US Veterans Research Articles

Validation of the EDDS-5 self-report survey against the SCID-5 diagnostic interview in US veterans

The aim of our study was to validate the Eating Disorder Diagnostic Scale (EDDS-5) updated for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) with a diverse veteran population against a clinician-administered interview based on the Structured Clinical Interview for DSM-5 (SCID-5). Our sample included 343 veterans, 18–75 years, recruited April 2019 to December 2022 who completed the EDDS-5 as well as other eating disorder and mental health measures. A subsample of these veterans received clinical interviews (n = 166), which were used to validate the EDDS-5. We found that despite multiple proposed modifications, the EDDS-5 performed poorly at correctly identifying diverse veterans who were diagnosed as having eating disorders through clinician-administered interviews. The sensitivity was very low, indicating that using the EDDS-5 did not identify many true positives and may also over diagnose those without true eating disorders. The EDDS-5 may not be the best for screening or diagnostic purposes among diverse samples like veterans.

Suicide Risk Among US Veterans With Military Service During the Vietnam War

There are persistent questions about suicide deaths among US veterans who served in the Vietnam War. It has been believed that Vietnam War veterans may be at an increased risk for suicide. To determine whether military service in the Vietnam War was associated with an increased risk of suicide, and to enumerate the number of suicides and analyze patterns in suicides among Vietnam War theater veterans compared with the US population. This cohort study compiled a roster of all Vietnam War-era veterans and Vietnam War theater veterans who served between February 28, 1961, and May 7, 1975. The 2 cohorts included theater veterans, defined as those who were deployed to the Vietnam War, and nontheater veterans, defined as those who served during the Vietnam War era but were not deployed to the Vietnam War. Mortality in these 2 cohorts was monitored from 1979 (beginning of follow-up) through 2019 (end of follow-up). Data analysis was performed between January 2022 and July 2023. The outcome of interest was death by suicide occurring between January 1, 1979, and December 31, 2019. Suicide mortality was ascertained from the National Death Index. Hazard ratios (HRs) that reflected adjusted associations between suicide risk and theater status were estimated with Cox proportional hazards regression models. Standardized mortality rates (SMRs) were calculated to compare the number of suicides among theater and nontheater veterans with the expected number of suicides among the US population. This study identified 2 465 343 theater veterans (2 450 025 males [99.4%]; mean [SD] age at year of entry, 33.8 [6.7] years) and 7 122 976 nontheater veterans (6 874 606 males [96.5%]; mean [SD] age at year of entry, 33.3 [8.2] years). There were 22 736 suicides (24.1%) among theater veterans and 71 761 (75.9%) among nontheater veterans. After adjustments for covariates, Vietnam War deployment was not associated with an increased risk of suicide (HR, 0.94; 95% CI, 0.93-0.96). There was no increased risk of suicide among either theater (SMR, 0.97; 95% CI, 0.96-0.99) or nontheater (SMR, 0.97; 95% CI, 0.97-0.98) veterans compared with the US population. This cohort study found no association between Vietnam War-era military service and increased risk of suicide between 1979 and 2019. Nonetheless, the 94 497 suicides among all Vietnam War-era veterans during this period are noteworthy and merit the ongoing attention of health policymakers and mental health professionals.

Incident Ocular Inflammation After COVID-19 Infection in a US Veteran Population

ABSTRACT Purpose To investigate whether COVID-19 infection is a risk factor for incident ocular inflammatory disease. Design Retrospective case-crossover study. Methods The US Veterans Health Administration Corporate Data Warehouse was used to identify patients with positive COVID-19 testing and incident ocular inflammatory disease between March 2020 and May 2022. The timing of incident ocular inflammation and COVID-19 testing was assessed for each participant to determine whether positive COVID-19 testing occurred 0–60 days prior to incident ocular inflammation diagnosis (risk period) or 15–75 days after incident ocular inflammation diagnosis (control period). The main outcome measure was the odds of positive COVID-19 testing in the risk period versus control period. Results Of the 1006 patients with incident ocular inflammation and a positive COVID-19 test in the study period, the age mean ± standard deviation was 62.6 ± 9.8 years and 840 (83%) were male. The odds of COVID-19 exposure was higher in the risk than control period (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.04–2.36; P = 0.03). Ocular inflammation was more likely to be bilateral in the risk period (OR, 3.97; 95% CI, 1.01–23.01; P = 0.03). Other ocular features and demographic characteristics were similar in the risk and control periods. Most cases of ocular inflammation were quiescent at the most recent eye examination. Conclusions Incident ocular inflammation is associated with COVID-19 infection, but the increased risk is small, and the ocular inflammation is typically acute.

