Male Veteran Population Research Articles

Trends in hip fracture rates in US male veterans.

In the United States, the annual incidence of osteoporotic hip fracture is estimated to be 250,000 to 300,000; the one-year mortality in some studies has been as high as 32%. Reports that hip fracture rates in US women 65years and older may no longer be declining led to this investigation of hip fracture in men, a less studied population. We assessed the trends in the incidence of hip fracture in US male veterans 50years and older of age as well as the rates of diagnosis and treatment in such men. We assessed the recent trends of hip fracture incidence in a nation-wide male veteran population 50years and older of age. Using data from the US Veterans Affairs Informatics and Computing Infrastructure (VINCI) 2002-2019, we calculated the annual age-standardized hip fracture incidence. Secondary objectives included evaluating the annual proportion of hip fracture patients who underwent dual-energy X-ray absorptiometry (DXA) before or after the fracture and/or received osteoporosis medication after the hip fracture over the study period. Hip fracture incidence increased in male veterans from 2006 to 2019. Fewer than 6% of men underwent a DXA scan and fewer than 0.5% received osteoporosis medications up to two years after a hip fracture. Despite available screening methods such as DXAs and medications for primary and secondary prevention of osteoporotic fractures, hip fracture incidence is not decreasing in older male veterans. Our study highlights a need for closerattention to fracture risk in men.

Prevalence of Sleep CALM nocturia factors in a male veteran population.

Nocturia is a complex and multifactorial condition, associated with several genitourinary abnormalities as well as a host of conditions beyond the urinary tract, and thus often poses a significant diagnostic challenge in real-world practice. Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications, the so-called "Sleep C.A.L.M." factors, are five common causes of nocturia requiring judicious evaluation according to current consensus guidelines. This study aims to assess the prevalence of the Sleep C.A.L.M. factors in a nocturia clinical population. Retrospective analysis of frequency-volume charts from men with ≥2 nocturnal voids as well as concurrent demographic, clinical, and medical history data to identify patients with each of the Sleep C.A.L.M. Comorbidities and medications were classified as a single group. A total of 213 subjects met the criteria for inclusion (median age 68.0 [63.5-75.5] years). The prevalence of 1) sleep disorders, 2) comorbidities and/or medication use, 3) actions (i.e., modifiable behaviors/lifestyle factors), and 4) lower urinary tract dysfunction was 31%, 31%, 19%, and 41%, respectively. Among included participants, 73% were found to have at least 1 Sleep C.A.L.M. factor, and 33% had multiple Sleep C.A.L.M. Results were similar upon stratification by age and nocturnal polyuria status. The Sleep C.A.L.M. factors are highly common among nocturia patients in the clinical urology setting. Although many of these factors are strongly associated with advanced age in community-based nocturia study samples, they appear common even among younger men in a nocturia patient population; the differential effect of age and individual Sleep C.A.L.M. factors on nocturia pathophysiology requires further investigation.

Differences in Characteristics and Outcomes of Central Nervous System Versus Systemic Relapse after First Line Therapy in DLBCL Patients: A Veterans Health Administration (VHA) Study

Introduction Around 30%-40% of patients with diffuse large B-cell lymphoma (DLBCL) will experience disease progression or relapse after first line (1L) chemoimmunotherapy with most patients relapsing within the first 12 months. Relapse may be systemic, isolated to the central nervous system (CNS), or both with CNS relapse occurring in 2-5% of patients. The purpose of this study is to evaluate the characteristics and outcome differences of Veterans diagnosed with DLBCL within the VHA who experienced systemic relapse, isolated CNS relapse or both. Methods A retrospective chart review of 6,266 lymphoma patients seen in the VHA nationwide between 01/01/2011 and 12/31/2021 was performed by trained abstractors. Patients diagnosed with DLBCL were included. Patients were excluded if they had a diagnosis other than DLBCL, had incomplete records or were diagnosed and treated outside the VHA, had baseline CNS involvement, did not receive treatment, or died before receiving a scan to assess response to 1L therapy. Outcomes including response to 1L treatment, time to relapse and overall survival (OS) defined as time from diagnosis to death were evaluated. Early relapse was defined as having primary refractory disease (stable or progressive disease (SD or PD) as best response to 1L therapy) or disease progression in ≤12 months in patients achieving a complete response (CR) or partial response (PR). Late relapse was defined as disease progression >12 months. Results A total of 2,658 patients met inclusion criteria for analysis with 97% of the population being male, 65% with stage III-IV disease, and 90% with an ECOG performance status of 0-2. Of the total cohort, 74% of patients received a CHOP-based regimen, 74% had an intermediate- or high-risk CNS International Prognostic Index (CNS-IPI) score, 81% did not receive a baseline diagnostic lumbar puncture (LP) and 86% did not receive any CNS prophylaxis. The median follow-up time for subjects in this study was 54 months. Relapse occurred in 29% of the total cohort with systemic only relapse occurring in 27% of patients, isolated CNS in 1%, and CNS + systemic in 1%. Of the 761 patients who experienced relapse, 77% had an early relapse with a median time to relapse of 4.4 months (IQR 2.8-6.7). For the 23% of patients with late relapse, the median time to relapse was 25 months (IQR 18-41). The characteristics of patients who experienced relapse were similar regardless of type of relapse or time to relapse (table 1). A higher percentage of patients with early relapse had a high-risk CNS-IPI score, bone marrow involvement, and renal or adrenal involvement. Autologous stem cell transplant was performed in 11% of patients, predominately in those with systemic only relapse. The median OS (mOS) was similar between relapse types with systemic, isolated CNS, and CNS + systemic having a mOS of 23.5 months (95% CI: 21-27), 30.6 months (95% CI: 15-71), and 29.6 months (95% CI: 20-45), respectively (p=0.75). Figure 1 describes mOS by relapse type and time to relapse. Overall, patients with early relapse had a poorer prognosis regardless of relapse type with a mOS of 17 months (95% CI: 15-18) compared to a mOS of 68 months (95% CI: 59-88) in patients with late relapse (p<0.001). The 24-month survival rate of those with early versus late relapse was 37% and 78%, respectively. Patients with a late systemic relapse had the longest mOS of 74 months (95% CI: 60-90). Conclusion This is the largest study reporting outcomes of Veterans who experienced relapsed DLBCL within the VHA. Although earlier data suggests specific features may correlate with early versus late relapse, all characteristics were similar in our population across relapse types regardless of time to relapse. The rate of relapse in the total cohort and the rates of CNS relapse were lower than previously reported, adding to recent data suggesting the use of CNS prophylaxis may have limited benefit. Patients with early relapse performed poorly and may benefit from novel therapies including chimeric antigen receptor T-cell therapy, which could not be evaluated with this study. The retrospective nature of this analysis, and a predominately male veteran population may limit external application.

