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To develop a nomogram that could predict spontaneous stone passage (SSP) in patients presenting with acute ureteric colic who are suitable for conservative management.A 2517 patient dataset was utilised from an international multi-centre cohort study (MIMIC, A Multi-centre Cohort Study Evaluating the role of Inflammatory Markers In Patients Presenting with Acute Ureteric Colic) of patients presenting with acute ureteric colic across 71 secondary care hospitals in the United Kingdom, Ireland, Australia, and New Zealand. Inclusion criteria mandated a non-contrast CT-KUB.SSP was defined as the 'absence of the need for intervention'. The model was developed using logistic regression and backwards selection (to achieve lowest AIC) in a subset from 2009-2015 (n=1728) and temporally validated on a subset from 2016-2017 (n=789).Of the 2517 patients, 1874 had SSP (74.5%). Mean age (±[SD]) was 47 (±14.7) years and 1892 were male (75.2%). At the end of the modelling process, gender: male (OR 0.8, 95%CI 0.64-1.01, p=0.07), neutrophil count (OR 1.03, 95%CI 1.00-1.06, p = 0.08), hydronephrosis (OR 0.79, 95%CI 0.59-1.05, p=0.1), hydroureter (OR 1.3, 95%CI 0.97-1.75, p =0.08), stone size5-7mm (OR 0.2, 95%CI 0.16-0.25, p0.0001), stone size7mm (OR 0.11, 95%CI 0.08-0.15, p0.001), middle ureter stone position (OR 0.59, 95%CI 0.43-0.81, p=0.001), upper ureter stone position (OR 0.31, 95%CI 0.25-0.39, p0.001) ), medical expulsive therapy use (OR 1.36, 95%CI 1.1 - 1.67, p = 0.001), oral NSAID use (OR 1.3, 95%CI 0.99 - 1.71, p=0.06), and rectal NSAID use (OR1.17, 95%CI 0.9 - 1.53, p=0.24) remained. Concordance-statistic (C-statistic) was 0.77 (95%CI 0.75 - 0.80) and a nomogram was developed based on these.The presented nomogram is available to use as an online calculator via www.BURSTurology.com and could allow clinicians and patients to make a more informed decision on pursuing conservative management versus early intervention.

To assess the relationship of white blood cell count (WBC) and other routinely collected inflammatory and clinical markers including stone size, stone position, and medical expulsive therapy use (MET), with spontaneous stone passage (SSP) in a large contemporary cohort of patients with acute ureteric colic, as there are conflicting data on the role of WBC and other inflammatory markers in SSP in patients with acute ureteric colic.Multicentre retrospective cohort study coordinated by the British Urology Researchers in Surgical Training (BURST) Research Collaborative at 71 secondary care hospitals across four countries (UK, Republic of Ireland, Australia, and New Zealand). In all, 4170 patients presented with acute ureteric colic and a computed tomography confirmed single ureteric stone. Our primary outcome measure was SSP, as defined by the absence of need for intervention to assist stone passage (SP). Multivariable mixed effects logistic regression was used to explore the relationship between key patient factors and SSP.In all, 2518 patients were discharged with conservative management and had further follow-up with a SSP rate of 74% (n = 1874/2518). Sepsis after discharge with conservative management was reported in 0.6% (n = 16/2518). On multivariable analysis neither WBC, neutrophils count, nor C-reactive protein (CRP) predicted SSP, with an adjusted odds ratio (OR) of 0.97 (95% confidence interval [CI] 0.91-1.04, P = 0.38), 1.06 (95% CI 0.99-1.13, P = 0.1) and 1.00 (95% CI 0.99-1.00, P = 0.17), respectively. MET also did not predict SSP (adjusted OR 1.11, 95% CI 0.76-1.61). However, stone size and stone position were significant predictors. SSP for stones5 mm was 89% (95% CI 87-90) compared to 49% (95% CI 44-53) for stones ≥5-7 mm, and 29% (95% CI 23-36) for stones7 mm. For stones in the upper ureter the SSP rate was 52% (95% CI 48-56), middle ureter was 70% (95% CI 64-76), and lower ureter was 83% (95% CI 81-85).In contrast to the previously published literature, we found that in patients with acute ureteric colic who are discharged with initial conservative management neither WBC, neutrophil count, nor CRP, helps determine the likelihood of SSP. We also found no overall benefit from the use of MET. Stone size and position are important predictors and our present findings represent the most comprehensive SP rates for each millimetre increase in stone size from a large contemporary cohort adjusting for key potential confounders. We anticipate that these data will aid clinicians managing patients with acute ureteric colic and help guide management decisions and the need for intervention.

