Factors In Clinical Settings Research Articles

Correlation of Serum Uric Acid With Cardiovascular Risk in Nigerian Patients.

Studies exploring the relationship between serum uric acid (sUA) and cardiovascular risk in the Nigerian population remain sparse. The study aimed to assess the association between sUA levels and two measures of cardiovascular risk, namely the Framingham 10-year Cardiovascular Risk Score (FRS) and the Atherogenic Index of Plasma (AIP). This retrospective study used data from clinical records of new, previously unregistered patients presenting at a private cardiac hospital over one year from November 2022 to October 2023. In total, 428 patients presented newly to the hospital in that period. The records of 138 patients were included in the project after various exclusions were made including for incomplete anthropometric and laboratory data. Statistical tests of association were used to determine the significance of the relationship between sUA levels and the measures of cardiovascular risk. Two-tailed p <0.05 was deemed statistically significant. Hyperuricemia was more prevalent in individuals with central obesity, i.e., waist circumference ≥94cm in males or 80cm in females (93.4% vs 6.6%; p=0.03). Serum uric acid also positively correlated with FRS (correlation coefficient: 0.190; p<0.05) and serum triglyceride levels and AIP (correlation coefficient: 0.259 and 0.294, respectively; p<0.001 for both). After multivariate analyses, uric acid was significantly and independently associated with high FRS and AIP after adjusting for age, smoking and diabetes history, blood pressure, total and high-density lipoprotein cholesterol, serum triglyceridesand waist circumference (p<0.001). The results emphasize the emergence of sUA as a pertinent cardiovascular risk factor in clinical settings. More research is needed to deduce the relationship, if any, between cardiovascular risk reduction and pharmacological reduction of sUA levels.

Beyond silence: evolving ultrasound strategies in the battle against cardiovascular thrombotic challenges.

Cardiovascular thrombotic events have long been a perplexing factor in clinical settings, influencing patient prognoses significantly. Ultrasound-mediated acoustic therapy, an innovative thrombolytic treatment method known for its high efficiency, non-invasiveness, safety, and convenience, has demonstrated promising potential for clinical applications and has gradually become a focal point in cardiovascular thrombotic disease research. The current challenge lies in the technical complexities of preparing ultrasound-responsive carriers with thrombus-targeting capabilities and high thrombolytic efficiency. Additionally, optimizing the corresponding acoustic treatment mode is crucial to markedly enhance the thrombolytic effectiveness of ultrasound-mediated acoustic therapy. In light of the current status, this article provides a comprehensive review of the research progress in innovative ultrasound-mediated acoustic therapy for cardiovascular thrombotic diseases. It explores the impact of technical methods, therapeutic mechanisms, and influencing factors on the thrombolytic efficiency and clinical potential of ultrasound-mediated acoustic therapy. The review places particular emphasis on identifying solutions and key considerations in addressing the challenges associated with this cutting-edge therapeutic approach.

The Effect of Body Mass Index on Melanoma Biology, Immunotherapy Efficacy, and Clinical Outcomes: A Narrative Review.

Recent studies indicate that a higher body mass index (BMI) might correlate with improved responses to melanoma treatment, especially with immune checkpoint inhibitors (ICIs), despite the general association of obesity with an increased risk of cancer and higher mortality rates. This review examines the paradoxical relationship between BMI and clinical outcomes in melanoma patients by exploring molecular links, the efficacy of immunotherapy, and patient survival outcomes. Our comprehensive literature search across the PubMed and Embase databases revealed a consistent pattern: increased BMI is associated with a better prognosis in melanoma patients undergoing ICI treatment. This "obesity paradox" might be explained by the metabolic and immunological changes in obesity, which could enhance the effectiveness of immunotherapy in treating melanoma. The findings highlight the complexity of the interactions between obesity and melanoma, suggesting that adipose tissue may modulate the immune response and treatment sensitivity favorably. Our review highlights the need for personalized treatment strategies that consider the metabolic profiles of patients and calls for further research to validate BMI as a prognostic factor in clinical settings. This nuanced approach to the obesity paradox in melanoma could significantly impact treatment planning and patient management.