Epidemiology of the 2022 Mpox Outbreak in the US Veterans Health Administration.

In May 2022, mpox cases were reported in nonendemic countries, including the United States. We examined mpox infections in the Veterans Health Administration (VHA). Mpox diagnostic and whole genome sequencing (WGS) results, demographics, risk factors, hospitalizations, exposures, deaths, and pharmacy and immunization data were obtained from VHA data sources (23 May 2022-31 May 2023). Of 1144 Veterans tested, 251 (21.9%) were presumptive positive for nonvariola orthopoxvirus (NVO) or confirmed positive for NVO and Monkeypox virus (MPXV). Incidence rate was 7.5 per 100 000 Veterans in care, with the highest rate observed in Veterans aged 25-34 years (13.83 cases per 100 000). Higher odds of NVO or NVO/MPXV positivity was associated with male sex; non-Hispanic Black race/ethnicity; syphilis or human immunodeficiency virus (HIV) positivity; or genital/rectal sample site, whereas older age and vaccination with JYNNEOS or vaccinia (smallpox) had lower odds. Among 209 with confirmatory testing, 90.4% reported intimate contact and/or an epidemiological link, 84.5% were men who have sex with men (MSM), 24.2% received tecovirimat, and 8.1% were hospitalized with 1 death. Eighty-six sequenced samples had evaluable WGS results. All were clade IIb, representing 10 different lineages from 20 states and the District of Columbia. Mpox affected younger, MSM, non-Hispanic Black, and HIV/syphilis-positive men among US Veterans. Viral diversity was noted across geographic regions. At-risk Veterans would benefit from vaccination and risk reduction strategies for mpox and other sexually transmitted infections.

Retention in Individual Trauma-Focused Treatment Following Family-Based Treatment Among US Veterans

Despite the availability of several empirically supported trauma-focused interventions, retention in posttraumatic stress disorder (PTSD) psychotherapy is poor. Preliminary efficacy data shows that brief, family-based interventions may improve treatment retention in a veteran's individual PTSD treatment, although whether this occurs in routine clinical practice is not established. To characterize receipt of family therapy among veterans diagnosed with PTSD and evaluate whether participation in family therapy is associated with an increased likelihood of completing individual trauma-focused treatment. This retrospective cohort study used the Veterans Health Administration (VHA) Informatics and Computing Infrastructure to extract electronic health record data of participants. All participants were US veterans diagnosed with PTSD between October 1, 2015, and December 31, 2019, who attended at least 1 individual trauma-focused treatment session. Statistical analysis was performed from May to August 2023. Receipt of any family psychotherapy and subtype of family-based psychotherapy. Minimally adequate individual trauma-focused treatment completion (ie, 8 or more sessions of trauma-focused treatment in a 6-month period). Among a total of 1 516 887 US veterans with VHA patient data included in the study, 58 653 (3.9%) received any family therapy; 334 645 (23.5%) were Black, 1 006 168 (70.5%) were White, and 86 176 (6.0%) were other race; 1 322 592 (87.2%) were male; 1 201 902 (79.9%) lived in urban areas; and the mean (SD) age at first individual psychotherapy appointment was 52.7 (15.9) years. Among the 58 653 veterans (3.9%) who received any family therapy, 36 913 (62.9%) received undefined family therapy only, 15 528 (26.5%) received trauma-informed cognitive-behavioral conjoint therapy (CBCT) only, 5210 (8.9%) received integrative behavioral couples therapy (IBCT) only, and 282 (0.5%) received behavioral family therapy (BFT) only. Compared with receiving no family therapy, the odds of completing individual PTSD treatment were 7% higher for veterans who also received CBCT (OR, 1.07 [95% CI, 1.01-1.13]) and 68% higher for veterans received undefined family therapy (OR, 1.68 [95% CI, 1.63-1.74]). However, compared with receiving no family therapy care, veterans had 26% lower odds of completing individual PTSD treatment if they were also receiving IBCT (OR, 0.74 [95% CI, 0.66-0.82]). In this cohort study of US veterans, family-based psychotherapies were found to differ substantially in their associations with individual PTSD psychotherapy retention. These findings highlight potential benefits of concurrently providing family-based therapy with individual PTSD treatment but also the need for careful clinical attention to the balance between family-based therapies and individual PTSD treatment.

