White Veterans Research Articles

Cumulative Disadvantage and Disparities in Depression and Pain Among Veterans With Osteoarthritis: The Role of Perceived Discrimination.

Perceived discrimination is associated with chronic pain and depression and contributes to racial health disparities. In a cohort of older adult veterans with osteoarthritis (OA), our objective was to examine how membership in multiple socially disadvantaged groups (cumulative disadvantage) was associated with perceived discrimination, pain, and depression. We also tested whether perceived discrimination mediated the association of cumulative disadvantage with depression and pain. We analyzed baseline data from 270 African American veterans and 247 White veterans enrolled in a randomized controlled trial testing a psychological intervention for chronic pain at 2 Department of Veterans Affairs medical centers. Participants were age ≥50 years and self-reported symptomatic knee OA. Measures included the Everyday Discrimination Scale, the Patient Health Questionnaire Depression Scale, the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale, and demographic variables. Cumulative disadvantage was defined as the number of socially disadvantaged groups to which each participant belonged (i.e., self-reported female sex, African American race, annual income of <$20,000, and/or unemployed due to disability). We used linear regression models and Sobel's test of mediation to examine hypotheses. The mean ± SD number of social disadvantages was 1.3 ± 1.0.Cumulative disadvantage was significantly associated with higher perceived discrimination, pain, and depression (P < 0.001 for all). Perceived discrimination significantly mediated the association between cumulative disadvantage and depression symptoms (Z = 3.75, P < 0.001) as well as pain severity (Z = 2.24, P = 0.025). Perceived discrimination is an important psychosocial stressor that contributes to worsening OA-related mental and physical health outcomes, with greater effects among those from multiple socially disadvantaged groups.

Coronavirus disease 2019 in veterans receiving care at veterans health administration facilities

PurposeVeterans represent a significant proportion of the U.S. population (7%), and the impact of the coronavirus disease 2019 (COVID-19) in this group of vulnerable patients has been largely overlooked. This analysis reports COVID-19 patient demographics, infection, mortality, and case-fatality rates in the veteran population. MethodsThis is a cross-sectional analysis using the Veterans Affairs informatics and computing infrastructure tool to assess the veterans' COVID-19 infections at the Veterans Affairs facilities from March 4th to June 23rd, 2020. ResultsOf the 10,621,580 veterans in this analysis, 59.7% were ≥65 yo, 92.5% were men, 68.7% were white, and 14.2% were black. Veterans ≥65 yo comprised 52.1% of cases and 89.9% of deaths. The relative mortality and case-fatality rates of black veterans, when compared with white veterans, were 2.83 (CI 2.56–3.14; P < .001) and 0.75 (CI 0.68–0.82; P < .001), respectively. Among the veterans who died from COVID-19, 87.4% had a history of cardiovascular disease, 56.5% had a history of diabetes, and 33.6% were obese. ConclusionsElderly veterans (≥65yo) and veterans with a history of cardiovascular disease represent a large proportion of the VA COVID-19 cases and deaths. Black veterans had higher mortality rates but lower case fatality rates when than white veterans.

Conscription and Military Service

Employing nonparametric bounds, we examine the effect of military service on incarceration outcomes using the Vietnam draft lotteries as a possibly invalid instrumental variable for military service. The draft is allowed to have a direct effect on the outcomes independently of military service, disposing of the exclusion restriction. We find: (i) suggestive but not strong statistical evidence that the direct effect of the draft increases the incarceration rate for violent offenses for a particular cohort of draft avoiders, and (ii) military service increases the incarceration rate for violent and nonviolent crimes of white volunteers and veterans in certain birth cohorts.

Why patients stop using their home telehealth technologies over time: Predictors of discontinuation in Veterans with heart failure

BackgroundDaily use of home telehealth (HT) technologies decreases over time. Barriers to continued use are unclear. PurposeTo examine predictors of drop-out from HT in Veterans with heart failure. MethodsData for Veterans with heart failure enrolled in the Veterans Affairs HT Program were analyzed using a mixed effects Cox regression model to determine risk of dropping-out over a 1-year period. FindingsOlder (hazard ratio [HR] 1.01), sicker (prior hospital readmission [HR 1.39]), higher probability of hospital admission/death [HR 1.23], functional impairments [1.14]) and white Veterans (compared to black; HR 1.41) had higher risk of drop-out in HT Programs. Users of VA's online patient portal (HR 0.90) had lower risk of drop-out. DiscussionOlder and sicker patients are at most risk of stopping HT use, yet use of a patient portal shows promise in improving continued use. Interventions targeting patients at high risk for HT discontinuation are needed to promote ongoing engagement.

