Cohort Of Veterans Research Articles

Normative Ranges for Oculomotor and Reaction Time Tests in U.S. Military Service Members and Veterans.

Oculomotor and reaction time tests are frequently used assessments of vestibular symptoms, traumatic brain injury (TBI), or other neurological disorders in both clinical and research contexts. When interpreting these tests it is important to have a reference interval (RI) as a comparison for what constitutes a typical/expected response; however, the current body of research has only limited information regarding normative ranges calculated according to established standards or for a military-specific sample. The purpose of the present study was to describe RIs for oculomotor and reaction time tests in a cohort of service members and veterans (SMVs) for use as comparators by clinicians and scientists. Descriptive. Participants were prospectively enrolled in the Defense and Veterans Brain Injury Center-Traumatic Brain Injury Center of Excellence 15-year Longitudinal Traumatic Brain Injury Study. Only SMVs without a history of TBI or blast exposure were included in the RI calculations. The test paradigms included in this analysis were: smooth pursuit, prosaccades, antisaccades, saccades and reaction time, predictive saccades, optokinetic nystagmus, auditory reaction time, and visual reaction time. Nonparametric methods, based on the U.S. Food and Drug Administration's recognized consensus standards, were used to calculate 95% RIs. A comparison between the calculated RIs and those available from previously published research is provided. Summary statistics and RIs were calculated for 47 outcome parameters from 13 oculomotor and reaction time tests. Sample sizes and age ranges varied across outcome parameters depending on the availability of reference values for RI calculations. The sample sizes used to calculate RIs ranged from 51 to 69. The age of SMVs included in each RI ranged from 19 to 61 years with mean ages ranging from 37 to 39 years. Similarities/differences between the RIs in the present study and those in previously published research are highly dependent on the outcome parameter; however, in general, the RIs in the present study tended to be somewhat wider. The RIs provided in this paper can serve as comparisons for clinicians and scientists who are utilizing these oculomotor and reaction time testing paradigms in similar cohorts of patients or research participants.

Validation and epidemiologic definition of the novel steatotic liver disease nomenclature in a national United States cohort with cirrhosis.

Novel steatotic liver disease (SLD) definitions were introduced in 2023. Accurate and meaningful classifications using clinical data are needed to study interventions and outcomes. In a national cohort of Veterans with cirrhosis and imaging-confirmed steatosis, seven algorithms differentially emphasizing cardiometabolic risk factors (CMRFs) and alcohol exposure were developed to define alcohol-associated liver disease (ALD), metabolic dysfunction associated SLD (MASLD), and MASLD with increased alcohol intake (MetALD). The primary outcome was classification of SLD, which was validated using hospitalizations for major acute cardiac events (MACE) and alcohol use disorder (AUD). Secondary outcomes included longitudinal CTP class, incident hepatocellular carcinoma, and all-cause mortality. In all, 31,514 patients with cirrhosis (median age 64 years) were included. CMRFs (98.8% ≥1) and hazardous alcohol use (65.3%) were highly prevalent. The distributions of MASLD, MetALD, and ALD varied substantially across classification methods with varying CMRF and alcohol criteria. For example, MetALD ranged from 4.7% to 47.2%. Using method 4, incidence rates of MACE hospitalizations in MASLD, MetALD, and ALD were 16.7, 14.5, and 8.4 per 100 person-years, respectively and incidence rates of AUD hospitalizations were 2.0, 26.1, and 47.6 per 100 person-years, respectively. Hypertriglyceridemia and low HDL were common across SLD subtypes, including ALD (67.3% hypertriglyceridemia, 48.2% low HDL). Patients with ALD (HR 1.41, 95% CI 1.34-1.48) had significantly higher hazards of mortality relative to MASLD. Classification of SLD is highly sensitive to relative weighting of CMRFs and alcohol use. Clinically relevant definitions should consider data availability on alcohol and the limitations of lipid measurements in distinguishing SLD subtypes.

Life After EBPs: Characterizing Subsequent Engagement in Evidence-Based Psychotherapy After Completion of an Initial Trauma-Focused EBP in a National Sample of VA Patients.

