Background The population of critically ill patients in the United States is growing, leading to higher resource utilization, costs and mortality. It has been suggested that ethnic disparities may be associated with higher mortality among critically ill patients, particularly veterans who tend to have increased medical complexity. There is uncertainty about whether these ethnic disparities are reflected in the Veterans Health Care System and how they impact survival among critically ill patients. The aim of this study is to investigate whether Hispanic versus non-Hispanic ethnicity is associated with higher 30- and 90-day mortality among critically ill veterans admitted to the Intensive care unit (ICU). We hypothesize that Hispanic ethnicity is associated with higher mortality in critically ill veteran patients. Methodology This is a retrospective cohort study conducted in the South Texas Veterans Health Care System during calendar year 2023. We included patients 50 years and older admitted to the ICU and excluded those who did not have ethnicity reported. The index date was date of ICU admission in the year of 2023. The variable of Interest was Patients that were categorized into two groups based on self-reported ethnicity: Hispanic and non-Hispanic. Data on patient demographics (e.g. age, sex, race), comorbidities included in the Charlson Comorbidity index (CCI) were extracted from electronic health records. The primary outcome was mortality at 30 days. The secondary outcome was mortality at 90 days. Results A total of 807 participants were included in this study, 238 (29.5%) were Hispanic and 569 (69.5%) were non-Hispanic. Among the patients enrolled, there appeared to be fewer females (6%) in total group with mean age 70 years. Among Hispanic veterans, 21 (8.82%) died within 30 days, In-contrast 57 (10.02%) in non-Hispanic veterans. Regarding 90-day mortality, 32 (13.4%) of Hispanic veterans died within 90 days, compared to 87 (15.3%) of non-Hispanic veterans. There were no statistically significant differences in mortality between Hispanic and non-Hispanic groups at 30 days (OR = 0.8, 95% CI [0.5-1.5], p=0.6) or 90 days (OR = 0.9, 95% CI [0.6-1.3], p=0.5). Summary Our study found no significant difference in 30- and 90-day mortality rates between Hispanic and non-Hispanic critically ill veterans in the South Texas Veterans Health Care System. This suggests that ethnicity may not be a major factor in mortality outcomes for this patient population.

Over 50% older Veterans (OV) live with disabling hearing loss (HL), often undiagnosed and/or untreated. HL consequences include increased depression/dementia risk, PTSD exacerbation, social isolation, caregiver-burden and adverse events when hospitalized. Homebound rural OV consequences of HL remain unknown. Investigate the relationship between HL, quality-of-life and caregiver-burden among homebound rural OV Homebound rural OV (Del Rio, TX) were evaluated for HL (audiometer), caregiver-burden (Zarit), hearing-loss-impact-on-quality-of-life measured with Hearing-Handicap-Scale (HHS), and overall quality-of-life (SF-12). N-19. Median Age 77 (74-81), 58% Hispanic, 100% male. Spouses were main caregivers. 58% had three-­or-more chronic conditions: 63% mental-health-related, 26% cardiac, 21% pulmonary. 42% reported toxic exposures. 90% OV had HL; 69% found to have moderate-to-severe HL (41-70 dB of loss, 84% bilateral). 57% OV exposed to agent-orange had severe HL (p = 0.089). Caregiver-burden scores were higher among OV with severe HL (p=NS) and quality-of-life was not significantly correlated with HL (Physical: p = 0.93, Mental: p = 0.47, Total: p = 0.71). OV with Mild or Normal HL had lower total values of HHS vs. moderate HL (p = 0.035) and severe HL (p = 0.016). Further, both emotional and social HHS components showed negative significant correlations with severe HL (p = 0.013 and p = 0.021, respectively). Homebound OV likely suffer from multiple chronic conditions including HL (90%). Severe HL affects quality-of-life and causes caregiver-burden. Self-perceived HL social/emotional impairment significantly correlates to HL severity. In-home interventions such as standardized screening and provision of simpler/cost-effective devices (pocket-talker, alternative to hearing-aids) are needed to avoid further decline among homebound rural populations.