Elevated White Blood Cell Count Resultant Atherogenesis is Associated With Panoramic-Imaged Carotid Plaque

Atherosclerotic plaques develop as a result of a low-grade, chronic, systemic inflammatory response to the injury of endothelial cells arising from lipid deposition within the intima. Increased white blood cell count (WBCC) is both a validated "biologic marker" of the extent of this inflammatory process and a key participant in the development of subsequent atherosclerotic ischemic heart disease manifesting as myocardial infarction. We sought to determine if calcified carotid artery plaque (CCAP) on a panoramic image (PI), also a validated risk indicator of future myocardial infarction, is associated with increased WBCC. We retrospectively evaluated the PI and medical records of White male military veterans aged 55years and older treated by a VA dental service. Established were 2 cohorts of patients, 50 having plaques (CCAP+) and 50 without plaques (CCAP-). Predictor variable was CCAP+; outcome variable was WBCC. Bootstrapping analysis determined the differences in mean WBCCs between groups. Statistical significance set at ≤ 0.05. The study group, (mean age 74; range 59 to 91years) demonstrated a mean WBCC of 8,062 permm3. The control group, (mean age 72 range; 57 to 94) evidenced a mean WBCC of 7,058 permm3. Bootstrapping analysis of WBCC values demonstrated a significant (P=.012) difference (95% confidence interval of difference of mean, -806, 742; observed effect size, 1004) between groups. The presence of CCAP demonstrated on PIs of older Caucasian men is associated with elevated WBCC. Concomitant presence of CCAP on PI and increased WBCC (≥7,800 per mm3) amplifies need for medical consultation before intravenous anesthesia and maxillofacial surgical procedures.

Differences in COVID-19 Related Testing and Healthcare Utilization by Race and Ethnicity in the Veterans Health Administration

Importance: Recent reports indicate differences in COVID-19 related care and outcomes between Black and White Americans.Objective: We examine the COVID-19 related healthcare utilization and mortality by race and ethnicity of patients tested for SARS-CoV-2 in the Veterans Health Administration (VHA).Design: A retrospective cohort study.Setting: We used the VHA COVID-19 shared data resources between February 1 and June 30, 2020.Participants: Veterans tested for SARS-CoV-2 virus by VHA.Exposure(s): Three racial-ethnicity groups of Black, Hispanic, and White (as reference).Main Outcome(s) and Measure(s): Main outcomes are testing rate, positivity rate, hospitalization rate, ICU admission rate, and in-hospital mortality. Controlling for sex, age and Elixhauser comorbidity index, we report adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) from logistic regression models.Results: Of 8,667,996 active veteran enrollees, 252,702 were tested by VHA from February to June, 2020, with 20,500 positive results and 4,790 hospitalizations. The testing rate was 4.4% among Black and 4.7% among Hispanic veterans compared to White veterans, 2.8%. The testing positivity rate was similarly elevated among Black and Hispanic veterans compared to White veterans. The aORs of hospitalization in Black veterans (1.88; 95% CI 1.74, 2.03) and Hispanic veterans (1.41; 95% CI 1.25, 1.60) were higher compared to White veterans. No significant differences by race and ethnicity were observed in OR or aOR of ICU admission and in-hospital death among hospitalized patients.Conclusions and Relevance: On a national level, the VHA was more likely to test and hospitalize Black and Hispanic veterans compared to White veterans, but there were no significant differences in ICU admission or in-hospital mortality among those hospitalized. This pattern of differences may relate to social determinants of health, implicit biases, or preferences for VHA care affecting initial care seeking, but not in-hospital outcomes.Funding Statement: The study is funded by seed funding from Baylor College of Medicine,Houston, Texas, United States, and the Center for Innovations in Quality, Effectiveness and Safety (VA HSRD CIN 13-413), Michael E. DeBakey VA Medical Center, Houston, Texas, United States. Declaration of Interests: None to declareEthics Approval Statement: The study was approved by the institutional review board (IRB) of Baylor College of Medicine and the Research and Development Committee of the Michael E. DeBakey VA Medical Center.

