Body mass index and Mini Nutritional Assessment-Short Form as predictors of in-geriatric hospital mortality in older adults with COVID-19.

BACKGROUND & AIMS: Overweight and obesity have been consistently reported to carry an increased risk for poorer outcomes in coronavirus disease 2019 (COVID-19) in adults. Existing reports mainly focus on in-hospital and intensive care unit mortality in patient cohorts usually not representative of the population with the highest mortality, i.e. the very old and frail patients. Accordingly, little is known about the risk patterns related to body mass and nutrition in very old patients. Our aim was to assess the relationship between body mass index (BMI), nutritional status and in-geriatric hospital mortality among geriatric patients treated for COVID-19. As a reference, the analyses were performed also in patients treated for other diagnoses than COVID-19. METHODS: We analyzed up to 10,031 geriatric patients with a median age of 83 years of which 1409 (14%) were hospitalized for COVID-19 and 8622 (86%) for other diagnoses in seven geriatric hospitals in the Stockholm region, Sweden during March 2020-January 2021. Data were available in electronic hospital records. The associations between 1) BMI and 2) nutritional status, assessed using the Mini-Nutritional Assessment - Short Form (MNA-SF) scale, and short-term in-geriatric hospital mortality were analyzed using logistic regression. RESULTS: After adjusting for age, sex, comorbidity, polypharmacy, frailty and the wave of the pandemic (first vs. second), underweight defined as BMI<18.5 increased the risk of in-hospital mortality in COVID-19 patients (odds ratio [OR] = 2.30; confidence interval [CI] = 1.17-4.31). Overweight and obesity were not associated with in-hospital mortality. Malnutrition; i.e. MNA-SF 0-7 points, increased the risk of in-hospital mortality in patients treated for COVID-19 (OR = 2.03; CI = 1.16-3.68) and other causes (OR = 6.01; CI = 2.73-15.91). CONCLUSIONS: Our results indicate that obesity is not a risk factor for very old patients with COVID-19, but emphasize the role of underweight and malnutrition for in-hospital mortality in geriatric patients with COVID-19.

A case report of systemic capillary leak syndrome (Clarkson's disease).

Systemic capillary leak syndrome (SCLS) is a very rare disorder also known as Clarkson's disease. The condition is characterized by recurrent episodes of severe capillary hyperpermeability resulting in severe hemoconcentration, hypoalbuminemia, hypovolemia and shock. We describe a 41-year-old previously healthy man who was admitted to hospital on several occasions with rapidly developing hypovolemic shock accompanied by extreme hemoconcentration and hypoalbuminemia. Our case is similar to other reports describing patients with SCLS where the initial suspicions have been pointing towards septic shock. He received a combination of prophylactic treatment with theophylline, beta-agonists, immunoglobulins and statins but eventually died after a severe episode of SCLS that ended with recurrent cardiac arrest. Clinical autopsy revealed pulmonary edema and acute and chronical organic fluid overload. SCLS should be kept in mind when treating patients suffering from attacks of severe idiopathic edema and mimics recurrent septic shock where no pathogen is found. The pathogenesis is unknown and the attacks may be lethal.

Characterization of blood vessels in bone marrow from patients with chronic myeloid leukemia and polycythemia vera.

Angiogenesis is a feature of hematological malignancies which may provide prognostic information. However, there is, as yet, no established marker for leukemia-associated vessels in bone marrow. In this study, immunohistochemical stainings for von Willebrand factor (vWf), CD34, Tie-2, angiomodulin, glycodelin, cycloxygenase-2 (Cox-2) and endoglin were compared in order to identify the bone marrow vasculature. Chronic myeloid leukemia (CML), a disease displaying intense angiogenesis, and polycythemia vera (PV), a disease with a low microvascular density (MVD), were studied, as well as normal bone marrow. Only vWf, CD34 and Tie-2 stained the bone marrow endothelium. Although more vessels were stained for vWf than for CD34, there was no evidence that vWf stained more disease-associated vessels. In double staining, Tie-2 co-localized with CD34, but vessels staining only for Tie-2 were also found. However, the number of Tie-2-positive vessels did not correlate to either the MVD or the disease. Angiomodulin, glycodelin, Cox-2 and endoglin did not stain vessel-like structures. In conclusion, estimating the MVD by means of CD34 staining appears to be the most reliable method, but none of the tested molecules qualified as a specific marker for leukemia-associated vessels in the bone marrow.