Nearly one million people are diagnosed with a venous thrombosis event (VTE) annually, mortality of 20% to 50%. There may be a higher risk of mortality among adults 50 years and older who have a higher comorbidity burden. The impact of comorbidity burden in the context of PE in adults is uncertain. Our aim was to determine if comorbidity burden impacts mortality in Veterans with PE. We hypothesized that Veterans with PE who have a comorbidity burden will have an increased mortality compared to those with no comorbidity burden.In a retrospective cohort study, we used an administrative dataset with Veterans in the South Texas VA Health System. We included Veterans with at least one encounter and a diagnosis of PE between 1/1/2023 and 12/31/2023. To minimize variable redundancy and focus on medical comorbidities, age was removed in our customized Charlson Comorbidity Index (CCI) score. We used CCI to stratify our population initially to represent no-comorbidity as 0 and comorbidity as 1+. As our analysis was limited, we expanded the high comorbidity burden group to include CCI greater than 3, i.e. multimorbidity. All analyses were done using a Chi-Square test and comparing odds ratios. Our primary outcome was 30- and 90-day mortality.We identified 896 Veterans had a PE. Patients with a CCI of 0 had no mortality at both timepoints. Patients with CCI score 1+ had a mortality at 30-day of 16.2% and 90-day of 22.0%. During secondary analysis, we found patients with CCI score <3 had a 30- and 90-day mortality were of 3.1% and 6.3% respectively. CCI score of ≥3 had a 30- and 90-day mortality of 25.6% and 31.6% respectively. Statistically significant increase in odds of mortality from PE was found comparing the following individual comorbidities at 30-days (cardiovascular disease (CVD), diabetes mellitus (DM), cancer (CA)) and 90-days (DM, CA, and Chronic Pulmonary Disease); cancer showing the most significant odds of mortality.Mortality in PE patients is associated with the morbidity burden in Veterans. Higher morbidity burden showed increased mortality within 30 and 90 days of diagnosis of PE. CVD, DM, and CA increased the odds of mortality by at least 2-fold. Limitations of this study do include generalizability with a limited sample size and comorbidities studied outside of CCI. Further research could be done with a larger sample size on patients with low, or absent, burden morbidity with PE to determine factors impacting their mortality.

Over 80% of older adults (OA) suffer from one or more chronic conditions which affect their ability to cope with injuries or disease exacerbations. When acutely ill, OA usually require intravenous medication administration (IVMA), which traditionally has been done when hospitalized, exposing them to increased adverse events. Home-care-programs have increased their scope-of-practice to allow home-IVMA with >85% goal that medication-enters-the-body (METB). Administration methodology comparisons between home infusions (HI) and intravenous-push-administration (IVP-100% METB) have not been studied. To compare the IVMA effectiveness using HI vs. IVP in a population of OA receiving IV-treatment at home. Using three infusion companies and guaranteeing nurses-led visits, first-part-of-study collected one-year detailed data on IVMA methodology/complications via HI. Subsequently, IVP was encouraged (vs. HI) whenever recommended by pharmacy. One-year data on recommendation follow-up/complications/satisfaction was analyzed. Overall, 67% were>65, 95%male, age=43-87. First-part-of-study: N = 15, 60% had>10 IVMA episodes using PICC/midline/porta-cath. Only 53% participants met >85% METB goal with standard HI. Second-part-of-study: N = 154, 28% IVMA were recommended to IVP, those subjects receiving 100% METB. When comparing the pre-and post-groups, complication rate was 10% for both, High satisfaction rates were found among the IVP group. On this preliminary study and when recommended by pharmacy, IVP was shown to be an effective IVMA method as demonstrated by 100%METB without higher complications compared to HI and indicated high patient satisfaction. Further research is needed to evaluate effectiveness of IVP vs. HI among OA, considering nurse manpower, cost-effectiveness (tubing/supplies/pump, infusion preparation, etc.), time-to-completion, METB rates, complications and patient-satisfaction.

INTRODUCTION:Diffuse large B-cell lymphoma (DLBCL) is the most prevalent subtype of non-Hodgkin lymphoma (NHL), accounting for 31% of NHL cases in Western populations with a median diagnosis age of 70.4 years. Despite the efficacy of standard treatments, older patients, particularly those aged 75 years and older, often face under-treatment and poor outcomes. This study examines treatment patterns and outcomes among older adults with DLBCL within the Veterans Health Administration (VHA), which provides a unique opportunity to analyze a cohort of older adults in a large integrated health care system. MATERIALS AND METHODS:Data was analyzed from the VHA and Department of Defense Joint Longitudinal Viewer (JLV). Between January 1, 2011 and December 31, 2021, 6,266 patients were diagnosed with DLBCL. Patients were categorized into four age groups: <65, 65-74, 75-84, and ≥ 85 years. Patients were excluded if they had incomplete demographic, treatment, or survival data within the JLV, or if diagnosis could not be confirmed in structured fields. Chi-squared tests assessed differences among age groups. Overall survival (OS) was analyzed using Kaplan-Meier method and hazard ratios calculated using the Cox Proportional Hazard model. RESULTS:A total of 3176 patients met inclusion criteria for analysis out of 6266 patients diagnosed with DLBCL between January 1, 2011 and December 31, 2021. Among the included cohort, 33.2% were aged <65, 40.8% aged 65-74, 19.2% aged 75-84, and 6.8% aged ≥85. The median OS was 143 months for <65 years, 72 months for 65-74 years, 43 months for 75-84 years, and 14 months for ≥85 years (p < 0.001). The likelihood of receiving first-line chemotherapy decreased significantly with increasing age, with 30.0% of patients aged 85 years or older receiving no chemotherapy. Among patients who received chemotherapy, completion rates declined with age. Palliative care consultations and hospice enrollment increased with age. DISCUSSION:Our findings highlight significant disparities in treatment initiation and completion among older patients with DLBCL. Advanced age negatively impacted survival outcomes. There is an urgent need for tailored treatment approaches and inclusion of geriatric patients in clinical trials to ensure equitable access to innovative therapies. Comprehensive geriatric assessments should guide treatment decisions to enhance outcomes in this vulnerable population.