Housing Status, Cancer Care, and Associated Outcomes Among US Veterans

Cancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described. To characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer. This retrospective cohort study identified all US veterans diagnosed with lung, colorectal, or breast cancer who received VA care between October 1, 2011, and September 30, 2020. Data analysis was performed from February 13 to May 9, 2023. Veterans were classified as experiencing homelessness if they had any indicators of homelessness in outpatient visits, clinic reminders, diagnosis codes, or the Homeless Operations Management Evaluation System in the 12 months preceding diagnosis, with no subsequent evidence of stable housing. The major outcomes, by cancer type, were as follows: (1) treatment course (eg, stage at diagnosis, time to treatment initiation), (2) surgical outcomes (eg, length of stay, major complications), (3) overall survival by cancer type, and (4) hazard ratios for overall survival in a model adjusted for age at diagnosis, sex, stage at diagnosis, race, ethnicity, marital status, facility location, and comorbidities. This study included 109 485 veterans, with a mean (SD) age of 68.5 (9.7) years. Men comprised 92% of the cohort. In terms of race and ethnicity, 18% of veterans were Black, 4% were Hispanic, and 79% were White. A total of 68% of participants had lung cancer, 26% had colorectal cancer, and 6% had breast cancer. There were 5356 veterans (5%) experiencing homelessness, and these individuals more commonly presented with stage IV colorectal cancer than veterans with housing (22% vs 19%; P = .02). Patients experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. These patients also demonstrated higher rates of all-cause mortality 3 months after diagnosis for lung and colorectal cancers, with adjusted hazard ratios of 1.1 (95% CI, 1.1-1.2) and 1.3 (95% CI, 1.2-1.4) (both P < .001), respectively. In this large retrospective study of US veterans with cancer, homelessness was associated with later stages at diagnosis for colorectal cancer. Differences in lung and colorectal cancer survival between patients with housing and those experiencing homelessness were present but smaller than observed in other settings. These findings suggest that there may be important systems in the VA that could inform policy to improve oncologic outcomes for patients experiencing homelessness.

SLEEP DISORDERS AND RISK OF MID- TO LATE-LIFE SUICIDE ATTEMPT

Abstract Sleep is a compelling target for suicide prevention in later life, as 50% of older adults experience sleep difficulties. The primary objective of the current study was to evaluate whether sleep disorders increase risk of late-life suicide attempt and death by suicide. We examined a nationally based cohort of over 5 million US veterans 50 years and older, who used Department of Veterans Affairs (VA) health services. Veterans with a sleep diagnosis (i.e., sleep apnea, insomnia, hypersomnia, and others) at baseline (October 1, 2011, to September 30, 2013) or earlier (October 1, 2007, to September 30, 2011) were propensity matched 1:1 with patients without these diagnoses based on demographic characteristics and Charlson Comorbidity Index (Total N=1,990,362; 995,181 each group). Secondary analyses examined psychiatric disorders as potential moderators. Fully adjusted models (additionally adjusted for psychiatric disorders) demonstrated that patients with sleep disorders had a 23% increased risk of any suicide attempt (HR 1.23, 95% CI [1.20-1.27]), while risk mitigated for lethality of attempt (HR 0.98, 95% CI [0.92-1.03]). Depression, PTSD, and generalized anxiety disorder were all approximately twice as prevalent among the sleep disorder group. Among veterans with a psychiatric disorder, any sleep disorder diagnosis was associated with a 28% increased risk for suicide attempt, which attenuated among those without a psychiatric diagnosis. In conclusion, sleep disorder diagnoses conferred increased risk for suicide attempt, especially in older adults with psychiatric disorders. These findings suggest that treatment of sleep disorders may mitigate risk of suicide attempts in older vulnerable veterans.