Systematic Review, Meta-Analysis, and Population Attributable Risk of Dementia Associated with Traumatic Brain Injury in Civilians and Veterans.

Traumatic brain injury (TBI) is an established risk factor for dementia. However, the magnitude of risk is highly variable across studies. Identification of sub-populations at highest risk, with careful consideration of potential sources of bias, is urgently needed to guide public health policy and research into mechanisms and treatments. We conducted a systematic review and meta-analysis of risk of all-cause dementia after all-severity TBI. We assessed for effect of participant age and sex, veteran status, research methods, and region. The search window covered January 1990 to January 2019. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Thirty-two studies met inclusion criteria. Data were pooled using random effects models. Population attributable risk (PAR) of dementia due to TBI in the U.S. was calculated by sex and veteran status. Pooled risk ratio (RR) for dementia after TBI was 1.66 (95% confidence interval 1.42-1.93). Younger age, male sex, and studies from Asia were associated with significantly higher risk; veteran status was not. Risk of dementia associated with "head injury/trauma" was not significantly different from that associated with "TBI" diagnosis specifically. PAR of dementia due to TBI among U.S. veterans was twice that of the general U.S. population, largely due to the high prevalence of TBI exposure in the majority male veteran population. This meta-analysis found that TBI is associated with nearly 70% increased risk of dementia. Risk may be highest among younger adults, men, and cohorts in Asia. Efforts to prevent TBI and also to prevent post-TBI dementia are of high importance. Additionally, improved methods for diagnosing and tracking TBI on a public health level, such as national registries, may improve the quality and generalizability of future epidemiological studies investigating the association between TBI and dementia.

S432 Fifty Percent Increase in Low-Grade Dysplasia Detection Using Probe-Based Confocal Endomicroscopy in a Metropolitan Veteran Cohort Undergoing Short Segment Barrett’s Esophagus Surveillance

Introduction: Seattle protocol (SP) is the standard method to biopsy Barrett’s esophagus. However, SP may miss dysplasia in all types of BE. Few studies have focused on pCLE in the diagnosis of dysplasia in short segment Barrett’s esophagus (SSBE). The primary aim of our study was to determine if pCLE was more effective in diagnosing dysplastic mucosa in patients undergoing surveillance endoscopy in SSBE. Methods: Patients undergoing surveillance endoscopy and diagnosed with SSBE between January 1, 2018 and January 1, 2021 at the VA Loma Linda Healthcare System (VALLHCS) were included. Patients who underwent pCLE were compared to those undergoing SP. Esophagogastroduodenoscopy (EGD) was performed using a high definition diagnostic upper endoscope (Olympus, Center Valley PA). All patients in both pCLE and SP group underwent high-definition white light examination (HD-WLE). All pCLE examinations were performed by two gastroenterologists (C.S.J.and N.S.) using GastroFlex UHD Confocal Miniprobe (Cellvizio, Mauna Kea Technologies). Age, sex, number of EGDs prior to a diagnosis of dysplasia, hiatal hernia length and pCLE findings were assessed. SSBE was defined using Prague criteria, circumference (C) ≤ 2cm and maximal length of Barrett's segment (M) ≤ 3cm. Two pathologists reviewed all biopsies with a diagnosis of dysplasia. Continuous variables were compared using a Fisher’s exact test with p≤0.05 as statistically significant. This study was approved by the institutional review board for VALLHCS. Results: Sixty-seven patients were identified as having SSBE. Sixteen patients underwent pCLE-targeted biopsies while 51 underwent SP. The mean age of the pCLE group was 64 years and 65.9 years for those who underwent SP. There was no difference in age, BMI, smoking status, statin, H2 blocker or PPI use in patients who underwent pCLE-targeted biopsies versus those who underwent SP. Low-grade dysplasia was detected in 17 patients (25.3%). Of these 17 patients, 11 were detected with pCLE, and 6 were detected with SP. The use of pCLE was significantly associated with detection of low-grade dysplasia (11/16, 68.7%) compared to (6/51, 11.7%) with a p-value of < 0.001. Conclusion: In a primarily male metropolitan veteran population, pCLE may be helpful in identifying low grade dysplasia in patients with SSBE. SP biopsy techniques may miss LGD during SSBE surveillance.