Many Veterans who complete prolonged exposure (PE) or cognitive processing therapy (CPT) report residual symptoms, but it is unclear how to best address the mental health needs of these individuals. Examining patterns of mental health service utilization following completion of these two treatments may provide insight into how to best serve this group of individuals. In a large cohort of Veterans (N = 12,514) who sought treatment in the Veterans Health Administration during Fiscal Years 2015-2019, logistic regression models were used to assess the odds of initiating an additional course of trauma-focused (i.e., PE or CPT) or depression-focused psychotherapy in the year following completion of PE or CPT based on demographic, psychiatric, and treatment effectiveness-related variables. Approximately 9% of Veterans engaged in either trauma-(6%) or depression-(3%) related psychotherapy in the year following discharge from PE or CPT. Factors associated with increased odds of trauma-focused treatment initiation included having a sleep disorder diagnosis (OR = 1.23), a substance use disorder diagnosis (OR = 1.27), or experiencing military sexual trauma (OR = 1.64). Factors associated with increased odds of depression-focused treatment initiation included having a depression diagnosis (OR = 2.02). This study suggests that certain subgroups of Veterans who engage in PE or CPT (e.g., Veterans with comorbid sleep or substance use problems) are more likely to seek additional evidence-based treatment and may require augmentations to maximize clinical benefits, either during the initial course of treatment or subsequent to PTSD treatment.

Tobacco use, cirrhosis, and age are predictors of readiness to change and continued drinking following brief alcohol intervention in veterans.

Alcohol use disorder is prevalent within the Veterans Health System, especially in patients being seen in hepatology clinics, and needs a point-of-care strategy. A brief alcohol intervention based on AUDIT-C (Alcohol Use Disorders Identification Test) may be needed for the management of hazardous alcohol intake, but feasibility is unclear. We aimed to define predictors of readiness to cease alcohol intake (0-10, 10 being ready to quit now) and continued drinking after using a brief alcohol intervention in veterans seen in hepatology clinics cross-sectionally and longitudinally over 6 months. A total of 414 men with liver disease (average age of 61y old, 48% with cirrhosis, 31% with concomitant psychiatric conditions, 44% with tobacco use, and 14% with prior alcohol use disorder therapy) were approached. One hundred forty-four patients (35%) had a positive AUDIT-C (8.9 ± 4.0) and were given the brief intervention. Eighty of these patients (56%) had a high readiness to change, listing "wanting to improve health" and "prior success at reducing alcohol intake" as their most frequent reasons. On regression analysis, concomitant tobacco use was associated with a significantly lower readiness to quit alcohol score. On longitudinal follow-up at 6 months, 34 (23%) patients were still drinking. These patients were older and more likely to have concomitant diagnoses of cirrhosis and anxiety. Overall, we found that in a large cohort of veterans seen in hepatology clinics in routine practice, a brief intervention targeted at alcohol use is feasible. Older patients with concomitant tobacco use, cirrhosis, and anxiety may need more longitudinal attention to ensure that the initial interest in reducing problem drinking is sustained.

Outcomes of Community-Acquired Acute Kidney Injury: A Cohort Study of US Veterans.

Community-acquired acute kidney injury (CA-AKI) occurs outside of the hospital and is the most common form of AKI. CA-AKI is not well understood, which hinders efforts to prevent, identify, and manage CA-AKI. Examine 30-day outcomes following CA-AKI using national administrative and lab data from the Veterans Health Administration (VA). Retrospective cohort study. VA primary care patients with recorded outpatient serum creatinine (SCr) with observed CA-AKI (cases) and a standardized mortality ratio propensity-weighted 5% comparator sample without observed CA-AKI in 2013-2017. CA-AKI was defined as a ≥1.5-fold relative increase in outpatient SCr or inpatient SCr (≤24h from admission) from a reference outpatient SCr ≤12 months prior. Outcomes were 30-day mortality and hospitalization and were assessed in separate weighted Cox regression models. Among 220,777 CA-AKI events and 492,539 comparators without observed CA-AKI, CA-AKI was associated with a higher risk of 30-day all-cause mortality [hazard ratio (HR)=4.17, 95% CI: 3.74, 4.63] and hospitalization (HR=1.82, 95% CI: 1.74, 1.90) versus comparator. Risks increased with severity (mortality HR=3.02, 7.67, and 12.22 for AKI stages 1-3, respectively). Outpatient CA-AKI was associated with a high risk of mortality (HR=2.04, 95% CI: 1.83, 2.28) and even higher for inpatient CA-AKI, present [≤24h from admission (HR=11.32, 95% CI: 10.16, 12.61)]. In a national cohort of Veterans, CA-AKI was associated with a 2-fold increased risk of hospitalization and a 3-11-fold risk of mortality. Improving identification and management is critical to mitigate adverse outcomes of CA-AKI.