L2SR: learning to sample and reconstruct for accelerated MRI via reinforcement learning

Magnetic resonance imaging (MRI) is a widely used medical imaging technique, but its long acquisition time can be a limiting factor in clinical settings. To address this issue, researchers have been exploring ways to reduce the acquisition time while maintaining the reconstruction quality. Previous works have focused on finding either sparse samplers with a fixed reconstructor or finding reconstructors with a fixed sampler. However, these approaches do not fully utilize the potential of joint learning of samplers and reconstructors. In this paper, we propose an alternating training framework for jointly learning a good pair of samplers and reconstructors via deep reinforcement learning. In particular, we consider the process of MRI sampling as a sampling trajectory controlled by a sampler, and introduce a novel sparse-reward partially observed Markov decision process (POMDP) to formulate the MRI sampling trajectory. Compared to the dense-reward POMDP used in existing works, the proposed sparse-reward POMDP is more computationally efficient and has a provable advantage. Moreover, the proposed framework, called learning to sample and reconstruct (L2SR), overcomes the training mismatch problem that arises in previous methods that use dense-reward POMDP. By alternately updating samplers and reconstructors, L2SR learns a pair of samplers and reconstructors that achieve state-of-the-art reconstruction performances on the fastMRI dataset. Codes are available at https://github.com/yangpuPKU/L2SR-Learning-to-Sample-and-Reconstruct.

Do healthcare providers consider the social determinants of health? Results from a nationwide cross-sectional study in the United States

BackgroundWhile the social determinants of health (SDOH) have a greater impact on individual health outcomes than the healthcare services a person receives, healthcare providers face barriers to addressing these factors in clinical settings. Previous studies have shown that providers often lack the necessary knowledge and resources to adequately screen for and otherwise assist patients with unmet social needs. This study explores the perceptions and behaviors related to SDOH among healthcare providers in the United States (US).MethodsThis cross-sectional study analyzed data from a 22-item online survey using Reaction Data’s research platform of healthcare professionals in the US. Survey items included demographic questions as well as Likert scale questions about healthcare providers’ perceptions and behaviors related to SDOH. Descriptive statistics were calculated, and further analyses were conducted using t-tests and analysis of variance.ResultsA total of 563 respondents completed the survey, with the majority being male (72.6%), White (81%), and located in urban areas (82.2%). In terms of perceptions, most providers agreed or strongly agreed that SDOH affect the health outcomes of all patients (68.5%), while only 24.1% agreed or strongly agreed that their healthcare setting was set up to address SDOH. In terms of behavior, fewer than half currently screened for SDOH (48.6%) or addressed (42.7%) SDOH in other ways. Most providers (55.7%) wanted additional resources to focus on SDOH. Statistical analyses showed significant differences by gender, with females being more likely than males to prioritize SDOH, and by specialty, with psychiatrists, pediatricians, and family/general medicine practitioners being more likely to prioritize SDOH.ConclusionMost healthcare providers understand the connection between unmet social needs and their patients’ health, but they also feel limited in their ability to address these issues. Ongoing efforts to improve medical education and shift the healthcare system to allow for payment and delivery of more holistic care that considers SDOH will likely provide new opportunities for healthcare providers. In addition to what they can do at the institutional and patient levels, providers have the potential to advocate for policy and system changes at the societal level that can better address the root causes of social issues.

Tumor mineralization-based cancer diagnosis and therapy

Biomineralization is a phenomenon that involves the deposition of inorganic ions onto organic substrates, resulting in the formation of hard tissue materials. Tumor mineralization, on the other hand, encompasses two key aspects: tumor calcification and tumor iron mineralization. The occurrence of spontaneous tumor calcification and regional lymph node calcification in colorectal cancer, lung cancer, and glioblastoma has been established as a favorable prognostic factor in clinical settings. Building upon this understanding, we propose the concept and advance the development of a compound that artificially induces bionic mineralization around the surface of cancer cells. This process has demonstrated exceptional efficacy in inhibiting the growth and metastasis of cervical, breast, and lung tumors. Moreover, it has exhibited outstanding performance in the early-stage diagnosis of cancer. Consequently, we anticipate that this concept holds significant potential for cancer-targeted mineralization therapy and diagnosis, offering a novel avenue for the development of anticancer drugs.