Wounded Warriors of the Future Disability Hierarchy in Avatar and Source Code

The article analyzes the representation of disabled veterans in James Cameron’s Avatar and Duncan Jones’s Source Code. The argument is that these two films use the figure of the heroic, technologically enhanced, white disabled veteran man to alleviate cultural anxieties, fears, and guilt about veterans and disabled people in the contemporary United States. In doing so, however, Avatar and Source Code perpetuate a disability hierarchy that reinforces a variety of oppressive cultural norms. The article, therefore, demonstrates how the films reflect the differential valuation and treatment of different kinds of disabled people in American culture at large via the genre of science fiction and its technological imaginative possibilities.

Comparison by Race of Conservative Management for Low-Risk and Intermediate-Risk Prostate Cancers in Veterans From 2004 to 2018

Conservative management (ie, active surveillance or watchful waiting) is a guideline-based strategy for men with low-risk and intermediate-risk prostate cancer. However, use of conservative management is controversial for African American patients, who have worse prostate cancer outcomes compared with White patients. To examine the association of African American race with the receipt and duration of conservative management in the Veterans Health Administration (VA), a large equal-access health system. This cohort study used data from the VA Corporate Data Warehouse for 51 543 African American and non-Hispanic White veterans diagnosed with low-risk and intermediate-risk localized node-negative prostate cancer between January 1, 2004, and December 31, 2013. Men who did not receive continuous VA care were excluded. Data were analyzed from February 1 to June 30, 2020. All patients received either definitive therapy (ie, prostatectomy, radiation, androgen deprivation therapy) or conservative management (ie, active surveillance or watchful waiting). Receipt of conservative management and (for patients receiving conservative management) time from diagnosis to definitive therapy. The median (interquartile range) age of the 51 543 veterans in our cohort was 65 (61-70) years, and 14 830 veterans (28.8%) were African American individuals. Compared with White veterans, African American veterans were more likely to have intermediate-risk disease (18 988 [51.7%] vs 8526 [57.5%]), 3 or more comorbidities (15 438 [42.1%] vs 7614 [51.3%]), and high disability-related or income-related needs (9078 [24.7%] vs 4614 [31.1%]). Overall, 20 606 veterans (40.0%) received conservative management. African American veterans with low-risk disease (adjusted relative risk, 0.95; 95% CI, 0.92-0.98; P < .001) and intermediate-risk disease (adjusted relative risk, 0.92; 95% CI, 0.87-0.97; P = .002) were less likely to receive conservative management than White veterans. Compared with White veterans, African American veterans with low-risk disease (adjusted hazard ratio, 1.71; 95% CI, 1.50-1.95; P < .001) and intermediate-risk disease (adjusted hazard ratio, 1.46; 95% CI, 1.27-1.69; P < .001) who received conservative management were more likely to receive definitive therapy within 5 years of diagnosis (restricted mean survival time [SE] at 5 years, 1679 [5.3] days vs 1740 [2.4] days; P < .001). In this study, conservative management was less commonly used and less durable for African American veterans than for White veterans. Prospective trials should assess the comparative effectiveness of conservative management in African American men with prostate cancer.

National trends in oropharyngeal cancer incidence and survival within the Veterans Affairs Health Care System.

Oropharyngeal squamous cell carcinoma (OPSCC) epidemiology has not been examined previously in the nationwide Veterans Affairs (VA) population. Joinpoint regression analysis was applied to OPSCC cases identified from VA administrative data from 2000 to 2012. We identified 12 125 OPSCC cases (incidence: 12.2 of 100 000 persons). OPSCC incidence declined between 2000 and 2006 (annual percent change [APC] = -4.27, P < .05), then increased between 2006 and 2012 (APC = 7.02, P < .05). Significant incidence increases occurred among white (APC = 7.19, P < .05) and African American (APC = 4.87, P < .05) Veterans and across all age cohorts. The percentage of never-smokers increased from 8% in 2000 to 15.7% in 2012 (P < .001), and 2-year overall survival improved from 31.2% (95% confidence interval (CI) [30-33.4]) to 55.7% (95% CI [54.4-57.1]). OPSCC incidence is increasing across all racial and age cohorts in the VA population. Smoking rates remain high among Veterans with OPSCC and gains in survival lag those reported in the general population.