Abstract 9061: Aortic Wall Stress Across Risk Groupings of Aortic Size and Height Indices in a Male Veteran Population With Ascending Thoracic Aortic Aneurysm

Introduction: Natural history studies of ascending thoracic aortic aneurysm (aTAA) identified maximum diameter as a predictor of aortic dissection, informing guidelines for prophylactic surgery. Studies have since challenged the biomechanical basis of diameter-based risk assessment. Indices of diameter with measures of body size were proposed to account for individual variation in diameter, including body surface area as aortic size index (ASI) or height as aortic height index (AHI). The goal of this study was to determine differences in aneurysm wall stresses across previously defined clinical risk groups for ASI and AHI. Methods: Height and weight measurements were retrospectively reviewed for 264 male veterans with aTAA. Wall stresses were previously simulated using finite element analyses on patient-specific geometries. Group differences in wall stress were assessed among ASI and AHI risk groups using the Kruskal-Wallis and Dunn tests. Results: Median ± interquartile range circumferential stresses among ASI risk groups were 486.5 ± 132.8, 510.7 ± 140.5, and 617.2 ± 201.6 kPa for groups 1-3 ( P = .19). Longitudinal stresses were 307.3 ± 70.8, 300.8 ± 67.9, and 359.1 ± 57.2 kPa ( P = .09). Among AHI risk groups, circumferential stresses were 476.9 ± 151.4, 503.3 ± 135.4, and 586.2 ± 102.6 kPa for groups 1-3 ( P = .008). Longitudinal stresses were 297.6 ± 80.7, 304.1 ± 64.7, and 361.2 ± 122.9 kPa ( P = .004). For both circumferential and longitudinal stresses, pairwise comparisons were significant between groups 1,3 and 2,3. No observations were classified as group 4 for ASI or AHI. Conclusions: Differences in wall stress were not significant across ASI risk groups and were significant between AHI groups 1,3 and 2,3. While both indices have been shown to stratify clinical outcomes, AHI-based risk groups may better reflect differences in biomechanical state. Prospective studies may further elucidate the relationship between biomechanical status and clinical outcomes.

Characteristics of Patients with Central Nervous System Relapse in Veterans with Diffuse Large B-Cell Lymphoma within the Veterans Health Administration