Growth Factor Delivery Using a Collagen Membrane for Bone Tissue Regeneration.

The use of biomaterials and bioactive agents has shown promise in bone defect repair, leading to the development of strategies for bone regeneration. Various artificial membranes, especially collagen membranes (CMs) that are widely used for periodontal therapy and provide an extracellular matrix-simulating environment, play a significant role in promoting bone regeneration. In addition, numerous growth factors (GFs) have been used as clinical applications in regenerative therapy. However, it has been established that the unregulated administration of these factors may not work to their full regenerative potential and could also trigger unfavorable side effects. The utilization of these factors in clinical settings is still restricted due to the lack of effective delivery systems and biomaterial carriers. Hence, considering the efficiency of bone regeneration, both spaces maintained using CMs and GFs can synergistically create successful outcomes in bone tissue engineering. Therefore, recent studies have demonstrated a significant interest in the potential of combining CMs and GFs to effectively promote bone repair. This approach holds great promise and has become a focal point in our research. The purpose of this review is to highlight the role of CMs containing GFs in the regeneration of bone tissue, and to discuss their use in preclinical animal models of regeneration. Additionally, the review addresses potential concerns and suggests future research directions for growth factor therapy in the field of regenerative science.

Examining How Social Risk Factors Are Integrated Into Clinical Settings Using Existing Data: A Scoping Review.

Integrating social care into clinical care requires substantial resources. Use of existing data through a geographic information system (GIS) has the potential to support efficient and effective integration of social care into clinical settings. We conducted a scoping literature review characterizing its use in primary care settings to identify and address social risk factors. In December 2018, we searched 2 databases and extracted structured data for eligible articles that (1) described the use of GIS in clinical settings to identify and/or intervene on social risks, (2) were published between December 2013 and December 2018, and (3) were based in the United States. Additional studies were identified by examining references. Of the 5,574 articles included for review, 18 met study eligibility criteria: 14 (78%) were descriptive studies, 3 (17%) tested an intervention, and 1 (6%) was a theoretical report. All studies used GIS to identify social risks (increase awareness); 3 studies (17%) described interventions to address social risks, primarily by identifying relevant community resources and aligning clinical services to patients' needs. Most studies describe associations between GIS and population health outcomes; however, there is a paucity of literature regarding GIS use to identify and address social risk factors in clinical settings. GIS technology may assist health systems seeking to address population health outcomes through alignment and advocacy; its current application in clinical care delivery is infrequent and largely limited to referring patients to local community resources.

Social identity and the mental health and wellbeing of male veterans.

Previous work has linked disruptions in one's social identity to increased levels of depression and suicide among veterans. This study examines the relationship between veteran social identity (as measured by the public and private regard subscales of the Warrior Identity Scale) and mental health and wellbeing among male veterans. Male veterans (N = 67) completed the Warrior Identity Scale as well as various measures of mental health and wellbeing. The hypotheses were supported in that more positive views of one's social identity (i.e., more private regard) predicted significantly fewer post-traumatic stress disorder (PTSD) symptoms, less depression, suicidal ideation, anxiety, stress, and more perceived social support. More public regard, on the other hand, was related to more PTSD symptoms. This research adds to the growing work on the importance of social identity (as measured by public and private regard) in predicting mental health symptomatology among male veterans, which may act as important risk factors in clinical settings.

Association between changes in loneliness identified through screening and changes in depression or anxiety in older adults.

