C.W. Bill Young VA Medical Center

Abstract Rationale Family members of critically ill patients hospitalized in the intensive care unit (ICU) often become caregivers, and they are at risk to develop adverse psychological outcomes. There is a need to understand the psychological impact of critical illness on family caregivers. Objectives The aim of this systematic review is to document the prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) in family caregivers of critically ill patients and identify potential risk factors for psychological outcomes to inform clinical and future research recommendations. Methods A literature search for psychological outcomes for family caregivers of critically ill patients was conducted. A total of 1,148 studies from PsycINFO, CINAHL, Web of Science, SCOPUS, and Medline were identified. Results Forty studies met inclusion criteria and were included in the review. The prevalence of psychological outcomes in family caregivers ranged from 4% to 94% for depression, 2% to 80% for anxiety, and 3% to 62% for PTSD. Caregiver depression, anxiety, and PTSD decreased in most studies that assessed longitudinal outcomes. Common risk factors identified for adverse psychological outcomes included younger caregiver age, caregiver relationship to the patient, lower socioeconomic status, and female sex. Conclusions The prevalence of depression, anxiety, and PTSD varies greatly across studies of family caregivers of critically ill patients. This finding highlights the need for more systematic investigations of psychological outcomes and the implementation of clinical interventions to prevent or reduce depression, anxiety, and PTSD in family caregivers of critically ill patients.

Male breast cancer is rare, and experience of it in any single institution is limited. Our current understanding regarding its biology, natural history, and treatment strategies has been extrapolated from its female counterpart. The aim of this study is to evaluate the expression patterns of estrogen receptor (ER), progesterone receptor (PR), MiB1 (Ki67), Her-2/neu (c-erbB2), and p53 and to correlate them with the prognosis, presentation, staging, management, and survival/outcome in male breast carcinoma identified through the Veterans Administration nationwide cancer registry. Sixty-five cases of male breast cancer were reviewed for classification. Tumor blocks were requested from each institution for immunohistochemical staining and evaluation of ER, PR, p53, Her2-neu, and MiB1. Seventeen age- and disease-matched male veteran patients with breast gynecomastia were used as controls. Traditional prognostic data were collected for comparison with female breast cancers (i.e., age, lymph node status, clinical staging, tumor size, histological grade, and disease-free and overall survival). Male breast carcinoma had worse disease-free survival than controls (P =.03). The clinical stage regardless of tumor size or lymph node metastasis was the single most significant prognostic factor (P <.0001). ER-positive patients appeared to have a better survival than did ER-negative patients (P =.03, univariate; P not significant in multivariate) and did not benefit from treatment with tamoxifen (P =.0027, univariate; P =.42, multivariate). MiB1 and PR expressions did not correlate with treatment or survival, and p53 was associated with shorter disease free survival (P =.07, univariate; P =.047, multivariate). Stage for stage, Her2-neu was associated with shorter disease-free survival (P <.0001) and correlated with positive lymph nodes (P =.08). Surgery alone versus surgery with adjuvant treatments (chemotherapy, radiotherapy, tamoxifen, or combination) did not show any survival difference. Adjuvant therapy seemed to be associated with worse outcome. In the Veterans Administration hospital setting, the clinical stage and the expressions of p53 and Her2-neu in male breast carcinoma may be prognostically useful markers in guiding future treatment in prospective studies, whereas ER, PR, and MiB1 expressions are of limited value.

Morphea and systemic sclerosis (SSc) are rare disorders of connective tissue characterized by increased skin thickness and fibrosis, with current treatment options having variable efficacies, many with limited therapeutic benefit. Janus kinase (JAK) inhibitors have been shown in preclinical studies to inhibit the fibrotic pathway in murine models of systemic sclerosis, by blocking TGF-beta mediated pathway of STAT protein activation. Additionally, case reports of the treatment of morphea and SSc with tofacitinib, a JAK 1/3 inhibitor, have shown improvement in skin sclerosis. Several JAK inhibitors have been developed and utilized in dermatologic and rheumatologic diseases. To date, tofacitinib has been by far the most commonly trialed JAK inhibitor in patients with SSc and morphea. Herein we review the preclinical studies reported in the literature supporting the use and efficacy of JAK inhibitors for the treatment of morphea and the cutaneous manifestations of SSc, as well as discuss the clinical cases published to date illustrating the benefits of JAK inhibitors in disease management. The pathogenesis and mechanism of action will be reviewed as it relates to the process of skin fibrosis in morphea and SSc, along with the murine models illustrating efficacy of JAK inhibitors in fibrotic disease. Based on available preclinical and clinical data as well as consideration of the mechanism of action of JAK inhibitors on the pathway for cutaneous fibrosis, there is promising evidence to support the use and further study of JAK inhibitors in the management of morphea and cutaneous fibrosis in SSc.