Sex, race, and risk of dementia diagnosis after traumatic brain injury among older veterans.

To investigate whether sex and race differences exist in dementia diagnosis risk associated with traumatic brain injury (TBI) among older veterans. Using Fine-Gray regression models, we investigated incident dementia diagnosis risk with TBI exposure by sex and race. After the exclusion of baseline prevalent dementia, the final sample (all veterans ≥55 years of age diagnosed with TBI during the 2001-2015 study period and a random sample of all veterans receiving Veterans Health Administration care) included nearly 1 million veterans (4.3% female; 81.8% White, 11.5% Black, and 1.25% Hispanic), 96,178 with TBI and 903,462 without TBI. Compared to those without TBI, Hispanic veterans with TBI were almost 2 times more likely (17.0% vs 10.3%; hazard ratio [HR] 1.74, 95% confidence interval [CI] 1.51-2.01), Black veterans with TBI were >2 times more likely (11.2% vs 6.4%; HR 2.15, 95% CI 2.02-2.30), and White veterans with TBI were nearly 3 times more likely to receive a dementia diagnosis (12.0% vs 5.9%; HR 2.71, 95% CI 2.64-2.77). A significant interaction between TBI and race for dementia diagnosis was observed (p < 0.001). Both male and female veterans with TBI were more than twice as likely (men 11.8% vs 5.9%, HR 2.60, 95% CI 2.54-2.66; women 6.3% vs 3.1%, HR 2.36, 95% CI 2.08-2.69) to receive a diagnosis of dementia compared to those without. There was a significant interaction effect between sex and TBI (p = 0.02), but the magnitude of differences was small. In this large, nationwide cohort of older veterans, all race groups with TBI had increased risk of dementia diagnosis, but there was an interaction effect such that White veterans were at greatest risk for dementia after TBI. Further research is needed to understand the mechanisms for this discrepancy. Differences in dementia diagnosis risk for men and women after TBI were significant but small, and male and female veterans had similarly high risks of dementia diagnosis after TBI.

Trajectories of body mass index and adolescent hair cortisol: importance of persistence, variability, and developmental timing

Longevity gene klotho (KL) is associated with age-related phenotypes including lifespan, cardiometabolic disorders, cognition, and brain morphology, in part, by conferring protection against inflammation. We hypothesized that the KL/inflammation association might be altered in the presence of psychiatric stress and operate via epigenetic pathways. We examined KL polymorphisms, and their interaction with posttraumatic stress disorder (PTSD) symptoms, in association with KL DNA methylation in blood. We further examined KL DNA methylation as a predictor of longitudinal changes in a peripheral biomarker of inflammation (C-reactive protein; CRP).The sample comprised 309 white non-Hispanic military veterans (93.5 % male; mean age: 32 years, range: 19–65; 30 % PTSD per structured diagnostic interview); 111 were reassessed approximately two years later.Analyses revealed a methylation quantitative trait locus at rs9527025 (C370S, previously implicated in numerous studies of aging) in association with a Cytosine-phosphate-Guanine site (cg00129557; B = −.65, p = 1.29 X 10−20), located within a DNase hypersensitivity site in the body of KL. There was also a rs9527025 x PTSD severity interaction (B = .004, p = .035) on methylation at this locus such that the minor allele was associated with reduced cg00129557 methylation in individuals with few or no PTSD symptoms while this effect was attenuated in those with elevated levels of PTSD. Path models revealed that methylation at cg00129557 was inversely associated with CRP over time (B = −.14, p = .005), controlling for baseline CRP. There was also an indirect effect of rs9527025 X PTSD on subsequent CRP via cg00129557 methylation (indirect B = −.002, p = .033).Results contribute to our understanding of the epigenetic correlates of inflammation in PTSD and suggest that KL methylation may be a mechanism by which KL genotype confers risk vs. resilience to accelerated aging in those experiencing traumatic stress.

Geographic and Racial/Ethnic Variation in Glycemic Control and Treatment in a National Sample of Veterans With Diabetes.

