❑ Appearance of the [[patient]]:<br>[[Cachexia]] is observed among [[patients]] with [[malignancy]]. Surgical scar marks demonstrating previous surgery for intentional weight loss or [[malignancy]] treatment<br> | ❑ Appearance of the [[patient]]:<br>[[Cachexia]] is observed among [[patients]] with [[malignancy]]. Surgical scar marks demonstrating previous surgery for intentional weight loss or [[malignancy]] treatment<br> | ||
❑ [[Vital signs]]<br> | ❑ [[Vital signs]]<br> | ||
:❑ [[Temperature]]: | :❑ [[Temperature]]: Low-grade/ high-grade fever with [[fatigue]] may demonstrate [[infection]], [[autoimmune]] disorders, [[thyroid]] disease, [[malignancy]], [[diabetes]] <br> | ||
:❑ [[Heart rate]]: [[Tachycardia]] with regular pulse may demonstrate [[infection]]. <br> | :❑ [[Heart rate]]: [[Tachycardia]] with regular pulse may demonstrate [[infection]]. <br> | ||
:❑ [[Respiratory rate]]: [[Tachypnea]] | :❑ [[Respiratory rate]]: [[Tachypnea]] ([[infection]]\ [[metastasis]]), [[dyspnea]] ([[heart failure]], [[COPD]], and lung [[infection]]<br> | ||
:❑ [[Blood pressure]]: [[Chronic hypertension]] or [[hypotension]] is common among elders.<br> | :❑ [[Blood pressure]]: [[Chronic hypertension]] or [[hypotension]] is common among elders.<br> | ||
:❑ [[Oxygen saturation]]: Low saturation may demonstrate [[respiratory system]] involvement or hematologic [[malignancies]], such as [[multiple myeloma]].<br> | :❑ [[Oxygen saturation]]: Low saturation may demonstrate [[respiratory system]] involvement or hematologic [[malignancies]], such as [[multiple myeloma]].<br> | ||
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❑ [[Hepatitis| medical therapy|Hepatitis]]<br> | ❑ [[Hepatitis| medical therapy|Hepatitis]]<br> | ||
❑ [[Chronic cholecystitis medical therapy|Chronic cholecystitis]]<br> | ❑ [[Chronic cholecystitis medical therapy|Chronic cholecystitis]]<br> | ||
❑ [[Hyperparathyroidism medical therapy|Hyperparathyroidism]]|D01=[[Esophageal cancer medical therapy|Esophageal cancer treatment]]|D02=<div style="float: left; text-align: left; width: 15em;">'''Treatment'''<div class="mw-collapsible mw-collapsed">❑ [[Peptic ulcer medical therapy|Peptic ulcer]]<br> | ❑ [[Hyperparathyroidism medical therapy|Hyperparathyroidism]]|D01=<div style="float: left; text-align: left; width: 15em;">'''Treatment'''<div class="mw-collapsible mw-collapsed">❑ Speech therapy for oropharyngeal issues<br>❑ Dentist referral for dental issues<br>❑ [[Esophageal cancer medical therapy|Esophageal cancer treatment]]|D02=<div style="float: left; text-align: left; width: 15em;">'''Treatment'''<div class="mw-collapsible mw-collapsed">❑ [[Peptic ulcer medical therapy|Peptic ulcer]]<br> | ||
❑ [[Celiac disease medical therapy|Celiac disease]]<br> | ❑ [[Celiac disease medical therapy|Celiac disease]]<br> | ||
❑ [[Whipple's disease medical therapy|Whipple's disease]]|D03=<div style="float: left; text-align: left; width: 15em;"> '''Treatment'''<div class="mw-collapsible mw-collapsed"> | ❑ [[Whipple's disease medical therapy|Whipple's disease]]|D03=<div style="float: left; text-align: left; width: 15em;"> '''Treatment'''<div class="mw-collapsible mw-collapsed"> | ||
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❑ [[Clinical depression medical therapy|Clinical depression medications]]|D04=<div style="float: left; text-align: left; width: 15em;">'''Treatment'''<div class="mw-collapsible mw-collapsed"> ❑ [[Surgical resection]]<br> ❑ [[Chemotherapy]]<br> | ❑ [[Clinical depression medical therapy|Clinical depression medications]]|D04=<div style="float: left; text-align: left; width: 15em;">'''Treatment'''<div class="mw-collapsible mw-collapsed"> ❑ [[Surgical resection]]<br> ❑ [[Chemotherapy]]<br> | ||