DESCRIPTION: In February 2022, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the management of major depressive disorder (MDD). This synopsis summarizes key recommendations. METHODS: Senior leaders within the VA and the DoD assembled a team to update the 2016 CPG for the management of MDD that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The guideline panel developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and distilled 36 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Select recommendations that were identified by the authors to represent key changes from the prior CPG are presented in this synopsis. RECOMMENDATIONS: The scope of the CPG is diverse; however, this synopsis focuses on key recommendations that the authors identified as important new evidence and changes to prior recommendations on pharmacologic management, pharmacogenomics, psychotherapy, complementary and alternative therapies, and the use of telemedicine.

PURPOSE: Results of a study to determine the utility of methicillin-resistant Staphylococcus aureus (MRSA) active surveillance via nasal-swab screening in predicting the results of clinical respiratory cultures are reported. METHODS: A retrospective chart review-based descriptive analysis was conducted at a Veterans Affairs (VA) medical center. VA databases were used to identify adult patients admitted to the facility over a one-year period who underwent both respiratory culture testing and active MRSA surveillance nasal-swab screening during the hospitalization; only data on patients who had a MRSA surveillance swab within 48 hours before or after respiratory culture testing were included in the analysis. The sensitivity, specificity, and positive and negative predictive values of the MRSA screening method were calculated. RESULTS: Data on a total of 297 respiratory cultures and corresponding nasal-swab results were reviewed. The positive predictive value of the nasal-swab method of MRSA surveillance screening was calculated as 37.5% (95% confidence interval [CI], 21.1-56.3%); the negative predictive value was 99.3% (95% CI, 97.3-99.9%). MRSA screening by nasal swab had a calculated specificity of 92.9% (95% CI, 89.3-95.6%) and sensitivity of 87.5% (95% CI, 57.2-98.2%). Using Fisher's exact test, it was determined that there was a significant association between swab and culture results (p < 0.001). CONCLUSION: This analysis demonstrated a notable association between negative results of nasal-swab screening for MRSA and an absence of MRSA growth on respiratory clinical cultures at the study site, suggesting that airway swab screening can be a useful tool for streamlining antimicrobial therapy.

Objective The study aimed to evaluate the impact of late swallowing dysfunction leading to percutaneous endoscopic gastrostomy (PEG) tube dependence on the overall survival (OS) in a cohort of locally advanced head and neck cancer patients treated and cured with definitive radiotherapy (RT) and concurrent systemic therapy (CST). Materials and methods A total of 62 patients with locally advanced head and neck cancer were included in the analysis based on the following selection criteria: stage III, IVA, or IVB disease, treated with definitive RT and CST, no major head and neck surgery, no evidence of local or distant recurrent disease, and at least one post-RT modified barium swallow study. Patients were classified as PEG dependent or PEG independent at the time of the last follow-up. Estimates of OS were calculated using the Kaplan-Meier method. Univariate and multivariate analyses were performed to evaluate the impact of various clinical factors on OS. Results The median follow-up was 48 months (range: 7.6-235 months). The five-year OS was 64.3% in the PEG-dependent group and 86.1% in the PEG-independent group (p=0.022). Age over 70 at diagnosis was also associated with poorer OS (p=0.044). On univariate analysis, PEG dependency maintained a significantly worse OS (hazard ratio [HR]: 2.59; 95% confidence interval [CI]: 1.11-5.99, p=0.028). On multivariate analysis, PEG dependency (HR: 4.25; 95% CI: 1.33-13.62; p=0.015), advanced N stage (HR: 4.74; 95% CI: 1.17-19.26, p=0.035), and older age at diagnosis (HR: 4.37; 95% CI: 1.21-15.84; p=0.025) were significantly associated with worse OS. Conclusions Late PEG dependency is associated with poor OS in head and neck cancer patients cured with definitive RT and CST. Interventions designed to help head and neck cancer patients maintain swallowing function may result in improved outcomes.