Early palliative care (EPC) has been shown to provide a myriad of benefits including improved quality of life for older adults. Despite this, there is continued underutilization of palliative care (PC) in the geriatric population, and many barriers to obtaining timely consultations. This Quality Improvement (QI) project utilized the IPAL-ICU screening tool with modifications (PCST) to prioritize PC consultations for seriously ill older adults. Building upon our original project “Increasing Palliative Care in the Progressive Care Unit”1, we expanded use of the PCST tool to two additional units within our veteran’s hospital from August 2023 -July 2024. Multiple QI strategies were used: dedicated RN-led QI project, RN unit champions, physician education campaigns, flyers, brochures, feedback gathering, and regular audits of progress. N = 621 PCST screens completed. 494 unique veterans, 96% male, 398 new and 223 established. The median age was 73 with an interquartile range (IQR) of 64 to 78. Of the new patients, 122 were seen inpatient and 146 were transferred to outpatient consultations. The PCST contributed to an increase in 40% of inpatient consultations and 30% increase in outpatient consultations, allowing for earlier PC access for seriously ill older adults. PCST is an effective means of prioritizing PC consultations for seriously ill older adults. Implications for Research, Policy, or Practice: Our QI process has led to optimizing a standardization tool for screening which can be disseminated on a national level to successfully move PC consultations earlier for seriously ill older adults.

Human aging presents an evolutionary paradox: while aging rates remain constant, healthspan and lifespan vary widely. We address this conundrum via salutogenesis-the active production of health-through immune resilience (IR), the capacity to resist disease despite aging and inflammation. Analyzing ~17,500 individuals across lifespan stages and inflammatory challenges, we identified a core salutogenic mechanism: IR centered on TCF7, a conserved transcription factor maintaining T-cell stemness and regenerative potential. IR integrates innate and adaptive immunity to counter three aging and mortality drivers: chronic inflammation (inflammaging), immune aging, and cellular senescence. By mitigating these aging mechanisms, IR confers survival advantages: At age 40, individuals with poor IR face a 9.7-fold higher mortality rate-a risk equivalent to that of 55.5-year-olds with optimal IR-resulting in a 15.5-year gap in survival. Optimal IR preserves youthful immune profiles at any age, enhances vaccine responses, and reduces burdens of cardiovascular disease, Alzheimer's, and serious infections. Two key salutogenic evolutionary themes emerge: first, female-predominant IR, including TCF7, likely reflects evolutionary pressures favoring reproductive success and caregiving; second, midlife (40-70 years) is a critical window where optimal IR reduces mortality by 69%. After age 70, mortality rates converge between resilient and non-resilient groups, reflecting biological limits on longevity extension. TNFα-blockers restore salutogenesis pathways, indicating IR delays aging-related processes rather than altering aging rates. By reframing aging as a salutogenic-pathogenic balance, we establish TCF7-centered IR as central to healthy longevity. Targeted midlife interventions to enhance IR offer actionable strategies to maximize healthspan before biological constraints limit benefits.

BackgroundThe purpose of this randomized, cross-over trial was to determine if a preoperative dose of dexamethasone administered submucosally is as effective as intravenous (IV) dexamethasone in reducing pain, swelling, and analgesic consumption after periodontal flap surgery.MethodsThirty-nine patients planned for two similar flap surgeries under IV sedation were included. Before the first surgery, patients were randomized to receive 8 mg of IV or submucosal dexamethasone. Via the alternate route, 0.9% sodium chloride (placebo) was administered. Dexamethasone was administered via the opposite route during the second surgery. A standardized regimen of 600 mg ibuprofen and 325 mg acetaminophen was used to manage postoperative pain. Patients recorded pain and swelling levels on a 21-point numerical rating scale (NRS-21) and a four-point visual rating scale (VRS-4), as well as analgesic usage via a phone application at 12, 24, 48, 72, and 168 h postoperatively.ResultsWhile NRS-21 and VRS-4 data suggest a trend toward decreased pain and swelling with IV administration, there were no significant differences in analgesic usage or pain at any time and a significant difference in swelling only at 72 h in favor of IV administration (p = 0.047).ConclusionsThere was no significant difference in pain or analgesic usage following periodontal flap surgery comparing IV and submucosal dexamethasone. A statistically significant difference in swelling between groups at 72 h is likely of limited clinical relevance. Submucosal dexamethasone is an effective way to mitigate pain following periodontal surgery, particularly when IV access for sedation is not required.