IntroductionAround 2-5% of patients with diffuse large B-cell lymphoma (DLBCL) will experience central nervous system (CNS) relapse resulting in a poor prognosis. The Central Nervous System International Prognostic Index (CNS-IPI) is a validated risk model used to help identify DLBCL patients receiving R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) chemotherapy who are at risk for CNS relapse. CNS prophylaxis is recommended for those with high-risk CNS-IPI scores; however, the role of CNS prophylaxis has been called into question given recent large datasets showing no impact on CNS relapse. The purpose of this study is to evaluate the characteristics of Veterans who experienced CNS relapse within the Veterans Healthcare Administration (VHA) and to validate the CNS-IPI risk stratification within this population.MethodsTrained abstractors performed a retrospective chart review of 3287 lymphoma patients seen in the VHA nationwide between 01/01/2011 and 12/31/2017. Figure 1 describes the selection of the study cohort. We evaluated baseline patient and disease characteristics including CNS-IPI score, performance of diagnostic lumbar puncture (LP) and first-line chemotherapy regimen. Pathology reports to identify cell of origin (COO), and additional risk factors for CNS relapse present at the time of original diagnosis including HIV associated lymphoma, testicular lymphoma, and high-grade B-cell lymphomas (HGBLs) defined as double or triple-hit DLBCL were evaluated. We also assessed response to first-line treatment, type of CNS prophylaxis used, including number of doses, and time to CNS relapse.ResultsA total of 1621 patients met criteria for analysis. Patients were predominately male, white, had a median age of 67, and presented with advanced disease (Table 1). At the time of diagnosis, 81% of the cohort had an ECOG performance status of 0-2, 73% received a CHOP based regimen, and 52% were designated as having a high-risk CNS-IPI score. Patients were about twice as likely to have a germinal center B-cell (GCB) COO rather than activated B-cell (ABC), but the COO was unavailable for almost 30% of the cohort. About 6% of the patients were known to have HGBLs, but the “hit status” of around 65% of the patients was unknown. Diagnostic LP was performed in 10%, 14%, and 19% of patients in the low-, intermediate-, and high-risk CNS-IPI groups respectively.The median follow-up time for the subjects in the study was 44 months. The low-risk group (12% of all patients analyzed), the intermediate-risk group (36%) and the high-risk group (52%) showed rates of CNS relapse of 1% (with a 95% CI: 0% to 2.4%), 2.4% (CI: 1.2% to 3.7%), and 2.4% (CI: 1.3% to 3.4%) respectively with no statistically significant difference across the risk groups (p=0.30). In patients with CNS relapse, only 35% of patients had a diagnostic LP. More than 90% of patients deemed high-risk for CNS relapse did not receive CNS prophylaxis. Among the 36 patients with CNS relapse, only 3 were given CNS prophylaxis at baseline (Table 2). Of the patients with CNS relapse, 75% of patients achieved a complete response with initial treatment. When categorized by the CNS-IPI score, there is no significant difference between intermediate- and high-risk based on type of CNS relapse, type of CNS prophylaxis used, response to first-line therapy, median time to relapse, median survival time, or median time from relapse to death. Those with CNS relapse had a shorter survival time compared to those with systemic relapse or no relapse (Figure 2).ConclusionsWhen compared to the previously validated CNS-IPI study, there were fewer instances of CNS relapse in our patient population in the intermediate- and high-risk groups, however, about a quarter of the patients in these groups did not receive CHOP based therapy. Although there is published data demonstrating COO and HGBLs as contributing factors to CNS relapse, our data did not show any statistically significant difference in relapse rates. Potential limitations include that the study is a retrospective chart review of a predominately male veteran population. Our data suggests the CNS-IPI may not identify patients at risk for CNS relapse with adequate accuracy. [Display omitted] DisclosuresNooruddin: AstraZeneca: Research Funding.

Polysomnographic Phenotypes of Obstructive Sleep Apnea and Incident Type 2 Diabetes: Results from the DREAM Study.

Rationale: Obstructive sleep apnea (OSA) is associated with cardiovascular disease and incident type 2 diabetes (T2DM). Seven OSA phenotypes, labeled on the basis of their most distinguishing polysomnographic features, have been shown to be differentially associated with incident cardiovascular disease. However, little is known about the relevance of polysomnographic phenotypes for the risk of T2DM. Objectives: To assess whether polysomnographic phenotypes are associated with incident T2DM and to compare the predictive value of baseline polysomnographic phenotypes with the Apnea-Hypopnea Index (AHI) for T2DM. Methods: The study included 840 individuals without baseline diabetes from a multisite observational U.S. veteran cohort who underwent OSA evaluation between 2000 and 2004, with follow-up through 2012. The primary outcome was incident T2DM, defined as no diagnosis at baseline and a new physician diagnosis confirmed by fasting blood glucose >126 mg/dL during follow-up. Relationships between the seven polysomnographic phenotypes (1. mild, 2. periodic limb movements of sleep [PLMS], 3. non-rapid eye movement and poor sleep, 4. rapid eye movement and hypoxia, 5. hypopnea and hypoxia, 6. arousal and poor sleep, and 7. combined severe) and incident T2DM were investigated using Cox proportional hazards regression and competing risk regression models with and without adjustment for baseline covariates. Likelihood ratio tests were conducted to compare the predictive value of the phenotypes with the AHI. Results: During a median follow-up period of 61 months, 122 (14.5%) patients developed incident T2DM. After adjustment for baseline sociodemographics, fasting blood glucose, body mass index, comorbidities, and behavioral risk factors, hazard ratios among persons with "hypopnea and hypoxia" and "PLMS" phenotypes as compared with persons with "mild" phenotype were 3.18 (95% confidence interval [CI], 1.53-6.61] and 2.26 (95% CI, 1.06-4.83) for incident T2DM, respectively. Mild OSA (5 ⩽ AHI < 15) (vs. no OSA) was directly associated with incident T2DM in both unadjusted and multivariable-adjusted regression models. The addition of polysomnographic phenotypes, but not AHI, to known T2DM risk factors greatly improved the predictive value of the computed prediction model. Conclusions: Polysomnographic phenotypes "hypopnea and hypoxia" and "PLMS" independently predict risk of T2DM among a predominantly male veteran population. Polysomnographic phenotypes improved T2DM risk prediction comared with the use of AHI.