CHILDHOOD TRAUMA AMONG US VETERANS AND THEIR NEGATIVE HEALTH AND RISKY BEHAVIORS IN LATER LIFE

Abstract Background Behavioral and health outcomes of childhood traumas are public health issues. Research on adverse childhood experiences (ACEs) have been explored among the general population; however, ACEs among persons with history of military service remains unknown. Methods Current study used secondary dataset obtained from CDC Behavioral Risk Factor Surveillance System (BRFSS) 2011. Study’s total sample size was 7,112. Data was weighted to account for the complex sampling design and nonresponse. Logistic regression was used to explore ACEs among US Veterans, and how early trauma correlates to long-term health problems, while controlling for their socioeconomic status. Results Our analyses suggested that compared to participants with 0 ACEs, those who reported 1 ACE (OR=1.38; CI=1.10-1.73), 2 ACEs (OR=2.30; CI=1.80-2.95), 3 ACEs (OR=2.81; CI=2.11-3.73), and 4+ ACEs (OR=4.04; CI=3.20-5.09) were more likely to report depression. Participants who reported for having 4+ ACEs were 4.16 times more likely to report in risky sexual behaviors (OR=4.16; CI= 1.83-9.46). Individuals with 4+ ACEs scores were 30% more likely to report binge drinking (OR=1.30; CI=1.02-1.67), 94% at risk for being a smoker (OR=1.94; CI=1.54-2.45) and had higher odds of developing poor health status (OR=1.67; CI=1.32-2.10). Conclusion Our research suggests that more ACEs score associates to a higher risk of developing health issues in later life. Research on ACEs has traditionally focused on health outcomes using secondary datasets among the general population. More research should be explored in longitudinal studies on ACEs, particularly with persons who have served in the military.

New statin use, mortality, and first cardiovascular events in older US Veterans by frailty status.

Statins are part of long-term medical regimens for many older adults. Whether frailty modifies the protective relationship between statins, mortality, and major adverse cardiovascular events (MACE) is unknown. This was a retrospective study of US Veterans ≥65, without CVD or prior statin use seen in 2002-2012, followed through 2017. A 31-item frailty index was used. The co-primary endpoint was all-cause mortality or MACE (MI, stroke/TIA, revascularization, or cardiovascular death). Cox proportional hazards models were developed to evaluate the association of statin use with outcomes; propensity score overlap weighting accounted for confounding by indication. We identified 710,313 Veterans (mean age (SD) 75.3(6.5), 98% male, 89% white); 86,327 (12.1%) were frail. Over mean follow-up of 8 (5) years, there were 48.6 and 72.6 deaths per 1000 person-years (PY) among non-frail statin-users vs nonusers (weighted Incidence Rate Difference (wIRD)/1000 person years (PY), -24.0[95% CI, -24.5 to -23.6]), and 90.4 and 130.4 deaths per 1000PY among frail statin-users vs nonusers (wIRD/1000PY, -40.0[95% CI, -41.8 to -38.2]). There were 51.7 and 60.8 MACE per 1000PY among non-frail statin-users vs nonusers (wIRD/1000PY, -9.1[95% CI, -9.7 to -8.5]), and 88.2 and 102.0 MACE per 1000PY among frail statin-users vs nonusers (wIRD/1000PY, -13.8[95% CI, -16.2 to -11.4]). There were no significant interactions by frailty for statin users vs non-users by either mortality or MACE outcomes, p-interaction 0.770 and 0.319, respectively. Statin use was associated with lower risk of all-cause mortality (HR, 0.61 (0.60-0.61)) and MACE (HR 0.86 (0.85-0.87)). New statin use is associated with a lower risk of mortality and MACE, independent of frailty. These findings should be confirmed in a randomized clinical trial.

