Abstract We evaluated the role of total body irradiation (TBI) and its interaction with smoking in relation to subsequent lung cancer after blood or marrow transplantation (BMT) by leveraging the BMT Survivor Study. Participants included individuals who underwent BMT (1974-2014) at 3 centers and who survived ≥2 years. The impact of TBI and smoking was evaluated using Fine-Gray subdistribution hazard models. Standardized incidence ratios were calculated using age- and sex-specific incidence rates obtained from the Surveillance, Epidemiology, and End Results Program. Of the 6981 BMT survivors (median age, 46 years; 58.5% male), 113 developed subsequent lung cancer at a median of 7 years after BMT, representing a 40% higher risk when compared with the general population (95% confidence interval [CI], 1.2-1.7). In the subcohort with smoking data available (n = 3767), there was a significant TBI-smoking interaction (P< .0001). When compared with no TBI never smokers, the risk was increased among TBI-exposed ≥10-year smokers (adjusted subdistribution hazard ratio [asHR], 3.9; 95% CI, 3.0-8.9) and no TBI ≥10-year smokers (asHR, 3.0; 95% CI, 1.3-5.6). Among the <10-year smokers, the risk was not increased, regardless of TBI exposure (TBI: asHR, 1.4; 95% CI, 0.9-3.5; no TBI: asHR, 1.1; 95% CI, 0.30-4.3; reference: no TBI never smokers). TBI exposure in the absence of smoking did not increase the risk (asHR, 0.6; 95% CI, 0.2-1.7). Additional risk factors included older age at BMT, male sex, and pre-BMT exposure to anthracyclines and/or topoisomerase II inhibitors. These findings support personalized surveillance for BMT survivors at heightened risk for subsequent lung cancer.

PURPOSE:Housing instability deleteriously affects health outcomes (i.e., lack of access to care, premature mortality). Veterans experiencing housing instability in rural areas-which often lack housing options, transportation, and services-have greater odds of residential relocation compared to urban Veterans, and they most frequently relocate to urban areas. Urban relocation is associated with changes in health outcomes, including increased services use, but studies have not examined the association between residential relocation and mortality. METHODS:This study used Veterans Affairs electronic health record data for 28,058 Veterans who experienced housing instability at a rural residence and then, within 2 years, changed their residential location by ≥40 mi or from a rural-to-urban location. We assessed the risk of mortality during the 6 months following residential relocation, controlling for sociodemographics, baseline comorbid health conditions, and time-varying services use. FINDINGS:One-third of the rural Veterans experiencing housing instability had a rural-to-rural relocation (n = 7227), whereas the remaining had a rural-to-urban relocation (n = 17,375). Veterans with a rural-to-rural relocation were older and had more comorbid medical conditions compared to Veterans with rural-to-urban relocation; however, Veterans with a rural-to-urban relocation had 28% greater odds of mortality during the 6 months following residential relocation than Veterans with rural-to-rural relocation. CONCLUSIONS:Rural-to-rural relocation was associated with reduced odds of mortality, even when controlling for services utilization, age, and baseline comorbidities. Future research should explore if and how remaining in rural environments is protective and identify ways to support care coordination following residential relocations among Veterans with experience of housing instability.