Changes in loneliness are associated with corresponding changes in depression, anxiety, and general health in population surveys, but few studies have assessed these associations through repeated screening in clinical settings. Retrospective cohort study among individuals ≥age 65 in an integrated health care system who completed loneliness screening before two annual wellness visits, separated by a mean of 12.9 (SD 2.0) months, between 2013 and 2018. Their responses identified four subgroups: individuals who were persistently lonely; not lonely; experienced an increase (recently lonely); or decrease (previously lonely) in loneliness. Loneliness was assessed with a single item. Depression was assessed with the Patient Health Questionnaire-2. Anxiety was assessed with the Generalized Anxiety Disorder-2. Fair/poor general health was assessed by a single item. Linear mixed effects models assessed changes in outcomes after covariate adjustment. The cohort comprised 24,666 individuals (19.2% of older adults in the system). Mean age was 73.7 years (SD 6.4); 54.6% were female, and 11.6% were members of racial and ethnic minority groups. Of these individuals, 1936 (7.8%) were persistently lonely, 1687 (6.8%) were recently lonely, 1551 (6.3%) were previously lonely, and 19,492 (79.0%) were not lonely at either time point. After adjustment for sociodemographic, clinical and social variables, recent loneliness was associated with increases in depression (adjusted odds ratio [aOR] 1.76, 95% confidence interval [CI] 1.41-2.19) and anxiety (aOR 1.67, 95% CI 1.32-2.10). Previous loneliness was associated with decreases in depression (aOR, 0.46, 95% CI 0.36-0.58) and anxiety (aOR 0.69, 95% CI 0.54-0.90). Changes in loneliness were not associated with changes in general health. Changes in loneliness identified through screening were associated with corresponding changes in depression and anxiety. These findings support the potential value of identifying social risk factors in clinical settings among older adults.

Biotin as a masking agent in chorionic gonadotropin assays utilizing biotinylated antibodies.

Biotin interference in streptavidin/biotin-based immunoassays has been recently recognized as a confounding factor in clinical settings. Depending on the nature of the assay, the presence of excess biotin in patient samples can cause falsely high or low results. One of the platforms known to be affected, Roche Cobas, is widely used in anti-doping laboratories to test for intact chorionic gonadotropin (hCG) in urine. While biotin levels in blood have been well studied, less is known about urinary biotin due to its limited clinical significance. Having analyzed over 4,000 urine samples, we have established a reference range for urinary biotin with a median concentration of approximately 12 ng/ml. However, a significant number of samples contain much higher amounts, with a maximum approaching 10μg/ml, suggesting biotin supplementation. Consequently, the tolerance of hCG STAT assay towards biotin was investigated over a wide concentration range. The apparent hCG concentration was found to decrease almost linearly as biotin increased from 100 to 1,000 ng/ml, with only 10% of the expected value reported by the assay as biotin reached 1,000 ng/ml. Further increase of biotin resulted in a progressive, albeit more moderate, decline in measured hCG concentration. To avoid a false negative result in the context of anti-doping analysis, it is highly recommended to monitor biotin in urine and perform diafiltration before hCG measurement in samples with elevated biotin to remove the interference.

Telerehabilitation During the COVID-19 Pandemic in Outpatient Rehabilitation Settings: A Descriptive Study.