Mortality among US veterans with a physician-documented diagnosis of pyruvate kinase deficiency

ABSTRACT Real-world studies of pyruvate kinase (PK) deficiency and estimates of mortality are lacking. This retrospective observational study aimed to identify patients with PK deficiency and compare their overall survival (OS) to that of a matched cohort without PK deficiency. Patients with ≥1 diagnosis code related to PK deficiency were selected from the US Veterans Health Administration (VHA) database (01/1995–07/2019); patients with a physician-documented diagnosis were included (PK deficiency cohort; index: date of first diagnosis code related to PK deficiency). Patients in the PK deficiency cohort were matched 1:5 to patients from the general VHA population (non-PK deficiency cohort; index: random visit date during match’s index year). OS from index was compared between the two cohorts. Eighteen patients in the PK deficiency cohort were matched to 90 individuals in the non-PK deficiency cohort (both cohorts: mean age 57 years, 94% males; median follow-up 6.0 and 8.0 years, respectively). At follow-up, patients in the non-PK deficiency cohort had significantly longer OS than the PK deficiency cohort (median OS: 17.1 vs. 10.9 years; hazard ratio: 2.3; p = 0.0306). During their first-year post-index, 75% and 40% of the PK deficiency cohort had laboratory-confirmed anemia and iron overload, respectively. Among patients who died, cause of death was highly heterogeneous. These results highlight the increased risk of mortality and substantial clinical burden among patients with PK deficiency. While the intrinsic characteristics of the VHA database may limit the generalizability of the results, this is the first real-world study to characterize mortality in patients with PK deficiency.

Prevalence of chronic non-cancer pain among military veterans: a systematic review and meta-analysis of observational studies

IntroductionChronic non-cancer pain is common among military veterans; however, the prevalence is uncertain. This information gap complicates policy decisions and resource planning to ensure veterans have access to healthcare services...

Risk of dementia in older veterans with multiple sclerosis

BackgroundWhile it is widely accepted that multiple sclerosis (MS) often causes cognitive dysfunction, it is thought that these cognitive symptoms rarely progress to dementia. However, this has not been thoroughly investigated. The objectives of this cohort study are to determine whether people with MS have an increased risk of dementia compared to the general population and to identify factors, such as geographic latitude, which may modify this association. MethodsWe studied data from a random sample of US veterans aged ≥ 55 years followed at Veterans Affairs Health Care Systems nationwide from 1999 to 2019. We identified all patients diagnosed with MS using ICD codes over a two-year baseline period. We then identified a comparison cohort of patients without MS matched 1:1 on sex, age, race, and first encounter date. We constructed Cox proportional hazards regression models to determine the association between MS and dementia while controlling for demographic factors and comorbidities, with additional models to examine subgroup effects. We used Fine-Gray subdistribution hazard models accounting for competing risk of death to evaluate the sensitivity of the findings. ResultsThe study included 4084 MS patients and a matched group of 4084 non-MS patients. Overall, patients had mean age 66, were 93.6% male, and 88.1% non-Hispanic White, with mean follow-up time 9.5 years (MS) and 10.8 years (non-MS). In unadjusted models, veterans with MS had greater risk of dementia compared to matched controls (cumulative incidence 16.7% vs 12.4%; Cox HR 1.58, 95% CI 1.41–1.78). The increased risk remained after adjustment for potential confounders (adjusted HR 1.56, 95% CI 1.39–1.76) and when considering death as a competing risk (Fine-Gray HR 1.36, 95% CI 1.21–1.53). The magnitude of the MS-dementia association increased with rising geographic latitude (North HR 1.86, 1.51–2.30; Central HR 1.61, 1.42–1.82; South HR 1.39, 1.18–1.64; interaction p = 0.04) and younger baseline age (interaction p<0.001). ConclusionsAmong older veterans with MS, risk of dementia diagnosis was higher compared to matched controls even after controlling for comorbidities. The risk difference was highest in northern regions and in younger patients. Clinicians caring for older MS patients should be aware of this risk and offer screening and treatment accordingly.

Well-Being of US Military Veterans

This survey study analyzed data from a nationally representative sample of US veterans to examine ratings and correlates of well-being.