Importance Blood or marrow transplant (BMT) recipients are at increased risk of developing subsequent cutaneous malignant neoplasms. There is a need to develop risk stratification tools to identify those at highest risk to inform dermatologic surveillance and evaluate risk mitigation strategies. Objective To develop and validate a risk stratification tool for subsequent cutaneous malignant neoplasms among BMT recipients that incorporates readily available patient and treatment information. Design, Setting, and Participants This prognostic study included participants in the multi-institutional, longitudinal BMT Survivor Study (BMTSS), which included individuals who underwent autologous or allogeneic BMT from January 1, 1974, to December 31, 2014, at 1 of 3 participating sites in California, Minnesota, and Alabama and survived 2 or more years after BMT. The present cohort was restricted to individuals who underwent a single transplant and completed at least 1 BMTSS survey. Data were analyzed from December 3, 2024, to June 3, 2026. Exposures Risk stratification models included the following candidate variables: age at BMT, sex, race, ethnicity, prior cutaneous malignant neoplasm, pretransplant exposure to monoclonal antibodies, total body irradiation, chronic graft vs host disease, and posttransplant immunosuppression. Main Outcomes and Measures The main outcomes were incident basal cell carcinoma (BCC), squamous cell carcinoma (SCC), or melanoma after BMT, ascertained based on participant report with medical record validation when available. Models for risk stratification were developed and validated using time-dependent area under the receiver operating characteristic (AUC) curve with repeated random partitioning into training and testing cohorts. Results were averaged to make a final model. Individuals were classified into low or high risk for subsequent cutaneous malignant neoplasm based on clinically meaningful risk stratification score thresholds. Results Of the 3448 included BMTSS participants (1917 [55.6%] male; mean [SD] age at BMT, 41.9 [19.2] years) who were alive without a cutaneous malignant neoplasm event 2 years after BMT, 282 (8.2%) were diagnosed with BCC, 183 (5.3%) with SCC, and 73 (2.1%) with melanoma. At 15 years after BMT, the test model AUCs were 0.81 (95% CI, 0.76-0.85) for BCC, 0.90 (95% CI, 0.86-0.93) for SCC, and 0.83 (95% CI, 0.74-0.90) for melanoma. The 15-year cumulative incidence of BCC, SCC, and melanoma in the low-risk group was 2.4% (95% CI, 1.5%-3.9%), 3.2% (95% CI, 2.4%-4.2%), and 0.8% (95% CI, 0.4%-1.5%), respectively. In the high-risk group, the 15-year cumulative incidence of BCC, SCC, and melanoma was 13.3% (95% CI, 11.6%-15.4%), 13.6% (95% CI, 11.2%-16.5%), and 4.4% (95% CI, 3.2%-6.1%), respectively. Conclusions and Relevance In this prognostic study, risk stratification models demonstrated excellent performance, highlighting potential utility for identifying BMT recipients who are at greatest risk of subsequent cutaneous malignant neoplasms.

Introduction: Housing instability is a significant issue among Veterans, with age-related variations in risk factors and outcomes. This study examines whether participation in Veterans Health Administration (VHA) Homeless Programs reduces suicide mortality among Veterans experiencing housing instability, and variation across age groups. Methods: This study analyzed a nationwide cohort of 662,682 Veterans with indicators of housing instability between 2014-2019. Logistic regressions estimated suicide mortality risk, stratified across five age categories (18-34, 35-44, 45-54, 55-64, 65 + years), controlling for demographic, military service, and health-related variables. Results: Suicide mortality rates were highest among Veterans <34 years (131 per 100,000 person-years) and lowest among those aged 55-64 and 65 + years (62 per 100,000 person-years and 70 per 100,000 person-years, respectively). Across all age groups, suicide mortality risk factors included White race, low or no service-connected disability compensation, and recent suicide ideation or attempts. Although Veterans aged 65 + were least likely to use VHA Homeless Programs, those who engaged with these services were 40% less likely to die by suicide, an effect only seen in this age group. Conclusions: Tailoring age-specific housing interventions to address Veterans' unique needs across the lifespan may significantly reduce suicide mortality risk among this population.

Housing instability, generally, is associated with a lack of access to care. The present study explores healthcare mobility among Veterans experiencing housing instability to identify the magnitude of this phenomenon and whether it is associated with certain patient characteristics or needs. The sample included 486,675 Veterans with 4 or more healthcare visits during the year following identification of homelessness. Analyses compared (a) baseline characteristics of Veterans who did and did not experience high healthcare mobility (i.e., receipt of healthcare services at 4 or more U.S. Department of Veterans Affairs Medical Centers) and (b) services use during the observation period. Among the sample, 0.7% experienced high healthcare mobility. Veterans with a rural residence had 30% greater odds of high healthcare mobility; baseline use of primary care was associated with reduced odds. The findings represent the combined challenges of accessing healthcare when experiencing housing instability and while residing in a rural area and highlight the need to ensure that there is access to needed care. Future work should assess Veterans' access to community-based resources, particularly in rural areas and new ways of delivering care in these areas.