OBJECTIVE: Extant literature has demonstrated that symptoms of postconcussive syndrome (PCS) persist well beyond the expected 3-month post-injury recovery period in a minority of individuals with mild traumatic brain injury (mTBI). Suboptimal performance on validity measures and pre- and post-injury psychosocial stressors - rather than actual mTBI or current cognitive functioning - have been identified as predictors of chronic PCS. Whether premorbid IQ has any influence on chronic PCS has been understudied, in the context of established psychogenic etiologies. METHOD: The sample included 31 veterans, who underwent mTBI neuropsychological evaluations six or more months post-injury in a VA outpatient neuropsychology clinic. A two-step multiple linear regression was conducted to examine the effects on the outcome variable, PCS (Neurobehavioral Symptom Inventory), of the following predictors: cognitive functioning (Repeatable Battery for the Assessment of Neuropsychological Status; Attention, Immediate Memory, and Delayed Memory Indices), performance validity, depression (Beck Depression Inventory-Second Edition), posttraumatic stress disorder (PTSD Checklist, Civilian Version), quality of sleep (Pittsburgh Sleep Quality Index), pain (Brief Pain Inventory), education, and Premorbid IQ (Wechsler Test of Adult Reading). RESULTS: The overall regression model containing all nine predictor variables was statistically significant. Depression (p < .05) and premorbid IQ (p < .05) were the most salient predictors of chronic PCS; in that lower premorbid IQ and greater endorsed symptoms of depression were associated with higher PCS scores. In Step 2 of the multiple linear regression, the WTAR explained an additional 6.7% of the variance in PCS after controlling for psychosocial stressors and current cognitive ability. CONCLUSION: The findings support premorbid IQ as a unique and relevant predictor of chronic PCS, with significance variance accounted for beyond education, cognitive functioning, and psychosocial variables. Given the predictive relationship between premorbid IQ and PCS, adapting postconcussive interventions to meet the specific needs of individuals with varying levels of intellect may be important in minimizing ongoing symptomatology.

BFHs classically present with multiple 1- to 2mm tan-to-brown-colored papules distributed on the face, scalp, neck, axilla, trunk, and pubic area. Differential diagnoses can include nevus sebaceous, lichen striatus, linear epidermal nevus, and basal cell nevus. BFH arises from a mutation in the patch gene, the same gene thought to cause nevoid BCC syndrome. Histologic examination of BFH lesions is essential to diagnosis. No standard of care exists for BFH; treatment options remain limited. This patient was treated with three rounds of pulsed dye laser (PDL) therapy and showed marked improvement in the treated areas. The authors propose PDL to be a safe, effective, and novel cosmetic treatment for BFH and potentially other adnexal tumors.

OBJECTIVES: Performing and interpreting endovaginal ultrasound is an important skill used during the evaluation of obstetric and gynecologic emergencies. This study aims to describe the level of proficiency and confidence achieved after performing 25 endovaginal examinations. METHODS: This is a prospective study at a single urban academic emergency department. Participants performed a minimum of 25 endovaginal ultrasounds under the supervision of a point-of-care ultrasound expert. Anatomical structures were identified by the expert under ultrasound prior to each session. Each examination was scored for agreement of findings between the participant and expert. The data were used to develop a performance curve identifying when proficiency was achieved, where experiential benefit diminished, and when participants felt confident. RESULTS: A total of 1117 endovaginal ultrasound examinations were performed by 50 participants. Agreement after 25 examinations was highest (>95%) for probe insertion and preparation, bladder and uterus identification, and directionality. Agreement was lowest for identification of the ovaries (76%). Experiential benefit plateaus occurred earliest (10 exams) for preparation and insertion followed by bladder identification and directionality. Surprisingly, ovarian experiential benefit plateaued at 16 exams. Participant confidence improved overall and was lowest for the identification of ovaries and abnormal pelvic anatomy. CONCLUSIONS: There is a significant learning curve when performing endovaginal ultrasound. Our data do not support the use of 25 examinations as a minimum standard for identification of the ovaries or abnormal ovarian pathology.

