VA New Jersey Health Care System

71 Background: Men with metastatic prostate cancer (mPC) experience high symptom burden and often require intensive end-of-life care. Inpatient palliative care (IPC) utilization patterns, including the impact of epidural spinal cord compression (ESCC), are incompletely studied. Methods: We used the National Inpatient Sample database (2016–2022) to identify adult mPC hospitalizations with and without IPC using ICD-10 codes. We compared cohort demographics using t-tests and chi-square tests. We performed multivariate logistic models assessing predictors of IPC and mortality with IPC as the exposure, adjusting for age, race, primary payer, income quartile, hospital characteristics, and Elixhauser Comorbidity Index (ECI). We evaluated ESCC as a primary exposure for IPC use and mortality. p <0.05 was considered significant. Results: We identified 93,018 mPC hospitalizations; IPC occurred in 15,633 (16.8%). mPC admissions rose from 12,050 to 14,471 (APC 2.4%; p =0.019). IPC increased numerically from 1,812 to 2,742, without a significant APC. Versus non-IPC, IPC admissions more often involved age ≥60 (92.4% vs 91.4%; p <0.001), urban hospitals (93.6% vs 91.8%; p <0.001), teaching hospitals (76.4% vs 73.8%; p <0.001), higher comorbidity (ECI≥3: 89.2% vs 86.1%; p <0.001), longer LOS (7.33 vs 5.93 days; p <0.001), and higher unadjusted mortality (24.2% vs 3.3%; p <0.001). In adjusted models, higher IPC use was associated with age ≥60 (aOR 1.187; p <0.001), Black vs White race (aOR 1.09; p <0.001), and Medicaid, private insurance, and self-pay vs Medicare (all p <0.001); lower use occurred in the Midwest and West vs Northeast (aOR 0.87 each; p <0.001), rural vs urban hospitals (aOR 0.83; p <0.001), and non-teaching vs teaching hospitals (aOR 0.89; p <0.001). Larger hospitals had higher use (aOR 1.09; p <0.001). Higher comorbidity was associated with lower IPC (ECI Q3 aOR 0.91; p =0.0015; ECI Q4 aOR 0.92; p =0.009). ESCC independently predicted IPC use (aOR 1.17; p <0.001). In the mortality model, IPC was associated with higher in-hospital death (aOR 9.37; p <0.001). Additional mortality associations included age ≥60 (aOR 1.26; p <0.001), Asian/Pacific Islander race (aOR 1.30; p =0.002), private insurance (aOR 1.34; p <0.001), Midwest region (aOR 1.19; p <0.001), rural location (aOR 1.39; p <0.001), non-teaching hospitals (aOR 1.09; p =0.026) and higher ECI (Q3 aOR 1.24; Q4 aOR 1.55; both <0.001). ESCC was associated with lower inpatient mortality (aOR 0.71; p <0.001). Conclusions: IPC was used in ~1 in 6 mPC admissions, increased over time, and varied by age, race, payer, and hospital factors. ESCC was an independent predictor of IPC use, yet it was associated with lower in-hospital mortality. Geographic and institutional disparities may reflect differences in palliative care availability. The observed IPC use aligns with estimates of need among patients with advanced cancer.

People with plaque psoriasis are more likely to live with obesity relative to individuals without psoriasis, which can affect response to biologic treatment. This pooled analysis of the phase III reSURFACE 1 and reSURFACE 2 trials explored efficacy and safety of tildrakizumab 100 mg and 200 mg in patients with plaque psoriasis who were living with obesity for up to 244 weeks of treatment. Both doses of tildrakizumab were effective long-term, with comparable safety profiles in patients who were living with obesity and those who were not. Patients who were not living with obesity experienced more improvement with treatment than those with obesity, and those living with obesity had more long-term improvement after treatment with tildrakizumab 200 mg vs. tildrakizumab 100 mg.

Traumatic brain injuries (TBI) frequently occur and can lead to lasting negative cognitive, physical, and mental health outcomes. The biological response to even mild TBIs (mTBI) includes well-characterized inflammatory sequelae that start immediately post-injury, remain for weeks, and can develop into long-term systemic inflammation. Studies have shown that TBI influences multiple physiological systems, including the gastrointestinal tract, through bidirectional communication modulated, in part, by the gut microbiome. Brainstem functioning post-TBI, as measured by acoustic startle sensorimotor processing, might play a role in this feedback loop. The current study investigated pre- to post-TBI (lateral fluid percussion injury model) changes in microbial communities and acoustic startle response in male and female rats. That is, the influence of mTBI on gut microbiome and sensorimotor processing was explored to examine: 1) overall and sex-specific differences in the gut microbiome and taxa in response to mTBI; 2) overall and sex-specific differences in sensorimotor processing following mTBI; and 3) associations between the gut microbiome and sensorimotor processing. Results showed mTBI had a limited effect on microbial diversity overall, and the same was observed in males and females independently. Yet, mTBI was associated with differences in 13 genus-level taxa. Further evaluation highlighted that 11 of the 13 genus-level taxa were sex-specific, with several being known to have short-chain fatty acid-producing capabilities. Alterations in sensorimotor processing were identified following mTBI; however, no sex-specific differences were evident. In addition, no associations were observed between sensorimotor processing and the gut microbiome. This study contributes longitudinal and sex-specific findings to the growing body of research examining the diverse effects of mTBI on the brain and gut microbial communities.