BACKGROUND:The association between skeletal, muscle, and adipose tissue (body composition) and early response using PET in pediatric Hodgkin lymphoma remains unstudied. METHODS:Patients enrolled on Children's Oncology Group studies AHOD0031 (intermediate-risk Hodgkin lymphoma) and AHOD0831 (high-risk Hodgkin lymphoma) with digital abdominal CT scans at diagnosis and PET scans after 2 cycles (PET2) were included. Two consecutive slices at the third lumbar vertebra were identified, and skeletal muscle index (SMI; in cm2/m2) and total adipose tissue index (TATI; in cm2/m2) were calculated using sliceOmatic and height at diagnosis. SMI and TATI were divided into quintiles [Q1 (lowest) to Q5 (highest)]. Body mass index (BMI) was calculated using height and weight at diagnosis. The association between baseline body composition (SMI, TATI, and BMI) and positive PET2 was examined using logistic regression, adjusting for age at diagnosis, sex, race/ethnicity, stage, histology, bulk disease, and "B" symptoms. RESULTS:Among 1,033 included patients, PET2 was positive in 314 (30.4%) patients. SMI was not associated with positive PET2. Extremes of TATI were associated with positive PET2, when compared with the middle TATI quintile [reference: Q3; ORQ1 = 1.63; 95% confidence interval (CI) = 1.03-2.60; P = 0.04; ORQ2 = 1.82; 95% CI = 1.17-2.82; P = 0.008; ORQ5 = 1.94; 95% CI = 1.23-3.05; P = 0.005]. The association between BMI in obesity range and positive PET2 trended toward significance (OR = 1.42; 95% CI = 0.98-2.04; P = 0.06; ref = normal weight). CONCLUSIONS:Extremes of adipose tissue at diagnosis influence early response among pediatric Hodgkin lymphoma. IMPACT:Validation of results from this study could inform studies investigating body composition-based chemotherapy dosing.