Safety and Efficacy of Clomiphene Citrate in the Treatment of Secondary Hypogonadism. A Retrospective Study

“Introduction: Clomiphene (Clomid) has an off-label indication to treat hypogonadism in select populations. “Based on clinical practice, this medication in certain types of hypogonadism is equally effective as testosterone in treating hypogonadism. It will lead to less side effects, lower treatment cost, and will decrease rates of infertility in the male veteran population.” Secondary hypogonadism can be most often caused by opioid use, obesity, sleep apnea, and diabetes.” “Aim of Study: To evaluate the safety and efficacy of Clomiphene Citrate in Treatment of Secondary Hypogonadism in comparison with testosterone. “Study Population: Data was obtained from the Veterans Administration Data Warehouse through the Veterans Administration Informatics and Computing Infrastructure. Data was extracted using SQL. There were 405,824 male patients with a diagnosis of hypogonadism (87.1%)and infertility (12.9%). nationally at the VA. Of these, 9566 patients have been treated with clomiphene citrate and 232,123 with various testosterone therapy. “ The two groups were then matched by propensity method to controls at a ratio of about 1:1 for Age, race, BMI and time for follow-up as potential confounding factors hat could have affected inclusion in the study controls. Patients without either Clomiphene or testosterone treatment were excluded. Statistical Analysis: SAS was used for propensity matching (PSM, greedy near) Categorical variables were evaluated as frequency counts with percentage within group, as well as ODDS ratio (OR) and differences were evaluated by a chi-square method. Comparisons of continuous variables were done were done by simple and paired t-test. Kaplan Meier plots and Cox Hazard ratio calculations were used to examine time dependent risk between treatments. Actual p-values are shown and p-values lower than 0.0001 are shown as such. All comparisons used a two-sided assumption. Measurements: Testosterone laboratory measures were recorded for start and end of trial. Survival was taken as the difference in days between start date and date of death. New diagnosis of Osteoporosis and Polycythemia was that which occurred after initiation of therapy. “Results: Clomid treatment normalized testosterone levels in 53.2% versus 46.8% in the testosterone group (OR 1.32 P<0.005). All-cause mortality was in the clomid group 0.16% and 1.62%in the testosterone group (OR 0.16 P<0.001). The incidence of new Osteoporosis for clomid was 3.9 % versus 5.9% for testosterone (OR 0.65 P<0.001)” Conclusion: This is a retrospective study comparing the efficacy and side effects of clomiphene versus testosterone for treatment of hypogonadism. The study showed that clomiphene is more effective than testosterone to treat secondary hypogonadism. We also found decreased overall mortality and incidence of polycythemia and osteoporosis.

Levetiracetam-associated irritability and potential role of vitamin B6 use in veterans with epilepsy.

Levetiracetam, a commonly prescribed antiseizure medication (ASM), may cause irritability, depression, and anger. The mechanisms underlying these behavioral effects and individual risk factors remain unknown. Mitigation strategies are limited, including discontinuation, supplementation with vitamin B6, or switching to an alternative ASM. Several retrospective studies and anecdotal reports, primarily in pediatric populations, suggest vitamin B6 supplementation may be helpful in reducing levetiracetam-associated irritability. Although data in adult patients is limited, and no data is available for Veterans. The objective of this project was to describe our preliminarily experience with vitamin B6 supplementation for alleviating levetiracetam-associated irritability in male Veterans with epilepsy. Retrospective chart reviews were completed for patients who had an active prescription for levetiracetam from the William S. Middleton Memorial Veterans Hospital from January 1, 2015 to June 1, 2020. A total of 26 charts were screened. Patients were excluded if not using vitamin B6 supplementation or if deceased at end of data collection. Baseline characteristics were compared, including age, sex, comorbidities, and concomitant medications. Charts were then reviewed to identify any clinical description of irritability, including subjective assessment of change in symptoms across multiple visits, and scores from standardized instruments including the patient health questionnaire (PHQ-9), generalized anxiety disorder questionnaire (GAD-7), and/or irritability in adult patients with epilepsy (I-EPI) questionnaire. These symptoms and scores were then compared pre- and post-B6 supplementation. Of 22 patients, data was available for 20 (91%). For patients with data available, 9 (45%) showed improved irritability following supplementation with vitamin B6 and 11 (55%) showed no improvement. This project suggests that vitamin B6 supplementation may have a role in mitigating levetiracetam-associated irritability in a male Veteran population. These results support future prospective controlled studies to assess further the efficacy of this approach and characteristics associated with successful treatment in veterans.