Limited data exist on long-term outcomes associated with postural orthostatic tachycardia syndrome (POTS). We designed an online questionnaire to assess outcomes for patients formerly managed in a single-center pediatric POTS program. Here, we report the educational, economic, and social long-term impacts of pediatric POTS. In part, the Long-Term POTS Outcomes Survey (LT-POTS) sought to evaluate education, employment, and social impact of POTS. Patients aged ≤18 years at the time of POTS diagnosis were included. The survey was emailed to patients diagnosed or managed in the Children's Hospital of Philadelphia POTS Program. Of 862 patients surveyed, 227 returned questionnaires with enough data for interpretation. Respondents were predominantly women (85%) and White individuals (97%). Half of patients missed >100 days of school, and 20% temporarily dropped out of school. More than 90% of patients graduated high school, and <50% graduated college. Only 26% of patients were able to work >40 hours/week, with 35% having reduced hours due to POTS symptoms. Significant loss of income and financial expenditures were associated with POTS. Loss of social relationships and inability to live independently were additional associated social impacts. POTS is a long-term disorder associated with significant physical disability as well as adverse educational, economic, and social impacts. Although certain accommodations may mitigate the impact of the disease on education and employment, POTS poses significant educational, economic, and socioemotional risks, requiring further understanding of its pathophysiology and optimization of its management to reduce individual and societal impact.

Left ventricular concentric remodeling (LVCR), a pathological process of adaptive myocardial change, may be a precursor state for systolic and diastolic dysfunction and LV hypertrophy. Potential cardiotoxic airborne hazards present in combat zones in excess may increase the risk for adverse cardiac remodeling in deployed veterans. One hundred and thirty-nine deployed veterans were included in this study and underwent evaluations including transthoracic echocardiography and cardiopulmonary exercise testing (CPET). Relative wall thickness was used to classify LV geometry as normal, concentric or eccentric hypertrophy, or LVCR. Observed rates of LVCR were compared to those reported in the Framingham Heart Study (FHS), and CPET results were compared between those with and without LVCR. Rates of LVCR in our veteran sample (12%-34%) were elevated compared to FHS (8%-21%), despite similar demographics and risk factors. Veterans with LVCR had reduced exercise capacity, greater ventilatory inefficiency, and increased heart rate reserve relative to those without. Deployment length was associated with increased odds of having LVCR (aOR = 1.04, 95% CI [1.01, 1.07]). Abnormal LV geometry, specifically LVCR, was common in our veteran sample and exceeded historical civilian rates. The presence of LVCR was associated with impaired exercise performance and was more likely in those with longer deployment lengths.

Abstract Rationale: An increased prevalence of respiratory symptoms, including dyspnea, has been reported among Veterans following deployment to the Southwest Asia Theater of Military Operations. Often these symptoms occur in the absence of clear abnormalities on traditional pulmonary function tests, which is a challenging clinical scenario. To better understand this clinical presentation, the VA's Post-Deployment Cardiopulmonary Evaluation Network (PDCEN) conducts specialty clinical evaluations that incorporates advanced testing including respiratory oscillometry. The objective of the present study was to examine associations between select oscillometry measures with a measure of breathlessness (dyspnea) severity among a subset of Veterans with preserved pulmonary function tests. Methods: Previously deployed Veterans were seen at one of six PDCEN sites and completed pulmonary function testing along with questionnaires as part of a standardized evaluation. Oscillometry (MGC Resmon Pro) was acquired in accordance with standard guidelines and select parameters (R5, X5, AX5, R5-R19) were identified for analyses. Breathlessness (“these days”) was assessed using the Dyspnea-12 (D12) questionnaire and included total score (range: 0-36; higher = more severe) as well as subscales for affective and physical components. Linear regression models were performed to examine the association between dyspnea severity and oscillometry parameters, adjusting for age, sex, race, BMI, cumulative deployment days. Analyses were restricted to those Veterans with complete data and preserved pulmonary function tests (FEV1/FVC ≥ LLN, TLC≥LLN, DLCO≥80%). Oscillometry parameters were deemed normal using z-score calculations. Results: Of the 155 Veterans with completed oscillometry and questionnaire data, 90 (58%) had preserved pulmonary function tests. Demographics and test results are reported in the Table. In adjusted analyses, D12 total score as well D12 physical and affective components were not associated with AX5 (D12 total, physical, affective: p=0.26, p=0.30, p=0.17), X5 (p=0.65, p=0.6, p=0.73), R5 (p=0.89, p=0.99, p=0.58) or R5-R19 (p=0.86, p=0.98, p=0.6). Conclusion: In our clinical sample of Veterans with preserved pulmonary function tests, approximately 80% had abnormal oscillometry parameters. Our lack of an observed association between oscillometry and D12 scores may reflect the mild intensity of dyspnea in our sample or the appropriateness of this scale for our population. Future analyses should consider the relationship between oscillometry parameters with other post-deployment respiratory symptoms.