Abstract Introduction: Clonal hematopoiesis of indeterminate potential (CHIP) is associated with an increased risk of stroke and all-cause mortality. A recent study reported that CHIP at a variant allele frequency (VAF) ≥1% was associated with a higher risk of recurrent stroke, myocardial infarction and all-cause mortality after ischemic stroke (PMID: 36441964). However, this study included only White individuals with a short follow up (3 years). The association between CHIP and mortality in diverse population groups with stroke followed long-term remains unstudied. We leveraged a large prospective study, the REasons for Geographic and Racial Differences in Stroke (REGARDS) to address this knowledge gap. Methods: REGARDS study recruited 30,239 self-identified Black and White individuals ≥45 years across the US between 2003 and 2007 and collected extensive health data by telephone and in-person exams. Participants also provided blood samples at study enrollment from which DNA was extracted. Details on identification and adjudication of stroke and other comorbidities were previously reported (PMC3595534). Participants were contacted by the study staff every 6 months to ascertain possible stroke, and this was confirmed by review of medical records. The current analysis included participants who developed incident ischemic stroke and had DNA samples available for CHIP testing. Participants with history of cardiovascular disease at baseline were excluded. Error-corrected targeted deep sequencing using Twist bioscience hybrid capture technology on the Illumina platform was used to detect coding sequences of 24 genes that identify >95% of CHIP mutations. VAF ≥2% was used to define CHIP. Cox proportional hazards models were used to calculate the hazard ratios (HRs) and 95% confidence intervals (CI) of mortality associated with CHIP, adjusting for clinically relevant variables that were significant with a p-value <0.1 in univariate analysis. We also adjusted for time between study enrollment and stroke to account for the known exponential growth pattern for CHIP mutations. We calculated HRs at different VAFs for the dominant mutation (≥2-10, >10%) and for the number of mutations (1, 2+). Stratified analysis was performed by age, sex and race due to known associations of CHIP with older age, male sex and White individuals. Results: Of the 1,580 participants who developed incident ischemic stroke in REGARDS (adjudicated by September, 2021), 1,112 had DNA samples available for CHIP analysis. Median age at study enrollment was 68 years (standard deviation [SD]: 8.8); 49.9% were male and 53.6% Black individuals. CHIP was present at study enrollment in 23.6% participants at VAF ≥2%. The majority (69.1%) had a single mutation; DNMT3A (57.6%) and TET2 (24.8%) were the most common mutations. Median time from study enrollment to stroke was 6 years and median time from stroke to last follow up for those alive was 5.5 years. Adjusted for age, hypertension, diabetes, dyslipidemia, smoking, atrial fibrillation and time from study enrollment to stroke, baseline CHIP (yes vs. no)was not associated with increased mortality overall (HR=1.02, 95% CI: 0.85-1.22). However, increased mortality risk was seen with multiple CHIP mutations (≥2 mutations vs. no CHIP) and high VAF CHIP (>10 vs. ≤10%) in specific demographic groups: 1) participants ≤65 years with ≥2 mutations (HR=2.63, 95% CI: 1.37-5.05) and with high VAF CHIP (HR=1.93, 95% CI: 1.05-3.55), and 2) men with ≥2 mutations (HR=1.52, 95% CI: 1.04-2.20) and with high VAF CHIP (HR=1.57, 95% CI: 1.13-2.19). For participants older than 65 years, overall CHIP (yes vs. no; HR=0.95, 95% CI: 0.78-1.17), ≥2 mutations (HR=0.89, 95% CI: 0.66-1.19) or high VAF CHIP (HR=0.92, 95% CI: 0.68-1.24) were not associated with mortality risk. High VAF CHIP was associated with lower mortality in women (HR=0.62, 95% CI: 0.40-0.97). Conclusion: In this study, CHIP was associated with increased risk of mortality after ischemic stroke only in individuals ≤65 years and men with multiple mutations or high VAF CHIP. Results may be used in future to refine personalized risk stratification after stroke and design interventions for vulnerable populations.

Introduction Preoperative education is a critical component of enhanced recovery programs. Factors associated with receipt of preoperative education are unknown. Methods We performed a retrospective cohort study of patients undergoing elective colorectal surgery (2019—2023) using data from our institution's enhanced recovery program dashboard and American College of Surgeons National Surgical Quality Improvement Program database. The primary outcome of patient-reported receipt of preoperative education was analyzed using multivariable linear regression and machine learning classification trees. Results Of 1175 patients, 87.7% reported receiving preoperative education. On multivariable analysis, patients undergoing extended colectomy and other procedures had marginal increases in receipt of education by 5.8% (P = 0.01) and 9.6% (P < 0.01), respectively, compared to partial colectomy. Compared to open surgery, patients undergoing minimally invasive surgery had a marginal increase of 4.9% (P = 0.04). Patients who reported education had a body mass index (BMI) 0.003 higher than those who did not (P = 0.03). Receipt of education varied significantly between surgeons (P < 0.05). Machine learning analysis identified surgeon, BMI, and procedure type as predictors of education for open procedures. Conclusions Surgeon, procedure type, operative approach, and BMI were associated with patient-reported receipt of preoperative education.