Background: Outcomes of large B cell lymphoma are heterogenous and are impacted by several factors including MYC rearrangement. MYC rearrangement, along with BCL2 and/or BCL6, is known to negatively affect prognosis, although isolated MYC rearrangement negatively impacts advanced stage (PMID: 38177113). Understanding the associations of these rearrangements with patient demographics, clinical characteristics, response and survival outcomes is crucial. This study aims to provide a comprehensive analysis of the differences between patients with and without MYC rearrangement. Methods: We performed a retrospective chart review of 3178 randomly selected large B cell lymphoma patients treated in the VHA nationwide between 1/1/2011 and 12/31/2021, and for this study included patients with data available on FISH rearrangement. Patients with Primary CNS lymphoma were excluded. The cohort was divided into two groups: MYC not rearranged, and MYC rearranged. The MYC rearranged group was further divided into those with additional rearrangements: MYC with only BCL2 rearranged, MYC with only BCL6 rearranged, and MYC with BCL2 and BCL6 rearranged. Various parameters including age, sex, race/ethnicity, ECOG performance status, IPI risk, cell of origin, extranodal involvement, disease stage, LDH levels, CNS prophylaxis, treatment regimens, response to first-line treatment, and survival outcomes were analyzed. Results: Out of the 3178 patients, 1,461 patients were included because FISH data was available. 1,226 (84%) had no MYC rearrangement, and 235 (16%) had MYC rearrangement. Median age at diagnosis was 68 years, 97% were males, 74% white race. Among those with MYC rearrangement, 72 (31%) patients had isolated MYC rearrangement, 100 (43%) had MYC with BCL2 rearranged, 27 (11%) had MYC with BCL6 rearranged, and 36 (15%) had MYC with rearrangements in both BCL2 and BCL6. The age, sex, race, stage and ECOG status were similar between MYC rearranged and non-rearranged groups. MYC rearranged patients had a higher IPI score with 57% patients having intermediate or higher score compared to 49% among those without rearrangement (p = 0.004). MYC rearranged patients were more likely to have a Germinal Center B cell of origin 67% vs 50%, (p<0.0001). MYC rearranged patients were also more likely to have extranodal involvement in at least 2 sites, 32% vs 23%, (p=0.004) and have an elevated LDH, 63% vs 55%, (p=0.005). CNS prophylaxis was used more frequently in MYC rearranged patients, 29% vs 15%, (p<0.0001). The vast majority of CNS prophylaxis in either group, when given, was intrathecal. MYC rearranged patients were more likely to receive DA-EPOCH-R, except those with isolated MYC rearrangement. Treatment regimens varied, with CHOP-based regimens less common in MYC rearranged patients compared to MYC non-rearranged patients, 40% vs 72%, (p<0.0001). MYC rearranged patients had a lower complete response rate to first-line treatment, 54% vs 64%, and a higher rate of progressive disease or death, 23% vs 16%, (p=0.02). MYC rearranged patients had 12-month and 24-month survival rates of 67% and 57%, respectively, compared to 79% and 69% in MYC non-rearranged patients, with a median overall survival (mOS) for MYC rearranged patients of 40.3 months (95% CI: 26.1 - 61.3) versus 72.9 months (95% CI: 66.4 - 84.3) for MYC non-rearranged patients (p=0.0003). There was no statistically significant difference in mOS when using CHOP-based (65 months) vs EPOCH (52 months) in MYC rearranged patients (p = 0.73). Conclusion: To the best of our knowledge, this is one of the largest study reporting survival data on large B cell lymphoma patients with MYC rearrangement within the VHA. MYC rearrangement in patients is associated with statistically significant higher IPI risk scores, more frequent extranodal involvement, reduced response to first-line treatment and worse survival outcomes compared to those without MYC rearrangement, irrespective of regimen used. This indicates a need for more precise tools to define subtypes of MYC-R lymphoma and enhanced treatment approaches for improved outcomes.