Cost-Effectiveness of Temporary Financial Assistance for Veterans Experiencing Housing Instability

The US Department of Veterans Affairs (VA) partners with community organizations (grantees) across the US to provide temporary financial assistance (TFA) to vulnerable veterans through the Supportive Services for Veteran Families (SSVF) program. The goal of TFA for housing-related expenses is to prevent homelessness or to quickly house those who have become homeless. To assess the cost-effectiveness of the SSVF program with TFA vs without TFA as an intervention for veterans who are experiencing housing insecurity. This study used a Markov simulation model to compare cost and housing outcomes in a hypothetical cohort of veterans enrolled in the SSVF program. Enrollees who are homeless receive rapid rehousing services, while those who are at risk of becoming homeless receive homelessness prevention services. The SSVF program with TFA for veterans who are experiencing housing insecurity. The effectiveness measure was the incremental cost-effectiveness ratio (ICER) with quality-adjusted life-years (QALYs). The model was parameterized using a combination of inputs taken from published literature and internal VA data. The model had a 2-year time horizon and a 1-day cycle length. In addition, probabilistic sensitivity analyses were conducted using 10 000 Monte Carlo simulations. The base case analyses found that the SSVF program with TFA was more costly ($35 814 vs $32 562) and yielded more QALYs (1.541 vs 1.398) than the SSVF program without TFA. The resulting ICER was $22 676 per QALY, indicating that TFA is the preferred strategy at a willingness-to-pay threshold of $150 000 per QALY. This ICER was $19 114 per QALY for veterans in the rapid rehousing component of the SSVF program and $29 751 per QALY for those in the homelessness prevention component of the SSVF program. At a willingness-to-pay threshold of $150 000 per QALY, probabilistic sensitivity analyses showed that TFA was cost-effective in 8972 of the 10 000 Monte Carlo simulations (89.7%) for rapid rehousing and in 8796 of the 10 000 Monte Carlo simulations (88.0%) for homelessness prevention only. This economic evaluation suggests that TFA is a cost-effective approach (ie, yields improved health benefits at a reasonable cost) for addressing housing insecurity for veterans enrolling in the SSVF program. Future research could examine the cost effectiveness of large, nationwide housing interventions such as this one among subpopulations of veterans such as those with certain comorbidities including severe mental illness or substance use disorders, those with chronic diseases, or those experiencing long-term housing instability vs acute loss of housing.

Distinct comorbidity phenotypes among post-9/11 Veterans with epilepsy are linked to diverging outcomes and mortality risks.

To investigate phenotypes of comorbidity before and after an epilepsy diagnosis in a national cohort of post-9/11 Service Members and Veterans and explore phenotypic associations with mortality. Among a longitudinal cohort of Service Members and Veterans receiving care in the Veterans Health Administration (VHA) from 2002 to 2018, annual diagnoses for 26 conditions associated with epilepsy were collected over 5 years, ranging from 2 years prior to 2 years after the year of first epilepsy diagnosis. Latent class analysis (LCA) was used to identify probabilistic comorbidity phenotypes with distinct health trajectories. Descriptive statistics were used to describe the characteristics of each phenotype. Fine and Gray cause-specific survival models were used to measure mortality outcomes for each phenotype up to 2021. Six distinct phenotypes were identified: (1) relatively healthy, (2) post-traumatic stress disorder, (3) anxiety and depression, (4) chronic disease, (5) bipolar/substance use disorder, and (6) polytrauma. Accidents were the most common cause of death overall, followed by suicide/mental health and cancer, respectively. Each phenotype exhibited unique associations with mortality and cause of death, highlighting the differential impact of comorbidity patterns on patient outcomes. By delineating clinically meaningful epilepsy comorbidity phenotypes, this study offers a framework for clinicians to tailor interventions. Moreover, these data support systems of care that facilitate treatment of epilepsy and comorbidities within an interdisciplinary health team that allows continuity of care. Targeting treatment toward patients with epilepsy who present with specific heightened risks could help mitigate adverse outcomes and enhance overall patient care.

Emergency department visits, inpatient hospitalizations, and non-fatal and fatal drug overdoses during COVID-19 among Veterans with opioid use disorder.