Background: With advances in antiretroviral therapy, aging people with HIV (PWH) are increasingly at risk for non–AIDS-defining cancers (NADCs) and chronic morbidities. This study examines whether PWH with NADCs face a higher risk of new-onset chronic health conditions compared with those without cancer. Patients and Methods: We conducted a retrospective cohort study using data from the CFAR (Centers for AIDS Research) Network of Integrated Clinical Systems (CNICS) for PWH enrolled between 1995 and 2018 from 8 US academic institutions. We included PWH with the 5 most common NADCs: anal cancer, non–small cell lung cancer (NSCLC), prostate cancer, classic Hodgkin lymphoma (HL), and hepatocellular carcinoma (HCC). A 1:2 matching for each NADC subgroup was performed based on age, cohort entry year, and sex (noncancer cohort). Chronic health conditions were graded using the CTCAE, with the primary outcome being the risk of new-onset grade ≥3 morbidities, analyzed using Cox regression. Results: The study included 693 PWH with NADCs and 1,345 matched PWH without cancer. At a median follow-up of 13.7 years for PWH with NADCs and 10.7 years for the noncancer group, the prevalence of grade ≥3 morbidities was significantly higher in the NADC group (24.8% vs 13.8%; P ≤.01). Multivariable Cox regression showed a higher risk of new-onset grade ≥3 conditions in the NADC group (hazard ratio, 2.94; P <.0001), specifically diabetes mellitus (all NADCs), myocardial infarction (NSCLC and HL), and congestive heart failure (prostate cancer). Conclusions: Our study showed an excess risk of new-onset morbidities among PWH with NADCs. These findings have critical implications for the care of survivors of HIV and cancer and underscore the importance of integrated care approaches to address late effects in this vulnerable population.

BACKGROUND:Surgical resection is a crucial component of pancreatic cancer treatment. However, multiple disparities in access to surgical resection have been reported. This systematic review aimed to critically assess and summarize these disparities to improve equity in cancer care. METHODS:PubMed, Web of Science, Embase, Medline, and Cochrane databases were searched from 2000 to 2023. Primary research articles from the United States specifically evaluating surgical resection for resectable pancreatic adenocarcinoma cancer were included. Bias assessment was performed using the modified Newcastle-Ottawa Scale. RESULTS:A total of 19 studies met the final inclusion criteria. 16 studies reported disparities among minority groups, with Black and Hispanic patients less likely to undergo surgery. 15 studies reported older age being predictive of nonreceipt of surgery. Lower socioeconomic status, reported in 8 studies, and nonprivate insurance, reported in 7 studies, were determined to be independent risk factors for decreased receipt of surgery. Five studies reported that patients treated at community hospitals were less likely to receive surgery, and 4 studies identified being single as an independent risk factor for nonreceipt of surgery. Finally, residence in a rural location, reported in 1 study, and male sex, reported in 1 study, were determined to be predictive of decreased receipt of surgery. DISCUSSION:Various sociodemographic factors influence the access to surgical resection for pancreatic cancer. These factors are proxies for multiple underlying barriers along the continuum of care, some of which may be modifiable. Identifying and understanding these barriers will allow us to develop targeted interventions to improve the delivery of oncologic care.

Housing instability is an important determinant of health and can lead to reduced life expectancy as well as other poor outcomes. While homelessness is often perceived as an urban phenomenon, it is also present in rural areas of the U.S. Compared with non-Veterans, Veterans are more likely both to be living in rural areas and experiencing housing instability. The U.S. Department of Veterans Affairs (VA) offers health care and social services—including a variety of responses to housing instability—in facilities across the U.S. The objective of the present study is to estimate the frequency of migration among Veterans with experience of homelessness, the characteristics of their migrations, and individual and community-level characteristics that may predict their migrations. We used VA administrative data for 559,513 Veterans with an indicator of housing instability between January 1, 2014, and December 31, 2018, with up to a 5-year observation period. The primary outcome of interest was migration, defined as a single geographic residential relocation (i.e., a change of residential address) of more than 40 miles or a geographic residential relocation of fewer than 40 miles but with a change in urban/rural status. Controlling for a variety of covariates, we utilized a discrete-time survival framework with person-quarter as the unit of analysis; this allowed us to directly model event rates over time with the inclusion of time-varying predictors. Across the observation period, about one-quarter of Veterans with an indicator of housing instability migrated, most frequently those who resided in a rural area and sought care at an urban facility; the majority migrated to or within an urban area and these migrations were of a greater distance than migrations to or within a rural area. Future work in this area should focus on investigating differences in findings across geographic regions, Veterans' reasons for migration, and the impact of migration on Veterans’ health and housing outcomes.