[New observations support the significance of angiogenesis in myeloma]. / Nya rön stödjer betydelsen av angiogenes vid myelom.

Angiogenesis appears to be a prominent feature of many hematological disorders, in particular multiple myeloma. The remissions achieved when treating patients with advanced myeloma with the angiostatic drug thalidomide suggested that the disease might be angiogenesis-dependent. However, the mechanisms for the beneficial effect of thalidomide are, at this time, rather unclear, and may involve other effects beside angiostasis. Nonetheless, these and other observations have spurred an interest in angiogenesis that might lead to new concepts and treatment modalities. Here, an update concerning angiogenesis and multiple myeloma is presented.

[Learning among medical students. Teachers' commitment a decisive factor]. / Inlärning hos läkarstuderande. Lärarnas engagemang en avgörande faktor.

During their medical education, students take many courses in a variety of scientific subjects. This is most noticeable during the 5th term, when 6 subjects are taught in parallel during a 10 week period. This makes the process of learning very important. Using a modified written questionnaire we asked for students' opinions on factors important for learning. For crucial parameters such as coherence in knowledge and study motivation the students considered teachers' interest in students' learning to be the critical factor.

Bone marrow in polycythemia vera, chronic myelocytic leukemia, and myelofibrosis has an increased vascularity.

Several studies have emphasized the significance of neoangiogenesis for tumor growth and progression, but few have focused on malignant hematological disorders. We studied vascular density and architecture in bone marrow samples of patients with chronic myeloproliferative disease (MPD). Vascular structures were immunostained (for von Willebrand factor/FVIII-RAG, CD 31/PECAM or Ulex europeus I for vessels and for vascular endothelial growth factor, VEGF) in samples from patients with polycythemia vera (PV) (n = 7), chronic myelocytic leukemia (CML) (n = 9), and myelofibrosis (MF) (n = 6) when diagnosed and were compared with normal bone marrow specimens (n = 9). We observed that the mean (+/- SD) vessel count per high-power microscopy field (HPF) was 5.3 (+/- 2.1) in normal bone marrow, 5.9 (+/- 2.1) in PV, 10.8 (+/- 3.2) in CML, and 14.4 (+/- 5.5) in MF (P < 0.001 for CMP and MF versus controls). Confocal microscopy, including three-dimensional reconstructions of the blood vessel architecture, confirmed this increased vessel density and revealed tortuous vessel architecture and increased branching in the MPD, particularly in CML and MF. Furthermore, the number of VEGF-positive bone marrow cells was increased in CML and, particularly, in MF. Numbers of VEGF-positive cells and vessels per HPF correlated significantly (r = 0.41; P = 0. 037). Thus the myeloproliferative diseases PV, CML, and MF exhibit neoangiogenesis that is related to diagnosis.

Properties of three isoforms of the 116-kDa subunit of vacuolar H+-ATPase from a single vertebrate species. Cloning, gene expression and protein characterization of functionally distinct isoforms in Gallus gallus.