1671. Diagnosis and management of Escherichia coli bacteriuria at a Veterans Affairs hospital

BackgroundThe IDSA recommends against screening for and treating ASB in all patients except for those pregnant or undergoing urologic procedures. Nevertheless, antibiotic treatment of ASB is widespread. We conducted a retrospective analysis of physician practices in diagnosis and management of Escherichia coli (E. coli) ASB in a male Veteran population, and compared outcomes in ASB patients treated or not treated with antibiotics.MethodsPatients with an E. coli positive urine culture during an ED visit or inpatient admission from 01/2017 to 12/2017 were screened. Patients admitted to the intensive care unit or diagnosed with a sexually transmitted infection, pyelonephritis, prostatitis, or epididymitis/orchitis were excluded. A total of 163 patients were included. Demographics, clinical comorbidities and severity of illness, and outcomes were compared in ASB patients managed with or without antibiotics. ANOVA and Chi-square or Fisher’s exact tests were utilized for comparing measurements.ResultsASB was present in 92/163 patients. The majority (74%) of these patients were given antibiotics. Regardless of qSOFA score or alternate infection, there were no significant differences in outcomes between ASB patients treated or not treated with antibiotics: 3-month mortality (15% vs 21%; p = 0.53), emergence of newly resistant bacterial pathogens (7% vs 13%; p = 0.43), recurrent urinary tract infections (61% vs 50%; p = 0.72), clearance of urinary pathogens (75% vs 58%; p = 0.45), length of hospital stay (7 vs 6 days, p = 0.67). Factors that were predictive of physician treatment of ASB included patient comorbid conditions such as benign prostatic hyperplasia, pyuria, and the absence of hematuria. The incidence of adverse events with antibiotic treatment of ASB was low.ConclusionThe rate of antibiotic treatment of E. coli ASB in male veterans is high. Outcomes do not differ among ASB patients managed with or without antibiotics. Future studies examining outcomes in patients prescribed antibiotics for multiple episodes of ASB may yield differences, particularly in emergence of resistant pathogens. Focusing on patients with comorbid conditions who are not critically ill would be a high yield target for provider education to reduce ASB treatment.Disclosures All Authors: No reported disclosures

The Relationship Between Number of Comorbidities and Age of Colorectal Cancer Diagnosis in US Male Veteran Population: A Single-Center Experience.

BackgroundComorbidities of tobacco and alcohol abuse and obesity are major risk factors for colon carcinogenesis. These risk factors are considered the most prevalent modifiable risk factors linked to malignancies including colorectal cancer (CRC) in both high- and low-income countries. The aim of this study was to investigate the relationship between number of comorbidities and age of CRC diagnosis in US male veteran population.MethodsA retrospective single-center study using chart review and the International Classification of Diseases, Ninth Revision (ICD-9) codes to identify patients with a diagnosis of CRC and comorbidities of tobacco abuse, alcohol abuse, hypertension (HTN), diabetes mellitus (DM) and chronic kidney disease (CKD). The primary aim was to study effect of these comorbidities on age of CRC diagnosis. Univariable and then multivariable logistic regression models were fit to age at diagnosis for each patient variable.ResultsA total of 362 patients were included in the study. The mean age of CRC diagnosis was 66.8. Eighty percent were Caucasians, and 20% were African Americans. African Americans were diagnosed with CRC 3.8 years younger compared to Caucasians (P = 0.01). Controlling for other variables in the multivariable model, age at CRC diagnosis was significantly lower for African Americans and for patients with higher total counts for tobacco and alcohol abuse and obesity. HTN, DM and CKD were not associated with a lower age of CRC diagnosis.ConclusionsTobacco and alcohol abuse and obesity have negative cumulative effect on age of CRC diagnosis in US male veteran population. Patients with increasing number of these comorbidities are associated with significantly lower age of CRC diagnosis. It is important to identify veterans with these comorbidities and encourage CRC screening.

Prevalence of Thyroid Incidentalomas from 1995 to 2016: A Single-Center, Retrospective Cohort Study.

Incidental detection of thyroid nodules on nonthyroid imaging may contribute to increased diagnosis of thyroid cancer. We investigated the prevalence of thyroid incidentalomas across imaging modalities among a predominately male veteran population. Thyroid nodules were identified on nonthyroid-directed radiology reports using natural language processing. All reports from 1995 to 2016 for chest computed tomography (CT), carotid ultrasound (US), and neck magnetic resonance imaging (MRI) were reviewed. Individuals with multiple studies were included at their initial study and duplicates removed. A total of 25 763 carotid US, 23 526 chest CTs with contrast, 39 262 noncontrast chest CTs, and 9503 MRIs were reviewed. With duplicates removed, 14 642 carotid US, 12 923 chest CTs with contrast, 17 416 noncontrast chest CTs, and 6926 MRIs were included. Mean age was 66.2 years and 1834 were female (3.53%). Thyroid nodules were reported on 0.84% carotid US, 3.45% MRIs, 5.84% chest CTs with contrast, and 5.14% noncontrast chest CTs. Women had a higher rate of thyroid nodules on MRI (6.46% vs 3.20%, P = .003), chest CT with contrast (9.80% vs 5.72%, P = .007), and noncontrast chest CT (8.77% vs 5.02%, P = .002), but not on carotid US (1.99% vs 0.81%, P = .12). Incidentaloma prevalence increased with age on MRI, chest CT with or without contrast, but not on carotid US, and were more commonly reported from 2007 to 2016 compared to before 2007 across all modalities. Thyroid incidentalomas are commonly reported, are more common among women, and increase with age. The rate of reported incidental thyroid nodules is increasing, likely contributing to the increase in thyroid cancer.

