Affecting an estimated 88 million Americans, prediabetes increases the risk for developing type 2 diabetes mellitus (T2DM), and independently, cardiovascular disease, retinopathy, nephropathy, and neuropathy. Nevertheless, little is known about the use of metformin for diabetes prevention among patients in the Veterans Health Administration, the largest integrated healthcare system in the U.S. This is a retrospective observational cohort study of the proportion of Veterans with incident prediabetes who were prescribed metformin at the Veterans Health Administration from October 2010 to September 2019. Among 1,059,605 Veterans with incident prediabetes, 12,009 (1.1%) were prescribed metformin during an average 3.4 years of observation after diagnosis. Metformin prescribing was marginally higher (1.6%) among those with body mass index (BMI) >= 35 kg/m2, age <60 years, HbA1c >= 6.0%, or those with a history of gestational diabetes, all subgroups at a higher risk for progression to T2DM. In a multivariable model, metformin was more likely to be prescribed for those with BMI >= 35 kg/m2 incidence rate ratio [IRR] 2.6 [95% confidence intervals (CI): 2.1-3.3], female sex IRR, 2.4 [95% CI: 1.8-3.3], HbA1c >= 6% IRR, 1.93 [95% CI: 1.5-2.4], age <60 years IRR, 1.7 [95% CI: 1.3-2.3], hypertriglyceridemia IRR, 1.5 [95% CI: 1.2-1.9], hypertension IRR, 1.5 [95% CI: 1.1-2.1], Major Depressive Disorder IRR, 1.5 [95% CI: 1.1-2.0], or schizophrenia IRR, 2.1 [95% CI: 1.2-3.8]. Over 20% of Veterans with prediabetes attended a comprehensive structured lifestyle modification clinic or program. Among Veterans with prediabetes, metformin was prescribed to 1.1% overall, a proportion that marginally increased to 1.6% in the subset of individuals at highest risk for progression to T2DM.

Veterans 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. MVP 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. The 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

Introduction: Linitis plastica is classically described in the literature as a thickening of the gastric walls that gives the appearance of a “leather bottle” and is associated with gastric adenocarcinoma. However, there have not been many case reports that show that B cell Lymphoma can simulate the appearance of linitis plastica. We present an unusual case of such in a patient that presented to our medical center. Case Description/Methods: A 78-year-old man initially presented to our hospital for concerns of altered mental status. Initial workup was remarkable for tachycardia at 131, hemoglobin 9.1, creatinine 1.31, calcium 12.3, lactic acid 3.1. Physical exam was unremarkable. CT scan without contrast of the head demonstrated multiple lucent lesions in the spine concerning for a myelomatous process. GI was consulted after the patient developed acute episodes of melena and drop in hemoglobin from 9.1 to 6.7. CT abdomen and pelvis with IV contrast was performed and demonstrated a thickening of the gastric walls measuring 1.4 cm that was deemed concerning for linitis plastica as well as extensive epigastric and retroperitoneal adenopathy. Upon further questioning of the wife, it was revealed that the patient had received an EGD a couple of months prior at the VA after an incidental gastric thickening was found on imaging for workup of his generalized hip and buttock pain. The procedure led to the discovery of a large ulcerating gastric mass that was biopsied and returned positive for high grade B cell lymphoma. Patient underwent a repeat EGD at our facility where a 5cm excavated large gastric ulcer with irregular appearing mucosa and multiple blood clots was visualized in the entire lesser curvature of the stomach (Figure 1). There was also friable and erythematous mucosa throughout the stomach and multiple duodenal nodules noted in D1 and D2. Hemospray was deployed to the region of the ulcer prior to termination of the procedure. The patient had no more episodes of melena after completion of the EGD but sadly passed before further workup could be completed. Discussion: Lymphoma presenting as linitis plastica is rarely seen. Treatment options include subtotal gastrectomy with gastrojejunostomy or total gastrectomy and esophagojejunostomy but only if they are within IE and IIE on the Ann Arbor classification. Ulceration is a feature frequently seen in linitis plastica lymphomas as shallow depressions, or deep and well demarcated. This case serves to highlight awareness to a unique manifestations of linitis plastica.Figure 1.: Ulceration seen on EGD.

