Orlando VA Medical Center

Idiopathic pure red cell aplasia (IPRCA) is a rare immune-mediated bone marrow failure syndrome characterized by isolated anemia and reticulocytopenia. Relapse after remission is incompletely described, and macrocytosis is an uncommon presenting feature that may delay recognition. We report the case of a 69-year-old man with longstanding macrocytic anemia who presented with severe isolated anemia and reticulocytopenia. Extensive evaluation excluded secondary causes, and bone marrow biopsy demonstrated near-complete absence of erythroid precursors, confirming IPRCA. Treatment with concurrent cyclosporine and prednisone resulted in remission within three months. One month after therapy discontinuation, the patient experienced biochemical relapse and achieved re-remission with re-treatment using the same regimen. Immunosuppressive therapy was subsequently discontinued, and the patient remains under active surveillance. To contextualize this case, we performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided review of published IPRCA case reports. Cyclosporine-based regimens were associated with the highest remission rates, while relapse and macrocytosis were infrequently reported. This case highlights macrocytosis as a potential atypical presenting feature of IPRCA and underscores the importance of recognizing relapse and ensuring long-term follow-up.

Salivary gland choristoma at the esophagogastric junction (EGJ) is a rare benign lesion, typically presenting as a nodule. Though heterotopic salivary tissue can appear in the head, neck, or GI tract, its occurrence at the EGJ is uncommon. It is often discovered incidentally during endoscopy for chronic GERD. The origin remains unclear, with theories including embryologic misplacement, inflammation-induced differentiation, or proliferation of native glandular cells. We report two cases of EGJ choristomas in patients with Barrett's esophagus and chronic GERD. We aim to emphasize the importance of recognizing choristoma as a potential differential diagnosis when encountering a new nodule.

Disclosure: S. Al Ashi: None. R. Shah: None. N. Iftikhar: None. P. Phan: None. I. Lingvay: None. M. Kinaan: None. I. Mansi: None.Background: Metabolic Dysfunction-Associated Steatotic-Liver Disease (MASLD) is the most common cause of chronic liver disease in the United States. MASLD can progress to liver cirrhosis and is associated with increased risk of major acute cardiovascular events (MACE). Purpose: To examine the association of Glucagon-like peptide 1 receptor agonists (GLP1-RA) use with liver disease progression, cardiovascular events and all-cause mortality among patients with MASLD. Methods: This retrospective study used national data of the Department of Veteran Affairs. Patients with MASLD who initiated either GLP1-RA or dipeptidyl-peptidase-4 inhibitor (DPP4-i) between October 1, 2005, and September 30, 2021, were included. Patients with other chronic liver disease etiologies or decompensated cirrhosis at baseline were excluded. Primary outcomes were: 1) liver disease progression and 2) MACE or all-cause mortality. GLP1-RA users and DPP4-I users were propensity score matched on 73 baseline characteristics including demographics, liver function tests and scores, measures of diabetes control, cardiovascular risks, other comorbidities, use of other medications, and frailty score. Results: We matched 58,157 pairs of GLP1-RA and DPP4-I users. GLP1-RA users had less liver disease progression (6.1%) compared with DPP4-I users (7.0%), hazard ratio (HR): 0.86; 95% confidence interval (95% CI): 0.82- 0.90 and a lower risk of MACE or all-cause mortality (11.1%), compared with DPP4-i users (14.7%), (HR: 0.72; 95% CI: 0.70-0.75). Conclusions: Among patients with MASLD, GLP1-RA use was associated with a lower risk of liver disease progression, and a lower risk of MACE or all-cause mortality compared to DPP4-I use.Presentation: Saturday, July 12, 2025