The COVID-19 pandemic had dramatic adverse impacts on people with opioid use disorder (OUD), as evidenced by significant disruptions to care and unprecedented increases in drug overdoses. In this study, we evaluated the impacts of COVID-19 on utilization of emergency and inpatient care, and fatal and non-fatal overdoses among veterans with OUD. We used Veterans Health Administration (VHA) electronic medical record and mortality data to compare emergency department (ED) visits, inpatient hospitalizations, and fatal and non-fatal overdoses between a pandemic-exposed cohort of veterans with OUD observed both pre- and post-pandemic onset (n = 53,803; observed January 2019-March 2021) to a matched pre-pandemic control group (n = 53,803; observed October 2017-December 2019). Compared to pre-pandemic trends, there were significant decreases in the odds of ED and inpatient admissions and total number of ED and inpatient admissions during COVID-19. There was a significant decrease in the odds of having a recorded non-fatal overdose. The odds of overdose death increased during the pandemic compared to pre-pandemic trends. We observed significant decreases in the utilization of ED and inpatient care services, and fewer non-fatal overdoses, post-pandemic onset. Healthcare disruptions limiting access to emergency and inpatient care could account for the lower number of recorded non-fatal overdoses, potentially reflecting an underestimate of risk. In contrast, fatal overdoses increased during the pandemic compared to pre-pandemic trends. Lower utilization of emergency and inpatient care, and higher rates of fatal overdoses during the pandemic, suggest an exacerbation of unmet treatment need post-pandemic onset.

Association of deployment characteristics and exposures with persistent ill health among 1990-1991 Gulf War veterans in the VA Million Veteran Program

BackgroundVeterans of the 1990–1991 Gulf War have experienced excess health problems, most prominently the multisymptom condition Gulf War illness (GWI). The Department of Veterans Affairs (VA) Cooperative Studies Program #2006 “Genomics of Gulf War Illness in Veterans” project was established to address important questions concerning pathobiological and genetic aspects of GWI. The current study evaluated patterns of chronic ill health/GWI in the VA Million Veteran Program (MVP) Gulf War veteran cohort in relation to wartime exposures and key features of deployment, 27–30 years after Gulf War service.MethodsMVP participants who served in the 1990–1991 Gulf War completed the MVP Gulf War Era Survey in 2018–2020. Survey responses provided detailed information on veterans’ health, Gulf War exposures, and deployment time periods and locations. Analyses determined associations of three defined GWI/ill health outcomes with Gulf War deployment characteristics and exposures.ResultsThe final cohort included 14,103 veterans; demographic and military characteristics of the sample were similar to the full population of U.S. 1990–1991 Gulf War veterans. Overall, a substantial number of veterans experienced chronic ill health, as indicated by three defined outcomes: 49% reported their health as fair or poor, 31% met Centers for Disease Control and Prevention criteria for severe GWI, and 20% had been diagnosed with GWI by a healthcare provider. Health outcomes varied consistently with veterans’ demographic and military characteristics, and with exposures during deployment. All outcomes were most prevalent among youngest veterans (< 50 years), Army and Marine Corps veterans, enlisted personnel (vs. officers), veterans located in Iraq and/or Kuwait for at least 7 days, and veterans who remained in theater from January/February 1991 through the summer of 1991. In multivariable models, GWI/ill health was most strongly associated with three exposures: chemical/biological warfare agents, taking pyridostigmine bromide pills, and use of skin pesticides.ConclusionsResults from this large cohort indicate that GWI/chronic ill health continues to affect a large proportion of Gulf War veterans in patterns associated with 1990-1991 Gulf War deployment and exposures. Findings establish a foundation for comprehensive evaluation of genetic factors and deployment exposures in relation to GWI risk and pathobiology.

Factors Associated With Influenza Vaccination in a National Veteran Cohort

IntroductionOnly 53% of American adults receive influenza vaccination, and disparities in vaccination exist amongst particular racial and ethnic groups. This study determines how race, ethnicity, sex, and rurality are associated with influenza vaccination adherence in a national Veteran Health Affairs Administration (VHA) cohort. MethodsWe examined differences in documented influenza vaccinations for the 2019-2020 influenza season among VHA patients in a retrospective cohort study using VHA administrative electronic health record data. We used logistic regression to model receipt of influenza vaccination in association with race, ethnicity, sex, and rurality while controlling for clinical diagnoses, demographics, and ambulatory care utilization. We also stratified the models by sex and rurality. ResultsAmong 5,943,918 veterans, 48.6% received influenza vaccination. Unadjusted comparisons showed those who were vaccinated were more likely to be white, male sex, and older. Similar proportions of unvaccinated and unvaccinated veterans were from rural settings. In adjusted models, Black race was most strongly associated with decreased vaccination (AOR=0.69, [0.69-0.70]), and American Indian/Alaskan Native race also had reduced odds of vaccination (AOR=0.94 [0.92-0.95]) compared to White race. Female veterans had increased odds of vaccination (AOR=1.20; [1.19-1.20]) compared to men. Rurality (AOR=0.97 [0.96-0.97]) was associated with a small decreased odds of vaccination compared to urban. In stratified models, Black veterans were less likely to receive influenza vaccination regardless of sex and rurality compared to White veterans. American Indian/Alaska Native female veterans had equal odds of vaccination as compared to White female veterans, while American Indian/Alaska Native male veterans had reduced odds of vaccination compared to White male veterans. ConclusionsDuring the 2019-2020 influenza season, Black and American Indian/Alaskan Native veterans had lower odds of vaccination. Despite the VHA's universal approach to healthcare, racial disparities still exist in preventive care.