Introduction: Anorectal malignant melanoma (ARMM) is a rare and highly malignant tumor, more often found in women and the elderly with lesions often located within 6cm of the anal rim. It is often misdiagnosed as hemorrhoids, polyps, or rectal cancer because symptoms are nonspecific. By the time the correct diagnosis is made, there is usually metastasis and poor outcomes. We present a case of metastatic ARMM that was earlier misdiagnosed as hemorrhoids. Case Description/Methods: A 90-year-old Asian woman with no past medical history was initially admitted for groin cellulitis. However, physical exam incidentally revealed a 4 cm tender firm mass in the rectum. Upon questioning, the patient reported constipation and rectal bleeding for 1 year and told that it was likely hemorrhoids. Initial labs showed WBC 22 AST 127, ALT 128, and lipase 70. CT abdomen/pelvis with IV contrast demonstrated a mass like thickening of the rectoanal junction, multiple small nodules in the lung bases, mass in the head and proximal body of pancreas measuring 3.2x2.2 cm with associated pancreatic duct dilatation, gastric masslike narrowing measuring 3.7x2.9 cm, partially occlusive thrombus in the main portal vein, and inflammatory changes in the left pelvic soft tissue region. Given these findings, she underwent endoscopic evaluation. EGD demonstrated multiple ulcers in the gastric body and a 5mm ulcer along the angularis with a hematin spot. Flexible sigmoidoscopy redemonstrated the large anal mass with edema extending into the rectum. Multiple biopsies were taken and demonstrated malignant melanoma. She underwent an EUS for further evaluation of pancreatic head mass which demonstrated a large 5-6 cm hypoechoic mass involving the head of the pancreas, multiple duodenal masses with ulceration highly consistent with metastatic disease. Because of involvement of the duodenum with masses, choledochoduodenostomy was performed to allow for decompression. The patient was evaluated by oncology and started on nivolumab. Discussion: ARMM survival has historically been poor with less than 20% survival at 5 years at all stages of the disease even with advances in immunotherapy. Nivolumab was the first confirmed monotherapy to treat AARM in a study done by Topalian et al. Preclinical evidence suggests synergistic combinations based on PD-1 pathway blockage can have more potent effects on treatment. The favorable therapeutic index of nivolumab as monotherapy supports its testing in treatment. More studies are needed to verify its efficacy.

The course of posttraumatic stress disorder (PTSD) symptoms varies among veterans of war zones, but sources of variation in long-term symptom course remain poorly understood. Modeling of symptom growth trajectories facilitates the understanding of predictors of individual outcomes over time. Although growth mixture modeling (GMM) has been applied to military populations, few studies have incorporated both predeployment and follow-up measurements over an extended time. In this prospective study, 1,087 U.S. Army soldiers with varying military occupational specialties and geographic locations were assessed before and after deployment to the Iraq war zone, with long-term follow-up assessment occurring at least 5 years after return from deployment. The primary outcome variable was the PTSD Checklist-Civilian Version summary score. GMM yielded four latent profiles, characterized as primarily asymptomatic (n = 194, 17.8%); postdeployment worsening symptoms (n = 84, 7.7%); mild symptoms (n = 320, 29.4%); and preexisting, with a chronic postdeployment elevation of symptoms (n = 489, 45.0%). Regression models comparing the primarily asymptomatic class to the symptomatic classes revealed that chronic symptom classes were associated with higher degrees of stress exposure, less predeployment social support, military reservist or veteran status at the most recent assessment, and poorer predeployment visual memory, ORs = 0.98-2.90. PTSD symptom course varies considerably over time after military deployment and is associated with potentially modifiable biopsychosocial factors that occur early in its course in addition to exposures and military status.

Introduction: Malignant melanoma typically spreads lymphatically and hematogenously to distant organs in its course of metastasis. Some of these common sites include the lungs, skin, brain, and the gastrointestinal (GI) tract. Within the GI tract, studies have shown that frequent sites for melanoma to metastasize to are the small bowel, colon, and anorectum. However, metastasis to the stomach is rare. We present an unusual case of an unfortunate young woman that had metastases of her melanoma in the form of a gastric polyp. Case Description/Methods: A 26-year-old African American woman with a known history of metastatic melanoma with metastases to bones and lungs presented to our hospital with the chief complaint of epigastric abdominal pain, nausea, and vomiting for 2 weeks. The patient was previously receiving immunotherapy but had stopped for the past 6 months because she wished to pursue more homeopathic measures. Physical exam demonstrated epigastric tenderness but vitals and laboratory studies were unremarkable. CT abdomen/pelvis with contrast demonstrated a 3.3 cm hepatic mass and a low density mass within the pancreatic head. Endoscopic evaluation for additional masses was performed and demonstrated a 7 mm normal appearing gastric polyp near the antrum. Biopsies were taken of the polyp and returned positive for metastatic malignant melanoma. Afterwards, the patient had subsequent improvement in her symptoms and was advised to follow up with her outpatient oncologist upon discharge (Figure 1). Discussion: Gastric metastases are considered to be an infrequent finding in general but even more so in metastatic melanoma. When they are discovered, it is usually post mortem during autopsies. Delay in discovery may be in part due to symptoms being non-specific and can include findings such as abdominal pain, GI bleeding, and GI tract obstruction. When endoscopic evaluation has taken place, lesions are usually hyperpigmented or ulcerated. Interestingly, our patient had a normal appearing gastric polyp with no evidence of hyperpigmentation or ulceration. Treatment modalities for melanoma metastases include surgical resection, immunotherapy, and targeted therapy. Early diagnosis can aid in guiding therapy and lead to possible better prognosis. This case demonstrates the importance of being thorough in evaluation for metastases in melanoma.Figure 1.: Gastric polyp visualized on EGD.