BackgroundIn the IMPROVE AKI (A Cluster‐Randomized Trial of Team‐Based Coaching Interventions to Improve Acute Kidney Injury) trial, a combination of team‐based coaching and data‐driven surveillance dashboards reduced the odds of AKI following cardiac catheterization by 46%. The objective of this study was to determine if improvements in AKI outcomes would be sustained after completion of the active intervention.Methods and ResultsA 2×2 factorial cluster‐randomized trial with an 18‐month active intervention phase (October 2019–March 2021) and an 18‐month sustainability phase (April 2021–September 2022) conducted among cardiac catheterization laboratories in 20 Veterans Affairs sites. Interventions included team‐based coaching in a virtual learning collaborative or technical assistance, with and without access to an automated surveillance reporting dashboard. Data were collected on procedures involving adult patients undergoing diagnostic coronary angiography or percutaneous coronary interventions and not receiving chronic dialysis. The main outcome was AKI within 7 days of cardiac catheterization among all participants and those with preexisting chronic kidney disease. In addition, survey and focused interview data were collected to understand barriers and facilitators to sustaining AKI improvements. In this phase, 440 of 4160 patients experienced AKI, including 216 of 1260 patients with chronic kidney disease. Compared with technical assistance alone, we observed a reduction in AKI among virtual learning collaborative + automated surveillance reporting sites (adjusted odds ratio, 0.60 [95% CI, 0.42–0.86]). Sites had implemented standardized orders (11), oral and intravenous hydration standing orders (13), and contrast limiting protocols (10).ConclusionsTeam‐based coaching coupled with data‐driven surveillance dashboards reduced AKI by 40% during the 18 months after active participation in the trial. Process improvement education, care process standardization, and automated outcome feedback may be effective and durable methods for reducing AKI.RegistrationURL: https://clinicaltrials.gov/; Unique Identifier: NCT03556293.

Colorectal cancer (CRC) is the second-leading cause of cancer-related deaths in the United States. Rural living poses special challenges to CRC screening and management, but it is unclear whether rural/urban disparities persist within the Veterans Health Administration (VHA). This study used VHA data to examine characteristics and mortality among veterans with newly diagnosed CRC. Urban areas were defined using Rural Urban Commuting Area categories 1.0 and 1.1; all other areas were classified as rural. Propensity score-matching analysis was used to address differences in baseline characteristics and compare mortality between rural and urban veterans with CRC. An additional propensity score-matching analysis focused on CRC among veterans aged ≤ 45 years. Of 2,460,727 individuals, there were 19,422 urban and 10,797 rural veterans with CRC (fiscal years 2016-2021). In rural areas, 83.6% of patients with CRC were White, compared to 67.8% in urban areas. Veterans with CRC in rural areas were also older, more likely to be obese, but had a lower Charlson Comorbidity Index (all P < .05). In the propensity score-matched cohort, baseline demographics and comorbidities were similar between rural and urban CRC patients. Total mortality occurred in 3702 urban veterans (34.3%) and 3763 rural veterans (34.9%) (hazard ratio [HR], 1.01; 95% CI, 0.97-1.06, P = .53). More patients with CRC were aged ≤ 45 years in urban areas (n = 391, 2.0%) than in rural areas (n = 160, 1.5%; P = .001), and their mortality was similar in the propensity score-matched group (HR, 0.97; 95% CI, 0.57-1.63). Veterans with CRC in rural or urban areas had similar survival outcomes. The study implies that an integrated health system may help alleviate disparities between rural and urban America.

BackgroundThe CDC recommends routine sexual histories (SH), yet they are rarely completed in primary care (PC) due to barriers ranging from patient discomfort to provider time constraints. We implemented a system wide nurse-led sexual health screening tool at a large VA hospital. Here we report on patient acceptability of sexual histories and sexual behaviors of Veterans at a population level.Table 1Demographics, Overall by Question 1 ResponseThis table describes demographics of those who agreed to discuss their sexual health, ie said Yes to Question 1MethodsWe deployed a short SH screening questionnaire to be conducted during PC visits. Administered mostly by nurses, the questionnaire began with a consent question. Those with an affirmative response proceeded to answer additional questions. We queried the VA’s electronic database to ascertain patient demographics including age, birth sex, sexual orientation, gender identity, race/ethnicity, Rural-Urban Commuting Area codes. We describe the population as medians and proportions.Table 2Demographics, Overall by Question 2 ResponseThis table describes demographics of those who agreed to discuss about sexual health and have more than one sexual partner, ie said Yes to Question 2ResultsOver 2-years (April 14, 2022-24) 130,986 SH screening questionnaires were offered to 95,490 unique Veterans, with 83,510 (87%) agreed at least once (Table 1). Birth sex females were more likely than males to agree to SH (91% vs. 87%). Most 65 and older agreed to the screening (85%). Supermajority of Veterans who have recorded a sexual identity as LGBQ+ agreed to SH (1688/1798, 94%). Similarly, 96% of those who have recorded self-identified gender as transgender man, transgender woman, or non-binary also agreed to SH. Racial or ethnic minority patients were more likely to agree to SH than Whites: 90% Black vs. 87% White; 91% vs. 87% non-Hispanic. Of 83,510 patients who agreed, 2754 (3%) had more than 1 sexual partner in the last 6 months, with younger age, LGBQ+ identity, Black race and Hispanic ethnicity associated with likelihood of more than 1 sexual partner (Table 2). Of these, 4% reported sexual partners of more than 1 gender, and 21% of this subset had a self-described sexual orientation as straight or heterosexual.Sexual Health QuestionsConclusionA brief SH screening questionnaire administered by nurses in PC settings is feasible and highly acceptable to patients. Patients who identify as minority racial, ethnic, sexual or gender identity groups are very willing to provide SH, in some cases at much higher rates than non-minority peers. Other healthcare systems can implement similar nurse-led screening tools to improve SH taking in PC settingsAge Breakdown for Question 1This table describes the age breakdown for those who said Yes to Question 1, indicating both young and old population agree to discuss about sex.DisclosuresAll Authors: No reported disclosures