Introduction The PROCESS guidelines were published in 2016 to provide a structure for reporting surgical case series. The PROCESS guidelines have since been widely endorsed by a number of journals. The requirement to report compliance with each item outlined in the PROCESS statement has improved the reporting transparency of case series across a number of surgical specialties. Here, we undertook a new Delphi consensus exercise to update the PROCESS guidelines. Methods All members of the previous Delphi group were invited to participate. In addition, researchers, editors, and reviewers who have previously published or reviewed case series with the International Journal of Surgery were invited to collaborate. An online questionnaire was sent to participants asking them to rate their agreement with amendments to each of the 29 items. Results 140 experts were invited to participate, 56 people agreed to participate, and 45 (80%) recipients completed the survey. There was a high level of agreement amongst the expert group, and unanimous consensus was reached in the first round. All except three proposed items were accepted, and the original guidelines were modified accordingly. Conclusion A modified and improved PROCESS checklist is presented, after a Delphi consensus exercise was completed.

Introduction The SCARE Guidelines were published in 2016 to provide a structure for reporting surgical case reports. Since their publication, SCARE guidelines have been widely endorsed by authors, journal editors, and reviewers, and have helped to improve reporting transparency of case reports across a range of surgical specialties. In order to encourage further progress in reporting quality, the SCARE guidelines must themselves be kept up to date. We completed a Delphi consensus exercise to update the SCARE guidelines. Methods A Delphi consensus exercise was undertaken. All members of the previous Delphi group were invited to participate, in addition to researchers who have previously studied case reports, and editors from the International Journal of Surgery Case Reports. The expert group was sent an online questionnaire where they were asked to rate their agreement with proposed changes to each of the 24 items. Results 56 people agreed to participate and 45 (80%) invitees completed the survey which put forward modifications to the original guideline. The collated responses resulted in modifications. There was high agreement amongst the expert group. Conclusion A modified and improved SCARE checklist is presented, after a Delphi consensus exercise was completed. The SCARE 2018 Statement: Updating Consensus Surgical CAse REport (SCARE) Guidelines.

A 64-year-old man presented with a 2 week history of progressive phimosis and painful ulcer on his penile meatus. He underwent penile preserving excision, and subsequent pathological examination confirmed T-cell non-Hodgkin lymphoma with immunohistochemical features of large cell transformation of mycosis fungoides. The penis was further treated with local external beam radiotherapy consisting of 27 Gy in 15 fractions and systemic mini-CHOP chemotherapy. An organ-preserving tissue response has since been achieved. This case is the first of its kind in the literature and firmly highlights the role of multidisciplinary management for this rare malignancy.

An increasing number of women are serving in the military. We initiated a retrospective study to evaluate vitamin D status and monitoring in female veterans, and to examine the potential link between vitamin D status, age, race, post-traumatic stress disorder (PTSD), health care costs, and utilization. Approximately 44 percent of the 3,608 female veterans evaluated between 2001 and 2010 were vitamin D deficient (25(OH)D20 ng/ml), a rate substantially higher than that of the general population. While younger (55 years) and older (55+ years) women did not differ significantly in initial vitamin D status, older women had significantly more vitamin D monitoring and follow-up testing than younger women. Approximately 44 percent of vitamin D deficient women did not receive follow-up vitamin D testing. Minority female veterans were most likely to be vitamin D deficient. Female veterans with PTSD did not differ from others regarding their initial vitamin D status; those that were initially deficient were significantly more likely to receive follow-up testing and were more likely to achieve a replete state. Vitamin D deficiency in female veterans was also associated with increased health-care costs. Appropriate monitoring and replacement of vitamin D should be offered to all female veterans.