ObjectiveCOVID-19 has widely affected delivery of health care. In response, telerehabilitation (TR) has emerged as alternative care model. Aims were: (1) describe baseline patient characteristics and available unadjusted outcomes for episodes of care administered during COVID-19 using TR vs. traditional in-person care, (2) describe TR frequency levels by condition and telecommunication modes.MethodsA descriptive retrospective observational design was used to report patient variables and outcomes including physical function, number of visits, and patient satisfaction, by TR frequency (few, most, or all visits) and telecommunication modes. Standardized differences were used to compare baseline characteristics between episodes with and without TR.ResultsSample consisted of 222,680 patients [59% female; mean age (SD) = 55(18)]. Overall TR rate was 6% decreasing from 10% to 5% between 2nd and 3rd quarters of 2020. Outcome measures were available for 90% to 100% of episodes. Thirty-seven percent of clinicians administered care via TR. Patients treated using TR compared to in-person care were more likely to be younger, and live in large metropolitan areas. From those with TR, 55%, 20%, and 25% had TR during few, most, or all visits, respectively. TR care was administered equally across orthopedic body parts, with lower use for non-orthopedic conditions such as stroke, edema, and vestibular dysfunction. TR was primarily administered using synchronous (video or audio) modes. The rate of patients reported being very satisfied with their treatment results was 3% higher for no TR compared to TR.ConclusionsThese results provide new knowledge about to whom and how TR is being administered during the pandemic in outpatient rehabilitation practices throughout the USA. The database assessed was found to be suitable for conducting studies on associations between TR and diverse outcome measures, controlling for a comprehensive set of patient characteristics, to advance best TR care models, and promote high quality care.ImpactThis study provided detailed and robust descriptive information using an existing national patient database containing patient health and demographic characteristics, outcome measures, and TR administration data. Findings support the feasibility to conduct future studies on associations between TR care and patient outcomes, adjusting for a wide range of patient characteristics and clinical setting factors that may be associated with the probability of receiving TR. Finding of limited and decreasing use of TR over the study period calls for studies aimed to better understand facilitators and inhibitors of TR use by rehabilitation therapists during everyday practice to promote its use when clinically appropriate.

Frequency and risk factors of pressure injuries in clinical settings of affiliated to Tabriz University of Medical Sciences.

AimPressure injuries are considered a common and costly problem in the care of patients. Prevention and identification of risk factors for pressure injuries are very important due to the high cost of treatment and the adverse consequences of pressure injuries. This study aimed to assess the prevalence of pressure injuries and its risk factors in clinical settings of affiliated to Tabriz University of Medical Sciences.DesignA descriptive‐analytical study.MethodsThis study was performed on 200 patients who were selected by random sampling. The data collection tool was a 3‐part questionnaire. Data were analysed using a t test, chi‐square, Fisher's exact test and logistic regression in SPSS v. 24.ResultsThe mean age of the participants was 51.93 (SD 14.99) years. The rate of pressure injuries in this study was 19.5%. The most susceptible area for pressure injuries were sacral (35.89%) and gluteal (20.51%), respectively. The pressure injuries was significantly associated with Braden's criteria, age, disease diagnosis and length of hospital stay (p < .05). But there was no statistically significant difference between sex and incidence of pressure injuries (p > .05).

Small Extracellular Vesicles from Human Fetal Dermal Cells and Their MicroRNA Cargo: KEGG Signaling Pathways Associated with Angiogenesis and Wound Healing.

The use of cell secreted factors in clinical settings could be an alternative to conventional cell therapy, with the advantage of limiting concerns generally associated with traditional cell transplantation, such as tumorigenicity, immunoreactivity, and carrying of infections. Based on our published data, we predict a potential role for extracellular vesicles (EVs) in contributing to the proangiogenic activity of human fetal dermal cell secretome. Depletion of nanosized EVs from secretome significantly impaired its ability to induce formation of mesh-like structures in vitro. The isolated EVs were characterized for size and concentration by nanoparticle tracking analysis, and for protein markers (Rab5+, Alix+, CD63+, and calnexin−). The microRNA profile of EVs revealed 87 microRNAs significantly upregulated (≥15-fold increase) in fetal compared to adult dermal cell-derived EVs. Interestingly, these upregulated microRNAs included microRNAs with a validated role in angiogenesis according to literature. Moreover, the DIANA-TarBase v7.0 analysis confirmed enrichment in the KEGG signaling pathways associated with angiogenesis and wound healing, with the identification of putative target genes including thrombospondin 1. To validate the in silico data, EVs were also characterized for total protein contents. When tested in in vitro angiogenesis, fetal dermal cell-derived EVs were more effective than their adult counterpart in inducing formation of complete mesh-like structures. Furthermore, treatment of fibroblasts with fetal dermal-derived EVs determined a 4-fold increase of thrombospondin 1 protein amounts compared with the untreated fibroblasts. Finally, visualization of CSFE-labeled EVs in the cytosol of target cells suggested a successful uptake of these particles at 4-8 hours of incubation. We conclude that EVs are important contributors of the proangiogenic effect of fetal dermal cell secretome. Hence, EVs could also serve as vehicle for a successful delivery of microRNAs or other molecules of therapeutic interest to target cells.