Background: Glucagon-like peptide 1 receptor agonists (GLP-1RAs) have shown efficacy for reducing cardiovascular morbidity and mortality in patients with diabetes mellitus (DM), but conflicting evidence exists regarding their impact on cardiac arrhythmias. Whereas some studies suggested a possible association between GLP-1RA use and arrhythmogenesis, other studies suggested decreased association with atrial fibrillation (AF). Overall, large-scale real-world data evaluating risk of AF in association with GLP-1RAs are lacking. Objective: To compare risk of incident AF after initiation of GLP1-RA vs Dipeptidyl peptidase-4 inhibitors (DPP4i), as active comparators, in patients with DM. Methods: This retrospective propensity score-matched cohort study was conducted within the Veterans Health Administration from fiscal years 2006 to 2021. The study included U.S. veterans aged 35 years or older who initiated either GLP1-RA or DPP4i prescriptions. The primary outcome assessed was a composite outcome of atrial fibrillation (AF), defined as a diagnosis of AF/flutter based on administrative codes or undergoing an AF procedure. Results: Out of 116,235 GLP1-RA users and 217,668 DPP4i users, we propensity score-matched 80,948 pairs, on 88 characteristics, including demographics, comorbidities, vital signs, cardiovascular risk score, healthcare utilization, DM control, laboratory investigation, and medications. Composite outcome of AF was similar in GLP-1RA group (4.1%) and DPP4i group (4.3%); odds ratio (OR) 0.96, 95% confidence interval (CI) 0.92-1.01. Secondary analyses stratified by medication use duration showed no significant differences in composite AF risk (P&gt;0.05). Notably, individuals achieving weight loss of 2%, 5%, or 10% of baseline body weight had significantly lower AF incidence, whereas no significant differences were observed in those with no weight loss or weight gain (OR 0.99, 95% CI 0.91-1.07). Conclusions: Use of GLP1-RA in patients with DM was not associated with a decreased risk of AF when compared with the use of DPP4i. In the subgroup analysis, significantly lower AF risk was seen in the GLP-1 RA group who achieved weight loss vs. DPP4i and this highlights weight loss as a potential modifier of cardiovascular outcomes in DM.

Bacterial hepatic abscesses are the most common kind of intraabdominal abscesses with higher incidence in elderly men.Symptoms are not specific and required close physical examination and imaging study to identify location of fluid collection.Treatment is usually empiric and drainage are commonly required via open or laparoscopic surgeries or percutaneously.Both methods are invasive and carry a risk of complications that increase morbidity and mortality.Endoscopic ultrasound (EUS) has emerged as a less invasive modality with fewer adverse outcomes.Hereby, we present a case of a pyogenic liver abscess in a critically ill elderly man that was successfully aspirated via transgastric approach using EUS technique, and subsequently drained with catheter placement by interventional radiology.EUS aspiration should be considered as an effective initial method of treatment in critically ill patients with pyogenic liver abscesses.

Heterotopic pancreas (HP) is the presence of pancreatic tissue outside of its normal anatomical position without vascular continuity from the main pancreas. HP is most commonly found within the gastrointestinal tract, particularly the stomach through the jejunum. This report shares the case of a 57-year-old man who presented with persistent vomiting despite medical therapy. Given the nonspecific and broad differential diagnosis, a histopathological examination was warranted for a definitive diagnosis that showed a uniquely large and well-differentiated type I HP in the lesser curvature of the stomach. Resection was completed which was followed with resolution of symptoms.