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Hembree T, Theou O, Thirlwell S, Reich RR, Cao B, Sehovic M, Syed M, Verma N, Nguyen TC, Keerty D, Wesolow J, Koverzhenko V, Extermann M, Huang J, Ramsakal A. A simple test-based frailty index to predict survival among cancer patients with an unplanned hospitalization: An observational cohort study. Cancer Med 2021; 10:5765-5774. [PMID: 34350715 PMCID: PMC8419777 DOI: 10.1002/cam4.4107] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/28/2021] [Accepted: 06/04/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Frailty is a state of increased vulnerability to stressors, and predicts risk of adverse outcomes, such as mortality. Frailty can be defined by a frailty index (FI) using an accumulation of deficits approach. An FI comprised of 20 items derived from our previously studied test-based frailty index (TBFI) and an additional 33 survey-based elements sourced from the standard CGA was developed to evaluate if predictive validity of survival was improved. METHODS One hundred eighty-nine cancer patients during acute hospitalization were consented between September 2018 and May 2019. Frailty scores were calculated, and patients were categorized into four groups: non-frail (0-0.2), mildly frail (0.2-0.3), moderately frail (0.3-0.4), and severely frail (>0.4). Patients were followed for 1-year to assess FI and TBFI prediction of survival. Area under the curve (AUC) statistics from ROC analyses were compared for the FI versus TBFI. RESULTS Increasing frailty was similarly associated with increased risk of mortality (HR, 4.5 [95% CI, 2.519-8.075] and HR, 4.1 [95%CI, 1.692-9.942]) and the likelihood of death at 6 months was about 11-fold (odds ratio, 10.9 [95% CI, 3.97-33.24]) and 9.73-fold (95% CI, 2.85-38.50) higher for severely frail patients compared to non-frail patients for FI and TBFI, respectively. This association was independent of age and type of cancer. The FI and TBFI were predictive of survival for older and younger cancer patients with no significant differences between models in discriminating survival (FI AUC, 0.747 [95% CI, 0.6772-0.8157] and TBFI AUC, 0.724 [95% CI, 0.6513-0.7957]). CONCLUSIONS The TBFI was predictive of survival, and the addition of an in-person assessment (FI) did not greatly improve predictive validity. Increasing frailty, as measured by a TBFI, resulted in a meaningfully increased risk of mortality and may be well-suited for screening of hospitalized cancer patients.
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Affiliation(s)
- Timothy Hembree
- Department of Internal and Hospital Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Olga Theou
- School of Physiotherapy, Dalhousie University, Halifax, Nova Scotia, Canada.,Geriatric Medicine Research Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Sarah Thirlwell
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Richard R Reich
- Biostatistics Core, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Biwei Cao
- Biostatistics Core, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Marina Sehovic
- Senior Adult Oncology Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Misbahuddin Syed
- Department of Internal and Hospital Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Neha Verma
- Department of Internal and Hospital Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Thu-Cuc Nguyen
- Department of Internal and Hospital Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Dinesh Keerty
- Department of Internal and Hospital Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jaqueline Wesolow
- Department of Internal and Hospital Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Viktoriya Koverzhenko
- Department of Internal and Hospital Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Martine Extermann
- Senior Adult Oncology Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jessica Huang
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Asha Ramsakal
- Department of Internal and Hospital Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Renduchintala K, Nanjappa S, Ramsakal A, Greene J. Successful Treatment of Community-Acquired Methicillin-Resistant Staphylococcus Aureus Necrotizing Pneumonia in the Setting of Chronic Graft-Versus-Host Disease. Cureus 2021; 13:e13123. [PMID: 33728140 PMCID: PMC7935285 DOI: 10.7759/cureus.13123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Necrotizing pneumonia (NP) is a rare complication of community-acquired pneumonia that results in tissue necrosis and permanent destruction of the lung parenchyma. This study presents a case of a 21-year old male patient with T-cell acute lymphoblastic lymphoma who was treated with chemotherapy and matched-unrelated donor stem cell transplantation. His post-transplant course included chronic graft-versus-host disease (GVHD) and subsequent community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) necrotizing pneumonia. In addition to antibiotics, steroids were used to help blunt the proinflammatory response following CA-MRSA pneumonia and this led to a rapid improvement in our patient’s clinical course. CA-MRSA pneumonia is often treated with vancomycin. Given the nature of necrotizing pneumonia, the use of a toxin reducing agent like linezolid and adjunct therapy with corticosteroids was beneficial in the management of this disease process in our patient with chronic GVHD. Further prospective studies are needed to evaluate this regimen as a therapeutic alternative.