❑ [[Radiotherapy]]<br> | ❑ [[Radiotherapy]]<br> | ||
❑ [[TNM]] staging|D05=<div style="float: left; text-align: left; width: 15em;">❑ | ❑ [[TNM]] staging|D05=<div style="float: left; text-align: left; width: 15em;">'''Treatment'''<div class="mw-collapsible mw-collapsed">❑ Decreased dietary restrictions<br>❑ Increase oral intake<br>❑ Nutritional supplements with regular meals<br>❑ Community support services if required<br>❑ Multidisciplinary approach |D06=<div style="float: left; text-align: left; width: 15em;"> '''Treatment'''<div class="mw-collapsible mw-collapsed"> | ||
❑ [[Chronic diarrhea medical therapy|Chronic diarrhea treatment]]<br> | ❑ [[Chronic diarrhea medical therapy|Chronic diarrhea treatment]]<br> | ||
❑ [[Tuberculosis medical therapy|Tb treatment]]<br> | ❑ [[Tuberculosis medical therapy|Tb treatment]]<br> | ||
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{{familytree | |`|-|-|-|^|-|-|-|^|-|-|-|+|-|-|-|^|-|-|-|^|-|-|-|'| | |}} | {{familytree | |`|-|-|-|^|-|-|-|^|-|-|-|+|-|-|-|^|-|-|-|^|-|-|-|'| | |}} | ||
{{familytree | | | | | | | | | | | | | |!| | | |}} | {{familytree | | | | | | | | | | | | | |!| | | |}} | ||
{{familytree | | | | | | | | | | | | | |!| | | | | | }} | {{familytree | | | | | | | | | | | | | |!| | | | | | }} | ||
{{familytree | | | | | | | | | | | | | E01 | | | | | | |E01=<div style="float: left; text-align: left; width: 20em;"> Follow-up in 1 or 3 months depending upon the cause.<br> }} | {{familytree | | | | | | | | | | | | | E01 | | | | | | |E01=<div style="float: left; text-align: left; width: 20em;"> Follow-up in 1 or 3 months depending upon the cause.<br> }} |
Revision as of 10:19, 8 September 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Javaria Anwer M.D.[2]
Synonyms and keywords: weight loss management guide, unintentional weight loss management guide, loss of weight resident survival guide, pathologic weight loss resident survival guide.
Lymphadenopathy resident survival guide microchapters |
---|
Overview |
Causes |
Diagnosis and Management |
Do's |
Don'ts |
Overview
A loss of >5% of the usual body weight within 6 - 12 months represents pathologic weight loss. Weight loss may be intentional or unintentional. Unintentional weight loss is more common among the elderly. Common causes of weight loss among patients aged >65 years include malignancies (specifically digestive and non-hematologic), dementia, stroke, parkinson's disease, and polymyalgia rheumatica. Endocrine disorders, infections, and psychiatric disorders make up the most part for the causes of weight loss among individuals aged <65 years. A thorough history from the patient or a caregiver provides useful insights to the cause. It is important to assess the availability of food, nutritional status first. A detailed physical exam and observing an elder patient have a meal in front of the physician may provide clues to neurocognitive dysfunctions. CBC, CMP provide a general picture of patient condition. Follow-up is necessary to completely treat the known and identify unknown causes of weight loss. A multidisciplinary approach ensures the optimum management option. Nutritional supplements may be warranted in selected cases but act as an adjunct to normal meals.
Causes
Life Threatening Causes
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. The life-threatening causes of weight loss include:
- Electrolyte disturbances as a result of malnutrition may lead to arrhythmias and be life-threatening of not corrected in time.[1]
Common Causes
Age >65 years[2]
- Malignancies (specifically digestive and non-hematologic)
- Dementia
- Stroke
- Parkinson's disease
- Polymyalgia rheumatica
- Oral disorders.