Acute health care utilization often occurs among persons experiencing homelessness. However, knowing which individuals will be persistent super-utilizers of acute care is less well understood.The objective of the study was to identify those more likely to be persistent super-utilizers of acute care services.We conducted a latent class analysis of secondary data from the Veterans Health Administration Corporate Data Warehouse, and Homeless Operations Management and Evaluation System. The study sample included 16,912 veterans who experienced homelessness and met super-utilizer criteria in any quarter between July 1, 2014 and December 31, 2015. The latent class analysis included veterans' diagnoses and acute care utilization.Medical, mental health, and substance use morbidity rates were high. More than half of the sample utilized Veterans Health Administration Homeless Programs concurrently with their super-utilization of acute care. There were 7 subgroups of super-utilizers, which varied considerably on the degree to which their super-utilization persisted over time. Approximately a third of the sample met super-utilizer criteria for ≥3 quarters; this group was older and disproportionately male, non-Hispanic white, and unmarried, with lower rates of post-9/11 service and higher rates of rural residence and service-connected disability. They were much more likely to be currently homeless with more medical, mental health, and substance use morbidity.Only a subset of homeless veterans were persistent super-utilizers, suggesting the need for more targeted interventions.

Surgical operation notes are crucial for medical record keeping and information flow in continued patient care. In addition to inherent medical implications, the quality of operative notes also has important economic and medico-legal ramifications. Further, well-documented records can also be useful for audit purposes and propagation of research, facilitating the improvement of delivery of care to patients. We aimed to assess the quality of surgical operation notes written by junior doctors and trainees against a set standard, to ascertain whether these standards were met.We undertook an audit of Urology and General Surgery operation notes handwritten by junior doctors and surgical trainees in a tertiary teaching hospital over a month period both in 2014 and 2015. Individual operative notes were assessed for quality based on parameters described by the Royal College of Surgeons of England guidelines.Based on the Royal College of Surgeons of England guidelines, a significant proportion of analysed surgical operative notes were incomplete, with information pertaining to the time of surgery, name of anaesthetist and deep vein thrombosis prophylaxis in particular being recorded less than 50% of the time (22.42, 36.36 and 43.03%, respectively).Overall, 80% compliance was achieved in 14/20 standards and 100% compliance was attained in only one standard.The quality of surgical operation notes written by junior doctors and trainees demonstrated significant deficiencies when compared against a set standard. There is a clear need to educate junior medical staff and to provide systems and ongoing education to improve quality. This would involve leadership from senior staff, ongoing audit and the development of systems that are part of the normal workflow to improve quality and compliance.

Objectives: Veterans of the armed forces, like most population groups, have a high prevalence of vitamin D deficiency, which may be associated with adverse outcomes in several types of cancer. Ultraviolet irradiation is inversely linked with the risk of bladder cancer, presumably through enhanced vitamin D synthesis. We hypothesized that variations in vitamin D status and monitoring predict adverse outcomes in bladder cancer among veterans. Methods: A retrospective analysis of data in the Veterans Integrated Service Network-9 (southeastern United States) was performed for patients diagnosed between October 1, 1999 and February 29, 2008. Age, tobacco exposure, body mass index, and latitude and seasonality of sampling were included as variables in addition to serum vitamin 25(OH)D levels. Results: Monitoring of vitamin D and vitamin D levels and status were closely linked to survival in bladder cancer. Both the chances of survival and longevity improved with enhanced vitamin D status and monitoring. Veterans with bladder cancer had better outcomes if the initial vitamin D level was higher and had more monitoring of the vitamin. Initial vitamin D levels were more strongly related to outcomes than follow-up levels. The link between vitamin D and outcomes remained after adjusting for background variables such as age, body mass index, latitude, seasonality, and tobacco exposure. Conclusions: Findings suggest that adequate vitamin D levels early in the course of the disease provide the best opportunity to improve outcomes. Ensuring that veterans with bladder cancer have adequate vitamin D reserves with appropriate monitoring may play a role in improving outcomes in bladder cancer.