1126 Preoperative Endoscopic Findings in Veterans Undergoing Bariatric Surgery: Prevalence and Predictors of Barrett's Esophagus

INTRODUCTION: The role of preoperative esophagogastroduodenoscopy (EGD) in patients seeking bariatric surgery remains unclear, as recommendations are based on data from a younger, largely female population. We aim to characterize and determine the frequency of EGD findings in a predominantly older, male Veteran population undergoing bariatric surgery. METHODS: This is a single-center retrospective analysis of Veterans who underwent Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy at a Veterans Affairs hospital between January 2008 and December 2017. All patients received a preoperative EGD. Data abstracted included demographics, comorbidities, preoperative laboratory values and EGD reports. Univariate and multivariate analyses using odds ratio (OR) were compared between those with a normal EGD and Barrett’s esophagus. RESULTS: Of the 260 Veterans included in our cohort, most were male (75%) aged 54.0 ± 9.0 years-old with a BMI of 44.9 ± 7.0 kg/m2 (Table 1). Most Veterans identified themselves as Caucasian (73.5%), followed by African American (9.2%), Hispanic (7.3%), Native American (1.2%), Asian (0.8%) and other (8.1%). The majority had hypertension (78.9%), previously smoked (63.9%), used a proton pump inhibitor (PPI) (53.1%) within 6 months of surgery, had gastroesophageal reflux disease (GERD) (49.2%) and diabetes (47.3%). One third of Veterans had a completely normal preoperative EGD. Common EGD findings included gastritis (35.8%), hiatal hernia (25.8%), esophagitis (20.8%), duodenitis (10.4%), Barrett’s esophagus (7.4%), H. pylori infection (4.6%) and gastric intestinal metaplasia (0.8%). On univariate analysis alone, male gender (OR 0.55, P = 0.041) and those with hypertension (OR 0.50, P = 0.025) were less likely associated with a normal EGD. On both univariate and multivariate analyses, those who recently used a PPI were also less likely to have a normal EGD (OR 0.38, P = 0.001; OR 0.030,P &lt; 0.001, respectively). In contrast, on both univariate and multivariate analysis, increasing age (OR 1.08, P = 0.020; OR 1.08; P = 0.040, respectively), recent PPI use (OR 5.20, P = 0.010; OR 10.1, P = 0.002, respectively) and recent histamine receptor 2 blocker (H2B) use (OR 5.58, P = 0.007; OR 8.87 P = 0.014, respectively), were associated with Barrett’s esophagus (Table 3). CONCLUSION: Preoperative factors can be used to identify patients at risk for gastroesophageal pathology. Our data support preoperative EGD in select populations that include older males with recent PPI or H2B use.

PTSD and Trauma-Informed Care in the Long-Term Care Setting

PTSD and Trauma-Informed Care in the Long-Term Care Setting

Media Review: Served Like a Girl

According to a recent report from the U.S. Department of Veteran Affairs, the number of homeless women veterans increased by seven percent from 2016 to 2017 compared to a one percent increase among the male veteran population. Served Like a Girl, by Lysa Heslov, situates discussions of the growing plight of the homeless women veteran population against the backdrop of the Ms. Veteran America pageant. The pageant, founded by Army veteran MAJ Jaspen Boothe, was created to bring awareness to the deficit found within existing veteran housing programs and to encourage financial support for the development of transitional services specific to the needs of women veterans. The documentary follows four pageant contestants, the master of ceremonies, the pageant director—also the first pageant winner, and the founder of the pageant as they prepare for the 2015 competition.

Correlation Between Polyp and Adenoma Detection Rate in Trainee Endoscopists

Introduction: The adenoma detection rate (ADR) is a widely accepted quality benchmark for screening colonoscopy, but calculation requires labor-intensive manual confirmation of histology. Previous studies have shown that the polyp detection rate (PDR) correlates well with ADR and may serve as a surrogate benchmark, although the ADR/PDR ratio may vary by colonic segment. In this study, we assessed the relationship between PDR and ADR in colonoscopies performed by trainees, for whom a surrogate benchmark may be a more practical method of tracking performance. Additionally, we evaluated the relationship between PDR and sessile serrated polyp (SSPDR) and advanced adenoma detection rates (AADR). Methods: We examined all outpatient colonoscopies performed by trainees at a VA facility from 8/16/16-12/29/17. We excluded incomplete procedures and those with Boston Bowel Preparation Scale scores less than 2 in any segment. Variables collected included patient demographics, year of fellowship, and endoscopic and histologic findings. Results: Table 1 shows patient characteristics, trainee status, and overall findings in 814 colonoscopies. Our population was predominantly (44%) black. The majority (88%) of procedures were performed for screening or surveillance, and most (47%) were performed by second-year fellows. The overall PDR, ADR, SSPDR, and AADR were 77%, 57%, 3%, and 17%. Table 2 shows the PDR, ADR, SSPDR, AADR, and the respective ratios overall as well as by colonic segment and year of training. The overall ADR/ PDR ratio was 0.74. The ratio was similar in the right (0.77) and transverse colon (0.75) but lower in the left colon (0.52). The same pattern was seen for the overall SSPDR/PDR and AADR/PDR ratios. When stratified by year of training, the overall ratios were consistent and a similar decline in ratios from the right to the left colon was observed in most cases. Notably, the AADR/PDR ratio in the right colon was substantially higher for third-year fellows, which suggests training may improve the efficiency of detecting advanced adenomas in the right colon. Conclusion: The overall ADR/PDR ratio in our study was higher than previously reported, which may reflect the predominantly male veteran population and the presence of a supervising physician. The overall ratios did not vary by year of training and but did decrease in the left colon. These results provide valuable preliminary data for how the PDR can be used to calculate the ADR, SSPDR, and AADR for trainee endoscopists.222_A Figure 1. Abbreviation: IQR, inter-quartile range a Advanced adenoma: any adenoma ≥10 mm in size, with villous component, or with high grade dysplasia OR any sessile serrated polyp ≥10 mm in size or with dysplasia222_B Figure 2. Abbreviations: ADR, adenoma detection rate; PDR, polyp detection rate; SSPDR, sessile serrated polyp detection rate; AADR, advanced adenoma detection rate.