Effects of In-Person Navigation to Address Family Social Needs on Child Health Care Utilization

While many organizations endorse screening for social risk factors in clinical settings, few studies have examined the health and utilization effects of interventions to address social needs. To compare the acute care utilization effects of a written resources handout vs an in-person navigation service intervention to address social needs. In this secondary analysis of a randomized clinical trial, 1809 adult caregivers of pediatric patients seen in primary and urgent care clinics of 2 safety-net hospitals in northern California were recruited between October 13, 2013, and August 27, 2015. Each participating family was randomly assigned to an in-person navigator intervention vs active control to address the family's social needs. Analyses were conducted between February 28, 2018, and September 25, 2019. Caregivers either received written information about relevant local resources related to social needs (active control) or met with a patient navigator focused on helping them resolve social needs (navigator intervention). After an initial in-person visit, navigation services included telephone, email, and/or in-person follow-up for up to 3 months. Child emergency department visit or hospitalization within 12 months of study enrollment. Among the 1300 caregivers enrolled in the study without missing follow-up data, most spoke English (878 [67.5%]) and were women (1127 [86.7%]), with a mean (SD) age of 33.0 (9.33) years. Most children were aged 0 to 5 years (779 of 1300 [59.9%]), 723 children (55.6%) had Hispanic ethnicity, and 462 children (35.5%) were in excellent health; 840 families (64.6%) were recruited from urgent care. In total, 637 families (49.0%) were randomized to the in-person navigator group and 663 (51.0%) to the active control group. There was no difference in risk of an emergency department visit between the 2 groups. Children enrolled in the in-person navigator group had a decreased risk of hospitalization within 12 months (hazard ratio, 0.59; 05% CI, 0.38-0.94; P = .03), making them 69% less likely to be hospitalized. In this randomized clinical trial evaluating heath care utilization effects of programs designed to address social needs among families, children enrolled in the navigation group were significantly less likely to be hospitalized after the intervention but equally likely to have an emergency department visit. These findings strengthen our understanding of the effects of addressing social needs in clinical settings as part of a comprehensive strategy to improve health and reduce health care utilization. ClinicalTrials.gov Identifier: NCT01939704.

Maternal psychosocial risk factors and lower respiratory tract infection (LRTI) during infancy in a South African birth cohort.

ObjectiveTo investigate the association between maternal antenatal and/or postnatal psychosocial risk factors (including depression, psychological distress, alcohol abuse and intimate partner violence (IPV) and infant lower respiratory tract infection (LRTI) in a low- and middle-income-country (LMIC).Study designPregnant women (n = 1137) enrolled in a South African birth cohort study, the Drakenstein Child Health Study (DCHS) were longitudinally assessed for psychosocial risk factors including depression, psychological distress, alcohol abuse and/or intimate partner violence (IPV). Infants were followed from birth until one year of age for the development of LRTI by active surveillance. Two outcomes were evaluated: any LRTI, and severe and/or hospitalised LRTI. Logistic regression was used to identify associations between individual maternal psychosocial risk factors and LRTI outcomes. Analyses stratified by age were also performed to determine which age groups related to infant LRTI were linked with maternal psychosocial risk factors.ResultsThere were 606 LRTI episodes in 369 infants in the first year (crude incidence rate = 0.53 episodes per person-year, 95%CI: 0.50; 0.56); 31% (n = 186) of episodes were severe or hospitalised events. Maternal psychosocial risk factors were associated with LRTI and severe LRTI, particularly postnatal and long-term maternal psychological distress, antenatal maternal alcohol consumption, and postnatal maternal IPV. Age stratified analyses found that antenatal maternal alcohol consumption was associated with early infant LRTI, while antenatal maternal depression was linked with infant severe LRTI between 3 and 6 months of age, and postnatal maternal IPV was associated with early LRTI and severe forms of LRTI.ConclusionThe associations between maternal psychosocial risk factors and infant LRTI highlight the potential value of screening for maternal psychosocial risk factors in clinical settings and developing targeted interventions. Such interventions may not only improve maternal well-being, but also help reduce the burden of infant LRTI in LMIC settings.