Introduction: The causes and differential diagnoses for dysphagia are broad and diagnostic approaches vary. Characterizing symptoms, occurrence with solids and/or liquids, and acuteness are important. Dysphagia may stem from structural abnormalities causing obstruction or narrowing or due to motility abnormalities. Endoscopy is often warranted as part of the work up and this case demonstrates the importance of direct visualization. Case Description/Methods: 79-year-old man with PMH atrial fibrillation, CKD Stage 3, diabetes, and neck surgeries including an anterior cervical discectomy and fusion after a motorcycle accident in 1997 initially presented to our institution with dizziness and dysphagia. He described a choking sensation with swallowing. He felt he could not coordinate swallowing both liquids and solids and as if solids would get stuck. While in the hospital he started to not be able to tolerate his own secretions and required suctioning. Speech therapy was consulted and performed a fiberoptic endoscopic evaluation of swallowing test and saw a metallic object along the posterior pharyngeal wall at the level of the epiglottis. The posterior pharyngeal wall was protruding into the pharynx with limited space between the epiglottis and posterior pharyngeal wall. During the test, the patient demonstrated reduced laryngeal elevation and epiglottic inversion with penetration to the level of the vocal cords. CT neck soft tissue without contrast demonstrated an inferior active aspect of the superior portion of the fixation plate protruding into the posterior aspect of the pharynx without definitive covering mucosa at approximately the level of C4-5 level. GI was consulted for PEG placement given inability to swallow and need for ongoing nutrition. Upon EGD, there was again noted metal protruding though the posterior pharynx, as well as an erosion of hardware in the proximal third of the esophagus (Figure 1). A gastrostomy tube was placed endoscopically for ongoing nutrition. Discussion: Few case reports have had similar presentations. Following anterior cervical spinal surgery, transient dysphagia unrelated to esophageal injury can occur and last up to 2 years but late onset dysphagia warrants further investigation. Anterior migration and esophageal migration must be in the differential, especially years after cervical spine surgery. Revisional cervical spine surgery with hardware removal, replacement, and myofascial repair or flap reconstruction are the standard of care for this condition.Figure 1.: Erosion of hardware through the posterior pharynx.

Introduction: Neuroendocrine neoplasms of the gastrointestinal tract and pancreas are considered a rare group of malignancies, and esophageal involvement is even less common. Risk factors for neuroendocrine neoplasms are not well known, however, some studies suggest that esophageal primary tumors may be associated with acid reflux, Barrett metaplasia, and prior history of achalasia. Most patients present with systemic or site-specific symptoms such as focal pain, dysphagia, or obstruction. We discuss a case of a man who presents with abdominal pain and dysphagia in the setting of obstructing esophageal neoplasm. Case Description/Methods: A 59-year-old White man without significant medical history presents with mid-epigastric and right upper quadrant abdominal pain that had been worsening over the previous 3 months. Patient reported associated dysphagia with solids and an unintentional 20 lb weight loss. Physical exam revealed bilateral upper quadrant tenderness to palpation with guarding, hypoactive bowel sounds, and without obvious superficial lymph node abnormalities or abdominal mass. CT imaging revealed hepatic and retroperitoneal nodal lesions with wall thickening and bulbous appearance of the distal esophagus. Endoscopic evaluation of the esophagus showed a large fungating mass that was infiltrating and nearly obstructing the esophageal lumen. Biopsy of the mass demonstrated poorly differentiated carcinoma with neuroendocrine differentiation. The patient started chemotherapy outpatient shortly after diagnosis, nevertheless after 5 months he returned to hospital for inability to tolerate oral intake. The following EGD showed a nearly obstructive esophagus and procedure was aborted (Figure 1). When presented surgical options, he elected to pursue hospice care and eventually succumbed to his disease. Discussion: Esophageal neuroendocrine tumors are aggressive and have frequently metastasized by the time of diagnosis. Symptoms can be systemic or associated with mass effect. Diagnosis requires biopsy with histologic examination and immunohistologic staining for synaptophysin, Cga and other markers. There is little information available pertaining to treatment of these neoplasms. Surgery may be curative, however chemotherapy plus radiation is the preferred treatment. Early diagnosis is crucial and emphasizes the importance of thorough investigation of patients with dysphagia. The purpose of this case report is to encourage continued research and reporting of such cases along with the effectiveness of treatment.Figure 1.: EGD with esophageal tumor.