Objective: Postural orthostatic tachycardia syndrome (POTS) affects up to 3 million people in the United States. Although 78%–83% of POTS patients are female, gynecologic comorbidity has not been well-studied. We created an online questionnaire to assess outcomes in female patients with POTS formerly followed at a single-center pediatric POTS program.Design: Cross-sectional study.Setting: Single-center pediatric POTS program.Population or Sample: All female patients ≤ 18 years at diagnosis.Methods: We developed and distributed The Long-Term POTS Outcomes Survey with questions about diagnosis, therapy, education, employment, social impact, quality of life (QoL), and gynecologic symptoms and management.Main Outcome Measures: Gynecologic symptoms and QoL.Results: Regular menstrual cycles were seen in 81/167 participants (49.1%). POTS symptoms worsened prior to and during menses in 118/167 subjects (72.4%); hormonal contraceptive therapy helped to control symptoms in 52/110 subjects (50%). Menorrhagia, polycystic ovary syndrome, and endometriosis were not reported in higher numbers compared to the general population.Conclusions: Menstrual flow disorders are not more prevalent in younger females with POTS. Symptoms often worsen perimenstrually, and hormone therapy can help to reduce symptom severity. Further research is needed to better define optimal hormone therapy in suppressing perimenstrual symptoms.

Introduction: Deucravacitinib, an oral, selective, allosteric tyrosine kinase 2 inhibitor, is approved in the US, EU, and other countries for treatment of adults with moderate to severe plaque psoriasis who are candidates for systemic therapy. Deucravacitinib was efficacious and well-tolerated in the global, 52-week, phase 3 POETYK PSO-1 (NCT03624127) and POETYK PSO-2 (NCT03611751) parent trials and through 2 additional years in the POETYK long-term extension (LTE) (NCT04036435) trial in patients treated with deucravacitinib from Day 1 of PSO-1/PSO-2. Here, long-term efficacy was assessed through 4 years in patients who crossed over from placebo to deucravacitinib at Week 16 in PSO-1 or PSO-2 and entered the LTE trial. Methods: PSO-1 and PSO-2 randomized patients 1:2:1 to oral placebo, deucravacitinib 6 mg once daily, or apremilast 30 mg twice daily. At Week 16, patients randomized to placebo crossed over to deucravacitinib. At Week 52, patients could enroll in the LTE and receive open-label deucravacitinib. Efficacy was evaluated in patients who crossed over from placebo to deucravacitinib at Week 16 of the parent trial and received continuous deucravacitinib through 4 years (Week 208; data cutoff, November 1, 2023). Outcomes included ≥75%/≥90% reduction from baseline in Psoriasis Area and Severity Index (PASI 75/90) and static Physician Global Assessment score of 0 (clear) or 1 (almost clear) (sPGA 0/1). Efficacy is reported using modified nonresponder imputation (mNRI) in patients who reached the Week 208 assessment or discontinued before Week 208. Results: Of 421 patients originally randomized to placebo, 348 crossed over to deucravacitinib at Week 16; 298 completed the parent trials and entered the LTE, with 291 meeting mNRI criteria. Efficacy response rates improved from Week 16 on placebo (PASI 75, 12.0% [95% CI, 8.5%-16.3%]; PASI 90, 3.4% [1.7%-6.2%]; sPGA 0/1, 10.0% [6.8%-14.0%]) through Week 52 on deucravacitinib (PASI 75, 75.2% [70.2%-80.2%]; PASI 90, 47.4% [41.6%-53.1%]; sPGA 0/1, 60.1% [54.5%-65.7%]). Response rates were maintained well through Week 208 (PASI 75, 75.6% [70.0%-81.2%]; PASI 90, 46.6% [40.4%-52.7%]; sPGA 0/1, 55.1% [48.8%-61.4%]). Conclusion: These findings support the long-term efficacy profile of once-daily oral deucravacitinib for treatment of moderate to severe plaque psoriasis.