Purpose: Living in a rural region is associated with significant health disparities and increased medical costs. Vitamin D deficiency, which is increasingly common, is also associated with many adverse health outcomes. The purpose of this study was to determine whether rural-urban residence status of veterans was related to vitamin D levels, and to determine if this factor also influenced medical costs/service utilization. Additionally explored was whether vitamin D differences accounted for part of the association between area of residence and medical costs/service utilization. Methods: Medical records of 9,396 veterans from 6 Veterans Administration Medical Centers were reviewed for variables of interest including county of residence, vitamin D level, medical costs and service utilization, and background variables. Rurality status was classified as large metropolitan, urban, and rural. Findings: The 3 rurality status groups differed significantly in vitamin D levels, with the highest levels observed for urban residents, followed by rural residents, and the lowest for large metro residents. Compared with urban residents, large metro residents were 49% more likely, while rural residents were 20% more likely, to be vitamin D deficient. Both rural and large metro residents had higher medical costs, and they were significantly more likely to be hospitalized. Vitamin D levels explained a statistically significant amount of the relationship between rurality status and medical costs/service utilization. Conclusions: Vitamin D deficiency may be an additional health disparity experienced by both rural and inner-city veterans, and patients residing in these locations should be considered at increased risk for deficiency and routinely tested.

Aim: Vitamin D deficiency is a global health issue associated with increased health-care costs, and could play a role in the pathogenesis and management of inflammatory bowel disease. Prior studies show a high prevalence of vitamin D deficiency in veterans with inflammatory bowel disease. We aimed to examine the outcome differences in patients with inflammatory bowel disease, comparing treatment with ergocalciferol to cholecalciferol. Methods: A retrospective review of electronic medical records of patients with inflammatory bowel disease at a Veterans Affairs Medical Facility in the Southeastern United States was carried out. Those with at least one serum 25(OH) vitamin D level were included. Initial and follow-up vitamin D values were recorded. The type of vitamin D supplementation, whether cholecalciferol or ergocalciferol, was documented. Costs in the year after measurement of vitamin D were divided into separate inpatient and outpatient categories. Results: Veterans (n = 108) with ulcerative colitis or Crohn’s disease and an available 25(OH) vitamin D level were studied. There were differences in follow-up vitamin D levels; those who received weekly ergocalciferol had higher subsequent levels than those who received cholecalciferol, especially at a second follow up, although differences did not achieve statistical significance. However, those who received vitamin D3 were less likely to use laboratory, pharmacy, radiology and fee-based services, and had lower laboratory and pharmacy costs. Conclusions: Our data suggest that cholecalciferol replacement might improve outcomes to a greater extent than ergocalciferol, and might be better in limiting health-care costs and expenses in patients with inflammatory bowel disease. Geriatr Gerontol Int 2012; 12: 475‐480.

Methicillin resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (P. aeruginosa) infections are frequently associated with hospitalization and increased healthcare costs. Vitamin D deficiency may contribute to increased costs for patients with these infections and there is evidence that vitamin D may have an antimicrobial role. To evaluate the role of vitamin D deficiency in the costs incurred with these infections, we studied the relationship of serum 25(OH)D levels to healthcare costs in veterans in the southeastern United States. Patients with both infections were vitamin D deficient to a similar extent and so were combined for further analysis. Vitamin D deficient patients had higher costs and service utilization than those who were not vitamin D deficient. Those with vitamin D deficiency had higher inpatient costs compared to the non-deficient group, and this difference was across most categories except for the number of inpatient hospitalizations or total number of days as an inpatient. Vitamin D deficiency was not significantly related to outpatient cost or service utilization parameters. We conclude that vitamin D deficiency is intimately linked to adverse healthcare costs in veterans with MRSA and P. aeruginosa infections. Vitamin D status should be assayed in patients with these infections.