Background: Patients with a new ostomy have high rates of unplanned healthcare utilization (UPHU). We used machine learning to assess which factors contributed the most to UPHU after ostomy construction. Methods: We retrospectively studied new ostomy patients between 2018 and 2021 at a single institution. The primary outcome was UPHU within 60 days of discharge. Factors that contributed the most to UPHU were assessed using a classification tree machine learning method. Results: Among 318 patients, 30.8 % of patients had an UPHU event. The classification tree identified diabetes mellitus as the most important factor associated with UPHU: 56 % of diabetics had UPHU. Smoking history was the next most important factor: 77 % of diabetics who smoked had UPHU. Patients who had diabetes, smoked, and had chronic kidney disease had the highest UPHU rate at 86 %. Discussion: Unplanned healthcare utilization after ostomy construction is highest among patients with diabetes, smoking history, and chronic kidney disease.

Introduction: Chest radiation-related lung cancer has been previously reported in cancer survivors (Lorigan et al, Lancet Oncology, 2005). The risk increases with dose (20-40Gy) and volume of radiation; cigarette smoking multiplies the risk associated with higher doses of radiation. Total body irradiation (TBI) delivers a smaller dose but larger volume of radiation to the lung compared to conventional radiation therapy (e.g., mediastinal radiation). Whether exposure to TBI (in the absence of chest radiation) increases the risk of lung subsequent neoplasms (SNs) and whether cigarette smoking interacts with TBI in increasing the risk of lung SNs remains unknown. We leveraged BMTSS to address these gaps in knowledge. Methods: BMTSS is a retrospective cohort study of individuals who were treated with BMT from 1974 to 2014 at three transplant centers and survived ≥2y. This report includes BMT survivors who completed a BMTSS survey at age ≥18y, providing information on demographics, health habits (including smoking history), and occurrence of chronic health conditions and SNs (including lung SNs). Disease and treatment characteristics were obtained from medical records and included exposure to pre-BMT radiation and chemotherapy (alkylating agents, anthracyclines), BMT conditioning (TBI, chemotherapies), donor type (autologous, allogeneic). The present analysis excluded patients who received chest radiation. Study participants were classified as never smokers, former smokers, and current smokers. TBI exposure was classified as: 0–799cGy and ≥800cGy. Fine-Gray proportional sub-distribution hazard models were used determine the hazard of lung SNs, treating other causes of death as competing risks. Time at risk was calculated from the date of BMT to the earliest of lung SN diagnosis, death, or last known follow-up (May 2024). Standardized incidence ratios (SIRs) quantified the excess risk of lung SNs among BMT recipients when compared with the general population. Results: A total of 3,767 BMT survivors were included. Median age at BMT was 48y (range, 0-78y), and median follow-up was 15.2y. Overall, 57% were male; 43% had received TBI ≥800 cGy; 34% were former smokers; and 4% were current smokers. Fifty-four individuals developed lung SNs at a median of 7.5y post-BMT. A significant multiplicative interaction between TBI and current smoking suggested effect modification; thus, a six-category combined exposure variable was created to examine joint effects. Standardized incidence ratios: Compared with the general population, the current smoker + TBI ≥800cGy group had a 4.6-fold increased risk of lung SNs (p=0.002). The risk of lung SNs was not statistically-significantly increased in the current smoker + TBI 0-799cGy group (SIR=2.6, p=0.2), the former smoker + TBI ≥800cGy group (SIR=1.4, p=0.3), or the never smoker + TBI ≥800cGy group (SIR=0.4, p=0.1). Multivariable models: Using the never smoker + TBI 0–799cGy as the reference group, the highest hazard for lung SNs was observed in the current smoker + TBI ≥800cGy group (aHR=5.9, p=0.003), followed by the current smoker + TBI 0–799cGy group (aHR=3.7, p=0.05) and the former smoker + TBI ≥800cGy group (aHR=2.6, p=0.03). The former smoker + TBI 0–799cGy group was not at increased risk of lung SNs (aHR=1.7, p=0.3). Notably, exposure to TBI ≥800cGy alone (in the absence of smoking) was not associated with an increased risk of lung SNs (aHR=0.9, p=0.8). Conclusions: This study shows no association between TBI and lung SNs in the absence of current cigarette smoking. The multiplicative interaction between TBI and current smoking informs the need for targeted surveillance and interventions in the highest risk group.