Geographic and racial/ethnic disparities related to diabetes control and treatment have not previously been examined at the national level. A retrospective cohort study was conducted in a national cohort of 1,140,634 veterans with diabetes, defined as two or more diabetes ICD-9 codes (250.xx) across inpatient and outpatient records. Main exposures of interest included 125 Veterans Administration Medical Center (VAMC) catchment areas as well as racial/ethnic group. The main outcome measure was HbA1c level dichotomized at ≥8.0% (≥64 mmol/mol). After adjustment for age, sex, racial/ethnic group, service-connected disability, marital status, and the van Walraven Elixhauser comorbidity score, the prevalence of uncontrolled diabetes varied by VAMC catchment area, with values ranging from 19.1% to 29.2%. Moreover, these differences largely persisted after further adjusting for medication use and adherence as well as utilization and access metrics. Racial/ethnic differences in diabetes control were also noted. In our final models, compared with non-Hispanic Whites, non-Hispanic Blacks (odds ratio 1.11 [95% credible interval 1.09-1.14]) and Hispanics (1.36 [1.09-1.14]) had a higher odds of uncontrolled HBA1c level. In a national cohort of veterans with diabetes, we found geographic as well as racial/ethnic differences in diabetes control rates that were not explained by adjustment for demographics, comorbidity burden, use or type of diabetes medication, health care utilization, access metrics, or medication adherence. Moreover, disparities in suboptimal control appeared consistent across most, but not all, VAMC catchment areas, with non-Hispanic Black and Hispanic veterans having a higher odds of suboptimal diabetes control than non-Hispanic White veterans.

What are the Predictors of Wait Times for Veterans Seeking Care in the VA and the Community through VA‐Purchased Care?

Research ObjectiveThe Veterans Choice Program (VCP) was passed in August 2014 in direct response to the VA wait time crisis of that year. It expanded the availability of community care (CC) by allowing VA enrollees who have to wait longer than 30 days or live more than 40 miles from a VA clinic to use community providers paid for by VA. While a few studies have evaluated whether VCP improved access to care, little attention has focused on whether VCP differentially affects Veteran subgroups that have historically experienced greater barriers to care (eg, rural Veterans, non‐white Veterans). To examine this, we compared wait times in CC and VA for the five most commonly authorized outpatient specialty services in CC (cardiology, physical therapy, optometry, ophthalmology, and dental) among Veterans since the inception of VCP.Study DesignRetrospective observational study conducted from Fiscal Year (FY) 2015 to FY18 (10/1/14‐9/31/18) using data from the VA’s Corporate Data Warehouse. Our outcome variable was “wait time,” defined as days from consult request to consult completion date. Independent variables included setting of care (VA vs CC), rural/urban status, demographic characteristics (eg, race), and comorbidities. Bivariate and multivariate analyses were used to determine predictors of mean wait times and to assess the probability of waiting &gt;45 days for care.Population StudiedAll Veterans receiving &gt;1 of selected outpatient services in VA and/or CC during the study time period.Principal FindingsIn FY15, black Veterans’ mean wait times were consistently longer than those for white Veterans (eg, mean wait times for PT services among blacks and whites were 28 and 25 days, respectively). Linear regression models, which adjusted for sociodemographic variables and comorbidities, found similar results: black race was associated with 2‐5 days longer wait times across services than white race in FY15. Wait times declined during the study period, but more so for blacks than whites. This eliminated the wait time disparity in FY18 for cardiology and optometry services but not for PT, ophthalmology, and dental (eg, in FY18, black mean wait times for PT were 28 days compared to 25 days for whites). In FY18, the percentage of blacks waiting &gt;45 days for care remained consistently higher than for whites for PT, ophthalmology, and dental, regardless of rurality and setting of care (eg, 31% of blacks compared to 25% of whites waited &gt;45 days for orthopedic services in rural CC). No other independent variables were meaningful predictors of wait times.ConclusionsAlthough we expected that rural Veterans would be at higher risk for delays in care compared to urban Veterans, their mean wait times were relatively comparable. Despite decreases in wait times since VCP implementation, black Veterans continued to have longer wait times than whites for most services.Implications for Policy or PracticeWhile VCP appears to have improved access to timely care for many Veterans, not all Veterans benefited equally from the policy change. Further study is needed to investigate whether the disparities we found in wait times are also present in other outcomes impacted by VCP.Primary Funding SourceDepartment of Veterans Affairs.