Vacuolar H+-ATPases (V-ATPases) are involved in a wide variety of essential cellular processes. An unresolved question is how the cell regulates the activity of these proton pumps and their targeting to distinct cellular compartments. There is growing evidence for the presence of subunit diversity amongst V-pumps, particularly regarding the 116-kDa subunit (called the a subunit). We have cloned and characterized three isoforms (a1, a2 and a3) of this subunit from chicken. The amino-acid sequences of these homologues are approximately 50% similar and their nucleotide differences indicate that they are products of distinct genes. The levels of mRNA expression of these isoforms was quantified by ribonuclease protection analysis. The a1 and a2 isoforms have a similar tissue distribution, with the highest level of mRNA expression in brain, an intermediate level in kidney and relatively low levels in liver and bone. In contrast, the highest level of expression of the a3 isoform is in bone and liver, with a moderate level in kidney, and the lowest level in brain. An antibody against the a1 isoform reacted with a 116 kDa protein in a brain V-ATPase preparation that was not detected in bone or liver V-ATPase preparations, whereas an antibody against the a3 isoform reacted with a 116-kDa peptide in bone and liver, but not brain V-ATPases preparations. The bone and brain V-ATPases showed differential sensitivity to the inhibitors bafilomycin and (2Z,4E)-5-(5,6-dichloro-2-indolyl)-2-methoxy-N-[4-(2, 2,6,6-tetramethyl)piperidinyl]-2,4-pentadienamide. Thus, this work demonstrates the presence of structurally and functionally distinct V-ATPases in a single vertebrate species.

Bile salt-stimulated lipase (BSSL) distribution in rat, mouse and transgenic mouse expressing human BSSL.

In some species, including man and mouse, bile salt-stimulated lipase (BSSL) in milk catalyzes the hydrolysis of triacylglycerides into glycerol and free fatty acids, a reaction that is of particular importance during suckling. The enzyme is also secreted by the pancreas (referred to as carboxyl-ester hydrolase, CEH). We wished to localize sources and storage sites for BSSL/CEH in rats, in wild-type mice, and in transgenic mice producing recombinant human BSSL in milk. Immunoreactivity against several BSSL fragments was strong in the pancreatic acinar cells and moderate in the absorptive cells of the small intestine and in salivary duct cells of the mice, as well as in rats. Sections from lactating mammary glands of mouse, but not rat, also showed immunoreactivity for BSSL; the signal was strongest in the transgenic mice. Radioactive riboprobes for BSSL mRNA hybridized on sections of rat and mouse pancreatic acinar cells, and mouse mammary glands (both wild-type and transgenic). Using RT-PCR, it was possible to amplify BSSL mRNA from wild-type mouse pancreas and mammary gland, from rat submandibular glands, and, in a few cases, from rat liver. In transgenic mice, the BSSL mRNA was highly expressed only in lactating mammary gland, but could be detected in a few other organs as well.

In situ hybridization of mRNA for the gastric H+,K(+)-ATPase in rat oxyntic mucosa.

The H+,K(+)-ATPase member of the phosphorylating ion motive ATPases is composed of two subunits, a large alpha-subunit composed of about 1030 amino acids and a smaller beta-subunit consisting of about 290 amino acids. By biochemical and immunological methods both subunits have been found in high abundance in the gastric parietal cell. In the present study in situ hybridization was used for localizing and comparing concentrations of the mRNA for the two subunits in the gastric epithelium. For this purpose 3H-labelled probes were preferred. Hybridization was detected only in the parietal cells. The older parietal cells in the bottom of the mucosa gave a weaker hybridization signal than the younger parietal cells closer to the surface. The margin of experimental ulcers, where the parietal cells are of low differentiation, showed very weak, if any, hybridization. The differences observed in hybridization densities may reflect differences in mRNA synthesis or stability. It is conceivable that older parietal cells, as well as parietal cells of low differentiation, produce relatively small amounts of H+,K(+)-ATPase.

Application of capillary electrophoresis to the post-polymerase chain reaction analysis of rat mRNA for gastric H+,K(+)-ATPase.