ImportanceCutaneous malignant neoplasms are the most common subsequent neoplasm after blood or marrow transplant (BMT), but a full assessment among survivors is lacking.ObjectiveTo identify risk factors for subsequent cutaneous malignant neoplasms using the BMT Survivor Study (BMTSS).Design, Setting, and ParticipantsThis retrospective cohort study included patients who underwent transplant from 1974 to 2014 at City of Hope, University of Minnesota, or University of Alabama at Birmingham and survived 2 years or longer, as well as a comparison cohort of siblings. Both groups completed the BMTSS survey. Data analysis took place from October 2022 to October 2024.ExposuresDemographics, pre-BMT and BMT-related therapeutic exposures, chronic graft-vs-host disease (cGVHD), and posttransplant immunosuppression.Main Outcomes and MeasuresIncident cutaneous malignant neoplasms (basal cell carcinoma [BCC], squamous cell carcinoma [SCC], and melanoma) after BMT. Exposures were evaluated for association with subsequent neoplasms using proportional subdistribution hazards models (reported as subdistribution hazard ratio [SHR] and 95% CI).ResultsAmong the 3880 BMT survivors (median [range] age at BMT, 44.0 [0-78.0] years; 2165 [55.8%] male; 190 [4.9%] Black, 468 [12.1%] Hispanic, 2897 [74.7%] non-Hispanic White, and 325 [8.4%] of other race [including Asian and Pacific Islander] and multiracial) who were followed up for a median (range) of 9.5 (2.0-46.0) years, 605 developed 778 distinct cutaneous neoplasms (BCC, 321; SCC, 231; melanoma, 78; and unknown type, 148). The 30-year cumulative incidence of any cutaneous malignant neoplasm was 27.4% (BCC, 18.0%; SCC, 9.8%; and melanoma, 3.7%). Seventy-year cumulative probabilities of BCC, SCC, and melanoma were considerably higher in BMT survivors than siblings (18.1% vs 8.2%, 14.7% vs 4.2%, and 4.2% vs 2.4%, respectively). Among BMT survivors, risk factors for subsequent cutaneous malignant neoplasms included age of 50 years and older at BMT (BCC: SHR, 1.76; 95% CI, 1.36-2.29; SCC: SHR, 3.37; 95% CI, 2.41-4.72), male sex (BCC: SHR, 1.39; 95% CI, 1.10-1.75; SCC: SHR, 1.85; 95% CI, 1.39-2.45), pre-BMT monoclonal antibody exposure (BCC: SHR, 1.71; 95% CI, 1.27-2.31), allogeneic BMT with cGVHD (BCC: SHR, 1.48; 95% CI, 1.06-2.08; SCC: SHR, 2.61; 95% CI, 1.68-4.04 [reference: autologous BMT]), post-BMT immunosuppression (BCC: SHR, 1.63; 95% CI, 1.24-2.14; SCC: SHR, 1.48; 95% CI, 1.09-2.02; melanoma: SHR, 1.90; 95% CI, 1.16-3.12), and transplant at City of Hope (BCC: SHR, 3.55; 95% CI, 2.58-4.89; SCC: SHR, 3.57; 95% CI, 2.34-5.47 [reference: University of Minnesota]) or University of Alabama at Birmingham (BCC: SHR, 2.35; 95% CI, 1.35-4.23; SCC: SHR, 2.63; 95% CI, 1.36-5.08 [reference: University of Minnesota]). Race and ethnicity other than non-Hispanic White were protective for BCC (Black: no cases; Hispanic: SHR, 0.27; 95% CI, 0.16-0.44; other race and multiracial: SHR, 0.26; 95% CI, 0.14-0.50 [reference: non-Hispanic White]) and SCC (Black: SHR, 0.17; 95% CI, 0.04-0.67; Hispanic: SHR, 0.28; 95% CI, 0.16-0.50; other race and multiracial: SHR, 0.13; 95% CI, 0.05-0.37 [reference: non-Hispanic White]). Total body irradiation was associated with BCC risk among those younger than 50 years at BMT (SHR, 1.92; 95% CI, 1.27-2.92).Conclusions and RelevanceIn this cohort study, the high risk of cutaneous malignant neoplasms and malignant-specific risk factors suggest a need for personalized patient counseling and posttransplant dermatologic surveillance.

