Geriatric assessment in elderly patients receiving oral anticoagulants: results of the nursing study

Background

It is well known that thrombosis and bleeding risk increases with age, in the same time prevalence of geriatric syndromes increases too. It can influence negatively on efficacy and safety of anticoagulant therapy. However, impact of geriatric syndromes is often underestimated in clinical practice.

Purpose

To evaluate prevalence of geriatric syndromes in elderly patients receiving oral anticoagulants (OAC).

Methods

This study enrolled 510 patients (19% male) aged 75–100 (mean 82±4) years hospitalized to our clinic consecutively from June to November in 2019. Nurses examined all patients according to specially designed nursing assessment algorithm that included Mini-Cog test, Morse Fall and Norton scales, Barthel Activities of daily living Index, Short Physical Performance Battery (SPPB) tests, Mini Nutritional Assessment (MNA) scale, Geriatric Depression Scale (GDS-15), and some other questionnaires. Before hospitalization, 61 patients (12%) received OAC due to atrial fibrillation (AF) (83,6%), venous thromboembolism (VTE) (9,8%) and AF+VTE (6,6%). In all patients, AF frequency was 21% (n=107), but OAC were prescribed in 51% (n=55) only. Patients receiving OAC (group 1; n=61) did not differ from those without OAC (group 2; n=449) by age, sex, frequency of hypertension, previous myocardial infarction and revascularization, stable angina, and some other chronic diseases.

Results

Patients in group 1 had lower score on Norton scale (17,2±2,3 vs 18,1±1,8; p=0,001), Barthel Index (87,9±19,1 vs 94,4±10,7; p<0,001), SPPB (4,5±3,1 vs 6,0±3,3; p=0,001), walk speed (0,50±0,44 vs 0,60±0,30 m/s; p=0,014) and higher score on Morse Fall scale (47,8±20,7 vs 39,8±20,6; p=0,005) compared to patients in group 2. They had higher frequency of frailty (SPPB tests ≤7 score) (82% vs 66%; p=0,011), functional dependence (Barthel Index ≤60 score) (71% vs 44%; p<0,001) and pressure ulcers high risk (Norton scale ≤13 score) (6,6% vs 1,6%; p=0,012). They also had higher frequency of fall in the past year (57% vs 41%; p=0,017), high fall risk (Morse Fall scale ≥51 score) (38% vs 28%; p=0,073) and subcutaneous hematomas (25% vs 12%; p=0,009). Univariate regression analysis with age and sex adjustment showed that patients receiving OAC had higher risk of functional dependence (OR 3,05; 95% CI 1,69–5,49; p<0,001), frailty (OR 2,31; 95% CI 1,16–4,62; p=0,018) and pressure ulcers high risk (OR 4,24; 95% CI 1,19–15,16; p=0,026). OAC therapy was also associated with falls in the past year (OR 1,94; 95% CI 1,13–3,35; p=0,016)

Conclusion

Patients receiving OAC had a higher incidence of some geriatric syndromes, such as frailty, functional dependence, falls, pressure ulcers high risk, and lower functional status compared to patients without OAC. Nursing assessment of geriatric patients provides physician with additional data that allows to identify factors potentially affecting the efficacy and safety of OAC therapy.

Funding Acknowledgement

Type of funding sources: None.

Elderly patients with chronic heart failure have higher risk of geriatric syndromes: results of the nursing study

Background

The prevalence of chronic heart failure (CHF) and geriatric syndromes increases with age, however the associations between these conditions have not yet been studied.

Purpose

To evaluate the associations between CHF and geriatric syndromes in elderly patients.

Methods

Four hundred and seventy-two in-patients (18% male) aged 75–100 (mean 81±4) years were included in the nursing study. Patients were examined by nurses with a specially designed nursing assessment algorithm that included Mini-Cog test, Morse Fall scale, Norton scale, Barthel Activities of daily living Index, Short Physical Performance Battery (SPPB) tests, Mini Nutritional Assessment (MNA) scale, Geriatric Depression Scale (GDS-15), and a number of other questionnaires.