Unintentional weight loss, primarily due to the loss of fat mass rather than muscle mass, is common among patients with Parkinson’s disease (PD) and is associated with poor quality of life and accelerated disease progression. Since transgenic mice overexpressing human wild-type α-synuclein (α-Syn mice) are modestly leaner than control mice, and since diabetes, a metabolic disorder, is a major risk factor for PD, we reasoned that high-fat diet-induced diabetes/metabolic dysregulation in α-Syn mice may serve as a robust tool for exploring how early α-synuclein pathology contributes to metabolic dysregulation, leading to weight loss in PD. Thus, α-Syn and age-matched controls were fed a high-fat diet (HFD) chow (60% fat calories) ad libitum for four months. Compared with controls on HFD (control-HFD), α-Syn mice on HFD (α-Syn-HFD) were dramatically leaner. The resistance to gaining weight in α-Syn-HFD mice was accompanied by improved glucose tolerance, a dramatic decrease in fat mass, and an increase in energy expenditure. Despite this leaner phenotype and better glucose tolerance, the mortality was much higher in male α-Syn-HFD mice than in all controls, but was unaffected in females, suggesting protective effects of female sex hormones, as well as lower α-synuclein levels. Immunoblot analysis of insulin signaling in the olfactory bulb, the proposed initial seeding site of α-synuclein pathology, revealed a decrease of IGF-IRβ, p GSK, and p mTOR in α-Syn-HFD mice. Since GSK-3β and mTOR regulate synaptic plasticity, we assessed levels of PSD-95 and synaptophysin in the olfactory bulb. As anticipated, we observed a significant decrease in the levels of PSD-95, along with a potentially compensatory increase in synaptophysin levels. Our results show that α-Syn mice, when challenged with diet-induced diabetes/metabolic dysregulation, clearly reveal a profile of robust metabolic dysfunction, thus providing a sensitive tool for assessing the underlying mechanism of metabolic dysfunction and its impact on weight loss and disease progression in PD. We propose a role for olfactory dysfunction in PD-related unintentional weight loss and suggest that strategies aimed at increasing body weight/BMI will improve the quality of life and prognosis for people living with PD.

Purpose This study retrospectively reviewed the outcomes of patients with advanced hepatocellular carcinoma (HCC) receiving atezolizumab with bevacizumab (A + B) therapy at the Veterans Health Administration (VHA).Patients and Methods Patients with advanced HCC who received first-line systemic therapy with A + B at the VHA between December 1, 2019, and March 1, 2022, were selected from electronic medical records (EMR) using ICD-9 and ICD-10 codes. Abstractors reviewed the EMR of the patients from their index date of A + B initiation until death or their last VHA visit, with the study period ending on January 31, 2023. The chi-square test was used to compare rates, and the Mann-Whitney test was used to compare medians.Results A total of 332 patients met the study criteria. The median age was 67 years; 99% were male, 63% were non-Hispanic Whites, 26% were Black, and 66% had an Eastern Cooperative Oncology Group performance status of >= 1. 84% had child Pugh score (CPS) class A, 16% had CPS classes B and C, 62% had a grade 2 albumin-bilirubin score, 56% had HCC caused by viral hepatitis, 80% had cirrhosis, and 67% had received prior local therapies. The 6-month progression-free survival (PFS) was 59%, while the 1-year PFS rate was 36%. Overall survival (OS) at 1-year was 52% in our study.Conclusion In real world, despite having similar PFS as the phase III IMbrave 150 trial, our OS at 12 months was lower (52% vs. 67%) because our study included a higher proportion of elderly patients with moderate liver dysfunction and a 40% non-White. This study provided real-world outcomes that differed from the study population in a pivotal trial. This study retrospectively reviewed the outcomes of patients with advanced hepatocellular carcinoma receiving atezolizumab with bevacizumab (A + B) therapy at the Veterans Health Administration.