Age <65 years[2]
- Endocrine disorders
- Infections such as TB and HIV
- Psychiatric disorders such as depression, anxiety, and OCD
- Malignancies such as hematologic
Common causes classified
- The chart below demonstrates the cause of unintentional weight loss in adult population. The incidence describes the full range of occurrence described in five studies in older individuals.[3][4][5][6][2][7][8][9][10][11]
- To read about other causes of unintentional weight loss click here.
Diagnosis and Management
Shown below is an algorithm summarizing the diagnosis of weight loss.[9][12][13][14][15][16][5][3]
Patient presents with weight loss/ incidental finding | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Loss of >5% of the usual body weight within 6 - 12 months | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
History ❑ Source of history:
❑ Systemic review:
❑ Past medical history: Communicable infectious diseases/ travel to high-risk areas. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Physical exam ❑ Appearance of the patient:
❑ BMI assessment or simply weight among immobile or bed-ridden patients.
❑ Observing the patient having a meal may demonstrate
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Intentional weight loss | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Assessment ❑ Assess for self-induced vomiting/ anorexigenic drugs/ diuretic/ laxative use ❑ Monitor BMI ❑ Serum electrolytes | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Unintentional weight loss | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Nutritional status/ caloric intake | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Adequate | Inadequate | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Suspect malabsorption | Suspect altered metabolism | Access to food | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Suspect cognitive dysfunction/ consider social factors | Consider oral or dental issues/ dysphagia/ dysgeusia | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Initial screening labs ❑ CBC with differential and peripheral smear
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Provisional diagnosis established | Progressive oropharyngeal or esophageal dysphagia/ oral/ dental issues | Peptic ulcer celiac disease, whipple disease | Potential depression Cognitive dysfunction | Suspected malignancy | Suspected nutritional deficiency | Suspected infection | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Specific tests ❑ Nephrotic syndrome: 24-hour urine collection (urine protein >3.5 g/day). | Specific tests | Specific tests ❑ Upper or lower GI endoscopy with biopsy ❑ Stool fat, anti-transglutaminase antibodies, elastase, lactoferrin ❑ Upper GI and small bowl series | Specific scales ❑ Geriatric Depression Scale | Specific tests ❑ CT (chest, abdomen, pelvis, head, etc) ❑PET scan | Specific tests ❑ Serum ferritin | Specific tests ❑ Chronic diarrhea: Stool osmotic gap, culture, ova and parasite, electrolytes, leukocytes, lactoferrin, and C. difficile test. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Treatment ❑ Nephrotic syndrome | Treatment ❑ Speech therapy for oropharyngeal issues ❑ Dentist referral for dental issues ❑ Esophageal cancer treatment | Treatment | Treatment ❑ Referral to a specialist (psychotherapist and/or a psychiatrist) | Treatment | Treatment ❑ Decreased dietary restrictions ❑ Increase oral intake ❑ Nutritional supplements with regular meals ❑ Community support services if required ❑ Multidisciplinary approach | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Follow-up in 1 or 3 months depending upon the cause. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Weight gain | No weight gain/ continued weight loss | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Continue monitoring | Reevaluate | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Cause identified | Cause unidentified | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ 6 months of presentation cause unidentified ❑ Labelled unexplained unintentional weight loss | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Consider medications for weight gain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do's
- Perform a thorough physical exam to evaluate for cause of weight loss.
- Assess the nutritional status of the patient.
- Assess the patient for possible depression.
- Assess serum electrolytes to assess for life-threatening electrolyte abnormalities.
Don'ts
- Do not miss the oral exam especially among the elderly.
- Do not rely on the patient history among patients with cognitioncognitive dysfunctions.
References
- ↑ Abed J, Judeh H, Abed E, Kim M, Arabelo H, Gurunathan R (September 2014). ""Fixing a heart": the game of electrolytes in anorexia nervosa". Nutr J. 13: 90. doi:10.1186/1475-2891-13-90. PMC 4168120. PMID 25192814.