Statins, Mortality, and Major Adverse Cardiovascular Events Among US Veterans With Chronic Kidney Disease

There are limited data for the utility of statins for primary prevention of atherosclerotic cardiovascular disease (ASCVD) and death in adults with chronic kidney disease (CKD). To evaluate the association of statin use with all-cause mortality and major adverse cardiovascular events (MACE) among US veterans older than 65 years with CKD stages 3 to 4. This cohort study used a target trial emulation design for statin initiation among veterans with moderate CKD (stages 3 or 4) using nested trials with a propensity weighting approach. Linked Veterans Affairs (VA) Healthcare System, Medicare, and Medicaid data were used. This study considered veterans newly diagnosed with moderate CKD between 2005 and 2015 in the VA, with follow-up through December 31, 2017. Veterans were older than 65 years, within 5 years of CKD diagnosis, had no prior ASCVD or statin use, and had at least 1 clinical visit in the year prior to trial baseline. Eligibility criteria were assessed for each nested trial, and Cox proportional hazards models with bootstrapping were run. Analysis was conducted from July 2021 to October 2023. Statin initiation vs none. Primary outcome was all-cause mortality; secondary outcome was time to first MACE (myocardial infarction, transient ischemic attack, stroke, revascularization, or mortality). Included in the analysis were 14 828 veterans. Mean (SD) age at CKD diagnosis was 76.9 (8.2) years, 14 616 (99%) were men, 10 539 (72%) White, and 2568 (17%) Black. After expanding to person-trials and assessing eligibility at each baseline, there were 151 243 person-trials (14 685 individuals) of nonstatin initiators and 2924 person-trials (2924 individuals) of statin initiators included. Propensity score adjustment via overlap weighting with nonparametric bootstrapping resulted in covariate balance, with mean (SD) follow-up of 3.6 (2.7) years. The hazard ratio for all-cause mortality was 0.91 (95% CI, 0.85-0.97) comparing statin initiators to noninitiators. The hazard ratio for MACE was 0.96 (95% CI, 0.91-1.02). Results remained consistent in prespecified subgroup analyses. In this target trial emulation of statin initiation in US veterans older than 65 years with CKD stages 3 to 4 and no prior ASCVD, statin initiation was significantly associated with a lower risk of all-cause mortality but not MACE. Results should be confirmed in a randomized clinical trial.

Association of long-term aspirin use with kidney disease progression.

Chronic microinflammation contributes to the progression of chronic kidney disease (CKD). Aspirin (ASA) has been used to treat inflammation for centuries. The effects of long-term low-dose ASA on CKD progression are unclear. We examined the association of long-term use of newly initiated low-dose ASA (50-200 mg/day) with all-cause mortality using Cox proportional hazard models; with cardiovascular/cerebrovascular (CV) mortality and with end stage kidney disease (ESKD) using Fine and Gray competing risk regression models; with progression of CKD defined as patients' eGFR slopes steeper than -5 mL/min/1.73m2/year using logistic regression models in a nationwide cohort of US Veterans with incident CKD. Among 831,963 patients, we identified 385,457 who either initiated ASA (N = 21,228) within 1 year of CKD diagnosis or never received ASA (N = 364,229). We used propensity score matching to account for differences in key characteristics, yielding 29,480 patients (14,740 in each group). In the matched cohort, over a 4.9-year median follow-up period, 11,846 (40.2%) patients (6,017 vs. 5,829 ASA users vs. non-users) died with 25.8% CV deaths, and 934 (3.2%) patients (476 vs. 458) reached ESKD. ASA users had a higher risk of faster decline of kidney functions, i.e., steeper slopes (OR 1.30 [95%CI: 1.18, 1.44], p < 0.01), but did not have apparent benefits on mortality (HR 0.97 [95%CI: 0.94, 1.01], p = 0.17), CV mortality (Sub-Hazard Ratio [SHR]1.06 [95%CI: 0.99-1.14], p = 0.11), or ESKD (SHR1.00 [95%CI: 0.88, 1.13], p = 0.95). Chronic low-dose ASA use was associated with faster kidney function deterioration, and no association was observed with mortality or risk of ESKD.