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Affiliation(s)
| | - Sowmya Nanjappa
- Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Asha Ramsakal
- Internal Medicine, Moffitt Cancer Center, Tampa, USA
| | - John Greene
- Infectious Diseases, Moffitt Cancer Center, Tampa, USA
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Abstract
Cefepime, a fourth-generation cephalosporin, remains an essential antibiotic targeting a broad spectrum of Gram-positive and Gram-negative organisms. However, it also remains an important, yet often unrecognized, cause of encephalopathy. We are here to discuss a case of a 74-year-old male with a common bile duct low-grade adenoma who presented to the hospital for lethargy. He was placed on intravenous cefepime for a Pseudomonas-infected hepatobiliary abscess. Approximately five days later, the patient’s spouse reported acutely worsening cognitive changes. The cefepime level was significantly elevated at 160 µg/mL. Although not completely understood, cefepime is felt to antagonize gamma-aminobutyric acid A (GABA-A) receptors and possibly inhibit GABA release. This risk is accentuated in patients with underlying renal dysfunction and increased inflammation across the blood-brain barrier. Clinical manifestations include an impaired level of consciousness, delirium, myoclonus, and seizures. The treatment of choice is the cessation of the antibiotic, which resolves the neurotoxicity within approximately 48 hours. It is important to recognize cefepime as a potential culprit of acute-onset encephalopathy in the appropriate clinical setting, and the cessation of therapy would lead to a complete resolution of its associated neurotoxicity.
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Affiliation(s)
- Dinesh Keerty
- Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, USA
| | - Naser A Shareef
- Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Asha Ramsakal
- Internal Medicine, Moffitt Cancer Center, Tampa, USA
| | - Elizabeth Haynes
- Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, USA
| | - Misbahuddin Syed
- Internal Medicine/ Infectious Disease, Moffitt Cancer Center, Tampa, USA
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Jaffer M, Chung M, Sharda E, Ramsakal A, Peguero E, Verma N, Mokhtari S. Immunotherapy Induced Myasthenic-Like Syndrome in a Metastatic Melanoma Patient With Amyotrophic Lateral Sclerosis. Clin Med Insights Oncol 2020; 14:1179554920978024. [PMID: 33447124 PMCID: PMC7780164 DOI: 10.1177/1179554920978024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 11/09/2020] [Indexed: 12/18/2022]
Abstract
Immunotherapy agents such as ipilimumab and nivolumab are immensely effective in the treatment of various malignancies. Despite this, neurologic immune-related sequelae (NIRS) have been observed. Prompt diagnosis and treatment is critical to improve patient outcomes. We present a case of a 63-year-old man with stage IV metastatic melanoma beginning treatment with ipilimumab and nivolumab. Gathered history from the patient showed that he had a 3-year presentation of bradykinesia, shuffling gait, and muscle cramping. After one dose, the patient began to have progressively worsening generalized weakness; after receiving the immunotherapy, there was a rapid decline in his health. In addition to weakness, the patient developed diplopia, impaired single breath count, lingual and upper/lower extremity fasciculations, and brisk reflexes. While the lumbar puncture and myasthenia panel were non-diagnostic, the electromyography (EMG) revealed axonal neuropathy and diffuse denervation/reinnervation changes. Furthermore, a magnetic resonance imaging (MRI) displayed fatty replacement of the tongue with a bright tongue sign. These results pointed to the diagnosis of amyotrophic lateral sclerosis (ALS) superimposed onto myasthenic-like syndrome. The patient was started on various treatments; however, unfortunately he died due to acute hypoxic respiratory failure. This case highlights important considerations that must be taken when using immunotherapy, especially in patients with pre-existing neurological deficits. Furthermore, it shows the importance of early diagnosis as treatment can potentially cure adverse sequelae.