Introduction Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma (NHL), constituting 25% of NHL cases (Teras, 2016). Although survival rates have improved, with a 5-year relative survival of 63.8% in the United States (SEER Cancer Statistics, 2018), outcomes in DLBCL remain heterogeneous with inferior survival amongst some patient subgroups. Racial and ethnic disparities in access to care and outcomes are well-established and are critical issues across a number of malignancies, including NHL (Shenoy, 2011; Griffiths, 2010). The purpose of this study was to assess for racial and ethnic differences in patient and disease characteristics at diagnosis, and in outcomes for patients diagnosed with DLBCL within the Veterans Health Administration (VHA), where access to care may be less susceptible to other socioeconomic factors. Methods Trained abstractors performed a retrospective chart review of 2036 randomly selected patients seen in the VHA nationwide who were diagnosed with lymphoma between 01/01/2011 and 12/31/2017. We included patients diagnosed with DLBCL and excluded patients based on the criteria in Figure 1. We evaluated baseline patient and disease characteristics, including Eastern Cooperative Oncology Group (ECOG) performance status, stage at diagnosis, International Prognostic Index (IPI) score, pathology reports to identify high-grade lymphomas, and response to first-line treatment. Results A total of 971 patients met inclusion criteria for analysis. Patients were predominantly male, white, had a median age of 67, and presented primarily with advanced disease (Table 1). Patients in each subgroup presented with similar rates of stage III and IV disease, with no statistically significant difference in stage at presentation amongst each racial subgroup (white vs black, P=0.85; white vs Hispanic, P=0.30; white vs other, P=0.11). Most patients in each racial/ethnic group had a good performance status at diagnosis, with ECOG 0-2 in 75.4 - 82.5% of patients in each subgroup. The entire study population had an objective response rate (ORR) of 87.4% (complete response (CR) rate 66%) (Table 2). Response rates were similar across the 4 subgroups, with the majority of patients achieving a complete response (CR) after first-line therapy (66.7%, 68.9%, 65.3%, and 70% for black, Hispanic, white, and other/unknown patients, respectively). There were no statistically significant differences in ORR amongst subgroups (white vs black, P=0.28; white vs Hispanic, P=0.75; white vs other, P=0.75). Median overall survival (OS) from the time of diagnosis was 40.5 months for the entire study population (Table 2). OS rates were similar regardless of race with a median OS of 43 months for black patients, 49.2 months for Hispanic patients, 40.5 months for white patients, and 33.3 months for other/unknown patients (Figure 2). There was no statistically significant difference in median OS between subgroups (white vs black, P= 0.84; white vs Hispanic, P=0.39; white vs other, P=0.18). The 1-year survival rates were similar at 75.8%, 72.1%, 76.4%, and 71.7% for black, Hispanic, white, and other/unknown patient subgroups, respectively. Between 60 - 68.5% of patients in each subgroup remained alive at 2 years, with no significant differences in survival rates at 1 or 2 years. Conclusions In this retrospective study of patients diagnosed with DLBCL in the VHA nationwide, we found that there were no statistically significant differences in baseline patient characteristics at diagnosis or in response rates to first-line chemotherapy, 1- and 2-year OS rates, or median OS amongst each racial subgroup. Potential limitations of this study include that the population is predominantly male and therefore, may not be applicable to the female population, and that there was missing/incomplete data for pathologic assessment of high grade lymphoma in 68.5% of our population, which could provide important data about expected outcomes. Further studies with a longer follow-up period are needed to help characterize potential differences in outcomes and relapse rates. Our data suggest that when standard of care therapy is given equally to patients with DLBCL, similar outcomes occur for black, Hispanic, and white patients. The development of interventions to address healthcare disparities and to ensure access to appropriate and timely care for all patient populations is of paramount importance. Disclosures No relevant conflicts of interest to declare.

Total knee arthroplasty (TKA) risks persistent pain and long-term opioid use (LTO). The role of social determinants of health (SDoH) in LTO is not well established. We hypothesized that SDoH would be associated with postsurgical LTO after controlling for relevant demographic and clinical variables. This study utilized data from the Veterans Affairs Surgical Quality Improvement Program, VA Corporate Data Warehouse, and Centers for Medicare and Medicaid Services, including Veterans aged >= 65 who underwent elective TKA between 2013 and 2019 with no postsurgical complications or history of significant opioid use. LTO was defined as > 90 days of opioid use beginning within 90 days postsurgery. SDoH variables included the Area Deprivation Index, rurality, and housing instability in the last 12 months identified via medical record screener or International Classification of Diseases, Tenth Revision codes. Multivariable risk adjustment models controlled for demographic and clinical characteristics. Of the 9,064 Veterans, 97% were male, 84.2% white, mean age was 70.6 years, 46.3% rural, 11.2% living in highly deprived areas, and 0.9% with a history of homelessness/housing instability. Only 3.7% ( n = 336) developed LTO following TKA. In a logistic regression model of only SDoH variables, housing instability (odds ratio [OR] = 2.38, 95% confidence interval [CI]: 1.09-5.22) and rurality conferred significant risk for LTO. After adjusting for demographic and clinical variables, LTO was only associated with increasing days of opioid supply in the year prior to surgery (OR = 1.52, 95% CI: 1.43-1.63 per 30 days) and the initial opioid fill (OR = 1.07; 95% CI: 1.06-1.08 per day). Our primary hypothesis was not supported; however, our findings do suggest that patients with housing instability may present unique challenges for postoperative pain management and be at higher risk for LTO.