Objectives Peripheral arterial disease (PAD) is a common and often overlooked entity responsible for considerable morbidity and mortality. Recent evidence suggests that nontraditional risk factors such as vitamin D may contribute to atherosclerosis. We hypothesized that vitamin D status was associated with cardiovascular risk factors and that vitamin D deficiency (25(OH)D Design We reviewed medical records of 1435 veterans between 2000 and 2008 in Tennessee via retrospective chart analysis using correlations, logistic regressions, t tests, and χ 2 analyses. Results Vitamin D status was significantly and inversely correlated with body mass index (BMI), glucose, and triglyceride values. Hypertension and diabetes but not smoking also emerged as significantly associated. Of the sample population, 5.2% (n = 75) had an amputation performed. Those individuals who were vitamin D deficient had a significantly higher amputation rate (6.7%) compared with patients who were nondeficient (4.2%). BMI, triglyceride, total cholesterol, hypertension, and diabetes were found to account for 5.7% of the variation in amputation status. Vitamin D concentration and deficiency status accounted for a nonsignificant amount of additional variance. Conclusions We conclude that vitamin D deficiency is closely linked to increased adiposity, triglyceride, and glucose measurements. Vitamin D deficiency was associated with an increased amputation risk in veterans with PAD and appears to mediate its effects through traditional risk factors.

Vitamin D insufficiency remains a costly pandemic in veterans. Treatment requires achievement of desired 25-hydroxyvitamin D [25(OH)D] concentrations. The frequency with which 25(OH)D should be measured following treatment remains speculative. A retrospective analysis of veterans with vitamin D insufficiency was conducted. The group was stratified on the basis of initial 25(OH)D and assessed for frequency of follow-up 25(OH)D concentrations. Over 3 years, 278 patients with insufficient 25(OH)D concentrations were identified. Of these, 87 (31%) patients had subsequent levels assessed in the year following initial documentation of vitamin D insufficiency. The likelihood of follow-up testing was unrelated to the initial vitamin D level. In the patients with follow-up 25(OH)D levels, 90% eventually achieved a serum level of 30 ng/mL or greater. Veterans with vitamin D insufficiency have inadequate serial monitoring of 25(OH)D concentrations.

Vitamin D deficiency is often unrecognized and has been linked to many chronic diseases. Vitamin D supplementation has been shown to ameliorate these chronic diseases and may reduce the prevalence of some cancers. We analyzed the health care costs associated with vitamin D deficiency in Veterans in Northeast Tennessee. A retrospective electronic chart analysis of the relationship of 25-hydroxyvitamin D [25(OH)D] status to health care costs, services, and utilization was done in 886 veterans. The overall costs were higher by 39% in the vitamin D-deficient group. Vitamin D deficiency was associated with increased service utilization in many areas including more frequent emergency room and clinic visits as well as increased inpatient stay and inpatient services. The serum level of vitamin D was also related to health care costs, although to a lesser extent. Vitamin D deficiency is closely linked to increased health care costs in veterans.

Prostate cancer remains the second most commonly diagnosed cancer among the male population worldwide. Vitamin D deficiency has been linked to prostate cancer and its aggressiveness. Herein, we initiated a retrospective study to evaluate vitamin D status and monitoring in veterans with prostate cancer, and to examine the potential link between vitamin D and survival status and length of survival in this population. We found that veterans who were initially vitamin D deficient were significantly less likely to survive than those who were not initially deficient, and that both initial and follow-up vitamin D deficiency were associated with decreased likelihood of survival after prostate cancer diagnosis. We recommend that vitamin D deficiency be replaced in veterans with prostate cancer.