BACKGROUND: Pre-hospital systemic vascular access with early resuscitation in the hypovolemic trauma patient can be problematic and is attempted through venous cut-downs, peripheral IV lines, and/or interosseous routes. This brief report examines an alternative for males via the corpus cavernosum (CC). METHODS: A systematic literature review using certain inclusion criteria including, but not limited to, corpus cavernosum access and resuscitation was conducted and a summary table created. FINDINGS: The six articles that met criteria revealed quick and easy CC access with rapid flow rates and resuscitation times in both humans and in animal models using either fluids or blood products. Only one article revealed a complication which was a shaft hematoma that resolved spontaneously over a period of a few days. DISCUSSION/IMPACT/RECOMMENDATIONS: Systemic vascular access and resuscitation via the CC could be considered as a safe and effective alternative if more traditional techniques fail in an appropriate pre-hospital hypovolemic male casualty (i.e., no genital or pelvic trauma that could interfere with the technique). If further studies are conducted and the technique more robustly validated it could be considered as a possible addition to pre-hospital treatment protocols such as TCCC. Possible publication bias could have been a limitation of this study.

This case report discusses the treatment of brachioradial pruritus (BRP) in a 57-year-old white male veteran with chiropractic and acupuncture. The patient presented with findings consistent with a diagnosis of BRP to include sharp pain, burning, and itching at the bilateral upper extremities over the C5 and C6 dermatomes with acquired excoriations over the affected regions. The only known palliative measure was applying icepacks. Plain film radiographs revealed mild degenerative change at the C4-C5 and C5-C6 levels and postural evaluation observed anterior head carriage with forward-rounded shoulders. He had pain upon palpation and motion restriction in the cervical spinal region. His trial of treatment consisted of manual cervical and thoracic spinal manipulation, manual cervical traction, prescription of a home exercise program, and acupuncture. At the conclusion of this trial, the patient's symptoms resolved and his acquired excoriations began to show signs of healing. A proposed etiology of BRP is cervical spine disease. There are limited case reports and retrospective studies in the literature that examine conservative care options targeting cervical spinal disease for the treatment of BRP. This case study reviews a patient diagnosed with BRP and confounding cervical spine disease who was treated with chiropractic and acupuncture, experiencing relief from his symptoms.

In the context of diminishing reimbursement and patient access demands, researchers continually refine performance validity measures (PVMs) to maximize efficiency while maintaining confidence in obtained data. This is particularly true for high PVM failure populations (e.g., mTBI patients). The TOMMe10 (number of errors on first 10 TOMM items) is one method this study utilized for classifying PVM performance as pass/fail (fail defined as failure on 2 of 6 PVM scores, pass defined as 0/1 failures). The present study hypothesized that the TOMMe10 would have equitable sensitivity/specificity for identifying non-credible cognitive performance among veterans with mTBI compared to previous research findings and commonly used performance validity measures (e.g., TOMM or WMT). Data were analyzed from 54 veterans assigned to a pass and fail group based on their performance across six recognized PVMs. Results revealed pass/fail groups were not significantly different regarding age, educational, or racial background. ROC analyses found the TOMMe10 demonstrated excellent discriminability (AUC = .803 ±.128), indicating that the TOMMe10 could have clinical utility within an mTBI veteran sample, particularly in conjunction with a second PVM. Specific population limitations are discussed. Additional research should elucidate this measure’s performance with additional populations, including non-veteran mTBI, dementia, moderate-severe TBI, and inpatient populations.

A simple surgical procedure is not without the risk of complications and when removing hardware from the bone, such as a previous patella fracture hardware, the surgeon must be well aware of this potential. Here we present the case of a 71-year-old male who presented for removal of retained hardware of united right patella fracture with overlying skin complications. Surgical intervention was uneventful. On post-operative day 1, the patient suffered a fall while using the restroom unassisted with a subsequent large amount of bleeding from the incision site. X-rays demonstrated a new displaced inferior pole patellar fracture. The patient returned to the operating room for debridement and repair of this new patellar fracture with primary closure. Intraoperative cultures of initial operative site were positive for Corynebacterium and Staphylococcus epidermidis. The patient was then started on intravenous Vancomycin based on culture sensitivities. The patella fixation/repair was protected with a knee immobilizer as there was increased risk of falls due to his age/underlying medical condition. This case discusses recommendations and guidelines for preventing and managing these various postoperative complications.

Fetal akinesia deformation sequence (FADS), or Pena-Shokeir phenotype is a constellation of deformational changes resulting from decreased or absent fetal movement, and include arthrogryposis, and craniofacial and central nervous system anomalies. We report an autopsy case of a 36-6/7week female neonate with a normal female karyotype and chromosome microarray demonstrating findings consistent with FADS. We provide a detailed examination of the severe and complex central nervous system abnormalities, including marked pontocerebellar hypoplasia and cortical and cerebellar migration and gyration defects. This case represents a rare detailed examination of the central nervous system of a patient with FADS.