Association of Neutrophil to Lymphocyte Ratio With Pulmonary Function in a 30-Year Longitudinal Study of US Veterans

Chronic obstructive pulmonary disease (COPD) is a critical public health burden. The neutrophil to lymphocyte ratio (NLR), an inflammation biomarker, has been associated with COPD morbidity and mortality; however, its associations with lung function decline and COPD development are poorly understood. To explore the associations of NLR with lung function decline and COPD risks. This longitudinal cohort study included white male veterans in the US with more than 30 years of follow-up to investigate the associations of NLR with lung function, COPD, and hypomethylation of cg05575921, the top DNA methylation marker of lung function changes in response to tobacco smoking. This study included 7466 visits from 1549 participants, each examined up to 13 times between 1982 and 2018. A subgroup of 1411 participants without COPD at baseline were selected to analyze the association of NLR with incident COPD. Data were analyzed from September 2019 to January 2020. The primary exposure was NLR, which was estimated using automated whole blood cell counts based on a blood sample collected at each visit. The methylation level of cg05575921 was measured in blood DNA from a subgroup of 1228 visits. The outcomes of interest were lung function, measured as forced respiratory volume in the first second (FEV1) in liters, forced vital capacity (FVC) in liters, percentage of FVC exhaled in the first second (FEV1/FVC), and maximal midexpiratory flow rate (MMEF) in liters per minute and COPD status, defined as meeting the Global Initiative for Chronic Obstructive Lung Diseases stage II (or higher) criteria. Both outcomes were measured as each visit. Among 1549 included men (mean [SD] age, 68.3 [9.3] years) with 7466 visits from 1982 to 2018, a 1-unit increase in NLR was associated with statistically significant mean (SE) decreases of 0.021 (0.004) L in FEV1, 0.016 (0.005) L in FVC, 0.290% (0.005) L in FVC, 0.290% (0.065%) in FEV1/FVC, and 3.65 (0.916) L/min MMEF. Changes in NLR up to approximately 10 years were associated with corresponding longitudinal changes in lung function. Furthermore, this increase in NLR was associated with 9% higher odds of COPD (odds ratio, 1.09 [95% CI, 1.03-1.15]) for all visits and 27% higher risk of incident COPD (odds ratio, 1.07 [95% CI, 1.07-1.51]) for participants without COPD at baseline. Additionally, a 1-unit increase in NLR was associated with a mean (SE) decrease of 0.0048 (0.0021 in cg05575921 hypomethylation, which may mediate the adverse association of NLR-related inflammation on lung function. These findings suggest that NLR may be a clinically relevant biomarker associated with high risk of lung function impairment and COPD alone or in combination with DNA methylation profiles.

Home Telehealth Technologies for Heart Failure: An Examination of Adherence Among Veterans.

The current retrospective cohort study uses Department of Veterans Affairs (VA) clinical and facility data of Veterans with heart failure enrolled in the VA Home Tele-health (HT) Program. General estimating equations with facility as a covariate were used to model percent average adherence at 1, 3, 6, and 12 months post-enrollment. Most HT patients were White, male, and of older age (mean = 71 years). Average adherence increased the longer patients remained in the HT program. Number of weekly reports of HT use, not having depression, and being of older age were all associated with higher adherence. Compared to White Veterans, Black and other non-White Veterans had lower adherence. These findings identify subgroups of patients (e.g., those with depression, of younger age, non-White) that may benefit from additional efforts to improve adherence to HT technologies. [Journal of Gerontological Nursing, 46(7), 26-34.].

Race, Ethnicity, and Clinical Features of Alcohol Use Disorder Among US Military Veterans: Results From the National Health and Resilience in Veterans Study.