Vitamin D deficiency is a global health issue associated with increased health-care costs, and could play a role in the pathogenesis and management of inflammatory bowel disease. Prior studies show a high prevalence of vitamin D deficiency in veterans with inflammatory bowel disease. We aimed to examine the outcome differences in patients with inflammatory bowel disease, comparing treatment with ergocalciferol to cholecalciferol.A retrospective review of electronic medical records of patients with inflammatory bowel disease at a Veterans Affairs Medical Facility in the Southeastern United States was carried out. Those with at least one serum 25(OH) vitamin D level were included. Initial and follow-up vitamin D values were recorded. The type of vitamin D supplementation, whether cholecalciferol or ergocalciferol, was documented. Costs in the year after measurement of vitamin D were divided into separate inpatient and outpatient categories.Veterans (n = 108) with ulcerative colitis or Crohn's disease and an available 25(OH) vitamin D level were studied. There were differences in follow-up vitamin D levels; those who received weekly ergocalciferol had higher subsequent levels than those who received cholecalciferol, especially at a second follow up, although differences did not achieve statistical significance. However, those who received vitamin D3 were less likely to use laboratory, pharmacy, radiology and fee-based services, and had lower laboratory and pharmacy costs.Our data suggest that cholecalciferol replacement might improve outcomes to a greater extent than ergocalciferol, and might be better in limiting health-care costs and expenses in patients with inflammatory bowel disease.

Objectives: Vitamin D deficiency has reached epidemic levels and has been frequently found in United States veterans. This deficiency has been linked to cardiovascular disease; however few studies have examined the relationship of vitamin D status to cardiac sonography. The purpose of the current study was to examine the relationship between vitamin D and echocardiography findings. Design: Retrospective chart review. Setting: Veterans administration hospital in the Southeastern United States. Participants: Thirty two eligible patients were included. Measurements: Charts were reviewed for key variables of interest, and patients with coronary artery disease and without vitamin D testing were excluded. Results: Several of the echocardiogram parameters were significantly associated with vitamin D level and status. Those with mitral regurgitation were more than twice as likely as remaining patients to be vitamin D deficient, as were those with pulmonary hypertension. In addition, patients with aortic sclerosis were almost twice as likely to be vitamin D deficient compared with patients who were negative. Conclusion: Pending additional studies to confirm the cardiac benefits of a vitamin D repletes state, we urge clinicians to monitor and appropriately treat vitamin D deficiency. The benefits of maintaining adequate vitamin D reserves combined with the low potential for toxicity with modest vitamin D supplementation provides clinicians with a door to improving wellbeing and possibly ameliorating cardiac valvular disease.

Relationship of Vitamin D status to cardiac arrhythmias in Veterans Islam T. MD MPH, Bailey B. PhD, Ferdous C. MD, Finton C. MD, Manning T. and Peiris A.N. MD PhD Introduction. Vitamin D deficiency is widespread and is associated with coronary artery disease. However, few studies have examined the link between Vitamin D status and cardiac arrhythmias. The present study was undertaken to explore this relationship. Method. We studied 34580 veterans in the southeastern USA and evaluated the relationship of Vitamin D status to both atrial and ventricular arrhythmias by retrospective chart review. Approximately 34.8 % (12030) patient were Vitamin D deficient (25(OH)D < 20 ng/ml). This group was more likely to be younger, have a significantly greater body mass index, more likely to be female and belong to a racial minority when compared to the Vitamin D replete group. The Vitamin D deficient group was also more likely to have hyperlipidemia, diabetes, hypertension and be tobacco users. Result. The presence of arrhythmias varied between 0.3 % (ventricular) to 25 % (Any arrhythmia plus heart block). Atrial and ventricular arrhythmias were significantly greater in the vitamin D deficient group. Vitamin D deficiency remained significantly associated with atrial and ventricular arrhythmias after adjusting for other variables through multivariate logistic regression analysis. Conclusion. To our knowledge, this is the first report indicating a significant link between vitamin D status and cardiac arrhythmias in Veterans. Vitamin D remained a significant predictor of this relationship even after adjusting for other variables. Emerging evidence suggest that Vitamin D replacement can improve cardiac ejection fraction. The potential for Vitamin D replacement to reduce an underlying arrythmogenic propensity is an exciting area for future research. Adjusted logistic regression model predicting atrial and ventricular arrhythmia by vitamin D level. Atrial Arrhythmia Present Absent p-value Vitamin D treated as Continuous variable, beta estimate -0.006 0 (ref.) 0.001 Categorical (low versus replete), odds ratio 1.18 1.00 (ref.) Ventricular Arrhythmia Present Absent p-value Vitamin D treated as Continuous variable, beta estimate -0.020 0 (ref.) 0.042 Categorical (low versus replete), odds ratio 1.48 1.00 (ref.) 0.055