- ↑ 2.0 2.1 2.2 Bosch X, Monclús E, Escoda O, Guerra-García M, Moreno P, Guasch N, López-Soto A (2017). "Unintentional weight loss: Clinical characteristics and outcomes in a prospective cohort of 2677 patients". PLoS ONE. 12 (4): e0175125. doi:10.1371/journal.pone.0175125. PMC 5384681. PMID 28388637.
- ↑ 3.0 3.1 Alibhai, S. M.H. (2005). "An approach to the management of unintentional weight loss in elderly people". Canadian Medical Association Journal. 172 (6): 773–780. doi:10.1503/cmaj.1031527. ISSN 0820-3946.
- ↑ Wu, Wen-Chih Hank; Bosch, Xavier; Monclús, Esther; Escoda, Ona; Guerra-García, Mar; Moreno, Pedro; Guasch, Neus; López-Soto, Alfons (2017). "Unintentional weight loss: Clinical characteristics and outcomes in a prospective cohort of 2677 patients". PLOS ONE. 12 (4): e0175125. doi:10.1371/journal.pone.0175125. ISSN 1932-6203.
- ↑ 5.0 5.1 Gaddey HL, Holder K (May 2014). "Unintentional weight loss in older adults". Am Fam Physician. 89 (9): 718–22. PMID 24784334.
- ↑ Lankisch P, Gerzmann M, Gerzmann JF, Lehnick D (January 2001). "Unintentional weight loss: diagnosis and prognosis. The first prospective follow-up study from a secondary referral centre". J. Intern. Med. 249 (1): 41–6. doi:10.1046/j.1365-2796.2001.00771.x. PMID 11168783.
- ↑ Sarkar SB, Sarkar S, Ghosh S, Bandyopadhyay S (October 2012). "Addison's disease". Contemp Clin Dent. 3 (4): 484–6. doi:10.4103/0976-237X.107450. PMC 3636818. PMID 23633816.
- ↑ Brymer C, Winograd CH (September 1992). "Fluoxetine in elderly patients: is there cause for concern?". J Am Geriatr Soc. 40 (9): 902–5. doi:10.1111/j.1532-5415.1992.tb01987.x. PMID 1512386.
- ↑ 9.0 9.1 Guigoz Y, Vellas B, Garry PJ (January 1996). "Assessing the nutritional status of the elderly: The Mini Nutritional Assessment as part of the geriatric evaluation". Nutr. Rev. 54 (1 Pt 2): S59–65. doi:10.1111/j.1753-4887.1996.tb03793.x. PMID 8919685.
- ↑ Morley JE, Kraenzle D (June 1994). "Causes of weight loss in a community nursing home". J Am Geriatr Soc. 42 (6): 583–5. doi:10.1111/j.1532-5415.1994.tb06853.x. PMID 8201141.
- ↑ Thompson MP, Morris LK (May 1991). "Unexplained weight loss in the ambulatory elderly". J Am Geriatr Soc. 39 (5): 497–500. doi:10.1111/j.1532-5415.1991.tb02496.x. PMID 2022802.
- ↑ Reber E, Gomes F, Vasiloglou MF, Schuetz P, Stanga Z (July 2019). "Nutritional Risk Screening and Assessment". J Clin Med. 8 (7). doi:10.3390/jcm8071065. PMC 6679209 Check
|pmc=
value (help). PMID 31330781. - ↑ Kondrup J, Allison SP, Elia M, Vellas B, Plauth M (August 2003). "ESPEN guidelines for nutrition screening 2002". Clin Nutr. 22 (4): 415–21. doi:10.1016/s0261-5614(03)00098-0. PMID 12880610.
- ↑ Gazewood JD, Mehr DR (July 1998). "Diagnosis and management of weight loss in the elderly". J Fam Pract. 47 (1): 19–25. PMID 9673603.
- ↑ Hu J, Van Valckenborgh E, Menu E, De Bruyne E, Vanderkerken K (November 2012). "Understanding the hypoxic niche of multiple myeloma: therapeutic implications and contributions of mouse models". Dis Model Mech. 5 (6): 763–71. doi:10.1242/dmm.008961. PMC 3484859. PMID 23115205.
- ↑ Biemer JJ (1984). "Hepatic manifestations of lymphomas". Ann. Clin. Lab. Sci. 14 (4): 252–60. PMID 6380395.