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Affiliation(s)
| | - Matthew Chung
- University of South Florida, Tampa, FL, USA.,MD Anderson Cancer Center, Houston, TX, USA
| | | | - Asha Ramsakal
- University of South Florida, Tampa, FL, USA.,Moffitt Cancer Center, Tampa, FL, USA
| | - Edwin Peguero
- University of South Florida, Tampa, FL, USA.,Moffitt Cancer Center, Tampa, FL, USA
| | - Neha Verma
- University of South Florida, Tampa, FL, USA.,Moffitt Cancer Center, Tampa, FL, USA
| | - Sepideh Mokhtari
- University of South Florida, Tampa, FL, USA.,Moffitt Cancer Center, Tampa, FL, USA
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Renduchintala K, Pabbathi S, Nanjappa S, Ramsakal A, Greene J. A Case of Alpha-1 Antitrypsin Deficiency and Organizing Pneumonia. Cureus 2020; 12:e12078. [PMID: 33489496 PMCID: PMC7805524 DOI: 10.7759/cureus.12078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2020] [Indexed: 11/23/2022] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD) is an autosomal dominant genetic disorder that presents with pulmonary complications and is most commonly manifested by panacinar emphysema and chronic obstructive pulmonary disease. A 49-year-old Caucasian female with a history of AATD and chronic tobacco use was referred to both infectious disease and thoracic surgery clinics with worsening cough and chronic intermittent hemoptysis for the evaluation of possible superimposed infection or malignancy. She had previously been treated with multiple antibiotics and Prolastin-CÒ (alpha-1-proteinase inhibitor). Initial CT of the chest showed known chronic bronchiectasis, severe lower lung emphysema, and right-sided lower lobe pulmonary masses. CT-guided biopsy of one mass showed nonspecific inflammation, negative cultures, and negative cytology. Subsequent follow-up with chest CT scans showed a decreasing size of right-sided pulmonary masses and new left-sided nodule formation, which later stabilized in growth. Based on symptoms and radiological and pathological findings, a diagnosis of organizing pneumonia was made. We present an unusual case of bilateral pulmonary masses mimicking infection and malignancy later found to be most consistent with an organizing pneumonia in a patient with underlying AATD.
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Affiliation(s)
| | | | - Sowmya Nanjappa
- Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Asha Ramsakal
- Internal Medicine, Moffitt Cancer Center, Tampa, USA
| | - John Greene
- Internal Medicine, Moffitt Cancer Center, Tampa, USA
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Keerty D, Das M, Hembree TN, Ramsakal A, Haynes E. Lymphocele Containing Staphylococcus lugdunensis. Cureus 2020; 12:e11666. [PMID: 33391904 PMCID: PMC7769740 DOI: 10.7759/cureus.11666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Staphylococcus species are a leading cause of community-acquired bacteremia. Of them, the most serious cause of mortality is from methicillin-resistant Staphylococcus aureus, with mortality rates as high as 40%. Another Staphylococcus species that has been noted to cause equal levels of infection and mortality is Staphylococcus lugdunensis (S. lugdunensis). It can cause harmless skin infections to life-threatening endocardial complications. We would like to report a rare presentation of S. lugdunensis bacteremia from a lymphocele that developed post surgery. An 80-year-old male presented to the emergency department with complaints of abdominal pain and fevers. Cultures of lymphocele fluid grew S. lugdunensis. A computed tomography of the abdomen and pelvis with contrast showed the presence of a large lymphocele. S. lugdunensis is a coagulase-negative staphylococci normally known to be a skin colonizer. Over the years, it has shown to cause a wide variety of infections especially involving prosthetic joints and heart valves. S. lugdunensis has been noted to be highly susceptible to penicillins, such as oxacillin, erythromycin, linezolid and a wide a variety of other antibiotics. S. lugdunensis produces a biofilm that makes treatment challenging even with susceptible antibiotics. However, the data on S. lugdunensis is growing as more case reports are being published in regards to source and susceptibilities.
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Affiliation(s)
- Dinesh Keerty
- Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, USA
| | - Manoj Das
- Internal Medicine/Nephrology, Geisinger Health System, Danville, USA
| | | | - Asha Ramsakal
- Internal Medicine, Moffitt Cancer Center, Tampa, USA
| | - Elizabeth Haynes
- Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, USA
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Afiat TPN, Hembree TN, Dean EA, Araujo C, Pena LR, Rosa M, Han HS, Hendrix K, Ramsakal A. Diffuse Intrasinusoidal Hepatic Metastasis from Breast Cancer Presenting as Liver Failure: Effective and Rapid Treatment with Weekly Low-Dose Adriamycin. Am J Case Rep 2020; 21:e924141. [PMID: 32877389 PMCID: PMC7491943 DOI: 10.12659/ajcr.924141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patient: Female, 28-year-old Final Diagnosis: Hepatic metastasis • metastatic breast cancer • sinusoidal occlusive syndrome Symptoms: Abdominal distension • abdominal pain • lower extremity edema • nausea • vomiting Medication:— Clinical Procedure: — Specialty: General and Internal Medicine • Oncology
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Affiliation(s)
- Thanh-Phuong N Afiat
- Department of Internal and Hospital Medicine, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Timothy N Hembree
- Department of Internal and Hospital Medicine, Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Erin A Dean
- Hematology and Oncology Fellowship, University of South Florida, Tampa, FL, USA
| | - Cyrillo Araujo
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Luis R Pena
- Department of Gastrointestinal Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Marilin Rosa
- Department of Pathology, Breast Pathology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Hyo S Han
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Breast Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kaitlin Hendrix
- Department of Medical Oncology, Breast, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Asha Ramsakal
- Department of Internal and Hospital Medicine, Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Abstract
Corynebacterium jeikeium is a multidrug-resistant gram-positive bacterium of the human skin flora and one of the most clinically important nondiphtherial corynebacteria in the acute care setting. C. jeikeium can cause different forms of infections, especially in immunocompromised patients with underlying risk factors and comorbidities. C. jeikeium was initially described in 1976 as a highly resistant coryneform bacteria causing severe sepsis in patients with hematologic malignancies and profound neutropenia. C. jeikeium infection has also been reported in the setting of endocarditis, septicemia, meningitis, pneumonia, and soft tissue infections. Management of disseminated C. jeikeium infection in immunocompromised cancer patients can be challenging due to its high virulence and rapid skin colonization. We present two cases of disseminated C. jeikeium infection in patients with acute myelogenous leukemia (AML) and underlying comorbidities. Both patients presented with neutropenic fever resistant to initial standard empiric antibiotic therapy.