OBJECTIVES Vitamin D deficiency is highly prevalent and has been linked to increased morbidity and mortality. There has been an increase in testing for vitamin D with a concomitant increase in costs. While individual factors are significantly linked to vitamin D status, prior studies have not yielded a model predictive of vitamin D status or 25(OH)D levels. The purpose of this investigation was to determine if a prediction model of vitamin D could be developed using extensive demographic data and laboratory parameters. METHODS Patient data from 6 Veterans Administration Medical Centers were extracted from medical charts. RESULTS For the 14,920 available patients, several factors including triglyceride level, race, total cholesterol, body mass index, calcium level, and number of missed appointments were significantly linked to vitamin D status. However, these variables accounted for less than 15% of the variance in vitamin D levels. While the variables correctly classified vitamin D deficiency status for 71% of patients, only 33% of those who were actually deficient were correctly identified as deficient. CONCLUSION Given the failure to find a sufficiently predictive model for vitamin D deficiency, we propose that there is no substitute for laboratory testing of 25(OH)D levels. A baseline vitamin D 3 daily replacement of 1000-2000 IU initially with further modification based on biannual testing appears to factor in the wide variation in dose response observed with vitamin D replacement and is especially important in high-risk groups such as ethnic minorities.

African Americans have lower vitamin D levels and reduced health outcomes compared to white Americans. Vitamin D deficiency may contribute to adverse health outcomes in African Americans. We hypothesized that race would be associated with vitamin D status and testing in African Americans veterans, and that vitamin D status is a major contributor to health care costs in African American veterans compared to white veterans. A retrospective analysis of the medical data in the Veterans Integrated Service Network 9 (southeastern United States) was performed, and 14148 male veterans were identified. Race was designated by the patient and its relationship to vitamin D levels/status and costs was assessed. Vitamin D levels were significantly lower and the percent of patients with vitamin D deficiency was significantly higher in African American veterans. This difference was independent of latitude and seasonality. Vitamin D testing was done significantly more in white veterans compared to African American veterans (5.4 % vs 3.8 %). While follow-up testing was 42% more likely if a patient was found to be vitamin D deficient, white veterans were 34% more likely than African American veterans to have at least 1 follow-up 25-hydroxyvitamin D performed. African American veterans had significantly higher health care costs, which were linked to lower vitamin D levels; however, the cost differential persisted even after adjusting for vitamin D status. Vitamin D deficiency is highly prevalent in African American veterans and needs improved management within the Veteran Administration system. Vitamin D status appears not to be the sole contributor to increased health care costs in African American veterans.

Vitamin D deficiency is a global pandemic associated with increased health care costs and could play a role in the pathogenesis and management of inflammatory bowel disease. This study examined vitamin D status in veterans with ulcerative colitis (UC) and Crohn's disease (CD) and assessed its relationship to health care costs and service utilization. Veteran patients (n = 125) with UC or CD and with an available 25-hydroxyvitamin D level were studied. CD patients were more likely to be vitamin D insufficient than the UC group. Despite the higher vitamin D levels among UC patients, they were significantly more likely to utilize laboratory and pharmacy services compared with CD patients, whereas patients with CD had significantly higher radiology and pharmacy costs. Thus, it is likely that disease-specific characteristics rather than vitamin D status determine the costs of health care services in veterans with established inflammatory bowel disease.