We have developed a competitive quantitative RNA/polymerase chain reaction (PCR) method using capillary electrophoresis in the post-PCR analysis for the quantitation of rat gastric H+,K(+)-ATPase mRNA. Analysis with CE allows quick and direct separation, evaluation, and characterization of DNA fragments similar in size, and it offers a convenient way of automatizing the post-PCR analysis. To estimate the magnitudes of different error contributions affecting the accuracy and reproducibility of the results, an analysis of variance was performed using the data obtained from quantitating mRNA levels in 10 different total RNA extracts from the Corpus region of Sprague-Dawley rats. The result showed that the reproducibility of the method of analysis was sufficient for the determination of H+,K(+)-ATPase mRNA levels among animals even when small fluctuations in RNA synthesis are to be measured. A comparison was also made of the mRNA levels of the beta- and alpha- subunits of H+,K(+)-ATPase, and the results were found to be in the same level.

Crystallization and preliminary crystallographic data for the azurin mutant End-121 from Pseudomonas aeruginosa.

Pseudomonas aeruginosa azurin has been crystallized from a mutant where residues from Met 121 to Lys128 have been deleted from the protein. The crystals form pale-blue well formed prisms in the orthorhombic space group P2(1)2(1)2(1), with cell dimensions a = 60.79 (5), b = 123.47 (5), c = 187.77 (5) A. The crystals diffract to 3.0 A and there are eight molecules in the asymmetric unit.

Reactivation of chronic hepatitis C after withdrawal of immunosuppressive therapy.

A patient with immune-mediated thrombocytopenia (ITP) and chronic hepatitis C virus (HCV) infection for 11 years was given immunosuppressive treatment because of an activation of his ITP. After 6 weeks of treatment with cyclophosphamide, cyclosporin A and cortisone the patient decided not to continue taking his medication. One month later he was readmitted to hospital due to fever, cough and jaundice. Clinical investigation revealed his condition to be caused by an activation of his HCV infection. It is concluded that, in parallel to the situation in hepatitis B, immunosuppressive treatment of patients with HCV infection may lead to increased viral replication, resulting in severe liver damage when immunocompetence is regained.

Intramolecular electron transfer in single-site-mutated azurins.

Single-site mutants of the blue, single-copper protein, azurin, from Pseudomonas aeruginosa were reduced by CO2- radicals in pulse radiolysis experiments. The single disulfide group was reduced directly by CO2- with rates similar to those of the native protein [Farver, O., & Pecht, I. (1989) Proc. Natl. Acad. Sci. U.S.A. 86, 6968-6972]. The RSSR- radical produced in the above reaction was reoxidized in a slower intramolecular electron-transfer process (30-70 s-1 at 298 K) concomitant with a further reduction of the Cu(II) ion. The temperature dependence of the latter rates was determined and used to derive information on the possible effects of the mutations. The substitution of residue Phe114, situated on the opposite side of Cu relative to the disulfide, by Ala resulted in a rate increase by a factor of almost 2. By assuming that this effect is only due to an increase in driving force, lambda = 135 kJ mol-1 for the reorganization energy was derived. When Trp48, situated midway between the donor and the acceptor, was replaced by Leu or Met, only a small change in the rate of intramolecular electron transfer was observed, indicating that the aromatic residue in this position is apparently only marginally involved in electron transfer in wild-type azurin. Pathway calculations also suggest that a longer, through-backbone path is more efficient than the shorter one involving Trp48. The former pathway yields an exponential decay factor, beta, of 6.6 nm-1. Another mutation, raising the electron-transfer driving force, was produced by changing the Cu ligand Met121 to Leu, which increases the reduction potential by 100 mV.(ABSTRACT TRUNCATED AT 250 WORDS)

Structural characterization of azurin from Pseudomonas aeruginosa and some of its methionine-121 mutants.

Azurin from Pseudomonas aeruginosa and two mutants where the methionine ligand has been mutated have been studied in order to directly investigate the functional and structural significance of this ligand in the blue copper proteins. Reduction potentials, X-ray absorption fine structure (XAFS), electron paramagnetic resonance (EPR), and optical spectra are obtained in an attempt to provide a direct correlation between the spectrochemical properties and the immediate structure of this redox center.