The Latvian Lost Cause: Veterans of the Waffen-SS Latvian Legion and Post-war Mythogenesis

During World War II, tens of thousands of Latvians served in German-led military formations, primarily in the Waffen-SS Latvian Legion. After the war, around 25,000 former Legionnaires transitioned from prisoner of war camps run by the Western Allies to civilian life in a variety of Western countries. They created veterans’ organisations — such as Daugavas Vanagi (‘Hawks of the Daugava’) — which also functioned as political advocacy groups and heritage organisations for the Latvian diaspora. These post-war organisations and platforms then allowed former Latvian Legionnaires to shape public memory of the war. In writings after 1945, a cohort of veterans crafted a narrative of the war that (1) presents their military service as representing a righteous cause defeated either by forms of betrayal or by the overwhelming might of the Soviet Union, (2) develops a cult of the fallen soldier, and (3) mystifies German war aims and the relationship of Latvian Legionnaires to them. Through analysis of memoirs and periodical publications by veterans along with forms of public commemoration, I argue that these materials and practices collectively constitute a ‘Lost Cause’ narrative, which, similar to the Lost Cause of the Confederacy — developed in the U.S. South after the American Civil War — became predominant among the Latvian diaspora before spreading to Latvia itself. This framework allows for productive comparisons with other European countries that experienced traumatic military defeats, representing a new approach to this controversial subject with potential application to similar cases in Ukraine and Estonia.

SGLT2 Inhibitors, Glucagon-Like Peptide 1 (GLP-1) Receptor Agonists, and the Risk of Hypokalemia and Hyperkalemia in a National Cohort of Veterans with Type 2 Diabetes

SGLT2 Inhibitors, Glucagon-Like Peptide 1 (GLP-1) Receptor Agonists, and the Risk of Hypokalemia and Hyperkalemia in a National Cohort of Veterans with Type 2 Diabetes

Insulin Glargine and SGLT2 Inhibitors Have Higher Risk of Major Adverse Cardiovascular Events (MACE) Compared with Glucagon-Like Peptide 1 Receptor Agonists (GLP-1 RAs) in a National Cohort of Veterans with Type 2 Diabetes (T2D) and CKD

Insulin Glargine and SGLT2 Inhibitors Have Higher Risk of Major Adverse Cardiovascular Events (MACE) Compared with Glucagon-Like Peptide 1 Receptor Agonists (GLP-1 RAs) in a National Cohort of Veterans with Type 2 Diabetes (T2D) and CKD

GLP1R Gene Expression and Kidney Disease Progression

Glucagon-like peptide 1 receptor agonists (GLP-1RAs) may have nephroprotective properties beyond those related to weight loss and glycemic control. To investigate the association of genetically proxied GLP-1RAs with kidney disease progression. This genetic association study assembled a national retrospective cohort of veterans aged 18 years or older from the US Department of Veterans Affairs Million Veteran Program between January 10, 2011, and December 31, 2021. Data were analyzed from November 2023 to February 2024. Genetic risk score for systemic GLP1R gene expression that was calculated for each study participant based on genetic variants associated with GLP1R mRNA levels across all tissue samples within the Genotype-Tissue Expression project. The primary composite outcome was incident end-stage kidney disease or a 40% decline in estimated glomerular filtration rate. Cox proportional hazards regression survival analysis assessed the association between genetically proxied GLP-1RAs and kidney disease progression. Among 353 153 individuals (92.5% men), median age was 66 years (IQR, 58.0-72.0 years) and median follow-up was 5.1 years (IQR, 3.1-7.2 years). Overall, 25.7% had diabetes, and 45.0% had obesity. A total of 4.6% experienced kidney disease progression. Overall, higher genetic GLP1R gene expression was associated with a lower risk of kidney disease progression in the unadjusted model (hazard ratio [HR], 0.96; 95% CI, 0.92-0.99; P = .02) and in the fully adjusted model accounting for baseline patient characteristics, body mass index, and the presence or absence of diabetes (HR, 0.96; 95% CI, 0.92-1.00; P = .04). The results were similar in sensitivity analyses stratified by diabetes or obesity status. In this genetic association study, higher GLP1R gene expression was associated with a small reduction in risk of kidney disease progression. These findings support pleiotropic nephroprotective mechanisms of GLP-1RAs independent of their effects on body weight and glycemic control.