Alcohol use disorder (AUD) is highly prevalent in US military veterans, though little is known about whether the psychiatric comorbidities and functional outcomes (ie, clinical features) of AUD differ across race/ethnic groups. We aimed to identify differences in the clinical features of veterans with AUD by race/ethnicity. In a sample of veterans with AUD (n = 1212) from the nationally representative National Health and Resilience in Veterans Study, we compared the clinical features associated with AUD across racial/ethnic groups using analysis of covariance and logistic regression. Black veterans (n = 60, 34.0%) were less likely to screen positive for lifetime AUD compared with white (n = 1099, 42.7%) and Hispanic (n = 53, 41.5%) veterans. Among those with lifetime AUD, Hispanic veterans were more likely than white veterans to have lifetime and current mood or anxiety disorders (adjusted odds ratio range [AORR] = 2.21-2.52, P < .05). Black veterans were more likely than white veterans to have current mood and anxiety disorders (AORR = 2.01-3.07, P < .05). Hispanic veterans reported poorer functioning and quality of life than white and black veterans (Cohen's d range = 0.12-0.37, P < .05). Black and Hispanic veterans with lifetime AUD may experience a higher disease burden relative to white veterans. Results underscore the importance of race/ethnicity-sensitive assessment, monitoring, and treatment of AUD for veterans. This is the first known study to examine differences by race/ethnicity in the clinical features of Veterans with AUD in a nationally representative sample. Findings suggest higher disease burden for racial/ethnic minority veterans. (Am J Addict 2021;30:26-33).

Racial disparities in definitive treatment and long-term mortality among US veterans with high-risk localized prostate cancer.

e19037 Background: Equal access to care may mediate racial disparities among men with localized prostate cancer. We examined the association between African-American race and long-term mortality among men with high-risk prostate cancer in a large equal-access health system. Methods: In this retrospective cohort study, we used the VA Corporate Data Warehouse to identify African-American (AA) and non-Hispanic White Veterans diagnosed with high-risk (prostate-specific antigen [PSA] ≥ 20 ng/mL, Gleason 8-10, or stage ≥ cT2c) localized prostate cancer between January 1st, 2001 and December 31st, 2011 and followed through January 1st, 2019. Veterans who did not receive continuous VA care were excluded. We used descriptive statistics to compare type of therapy received and multivariable Cox proportional hazards regressions to estimate the association between mortality and race. Cox models were adjusted for age, pre-treatment PSA, year of diagnosis, enrollment priority (an individual-level proxy for income and disability need), marital status, Elixhauser comorbidity index, and primary treatment. Results: Among 14,877 Veterans (median age 67 years [interquartile range [IQR] 62-75]), 4,160 (28.0%) were AA. Median followup was 9.0 years (IQR 6.1-11.4). Compared to White men, AA men were more likely to have PSA ≥ 20 (49.9% vs. 40.9%), be unmarried (59.3% vs. 43.3%), have ≥3 comorbidities (46.4% vs. 41.0%), and have high disability and income need (22.0% vs. 18.6%) (all p &lt; 0.001). Over time, AA Veterans were consistently less likely to receive prostatectomy (18.9% vs. 24.9%). Crude mortality rates were 50.6 and 61.6 deaths per 1000 patient-years for AA and White Veterans, respectively. After adjusting for all covariates, AA Veterans had lower all-cause mortality (adjusted hazard ratio [aHR] 0.83, 95% CI 0.79-0.88, p &lt; 0.001) compared to White Veterans. This association was consistent across pre-specified subgroups (Table). Conclusions: Among men with high-risk prostate cancer who received continuous care within a large equal-access health system, African-Americans had lower all-cause mortality compared to Whites. Equal access to care may mitigate or reverse traditional racial disparities in mortality among men with prostate cancer. [Table: see text]

Alzheimer's Disease and Alzheimer's Disease-Related Dementias in Older African American and White Veterans.

Background:Racial disparity in the epidemiology of Alzheimer’s disease and Alzheimer’s disease-related dementias (AD/ADRD) has been reported. However, less is known about this disparity among Veterans.Objective:To estimate the racial disparity in AD/ADRD among the Veterans.Methods:Of the 5,413,418 Veterans≥65 years receiving care at the Veterans Health Administration (1999–2016), 4,045,269 were free of prevalent AD/ADRD, schizophrenia, or bipolar disorder at baseline. Of these, 432,469 were African American. Race was self-identified and incident AD/ADRD during 20 (median 6.7) years of follow-up was ascertained using International Classification of Diseases codes.Results:Patients had a mean age of 70.4 (±6.6) years and 97.8% were men. Age-sex-adjusted incidence of AD/ADRD per 1,000 person-year was 19.3 and 10.8 for African American and white Veterans, respectively (age-sex-adjusted hazard ratio associated with African American race, 1.77; 95% confidence interval, 1.75–1.79; p < 0.0001). This association remained essentially unchanged after multivariable adjustment (hazard ratio, 1.67; 95% confidence interval, 1.65–1.69; p < 0.0001). Among the key baseline characteristics that were significant predictors of AD/ADRD in both races, stroke was a significantly stronger predictor among African Americans, and Hispanic ethnicity and depression among whites (p-value for all interaction,<0.0001).Conclusion:The findings of a higher incidence of AD/ADRD among African American Veterans is consistent with the findings in the general population reported in the literature, although the overall incidence appears to be lower than that in the general population. Future studies need to examine this disparity in incidence as well as the between-race heterogeneity in AD/ADRD risk.