OBJECTIVE:To characterize the relationship between the frequency of idiopathic osteoarthritis (OA) and characteristics including demographics, comorbidities, military service history, and physical health in a veteran population. METHODS:We performed a cohort study in the Million Veteran Program (MVP) using International Classification of Diseases, 9th and 10th revision codes to define the frequency of site-specific OA across 3 joints or unspecified OA in veterans with respect to demographics (eg, age, sex, race and ethnicity), military service data, detailed electronic health records, military branch, and war era. RESULTS:We validated previous reports of sex- and age-dependent differences in OA frequency, and we identified that unspecified OA was associated with a higher frequency of 16 Deyo-Charlson comorbidities. These associations generally persisted within each isolated joint site-specific OA. Depending on military branch, prior military engagement was differentially associated with the frequency of OA. Prior United States Army and Navy service were associated with higher and lower risk, respectively, of OA across all joint sites; however, multivariable-adjusted models adjusting for a range of covariates, including age, sex, and ancestry, reversed the apparent protective effect of prior Navy service. CONCLUSION:These findings highlight the breadth of factors associated with OA in the MVP veteran population and suggest that physical status may be a modifiable risk factor for OA. This work may help in the design of strategies to optimize appropriate detection, intervention, treatment, and even rehabilitation for OA in veterans and the general population.

Background/Objective Gout is the most common inflammatory arthritis, and its morbidity can be substantially reduced through urate-lowering therapy. However, adherence to allopurinol-the most common urate-lowering therapy-is notoriously poor. Prior studies have not fully elucidated factors associated with allopurinol adherence, particularly psychosocial factors. Methods We used 2018-2021 data from the Medical Expenditure Panel Survey, a national longitudinal survey on health care expenditures and utilization. We calculated the medication possession ratio (MPR) for allopurinol for participants with gout and categorized each as follows: no allopurinol fills, low adherence (MPR <= 0.8), or high adherence (MPR >0.8) to allopurinol. We used multivariable logistic regression to identify factors associated with high adherence, using person-year as the unit of measure and accounting for clustering for participants who contributed more than 1 person-year. Results The analyses included 919 respondents (1453 person-years), representing a weighted total of 15,084,439 person-years. Across all years, 27.4% had no allopurinol fills, 37.4% had low adherence, and 35.2% had high adherence. In multivariable models for high adherence, Black race (odds ratio, 0.49; 95% confidence interval, 0.33-0.73, compared with White) and residence in the South US region (odds ratio, 0.54; 95% confidence interval, 0.35-0.82, compared with Northeast) were negatively associated with high adherence. Conclusions Black race and residing in the Southern US were associated with lower allopurinol adherence among gout patients. Interventions to improve adherence, particularly among Black patients in the South, are needed to maximize the potential benefits of allopurinol.