Clostridium difficle (C. diff) is a well known cause of infectious diarrhea across hospitals in the developed world. An anaerobic, gram positive rod bacteria, C. diff is part of the normal flora of the human colon; however, alterations to the microbiome can promote proliferation leading to pathogenic behavior. Typical symptoms include watery diarrhea in excess of three or more times a day, for at least two days, and abdominal cramping. While most infections do not lead to long term complications, the two complications that are most deleterious to health are toxic megacolon and bowel perforation. Patients with an inflammatory bowel disease are at a higher risk of complications, and thus need to be managed appropriately. This case presents a 39-year-old male, with pertinent medical history of poorly controlled ulcerative colitis, who presented to general surgery with imaging suggesting rectal perforation secondary to a C. diff infection. Due to the free air visualized in the rectum, the patient was urgently transported to the operating room to undergo a total colectomy and end ileostomy surgery. This case discusses the well-known complication of bowel perforation, in order to raise awareness about the management and guidelines. This case is important and significant as it details the appropriate guidelines and structure to follow amongst this unique, and vulnerable to complications, population in order to manage a potentially devastating manifestation of C. diff.

Despite the many benefits of total knee arthroplasty (TKA) in the treatment of degenerative arthritis, infection of the total knee prosthesis presents a dangerous post-operative complication affecting 0.5-1.9% of all cases. Infection after the first three post-operative weeks is treated with either one or two-stage revision operations involving the removal of all prosthetic components. Two-stage revision operations are more commonly used and involve the removal of prosthetic components followed by the implantation of a cement mold infused with antibiotics (antibiotic spacer) as well as systemic antibiotic treatment for four to six weeks before prosthetic reimplantation. This case report details a TKA revision in a patient with osteoarthritis of the knee. The patient presented with an elevated erythrocyte sedimentation rate, C-reactive protein, and white blood cell count nearly two years after the primary operation and was found to have an infected total knee prosthetic. A two-stage revision was planned but due to scheduling disruption by the coronavirus disease 2019 pandemic, the second stage of the operation was delayed until 12 months after the stage one operation. The patient ambulated without pain on an antibiotic spacer for 12 months, providing information about the long-term use of spacers. This case also offers a look at a potential benefit to one-stage operations, which have been shown in the literature to have similar outcomes as two-stage operations. The patient had a medical history of psoriasis and immunosuppressive treatment with methotrexate, two risk factors for prosthetic joint infection, and may have benefited from prophylactic antibiotic therapy extending beyond the perioperative period. The goal of this case report is to detail the prolonged use of an antibiotic spacer, examine the risks and benefits of one and two-stage total knee revisions, and discuss prophylactic antibiotic use in high-risk patients following TKA.

Glucagon-like peptide-1 receptor agonists (GLP-1RAs), widely prescribed for diabetes and weight loss, are well-known for their side effects. We present a case report of elderly, medically complex patient on a GLP-1RA and prednisone therapy who presented to the emergency department with abdominal pain and the radiographic finding of pneumatosis intestinalis (PI) but was found to have healthy bowel on exploratory laparotomy. This case is the second report of PI in a patient taking a GLP-1RA. It highlights the importance for clinicians to recognize non-emergent causes of PI-including the potential contributory role of corticosteroids, particularly in patients with multiple comorbidities to avoid unnecessary surgical intervention.