Introduction: Duodenal adenocarcinoma (DA) remains a rare entity representing less than 1% of all gastrointestinal cancers. Most originate in the second part of the duodenum. Due to low incidence, difficulty in diagnosis, treatment strategies may also be challenging. This case exhibits the vagueness of symptoms as well as delay in presentation of a primary duodenal adenocarcinoma. Case Description/Methods: 63-year-old man presented to our hospital for nausea and bilious vomiting. His symptoms began 4 months prior with episodes usually lasting a few days but progressively worsened and caused an associated 50 lb weight loss. Labs showed microcytic anemia with Hgb 9.8 and MCV 71. CT abdomen with oral contrast showed a mesenteric soft tissue lesion with associated compression of bowel. There was proximal dilation of the duodenum and stomach indicating some obstruction. Given these findings, he underwent EGD which noted a circumferential intraduodenal mass with surrounding ulceration in D2/D3. Biopsies noted adenomatous epithelium with high grade dysplasia. Follow up CT chest, abdomen and pelvis redemonstrated abnormal wall thickening and narrowing of the duodenal sweep or proximal fourth portion of the duodenum with suspicious appearing metastatic adenopathy and tiny hypodensities in the liver and kidney. He underwent exploratory laparotomy which found an unresectable, firm mass at the duodenojejunal junction invading into the retroperitoneum and mesentery consistent with carcinoma. There was a small perforation noted which was repaired followed by a Graham patch, and an Antecolic gastrojejunostomy was performed along the greater curvature of the stomach. A metastatic lesion was also found in the liver. Biopsies were consistent with invasive adenocarcinoma. As the mass was deemed unresectable, he was evaluated by oncology and underwent chemotherapy treatments with FOLFOX. After 2 rounds, his symptoms improved. Discussion: Diagnosis was not made until the mass was causing outlet obstruction, but there were already metastases to the liver. Often resection of the tumor is futile at this point. Even though the optimal surgical procedure remains controversial, many agree that a radical surgical approach that achieves complete tumor resection is of utmost benefit whenever feasible. Recently, DA is being treated similarly to colorectal adenocarcinoma with oxaliplatin-based chemotherapy. Given the tendency of this disease to recur systemically, the role of adjuvant chemotherapy warrants further investigation.

Introduction: Obstructive jaundice can be caused by malignancy, stones, strictures, or external compression of the biliary tree. Malignancies known to cause obstructive jaundice are pancreatic adenocarcinoma, gallbladder tumor, cholangiocarcinoma, periampullary cancer, or less commonly lymphoma. We present a case of B-Cell Lymphoma presenting as obstructive jaundice. Case Description/Methods: 61-year-old male with coronary artery disease, diabetes mellitus, hypertension, and chronic kidney disease presented with 2 days of jaundice, abdominal pain and distension, reduced appetite, and unintentional weight loss. He denied history of IV drug or alcohol use. Initial labs showed total bilirubin 6.4, conjugated bilirubin 5.3, alkaline phosphatase 367, AST 99, ALT 211, and Ca 19-9 833. CT abdomen pelvis with IV contrast demonstrated a focal area of retroperitoneal lymphadenopathy 10.5 x 7.7 x 11.6 cm encasing the abdominal aorta, inferior vena cava, superior mesenteric artery, portal vein with a mass effect displacing the pancreatic head and obstructing the common bile duct. MRCP showed intrahepatic biliary dilatation with extrinsic compression from lymphadenopathy. The dilated common bile duct (CBD) measured 15mm. Also noted were subtle signal abnormalities seen in the liver. No filling defects or strictures were visualized. An Endoscopic Ultrasound with biopsy revealed a large hypoechoic lesion overlapping the pancreatic head with enlarged lymph nodes. Multiple biopsies were taken of the lesion consistent with aggressive B cell lymphoma. An ERCP was then performed. Cholangiography revealed narrowing of the distal two-thirds of the CBD with upstream dilatation of 12 mm. A plastic stent was placed in the CBD with subsequent normalization of the LFTs (Figure 1). Chemotherapy was initiated with Etoposide, Prednisone, Oncovin, Cyclophosphamide, hydroxydanurubicin, and Rituximab (EPOCH-R). Follow up CT Abdomen Pelvis without contrast 5 months after initiation of chemotherapy showed marked improvement. Discussion: Certain chemotherapeutic drugs can be hepatotoxic such as cyclophosphamide and other medications of the EPOCH-R regimen are metabolized by the liver. Biliary decompression should take precedence before chemotherapy to prevent toxic accumulation of these medications. Patients that had biliary drainage via stent placement resolved their obstruction without return of hyperbilirubinemia. Uncommonly, lymphoma can cause obstructive jaundice and decompression of the biliary tree should be performed prior to chemotherapy.Figure 1.: Retroperitoneal Adenopathy on CT abd/pelvis w/ contrast.