Geriatric Elements and Oral Anticoagulant Prescribing in Older Atrial Fibrillation Patients: SAGE-AF.

Oral anticoagulants are the cornerstone of stroke prevention in high-risk patients with atrial fibrillation (AF). Geriatric elements, such as cognitive impairment and frailty, commonly occur in these patients and are often cited as reasons for not prescribing oral anticoagulants. We sought to systematically assess geriatric impairments in patients with AF and determine whether they were associated with oral anticoagulant prescribing. Cross-sectional analysis of baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) prospective cohort study. Multicenter study with site locations in Massachusetts and Georgia that recruited participants from cardiology, electrophysiology, and primary care clinics from 2016 to 2018. Participants with AF age 65 years or older, CHA2 DS2 -VASc (congestive heart failure; hypertension; aged ≥75 y [doubled]; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65-74; female sex) score of 2 or higher, and no oral anticoagulant contraindications (n = 1244). A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Oral anticoagulant use was abstracted from the medical record. A total of 1244 participants (mean age = 76 y; 49% female; 85% white) were enrolled; 42% were cognitively impaired, 14% frail, 53% pre-frail, 12% socially isolated, and 29% had depressive symptoms. Oral anticoagulants were prescribed to 86% of the cohort. Oral anticoagulant prescribing did not vary according to any of the geriatric elements (adjusted odds ratios [ORs] for oral anticoagulant prescribing and cognitive impairment: OR = .75; 95% confidence interval [CI] = .51-1.09; frail OR = .69; 95% CI = .35-1.36; social isolation OR = .90; 95% CI = .52-1.54; depression OR = .79; 95% CI = .49-1.27; visual impairment OR = .98; 95% CI = .65-1.48; and hearing impairment OR = 1.05; 95% CI = .71-1.54). Geriatric impairments, particularly cognitive impairment and frailty, were common in our cohort, but treatment with oral anticoagulants did not differ by impairment status. These geriatric impairments are commonly cited as reasons for not prescribing oral anticoagulants, suggesting that prescribers may either be unaware or deliberately ignoring the presence of these factors in clinical settings. J Am Geriatr Soc 68:147-154, 2019.

Do review tribunals consider protective factors in their decisions about patients found not criminally responsible?

ABSTRACTViolence risk assessment has been a routine part of clinical practice for several decades, and there are a number of risk factors that have been empirically demonstrated to predict recidivism. While research demonstrates their ability to predict future violence, risk factors are not always included in decision-making discussions regarding treatment or movement through the forensic system. Recently, research has demonstrated that protective factors provide incremental predictive validity over risk factors alone. We aimed to determine how or if these protective factors are being used by review boards for individuals found NCRMD (Not Criminally Responsible on Account of Mental Disorder). Using a random sample of 116 cases, and a retrospective file review design, we coded hospital reports and review board reasons documents for references to items from the Structured Assessment of Protective Factors (SAPROF). Results indicated that, on average, less than half of the SAPROF items are mentioned, but that hospital reports do mention more items than reasons documents. In addition, more items were referenced when individuals were moved to less secure settings. Protective factors may have some impact on decision-making however many protective factors are not being considered. Implications for the use of protective factors in clinical settings are discussed.

Factors Associated with Outcome in Patients with Acute Upper Gastrointestinal Bleeding in a Tertiary Referral Center in Northern Iran.