The Bidirectional Association of TBI and Dementia/MCI among older US Veterans

AbstractBackgroundPrior studies have reported a link between traumatic brain injury (TBI) and risk of adverse neuropsychiatric outcomes including dementia. However it is unclear how prevalent these conditions are prior to TBI and if they are predisposing factors in addition to sequalae.MethodsWe studied older (age &gt;55 years) US veterans who were followed for care at Veterans Affairs Medical Centers across the nation from 2000 to 2019. We first identified all veterans with an incident TBI diagnoses defined as no prior TBI diagnosis, having been seen in an emergency department (ED), having a brain imaging scan (primarily CT) within one day of ED visit and with a subsequent new TBI diagnosis in the electronic medical record (EMR). We then determined 2‐year age‐adjusted prevalence rates (rate per 1000 person‐years and 95% confidence interval or CI) for dementia and mild cognitive impairment (MCI) prior to and post incident TBI. We also compared prior TBI prevalence to prevalence among 1:3 matched (on age and index date) veterans without TBI.ResultsThere were 13,709 primarily male veterans with incident TBI with mean age of 77.7 sd 9.1 years, 81% were non‐Hispanic White. Compared to the 41,127 veterans without TBI (mean age = 77.9, sd 9.1), veterans prior to having an incident TBI had almost a six‐fold greater pre‐TBI age‐adjusted prevalence of dementia (104.9; 95% CI 100.8‐109.0 vs 18.6; 95% CI 17.6‐19.7, p&lt;0.001) and MCI (48.0; 95% CI 45.2‐50.7 vs 8.1; 95% CI 7.4‐8.8, p&lt;0.001). After the incident TBI diagnosis, the age‐adjusted prevalence rates were even higher: dementia (193.5; 95% CI 187.7‐199.2) and MCI (59.3; 95% CI 56.0‐62.6).ConclusionsAmong older US veterans, there is a bidirectional association with dementia/ MCI and TBI with very high prevalence prior to TBI (compared to those without TBI) and even greater prevalence after TBI. These findings highlight the importance of prevention strategies for both pre‐ and post‐TBI cognitive impairment.

Antidepressant exposure and long‐term dementia risk in a nationwide study on U.S. Veterans with major depressive disorder

AbstractBackgroundMajor depressive disorder (MDD) is associated with dementia risk. The use of antidepressants in MDD has been reported to influence long term risk of Alzheimer’s disease and related dementias (ADRD), but studies are conflicting.MethodsWe used inverse probability weighted Cox models with time‐varying covariates in a retrospective cohort study among Veterans with MDD within the US Veterans Affairs health‐care system from 1/1/2000 to 6/1/2022. We focused on patients receiving their first diagnosis of MDD at the age of 60 or above. Our outcome was incident ADRD and unrelated death was considered as a competing risk event. Exposed intervals were defined using prescription data. Models were weighted for the inverse probability of falling in each of the treatment arms (exposed or not) at the beginning of each treatment period based on demographic and clinical covariates updated with most recent information (1‐year prior). The cumulative effect of antidepressant exposure (No. days) was also studied.ResultA total of 24,964 patients with MDD were identified, of which 45% were on antidepressants (Table 1). Median treatment time was 4.10 years [2.56, 6.10]. No relationship was observed between the number of days on antidepressants and the risk of ADRD (Figure 1). No significant associations were seen for the effect of being exposed to antidepressants (any) vs unexposed (HR = 0.94, 95%; CI: 0.81‐1.09) or exposed to each antidepressant drug classes vs unexposed (SSRI HR = 0.93, 95%; CI: 0.79‐1.10; NDRI HR = 0.80, 95%; CI: 0.42‐1.54; SNRI HR = 0.87, 95%; CI: 0.54‐1.41). (Table II). In sensitivity analysis stratified by sex, a reduction in risk due to antidepressant exposure was suggested in female patients, however the number of cases was small (HR = 0.30, 95%; CI: 0.12‐0.81; P = 0.02)).ConclusionOur study conducted in a large population and after accounting for confounders shows that antidepressant exposure has no effect on ADRD risk. Our result suggesting an association in female patients should be interpreted with caution due to a small sample size and deserves further attention. Replication of results in an external population with a larger representation of female patients is needed for further validation

Adverse COVID-19 outcomes in American Veterans with age-related macular degeneration: a case–control study

ObjectivesPrior studies suggest that patients with age-related macular degeneration (AMD) have poorer COVID-19 outcomes. This study aims to evaluate whether AMD is associated with adverse COVID-19 outcomes in a large...