Importance:Evaluating how social determinants of health (SDOH) influence veteran outcomes is crucial, particularly for quality improvement. Objective:To measure associations between SDOH, care fragmentation, and surgical outcomes using a Desirability of Outcome Ranking (DOOR). Design, Setting, And Participants:This was a cohort study of US veterans using data from the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP; 2013-2019) limited to patients aged 65 years or older with inpatient stays between 2 and 30 days, merged with multiple data sources, including Medicare. Race and ethnicity data were retrieved from VASQIP, Medicare and Medicaid beneficiary summary files, the Veterans Health Administration Corporate Data Warehouse, and the United States Veterans Eligibility Trends and Statistics file. Data were analyzed between September 2023 and February 2024. Exposure:Living in a highly deprived neighborhood (Area Deprivation Index >85), race and ethnicity used as a social construct, rurality, and care fragmentation (percentage of non-VA care days). Main Outcomes and Measures:DOOR is a composite, patient-centered ranking of 26 outcomes ranging from no complication (1, best) to 90-day mortality or near-death complications (6, worst). A series of proportional odds regressions was used to assess the impact of SDOH and care fragmentation adjusted for clinical risk factors, including presentation acuity (presenting with preoperative acute serious conditions and urgent or emergent surgical procedures). Results:The cohort had 93 644 patients (mean [SD] age, 72.3 [6.2] years; 91 443 [97.6%] male; 74 624 [79.7%] White). Veterans who identified as Black (adjusted odds ratio [aOR], 1.06; 95% CI, 1.02-1.10; P = .048) vs White and veterans with higher care fragmentation (per 20% increase in VA care days relative to all care days: aOR, 1.01; 95% CI, 1.01-1.02; P < .001) were associated with worse (higher) DOOR scores until adjusting for presentation acuity. Living in rural geographic areas was associated with better DOOR scores than living in urban areas (aOR, 0.93; 95% CI, 0.91-0.96; P < .001), and rurality was associated with lower presentation acuity (preoperative acute serious conditions: aOR, 0.88; 95% CI, 0.81-0.95; P = .001). Presentation acuity was higher in veterans identifying as Black, living in deprived neighborhoods, and with increased care fragmentation. Conclusions and Relevance:Veterans identifying as Black and veterans with greater proportions of non-VA care had worse surgical outcomes. VA programs should direct resources to reduce presentation acuity among Black veterans, incentivize veterans to receive care within the VA where possible, and better coordinate veterans' treatment and records between care sources.

IntroductionVeterans Affairs Surgical Quality Improvement Program (VASQIP) benchmarking algorithms helped the Veterans Health Administration (VHA) reduce postoperative mortality. Despite calls to consider social risk factors, these algorithms do not adjust for social determinants of health (SDoH) or account for services fragmented between the VHA and the private sector. This investigation examines how the addition of SDoH change model performance and quantifies associations between SDoH and 30-d postoperative mortality.MethodsVASQIP (2013-2019) cohort study in patients ≥65 y old with 2-30-d inpatient stays. VASQIP was linked to other VHA and Medicare/Medicaid data. 30-d postoperative mortality was examined using multivariable logistic regression models, adjusting first for clinical variables, then adding SDoH.ResultsIn adjusted analyses of 93,644 inpatient cases (97.7% male, 79.7% non-Hispanic White), higher proportions of non-veterans affairs care (adjusted odds ratio [aOR] = 1.02, 95% CI = 1.01-1.04) and living in highly deprived areas (aOR = 1.15, 95% CI = 1.02-1.29) were associated with increased postoperative mortality. Black race (aOR = 0.77, CI = 0.68-0.88) and rurality (aOR = 0.87, CI = 0.79-0.96) were associated with lower postoperative mortality. Adding SDoH to models with only clinical variables did not improve discrimination (c = 0.836 versus c = 0.835).ConclusionsPostoperative mortality is worse among Veterans receiving more health care outside the VA and living in highly deprived neighborhoods. However, adjusting for SDoH is unlikely to improve existing mortality-benchmarking models. Reduction efforts for postoperative mortality could focus on alleviating care fragmentation and designing care pathways that consider area deprivation. The adjusted survival advantage for rural and Black Veterans may be of interest to private sector hospitals as they attempt to alleviate enduring health-care disparities.