BACKGROUND Upper gastrointestinal bleeding (UGIB) is a major healthcare problem and is the most frequent gastrointestinal reason for admission to hospital. We aimed to investigate the prognosis of patients with UGIB referred to a referral hospital in northern Iran in 2013. METHODS All patients with UGIB who admitted to Sayyad Shirazi Hospital, in Gorgan, northern Iran, in 2013 were enrolled. The patients’ demographic data as well as data about admission, diseases, drug history, and patients’ prognosis were collected by structured questionnaire using information in hospital files. The relationships between different factors with the proportion of mortality and recurrence were assessed using Chi-square test. RESULTS In total, 168 patients were enrolled of whom 109 (64.9%) were male. The mean (SD) age of the patients was 59.4 (18.2) years. Mortality and recurrence occurred in 23.2% and 34.5% of the subjects, respectively. We found significant relationships between older age and diagnosis of malignancy with mortality (p =0.03 and p <0.01) and recurrence (p<0.01 and p <0.01). CONCLUSION We found relatively high rates of mortality and recurrence among patients with UGIB. Our results suggested older age and diagnosis of malignancy as the most important indicators of mortality and recurrence in such patients. Considering these factors in clinical settings may result in better and more effective management of patients with UGIB.

491. Messenger RNA (mRNA)-Based Gene Therapy for Introducing Anti-Apoptotic Factor

In gene therapy, mRNA delivery lacks the risk of random integration to host genome in contrast to DNA delivery. In introduction of anti-apoptotic factors, uncontrollably enhanced and prolonged expression of such factors after genomic integration would cause cancer, and thus DNA delivery cannot be used for introducing these factors in clinical settings. In this study, we tried to treat fulminant hepatitis, a disease associated with excessive apoptosis, by mRNA-based introduction of an anti-apoptotic factor, Bcl-2. For efficient mRNA delivery with minimal inflammatory responses, mRNA was loaded into our original carrier, polyplex nanomicelles (Adv Drug Deliv Rev 2001, 47, 113, PLoS One 2013, 8, e56220), which are composed of polyethyleneglycol-coated surface and mRNA-containing core, for hydrodynamic injection into mouse liver.In a reporter assay using GFP-expressing mRNA, the nanomicelles effectively introduced mRNA into liver cells by preventing degradation of mRNA, resulting in significantly higher level of GFP expression in liver compared to that after naked mRNA injection. This result is quite different from that of naked plasmid DNA (pDNA) delivery, strongly suggesting that mRNA is unstable in mouse body, and a proper carrier is required for mRNA delivery.In tissue distribution analysis of GFP expression, mRNA delivery induced GFP expression uniformly in almost 100% of liver cells, whereas only a small percentage of liver cells became GFP positive after pDNA delivery. After delivery of Cy5-labeled pDNA, nuclear localization of pDNA was undetected in a large percentage of cells, indicating that nuclear entry was a large obstacle in DNA delivery. In contrast, protein expression from mRNA requires only cytoplasmic uptake of mRNA, and this was observed in almost all liver cells, resulting in uniform GFP expression profile.Then, we performed the treatment of fulminant hepatitis using Bcl-2-expressing gene, after preparing a mouse model of the disease by injecting Fas ligand. After mRNA-based introduction of Bcl-2, the number of apoptotic cells in liver was significantly reduced when compared to saline-treated control. In contrast, delivery of Bcl-2-expressing pDNA had almost no therapeutic effect. It is suggested that, in pDNA delivery, a large percentage of cells were unprotected from apoptotic signals because of inhomogeneous protein expression profile. Thus, these results indicate that mRNA delivery is more suitable for introducing intracellular signaling factors than DNA delivery, because such factors require homogeneous expression to obtain therapeutic effect. This is in sharp contrast to the case of secretable factors, where efficient introduction to only a small percentage of cells is sufficient to obtain therapeutic effect.In summary, mRNA delivery has two advantages over pDNA delivery: homogeneous distribution profile of protein expression, and lack of random genomic integration. Thus, mRNA delivery is promising for the treatment of various intractable diseases associated with massive apoptosis.