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Affiliation(s)
| | - Raj H Patel
- Internal Medicine, University of South Florida, Tampa, USA
| | - Asha Ramsakal
- Internal Medicine, Moffitt Cancer Center, Tampa, USA
| | - John Greene
- Internal Medicine, Moffitt Cancer Center, Tampa, USA
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10
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Ramsakal A, Dass VL, Dass VL. Cancer: Personal, Professional, and Practice Impact. J Gen Intern Med 2020; 35:1300-1301. [PMID: 31677099 PMCID: PMC7174447 DOI: 10.1007/s11606-019-05374-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 09/12/2019] [Indexed: 11/28/2022]
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Patel RH, Denham JD, Ramsakal A, Nanjappa S, Greene JN. Recurrent Bacteremia Due to an Infected Inferior Vena Cava Graft in a Patient With Metastatic Renal Cell Carcinoma. Infect Dis Clin Pract 2019. [DOI: 10.1097/ipc.0000000000000788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hembree TN, Thirlwell S, Reich RR, Pabbathi S, Extermann M, Ramsakal A. Predicting survival in cancer patients with and without 30-day readmission of an unplanned hospitalization using a deficit accumulation approach. Cancer Med 2019; 8:6503-6518. [PMID: 31493342 PMCID: PMC6825978 DOI: 10.1002/cam4.2472] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 07/01/2019] [Accepted: 07/23/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND For cancer patients with an unplanned hospitalization, estimating survival has been limited. We examined factors predicting survival and investigated the concept of using a deficit-accumulation survival index (DASI) in this population. METHODS Data were abstracted from medical records of 145 patients who had an unplanned 30-day readmission between 01/01/16 and 09/30/16. Comparison data were obtained for patients who were admitted as close in time to the date of index admission of a study patient, but who did not experience a readmission within 30 days of their discharge date. Our survival analysis compared those readmitted within 30 days versus those who were not. Scores from 23 medical record elements used in our DASI system categorized patients into low-, moderate-, and high-score groups. RESULTS Thirty-day readmission was strongly associated with the survival (adjusted hazard ratio [HR] 2.39; 95% confidence interval [CI], 1.46-3.92). Patients readmitted within 30 days of discharge from index admission had a median survival of 147 days (95% CI, 85-207) versus patients not readmitted who had not reached median survival by the end of the study (P < .0001). DASI was useful in predicting the survival; median survival time was 78 days (95% CI, 61-131) for the high score, 318 days (95% CI, 207-426) for the moderate score, and not reached as of 426 days (95% CI, 251 to undetermined) for the low-score DASI group (P < .0001). CONCLUSIONS Patients readmitted within 30 days of an unplanned hospitalization are at higher risk of mortality than those not readmitted. A novel DASI developed from clinical documentation may help to predict survival in this population.
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Affiliation(s)
- Timothy N Hembree
- Department of Internal and Hospital Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Sarah Thirlwell
- Department of Supportive Care Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Richard R Reich
- Biostatistics Core, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Smitha Pabbathi
- Department of Internal and Hospital Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Martine Extermann
- Senior Adult Oncology Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Asha Ramsakal
- Department of Internal and Hospital Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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14
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Affiliation(s)
- A Ramsakal
- Department of Medicine, University of South Florida, College of Medicine, James A Haley Veterans Hospital, Tampa, USA
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