Frailty score does not explain differences in mortality between underweight black and white veterans after stroke

Background Previous studies suggest being underweight may increase risk of mortality after stroke. Paradoxically, in several studies of U.S. Veterans, black stroke patients have better survival compared to whites, even at lower body mass index (BMI). We hypothesized that frailty status may explain the observed differences. Methods A nationwide sample of Veterans hospitalized for first ischemic stroke in the Veterans Health Administration (VA) between 2002-2012 were studied. Veterans had a frailty index derived from the electronic health record and calculated on those over age 65 years. BMI (kg/m2) was calculated using VA outpatient measurements. Death was determined using the National Death Index. We grouped the cohort by race (non-Hispanic white, non-Hispanic black) and frailty status (frail, not frail). Hazard ratios (HRs) for mortality for eight BMI categories were estimated from Cox models with high normal BMI (22.5 Results There were 8,541 incident ischemic strokes; 1,772 were black veterans (21%) and 6,769 white veterans (79%). Average age and BMI were 76.4±7 years and 28.1±5.3 respectively. There were 5,697 deaths; 2,428 (43%) within one year after stroke and 1,025 (18%) within 30 days. Underweight non-frail and frail black veterans (BMI Conclusion Underweight white veterans have higher risk of 1-year mortality after stroke, despite frailty. The prevalence of AF between races may contribute to the increased risk for underweight white veterans, given that AF may cause more severe strokes. Factors contributing to higher mortality for underweight stroke patients likely include characteristics beyond frailty, including race and specific comorbidities.

PTSD and the klotho longevity gene: Evaluation of longitudinal effects on inflammation via DNA methylation

BackgroundLongevity gene klotho (KL) is associated with age-related phenotypes including lifespan, cardiometabolic disorders, cognition, and brain morphology, in part, by conferring protection against inflammation. We hypothesized that the KL/inflammation association might be altered in the presence of psychiatric stress and operate via epigenetic pathways. We examined KL polymorphisms, and their interaction with posttraumatic stress disorder (PTSD) symptoms, in association with KL DNA methylation in blood. We further examined KL DNA methylation as a predictor of longitudinal changes in a peripheral biomarker of inflammation (C-reactive protein; CRP). MethodsThe sample comprised 309 white non-Hispanic military veterans (93.5 % male; mean age: 32 years, range: 19–65; 30 % PTSD per structured diagnostic interview); 111 were reassessed approximately two years later. ResultsAnalyses revealed a methylation quantitative trait locus at rs9527025 (C370S, previously implicated in numerous studies of aging) in association with a Cytosine-phosphate-Guanine site (cg00129557; B = −.65, p = 1.29 X 10−20), located within a DNase hypersensitivity site in the body of KL. There was also a rs9527025 x PTSD severity interaction (B = .004, p = .035) on methylation at this locus such that the minor allele was associated with reduced cg00129557 methylation in individuals with few or no PTSD symptoms while this effect was attenuated in those with elevated levels of PTSD. Path models revealed that methylation at cg00129557 was inversely associated with CRP over time (B = −.14, p = .005), controlling for baseline CRP. There was also an indirect effect of rs9527025 X PTSD on subsequent CRP via cg00129557 methylation (indirect B = −.002, p = .033). ConclusionsResults contribute to our understanding of the epigenetic correlates of inflammation in PTSD and suggest that KL methylation may be a mechanism by which KL genotype confers risk vs. resilience to accelerated aging in those experiencing traumatic stress.