Phenotypic heterogeneity of the B lymphocyte population in the context of post-traumatic stress disorder in veterans of modern wars

Post-traumatic stress disorder in combat veterans has certain characteristics common to combatants. B lymphocytes may aggravate neurocognitive impairment by demonstrating a significant proinflammatory tendency through the production of immunoglobulins and a number of proinflammatory factors. Objective: to study the phenotypic heterogeneity of B lymphocyte subpopulations in veterans with post-traumatic stress disorder. Studies were conducted in a cohort of veterans of the special military operation in Ukraine (SVO), including 26 combatants with clinically verified PTSD who made up the main (1) group, and 30 veterans were included in the comparison group (2). The diagnosis was verified on the basis of neuropsychological and pathopsychological examination. Determination of IL-10 levels (pg/mL) using a multiplex analysis on a Luminex Magpix 100 immunoanalyzer (USA) using the Bio-Plex multiplex analysis test system (MERZ, Germany) was performed. Gating of the B lymphocyte population was performed on a Navios flow cytofluorimeter (Beckman Coulter, USA) using a standardized technology for assessing the lymphocyte component of immunity. In the group of SVO veterans with PTSD, we showed an increase in blood cells with the CD45+CD3-CD19+CD5+ phenotype in comparison with the indicators of groups 2 and 3. B lymphocytes expressing the CD5+ marker are found in various human tissues and can also produce autoantibodies. Analysis of subpopulations of B lymphocytes with markers of memory cells showed a significant decrease in the blood of SVO veterans in the total number of memory B lymphocytes (CD45+CD3-CD19+CD27+), against the background of an increase in the concentration of cells positive for CD5 and CD27 with the phenotype CD45+CD3-CD19 +CD5+CD27+CD27+. B cells play a critical role in the mechanisms of intercellular interaction. The phenotypic diversity of B lymphocyte subpopulations that we have established in veterans with post-traumatic stress disorder is characterized by an increase in the circulation of B lymphocytes with CD5 and CD27 molecules, against the background of a general decrease in memory B cells. This indicates a possible autoimmune orientation of neuroinflammatory processes in the brain, associated both with a stress-induced increase in the permeability of the blood-brain barrier, and with the need to control excessive activation of immunocompetent cells.

Abstract A062: Glycemic control and risk of total and advanced prostate cancer in Veterans with diabetes: analysis of disparities by race/ethnicity

Abstract Introduction Access to quality healthcare is considered a key driver in the multifactorial process giving rise to racial inequities in two of the most common complex diseases in adult men in the US - prostate cancer and diabetes. Whether inequities in diabetes treatment and outcomes, and/or related metabolic and hormone signaling pathways contribute to racial differences in prostate cancer outcomes in an equal access setting is unknown. Our objective is to determine if associations between glycemic control assessed by routine clinically measured hemoglobin A1c (A1c), among men with diabetes and risk of total and advanced prostate are similar in Black and White men receiving care from the Veterans Health Administration (VHA). Methods We used clinical data from the VHA to construct a longitudinal cohort of male Veterans &amp;gt;=45 years of age with diagnosed diabetes free of any cancer from 01/01/2010 to 12/31/2019. We classified men with total prostate cancer if the date of prostate cancer diagnosis preceded any other cancer diagnosis. Advanced prostate cancer was classified as prostate cancer diagnosis with Gleason score &amp;gt;=8, or PSA &amp;gt;=100 ng/mL, or metastasis, or death from prostate cancer. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CI) for time-updated annual mean A1c (&amp;lt;7% [ref]; 7-8%; &amp;gt;8%) and total and advanced prostate cancer risk adjusted for age; marital status; rurality, smoking; annual primary care visits; service-connected disability; comorbidities; statin use; and oral diabetes medication use for non-Hispanic Black (NHB) and non-Hispanic White (NHW) men separately. Results Among 736,964 Veterans with diabetes, we observed 31,330 prostate cancer events including 6,779 advanced prostate cancers. For NHW men, poor glycemic control (A1c &amp;gt;8%) and moderate control (A1c 7-8%) were associated with a 19% (HR=0.81; 95%CI=0.78-0.84) and 8% lower risk (HR=0.92; 95%CI=0.89-95) of total prostate cancer incidence (p-trend&amp;lt;0.001). Among NHB men, inverse associations were attenuated for poor (HR=0.90; 95% CI=0.86-0.95) and moderate (HR=1.01; 95% CI=0.96-1.06) glycemic control and total prostate cancer risk (p-trend &amp;lt;0.001). For advanced prostate cancer, associations were inverse for poor (HR=0.90; 95% CI=0.83-0.97) and moderate glycemic control (HR=0.90; 95% CI=0.84-0.97) and advanced prostate cancer risk in NHW men, while non-statistically significant associations were observed in NHB men with poor HR=1.06; 95%CI=0.96-1.18) and moderate glycemic control (HR=1.04; 95%CI=0.94-1.16). Conclusion In the largest equal access healthcare system in the US, inverse associations for glycemic control and risk of total and advanced prostate cancer varied by race/ethnicity with stronger inverse associations observed in NHW men compared to NHB men. Whether the racial differences in diabetes treatment and care contribute to the observed disparities in total and advanced prostate cancer risk could inform precision public health efforts aimed at reducing inequities in both diabetes and prostate cancer outcomes. Citation Format: Michael T. Marrone, Kinfe G. Bishu, Neal Axon, Hermes Florez, Robert L. Grubb, Mulugeta Gebregziabher. Glycemic control and risk of total and advanced prostate cancer in Veterans with diabetes: analysis of disparities by race/ethnicity [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A062.