Effectiveness of Sotrovimab in Preventing COVID-19-Related Hospitalizations or Deaths Among US Veterans During Omicron BA.1.

The real-world clinical effectiveness of sotrovimab in preventing coronavirus disease 2019 (COVID-19)-related hospitalization or mortality among high-risk patients diagnosed with COVID-19, particularly after the emergence of the Omicron variant, needs further research. Using data from the US Department of Veterans Affairs (VA) health care system, we adopted a target trial emulation design in our study. Veterans aged ≥18 years, diagnosed with COVID-19 between December 1, 2021, and April 4, 2022, were included. Patients treated with sotrovimab (n = 2816) as part of routine clinical care were compared with all eligible but untreated patients (n = 11,250). Cox proportional hazards modeling estimated the hazard ratios (HRs) and 95% CIs for the association between receipt of sotrovimab and outcomes. Most (90%) sotrovimab recipients were ≥50 years old, and 64% had ≥2 mRNA vaccine doses or ≥1 dose of Ad26.COV2. During the period that BA.1 was dominant, compared with patients not treated, sotrovimab-treated patients had a 70% lower risk of hospitalization or mortality within 30 days (HR, 0.30; 95% CI, 0.23-0.40). During BA.2 dominance, sotrovimab-treated patients had a 71% (HR, 0.29; 95% CI, 0.08-0.98) lower risk of 30-day COVID-19-related hospitalization, emergency room visits, or urgent care visits (defined as severe COVID-19) compared with patients not treated. Using national real-world data from high-risk and predominantly vaccinated veterans, administration of sotrovimab, compared with contemporary standard treatment regimens, was associated with reduced risk of 30-day COVID-19-related hospitalization or all-cause mortality during the Omicron BA.1 period.

Metformin use and stroke risk in Hispanic and non‐Hispanic veteran men with type 2 diabetes

AbstractBackgroundStroke is a strong risk factor for dementia in the elderly. Traditional stroke risk factors such as hypertension and diabetes are also associated with the incidence and progression of dementia. There is a lack of data characterizing the effect of metformin use on stroke in racially/ethnically diverse cohorts. We sought to evaluate the impact of metformin as a preventative treatment in reducing the incidence of stroke risk in a cohort of older US veteran men with type 2 diabetes (T2D).MethodOur cohort included men with T2D, ≥65 years old, insulin/thiazolidinediones naïve, and without stroke history. Metformin use was defined as ≥180 days of prescription during 2002‐2003. Stroke incidence was identified by ICD9 codes 430‐438 (excluding TIA, 435) from inpatient/outpatient visits every year during 2004‐2012. Generalized estimating equations were used to estimate the odds ratios (OR) of stroke diagnosis over time associated with metformin use, where inverse propensity score weights (IPSW) for metformin use were incorporated to minimize confounding. Furthermore, the generalizability method was used to compare IPSW adjusted ORs between race/ethnicity groups after calibrating covariates between groups. Finally, inverse probability weights for survival were incorporated to project the adjusted ORs among the survivors.ResultAmong 19,705 men with T2D, 81.3% were non‐Hispanic White, 5.3% Hispanic White, and 13.4% were non‐Hispanic Black. Overall, 26.7% used metformin (35.2% of Hispanic Whites, 27% of non‐Hispanic Whites, and 21.4% of non‐Hispanic Blacks). Metformin use was associated with attenuating the temporal increase in stroke risk during 2009‐2012 (vs. 2004‐2008) among Hispanic White (log(aOR) = ‐0.05, p‐value = 0.02), This stroke risk attenuation effect by metformin use was marginally different between Hispanic White with non‐Hispanic Black (p = 0.056) and significantly different between Hispanic White and non‐Hispanic White (p = 0.02). The stroke risk attenuation effect of metformin was not significant conditioned on survival.ConclusionOur study suggests that metformin use is associated with a reduced distal stroke risk amongst men of Hispanic ethnicity compared to non‐Hispanics. Further studies are needed to elucidate the putative biological or pharmacological mechanism for this difference and to uncover the impact on dementia risk.