Abstract Background Point-of-care ultrasound (POCUS) has emerged as an essential bedside tool for clinicians, but lack of access to ultrasound equipment has been a top barrier to POCUS use. Recently, several handheld ultrasound devices (“handhelds”) have become available, and clinicians are seeking data to guide purchasing decisions. Few comparative studies of different handhelds have been done. We conducted a cross-sectional study comparing 6 handhelds readily available in the United States (Butterfly iQ + ™ by Butterfly Network Inc.; Clarius™ by Clarius Mobile Health; Kosmos™ by EchoNous; TE Air™ by Mindray; Vscan Air™ SL and CL by General Electric; and Lumify™ by Philips Healthcare). A multi-specialty group of physician POCUS experts (n = 35) acquired three standard ultrasound views (abdominal right upper quadrant, cardiac apical 4-chamber, and superficial neck and lung views) in random order on the same standardized patients and rated the image quality. Afterward, a final survey of the overall ease of use, image quality, and satisfaction of each handheld was completed. Results Thirty-five POCUS experts specializing in internal medicine/hospital medicine, critical care, emergency medicine, and nephrology acquired and rated right upper quadrant, apical 4-chamber, and superficial neck and lung views with 6 different handhelds. For image quality, the highest-rated handhelds were Vscan Air™ for the right upper quadrant view, Mindray TE Air™ for the cardiac apical 4-chamber view, and Lumify™ for superficial views of the neck and lung. Overall satisfaction with image quality was highest with Vscan Air™, Lumify™, and Mindray, while overall satisfaction with ease of use was highest with Vscan Air™. The 5 most desirable characteristics of handhelds were image quality, ease of use, portability, probe size, and battery life. Ultimately, all 6 handhelds had notable advantages and disadvantages, with no single device having all desired qualities or features. Conclusions The overall satisfaction with image quality was rated highest with Vscan Air™, Lumify™, and Mindray TE Air™when acquiring right upper quadrant, apical 4-chamber, and superficial neck and lung views. No single handheld was perceived to be superior in image quality for all views. Vscan Air™ was rated highest for overall ease of use and was the most preferred handheld for purchase by POCUS experts.

4109 Background: The incidence and mortality of HCC are increasing in the USA. HCC disparities have been reported across the entirety of the cancer timeline, from screening to local and systemic treatment and liver transplant. We aim to analyze the clinical characteristics, outcomes, and racial disparities in patients with advanced HCC receiving first-line Atezolizumab plus Bevacizumab (A+B) in the Veterans Health Administration (VHA) – the only health care system in the USA that provides equal access to all patients. Methods: Patients were followed from their A+B initiation date through the earliest of the last VHA visit, loss to follow-up, death, or end of study on Jan 31, 2023. Structured electronic health record and chart review data were retrospectively collected to determine patient baseline characteristics, including self-reported race, number of A+B doses, treatment response, subsequent line of treatment, length of follow-up, and overall survival (OS). The Chi-Squared test was used to compare rates, and Mann-Whitney test was used to compare medians. Results: Three hundred twenty-five patients were included. 64% were non-Hispanic White (NHW), and 36% were all other (AO) ethnicities or races combined (26% Black, 8% Hispanic, 2% Asian or Indigenous). The median age for each cohort was similar (66 years for AO vs. 68 for NHW), and ECOG performance was <1 in nearly 90% of each cohort. Viral hepatitis accounted for 70% and 48% of AO and NHW, respectively (p=0.0001). Despite clinical differences in OS and progression free survival (PFS), they were not statistically significant. Conclusions: Our VHA real-world data shows that despite having statistically significant etiologies, there was no statistically significant difference in the PFS and OS of patients with advanced HCC receiving first-line A+B in an equal access care system. This study supports our group’s findings in other malignant cohorts within VHA where equal healthcare access can mitigate other socio-demographic and biological factors. [Table: see text]

e16195 Background: Atezolizumab plus Bevacizumab (A+B) has been the standard first-line therapy for advanced hepatocellular carcinoma (HCC) patients. There needs to be more data on the efficacy and selection of optimal sequences following resistance to A+B. Our study aims to review treatment patterns for disease progression following A+B, focusing on the most common 2nd line treatment utilized by the Veterans Health Administration (VHA). Methods: Patients with advanced HCC receiving line A+B at the VHA between Dec 1, 2019, to Mar 1, 2022, were selected electronically using ICD-9 and ICD-10 codes. Abstractors reviewed EMR following each patient from their index date of A+B initiation, sequential therapies, until death, or their last VHA visit, with the study period ending on Jan 31, 2023. Results: Three hundred thirty-two patients received A+B during our study period, and 1/3rd (n = 107) of these patients went on second-line treatments. 87 % started Tyrosine Kinase Inhibitors with 52, 29,12, and 1 on Lenvatinib, Sorafenib, Cabozantinib, and Regorafenib, respectively. Two second-line cohorts were selected, A (52 on Lenvatinib) and B (29 on sorafenib). The median age was 66 yrs vs. 65 yrs in cohorts A and B, respectively. In both cohorts, 60% non-Hispanic White and 90% with ECOG ≤1, there were no statistically significant differences between both cohorts in overall and progression-free survival. The outcomes are shown. Conclusions: Despite minimal improvement in PFS and a lower discontinuation rate due to toxicity favoring Lenvatinib over Sorafenib, Sorafenib had slightly better overall survival. This study is one of the most significant projects that describes 2nd line treatment patterns post-A+B failure. Further studies are warranted to evaluate larger cohorts to study treatment sequencing in the second and third lines.[Table: see text]