CABG Case Volume and Patient Outcomes at the Veterans Healthcare Administration: On-Pump versus Off-Pump

Objective: To evaluate use trends and perioperative outcomes of on- and off-pump coronary artery bypass graft (CABG) in US Veterans. Methods: We retrospectively reviewed 44,960 Veteran Health Administration (VHA) patients who underwent isolated CABG between 2008–2021. Multivariable logistic regression was used to analyze associations between surgical technique and outcomes. Adjusted hazard ratios (aHR) are reported. p &lt; 0.05 using two sided tests was considered significant. Results: 6169/44,960 (13.7%) patients underwent isolated off-pump CABG and 38,791/44,960 (86.3%) patients underwent on-pump CABG. Between 2008 and 2021, the proportion of off-pump procedures decreased: 18.8% between 2008–2012, 11.6% between 2013–2017, and 8.6% between 2018–2021 (χ2 = 712.78, df = 2, p &lt; 0.001). Groups were found to be well balanced with respect to age, history of chronic obstructive pulmonary disease (COPD), history of diabetes, history of prior cardiac surgery, as well as left ventricular ejection fraction and history of smoking, and thus an analysis was conducted using the entire cohort. After covariate adjustment, group status was found to not be a predictor of death (aHR = 0.92, 95% confidence interval (95% CI) = 0.66–1.28, p = 0.62), stroke (aHR = 1.33, 95% CI = 0.83–2.12, p = 0.23), myocardial infarction (MI) (aHR = 0.86, 95% CI = 0.51–1.46, p = 0.58). However, given the large imbalance between group size, the groups were then propensity matched on age, history of chronic obstructive pulmonary disease (COPD), diabetes hypertension, smoking, prior cardiac surgery, and left ventricular ejection fraction, resulting in a smaller cohort of 12,130 patients: 5961 (49.1%) on pump and 6169 (50.9%) off pump. After covariate adjustment, the on-pump group in the matched cohort had increased risk of the following within 30 days: death (aHR = 2.60, 95% CI = 1.50–4.51, p &lt; 0.001), stroke (aHR = 1.61, 95% CI = 1.09–2.38, p = 0.016), acute renal failure (aHR = 2.31, 95% CI = 1.46–3.66, p &lt; 0.001), atrial fibrillation (aHR = 1.39, 95% CI = 1.23–1.57, p &lt; 0.001), intraoperative death (aHR = 1.67, 95% CI = 1.07–2.59, p = 0.023), and prolonged intubation (aHR = 1.53, 95% CI = 1.27–1.85, p &lt; 0.001). They also experienced increased length of stay (Beta = 0.05, p &lt; 0.001). Group did not predict risk of reintubation, perioperative myocardial infarction, or postoperative cardiac arrest requiring cardiopulmonary resuscitation (CPR). Conclusions: In a propensity matched cohort of veterans undergoing isolated CABG, off-pump technique was associated with decreased risk of multiple perioperative outcomes measures. However, the proportion of off-pump procedures within the VHA decreased between 2008–2021. This may be secondary to more selective use as overall volume has decreased, though additional study is needed to evaluate these trends.

Association of hepatitis delta virus infection and hepatocellular carcinoma, hepatic decompensation, all-cause and liver-related death in a national cohort.