Thyroid Fine Needle Aspiration: Successful Prospective Implementation of Strategies to Eliminate Unnecessary Biopsy in the Veteran Population

Thyroid nodules are prevalent in over half the general population. Several multidisciplinary societies have management recommendations. However, the majority of data to support these guidelines are derived from studies of predominantly younger and female populations. This study's aim was to evaluate characteristics of thyroid nodules in a largely older and male Veteran population and apply these findings prospectively to reduce unnecessary thyroid fine needle aspiration (FNA). Over a 4-year period, all ultrasound-guided FNA of thyroid nodules performed in our department were reviewed. Sonographic features, patterns, and histopathology were evaluated. A prospective strategy of avoiding FNA in all lesions matching imaging patterns of benignity was implemented and positive predictive value (PPV) of malignancy was calculated and compared to the retrospective data. Retrospectively, FNA was performed on 351 successive thyroid nodules, 9 of which were malignant. Statistically significant malignant features include presence of microcalcifications, irregular or amorphous morphology, taller-than-wide shape, spiculated margins, vascularity, and lymphadenopathy. PPV of thyroid FNA was 2.6% in this period. Four sonographic patterns were 100% specific for benignity, including: "spongiform," "cyst with a colloid clot," "giraffe," and "white knight" patterns. Over 23 months, prospective avoidance of FNA of lesions characterized as a benign pattern (159 nodules) was implemented and PPV was calculated as 7.2% resulting in a cost savings of $477,000. Four sonographic patterns were 100% specific for benignity in the older and predominantly male Veteran population. Strict prospective application of avoiding biopsy in these benign patterns resulted in a decrease of unnecessary biopsies, decrease in patient morbidity, and improved allocation of health care resources.

Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women's health primary care.

The Veterans Health Administration (VHA) has undertaken primary care transformation based on patient-centered medical home (PCMH) tenets. VHA PCMH models are designed for the predominantly male Veteran population, and require tailoring to meet women Veterans' needs. We used evidence-based quality improvement (EBQI), a stakeholder-driven implementation strategy, in a cluster randomized controlled trial across 12 sites (eight EBQI, four control) that are members of a Practice-Based Research Network. EBQI involves engaging multilevel, inter-professional leaders and staff as stakeholders in reviewing evidence and setting QI priorities. The goal of this analysis was to examine processes of engaging stakeholders in early implementation of EBQI to tailor VHA's medical home for women. Four inter-professional regional stakeholder planning meetings were conducted; these meetings engaged stakeholders by providing regional data about gender disparities in Veterans' care experiences. Subsequent to each meeting, qualitative interviews were conducted with 87 key stakeholders (leaders and staff). Stakeholders were asked to describe QI efforts and the use of data to change aspects of care, including women's health care. Interview transcripts were summarized and coded using a hybrid deductive/inductive analytic approach. The presentation of regional-level data about gender disparities resulted in heightened awareness and stakeholder buy-in and decision-making related to women's health-focused QI. Interviews revealed that stakeholders were familiar with QI, with regional and facility leaders aware of inter-disciplinary committees and efforts to foster organizational change, including PCMH transformation. These efforts did not typically focus on women's health, though some informal efforts had been undertaken. Barriers to engaging in QI included lack of communication across clinical service lines, fluidity in staffing, and lack of protected time. Inter-professional, multilevel stakeholders need to be engaged in implementation early, with data and discussion that convey the importance and relevance of a new initiative. Stakeholder perspectives on institutional norms (e.g., gender norms) and readiness for population-specific QI are useful drivers of clinical initiatives designed to transform care for clinical subpopulations.

A5120 - Bariatric Surgery in the Elderly Male Veteran Population: Low Readmission Rates and Successful Outcomes

A5120 - Bariatric Surgery in the Elderly Male Veteran Population: Low Readmission Rates and Successful Outcomes