Vitamin D deficiency remains a poorly recognized pandemic and is closely linked to increased health care costs in veterans. Projected health care needs in veterans are expected to increase over the next decade. Intensive care unit (ICU) costs contribute significantly to hospital costs and stem from intervention services and management of sepsis including nosocomial infections. Vitamin D has immunomodulating and antimicrobial properties through antimicrobial peptides such as cathelicidin.A retrospective study was undertaken to evaluate if vitamin D deficiency was associated with less than optimal ICU outcomes in veterans. The study included 136 veterans with 25(OH)D levels drawn within a month of admission to ICU.The average 25(OH)D level was 24.6 ng/mL (normal range 30-100) with 38% of patients falling in the vitamin D-deficient category (20 ng/mL). ICU survivors had a significantly lower rate of vitamin D deficiency compared with nonsurvivors (28% versus 53%). Twenty-nine percent of vitamin D-replete patients were in ICU 3 days or more, whereas 58% of patients with vitamin D deficiency stayed in ICU 3 days or longer. This difference was highly significant translating to twofold increased risk (2.0 Relative Risk [RR]) for 3-day or longer stay in ICU for patients with vitamin D deficiency. Moreover, the risk of death was significantly higher in ICU patients with vitamin D deficiency (RR 1.81).A vitamin D-replete state may reduce costs and confer survival advantages in critical illness. We recommend that 25(OH)D levels be routinely checked and deficiencies treated in ICU patients.

SUMMARYClostridium difficile and staphylococcal infections are associated with increased morbidity, mortality and healthcare costs. Vitamin D deficiency may also contribute to increased healthcare costs. There is increasing evidence that vitamin D may have an antimicrobial role. We examined the relationship of serum 25(OH)D levels to staphylococcal and C. difficile infections to determine if vitamin D deficiency was associated with adverse outcomes. In the outpatient setting, vitamin D deficiency in patients with C. difficile and staphylococcal infections were associated with significantly increased total outpatients costs and fee-based consultation. Laboratory expenses had a trend towards higher costs in the vitamin D-deficient group but did not reach statistical significance. The differences were most clearly seen in the in-patient group with enhanced laboratory, pharmacy and radiology costs. These differences resulted in vitamin D-deficient patients with C. difficile or staphylococcal infections having costs more than five times higher than the non-deficient patients. The total length of hospital stay was four times greater in the vitamin D-deficient group. In addition, the total number of hospitalizations was also significantly greater in the vitamin D-deficient group. Surgery costs demonstrated a tendency to be higher in the vitamin D-deficient group but failed to reach statistical significance. Vitamin D deficiency is intimately linked to adverse health outcomes and costs in Veterans with staphylococcal and C. difficile infections in North East Tennessee. We recommend that vitamin D status be checked in patients with these infections and appropriate therapy be instituted to restore vitamin D level to normal in an expeditious manner.

Objective The present study was undertaken to determine if a seasonal bias was present for vitamin D testing among Northeast Tennessee veterans, in whom vitamin D deficiency is common. Design Medical chart review. Setting VA Medical Center. Participants Participants were 9447 patients with initial 25(OH) vitamin D levels obtained over a 3-year period. Measurement Serum 25-hydroxyvitamin D (25[OH]D) level, date of testing, patient background factors. Results Vitamin D testing occurred more frequently in September, October, November, and December, whereas the lowest levels of 25(OH) vitamin D levels were found in January, February, and March. Similar results were observed in quarterly data with the greatest number of tests noted in the last quarter of the year, yet the lowest 25(OH) vitamin D levels were noted in the first quarter. The average monthly 25(OH) vitamin D levels were below 30 ng/mL throughout the year in the study population, consistent with highly prevalent vitamin D deficiency. Conclusion Clinicians may have a seasonal bias, favoring testing for vitamin D status in the latter part of the year even though the lowest vitamin D levels are observed in the first part of the year. Although an argument could be made to check for peak 25(OH) vitamin D levels in September and trough levels in March, the seasonal contribution to vitamin D deficiency is overshadowed by ongoing vitamin D deficiency throughout the year. Thus, it may be prudent to test for vitamin D deficiency in patients presenting with fatigue, myalgias, and arthralgias regardless of the season of presentation.