Reactivity of cytochromes c and f with mutant forms of spinach plastocyanin.

The reduction of plastocyanin by cytochromes c and f has been investigated with mutants of spinach plastocyanin in which individual, highly conserved surface residues have been modified. These include Leu-12 and Phe-35 in the 'northern' hydrophobic patch and Tyr-83 and Asp-42 in the 'eastern' acidic patch. The differences observed all involved binding rather than the intrinsic rates of electron transfer. The Glu-12 and Ala-12 mutants showed small but significant decreases in binding constant with cytochrome c, even though the cytochrome is not expected to make contact with the northern face of plastocyanin. These results, and small changes in the EPR parameters, suggested that these mutations cause small conformational changes in surface residues on the eastern face of plastocyanin, transmitted through the copper centre. In the case of cytochrome f, the Glu-12 and Ala-12 mutants also bound less strongly, but Leu12Asn showed a marked increase in binding constant, suggesting that cytochrome f can hydrogen bond directly to Asn-12 in the reaction complex. A surprising result was that the kinetics of reduction of Asp42Asn were not significantly different from wild type, despite the loss of a negative charge.

Flash-photolysis studies of the electron transfer from genetically modified spinach plastocyanin to photosystem I.

Plastocyanin (Pc) has been modified by site-directed mutagenesis at two separate electron-transfer (ET) sites: Leu-12-Glu at a hydrophobic patch, and Tyr-83-His at an acidic patch. The reduction potential at pH 7.5 is decreased by 26 mV in Pc(Leu-12-Glu) and increased by 35 mV in Pc(Tyr-83-His). The latter mutant shows a 2-fold slower intracomplex ET to photosystem I (PSI) as expected from the decreased driving force. The affinity for PSI is unaffected for this mutant but is drastically decreased for Pc(Leu-12-Glu). It is concluded that the hydrophobic patch is more important for the ET to PSI.

Cassette mutagenesis of Met121 in azurin from Pseudomonas aeruginosa.

Cassette mutagenesis was used to exchange the suggested copper ligand Met121 in azurin to all other amino acids, and a stop codon. The mutant proteins were characterized by optical absorption spectroscopy and EPR. At low pH, all mutants exhibit the characteristics of a blue type 1 copper protein, indicating that methionine is not needed to create a blue copper site. At high pH, the Glu121 and the Lys121 mutants constitute a new form of protein-bound copper that is outside the range of type 1 copper.

Expression of spinach plastocyanin in E. coli.

An expression vector designed for overexpression of plastocyanin in the periplasmic space of E. coli has been developed. The vector contains the signal peptide sequence of Pseudomonas aeruginosa azurin and the mature sequence of spinach plastocyanin. The precursor is efficiently translocated to the periplasmic space and correctly processed to mature plastocyanin. No detectable amount of plastocyanin was present in the cytoplasmic or in the membrane fraction. A large scale preparation of the recombinant plastocyanin in a 20 litre fermentor yielded approximately 30 mg of pure plastocyanin. The recombinant protein obtained from E. coli shows CD, EPR and optical properties identical to plastocyanin isolated from spinach.

The structural gene for cytochrome c551 from Pseudomonas aeruginosa. The nucleotide sequence shows a location downstream of the nitrite reductase gene.

The gene coding for Pseudomonas aeruginosa cytochrome c551 has been cloned and its nucleotide sequence determined. Cytochrome c551 is expressed as a 104 amino acid pre-protein from which a signal peptide of 22 amino acids is cleaved off during the translocation across the cytoplasmic membrane. The gene is located just downstream of the gene coding for nitrite reductase on the Pseudomonas aeruginosa chromosome, suggesting that these genes form an operon.