Abstract Rationale The Miami VA Medical Center found a 83.5% concordance between the Positron emission tomography (PET) CT scan and the final lung cancer diagnosis and stage in their database. Regional variability in endemic fungi and other diseases causing lung nodules could confound a PET CT scan’s ability to accurately identify final lung cancer pathological stage. Methods A consortium of 13 regionally diverse VAMCs provided institutional data for the most recent lung cancer diagnoses. Using REDCap, data on stage suggested by PET CT, final pathological stage, biopsy strategies used, complications and timing of significant events during diagnostic evaluation and management were collected and analyzed. Results 121 cases of lung cancer were submitted including: 65.3% stage I, 12.9% stage II, 18.8% stage III and 3.0% stage IV. Mean risk scores for all nodules using the Brock and Mayo risk prediction algorithms were 29.9% and 60.3%, respectively. Transcutaneous (41%) and bronchoscopic (45%) techniques were primarily used for diagnosis. For cases diagnosed by bronchoscopy, 77.8% used curvilinear EBUS and 66.7% used navigational bronchoscopy. Twenty percent of cases were diagnosed by surgical biopsy and 2% by mediastinoscopy. Pneumothorax complications occurred in 18 patients (14.9%) with 2% requiring observation and 16.2% requiring a chest tube. Nineteen patients had bleeding complications with 16.2% described as minor and 3% described as major. For treatment, 65% received surgery, 31.6% received chemotherapy and 35.7% received radiation. PET CT accurately predicted the final pathological stage in 46.5% of the cases, erroneously upstaging and downstaging patients 20.8% and 32.7%, respectively. The percentage of patients out of the entire population where PET CT predicted final pathological stage accurately, downstaged or upstaged; stage I (31%, 10%, 13%), stage II (4%, 6%, 2%); stage III (6.9%, 1.0%, 7.9%) and stage IV (2%, 1%, 0%). In three patients (3.0%), PET CT erroneously suggested surgery was an option whereas in one patient (1%), PET CT suggested they were not a surgical candidate when they were. Median time from chest image to treatment was 105.5 days and PET CT to treatment was 74 days. Conclusions Marked differences in the accuracy of the PET CT to predict final pathological stage exist when evaluated across the nation, compared to solely in Miami. This variation may result from the effect lung cancer screening had on the two groups, as this current cohort had higher proportion (65.3%) stage I compared to theMiami data (40%). This abstract is funded by: VA LPOP (CU000172) CSP Project ID (L0019)

Abstract Introduction Sexual dysfunction is a prevalent issue affecting quality of life. Skeletal muscle mass and strength are emerging biomarkers for overall health and well-being. Considered in tandem, sexual function and muscle mass have significant implications for well-being. Endothelial function and metabolic regulation are two primary mechanisms by which muscle maintains sexual function. Objective We aim to explore the relationship between skeletal muscle parameters and sexual function via mechanisms and the role of testosterone. Methods A PubMed literature search was conducted using the following MeSH terms: “Muscle, Skeletal”, “Sexual Dysfunctions, Physiological”, and “Sexual Dysfunctions, Psychological”. Keywords included "sarcopenia", "muscle mass", "muscle strength", "hand strength", "resistance training", "skeletal muscle", "weight lifting", "sexual function", "sexual dysfunction", "erectile function", "erectile dysfunction", and "male sexual function”. Inclusion criteria encompassed original research and review articles, with no restriction placed on publication dates to capture the evolution of the scientific discourse. Results This yielded 355 results, and 32 were selected for inclusion. Skeletal muscle mass and strength contribute independently to healthy sexual function through metabolic and endothelial mechanisms, particularly in aging adults and men with comorbidities like sarcopenia, diabetes, and obesity (Table 1). Cross-sectional studies using muscle volume, hand-grip strength (HGS), and bioelectrical impedance assessment (BIA) show correlations between muscle parameters and erectile function, sexual desire, and overall sexual satisfaction. The odds of experiencing negative sexual symptoms lessen with the maintenance of muscle strength and grow with BMI. In older men, HGS correlates with a decreased risk of erectile dysfunction (ED) (OR: 0.86 per 5 kg, 95% CI: 0.78–0.96). Participation in muscle-strengthening activities significantly lowers the risk of ED in men 40 and older (OR 0.67; 95% CI: 0.51–0.89). The relationship between low muscle strength and ED persists in men with chronic inflammation, including those with metabolic syndrome (OR 15.35, 95% CI: 5.64–41.81), rheumatoid arthritis, and renal dysfunction. Despite the established influence of testosterone on muscle and endothelial health, an independent correlation between HGS and IIEF5 persists after adjustment for serum testosterone (β = 0.169, p = .037), showing the strength of the relationship independent of testosterone. Conclusions A positive correlation exists between erectile function and muscle health. Maintenance of skeletal muscle with nutrition and physical activity improves erectile and overall health outcomes in both healthy and comorbid populations. Sexual function may see further benefits from therapies that target sexual function and muscle health simultaneously (e.g., testosterone and L-carnitine). Future studies are warranted to strengthen and elucidate this relationship and to follow the longitudinal outcomes of these therapies on sexual health. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Besins, Boston Scientific, Coloplast, Endo, Marius, Petros, Sprout

A significant number of patients diagnosed with multiple sclerosis are not receiving promising new disease-modifying agents.