Hepatitis Delta Virus (HDV) infection is the most severe form of chronic hepatitis. However, studies on outcomes and causes of death in a United States-born population, with primarily horizontal transmission of HDV, are lacking. The aim of this study was to conduct a national study of patients with hepatitis D to understand the natural history and outcomes compared to patients with hepatitis B virus (HBV). infection. In a national cohort of 4,817 HBV infected veterans tested for HDV (99.6% US-born, 3.3% HDV positive) over a 23-year period, we used multivariable models to identify the factors associated with a composite outcome of hepatocellular carcinoma (HCC), decompensation, and liver-related mortality (LRM), as well as all-cause mortality of patients with HDV compared to HBV mono-infection. HDV coinfection (vs. HBV monoinfection) was associated with a significantly higher incidence of composite liver-related outcomes at both 5 (23.84 vs. 7.98, p<0.001), and 10 years (19.14 vs. 10.18, p<0.001) respectively. The most common cause of death was liver-related (33.8% for HDV vs. 24.7% for HBV), followed by non-hepatic malignancies, (15.6 vs. 14.8%),cardiac (11.7 vs. 15.2%), and lung disease (5.2 vs. 3.7%). In multivariable models, HDV was associated with an increased risk of composite liver outcomes (aHR 2.57, 95% CI 1.87-3.52, p<0.001), and all-cause mortality (aHR 1.52, 95% CI 1.20-1.93, p<0.001). In a predominantly U.S born cohort of Veterans, HDV co-infection was associated with an increased risk of liver-related outcomes and all-cause mortality. Our findings support widespread testing for early identification of HDV.

Post-Traumatic Stress Disorder and Risk of Parkinson's Disease in a Veteran Cohort.

Post-traumatic stress disorder (PTSD) may be a risk factor for Parkinson's disease (PD). We examined the relation between PTSD and PD in a cohort of 158,122 Veterans who had any Veterans Health Administration (VHA) or Medicare health care utilization between 10/1/1999- 2/17/2021. Using a nested case-control design we matched 10 controls to each Veteran with PD by sex, race, and rank. In conditional logistic regression models adjusted for camp and smoking, a PTSD diagnosis was significantly associated with PD (OR = 1.35; p = 0.0002); odds were higher if PTSD was coded before PD (OR = 1.53, p < 0.0001). PTSD may be a risk factor for PD.

Abstract P121: Weight Loss is not a Major Mediator of GLP1-Receptor Agonists’ Risk Reduction in Heart Failure with Preserved Ejection Fraction

The cardioprotective effects of GLP1-Receptor Agonists (GLP1-RA) and SGLT2 Inhibitors (SGLT2i) are incompletely understood. We compared these two drug classes and their effect on HFpEF hospitalizations and examined the hypothesis that weight loss is a significant mediator of these agents’ HFpEF protection. Methods: Using the VA Informatics and Computing Infrastructure, we generated a national cohort of veterans with type 2 diabetes on metformin who initiated SGLT2i, GLP1-RA or Insulin Glargine for the first time from 1/1/18 to 12/31/21. The index date was the date of first outpatient prescription fill. We defined 6-month weight change as change from baseline weight (closest outpatient value prior to index date within 1 year) to 6 months (all averaged outpatient weights from index date to 6 months). Those with prior prescriptions for the study drugs from 1/1/08 and missing baseline or 6-month weights were excluded. HFpEF hospitalizations were defined by a previously-validated natural language processing algorithm using inpatient HF diagnostic codes and cardiac imaging dated closest to and within 180 days of the new code with ejection fraction ≥50%. Follow up was through 3/31/23. We performed mediation analyses to separate the direct effects (independent of 6-month weight change) and indirect effects (mediated through 6-month weight change) of the drug classes on time to HFpEF hospitalizations, adjusted for demographics, comorbidities, baseline labs and other medications, and diabetes severity. Results: Overall, 161,405 veterans initiated one of the study drugs and 105,439 had weight data. After excluding 760 veterans with HFpEF hospitalizations in the first 6 months, 104,679 were included in the analysis. Baseline demographics included mean age 64±11 years, 94% male and 75% white. Baseline BMI was 33±6 kg/m 2 . There were 1494 HFpEF hospitalizations/ 256,101 years of follow-up. Figure 1 shows weight over time by study drug class. Table 1 shows mediation analyses results. Conclusion: GLP1-RA lowered the risk of HFpEF hospitalizations versus the active comparator insulin glargine. This cardioprotection was not mediated by weight loss. GLP1-RA and SGLT2i show equivalent risk reduction. These agents' direct cardiac and vascular effects deserve further exploration.