Results

CHF was observed in 180 patients (38%). Functional class (FC) of II (NYHA) was diagnosed in 133 (74%) of them, FC of III – in 47 (26%). Patients with and without CHF did not differ by age and gender. CHF patients had lower points on Norton scale (17,6±2,0 vs 18,2±1,8; p<0,001), Barthel Index (92,0±13,9 vs 95,0±9,1; p=0,009), SPPB (5,3±3,2 vs 6,0±3,3; p=0,018), and higher points on Morse Fall scale (44,3±19,9 vs 39,3±21,1; p=0,007) and GDS-15 (4,7±3,2 vs 4,2±3,3; p=0,041) compared to non-CHF patients. CHF patients had higher frequency of frailty (75% vs 65%; p=0,029), depression (47% vs 38%; p=0,041), and cognitive impairment (54% vs 41%; p=0,008). Univariate regression analysis showed that CHF presence increased the frailty risk by 1,6 times (OR 1,59; 95% CI 1,05–2,40; p=0,029), the depression risk – by 1,5 times (OR 1,48; 95% CI 1,02–2,16; p=0,041), and the cognitive impairment risk – by 1,7 times (OR 1,65; 95% CI 1,14–2,40; p=0,009). Among CHF patients, severity of CHF clinical manifestations correlated with severity of geriatric syndromes. CHF patients with FC of II had higher points of Norton scale (17,8±1,9 vs 16,9±2,1; p=0,005), Barthel Index (93,4±12,9 vs 88,3±15,8; p=0,005), SPPB (4,4±3,3 vs 3,9±3,0; p=0,001), walk speed (0,58±0,26 vs 0,45±0,22 m/s; p=0,002), and lower points of GDS-15 (4,4±3,3 vs 5,5±2,9; p=0,008) compared to CHF patients with FC of III. The frequency of depression was higher in CHF patients with FC of III (64% vs 41%; p=0,008). Univariate regression analysis showed that in CHF patients with FC of III the depression risk was higher by 2,5 times (OR 2,50; 95% CI 1,26–4,98; p=0,009) compared to CHF patients with FC of II.

Conclusion

Elderly CHF patients had higher risk of geriatric syndromes such as frailty, depression, and cognitive impairment. Among CHF patients, severity of CHF clinical manifestations correlated with severity of geriatric syndromes.

Funding Acknowledgement

Type of funding source: None

Protective Allele for Multiple Sclerosis HLA-DRB1*01:01 Provides Kinetic Discrimination of Myelin and Exogenous Antigenic Peptides

Risk of the development of multiple sclerosis (MS) is known to be increased in individuals bearing distinct class II human leukocyte antigen (HLA) variants, whereas some of them may have a protective effect. Here we analyzed distribution of a highly polymorphous HLA-DRB1 locus in more than one thousand relapsing-remitting MS patients and healthy individuals of Russian ethnicity. Carriage of HLA-DRB1*15 and HLA-DRB1*03 alleles was associated with MS risk, whereas carriage of HLA-DRB1*01 and HLA-DRB1*11 was found to be protective. Analysis of genotypes revealed the compensatory effect of risk and resistance alleles in trans. We have identified previously unknown MBP_153-161 peptide located at the C-terminus of MBP protein and MBP_90-98 peptide that bound to recombinant HLA-DRB1*01:01 protein with affinity comparable to that of classical antigenic peptide 306-318 from the hemagglutinin (HA) of the influenza virus demonstrating the ability of HLA-DRB1*01:01 to present newly identified MBP_153-161 and MBP_90-98 peptides. Measurements of kinetic parameters of MBP and HA peptides binding to HLA-DRB1*01:01 catalyzed by HLA-DM revealed a significantly lower rate of CLIP exchange for MBP_153-161 and MBP_90-98 peptides as opposed to HA peptide. Analysis of the binding of chimeric MBP-HA peptides demonstrated that the observed difference between MBP_153-161, MBP_90-98, and HA peptide epitopes is caused by the lack of anchor residues in the C-terminal part of the MBP peptides resulting in a moderate occupation of P6/7 and P9 pockets of HLA-DRB1*01:01 by MBP_153-161 and MBP_90-98 peptides in contrast to HA_308-316 peptide. This leads to the P1 and P4 docking failure and rapid peptide dissociation and release of empty HLA-DM-HLA-DR complex. We would like to propose that protective properties of the HLA-DRB1*01 allele could be directly linked to the ability of HLA-DRB1*01:01 to kinetically discriminate between antigenic exogenous peptides and endogenous MBP derived peptides.

Upgraded Methodology for the Development of Early Diagnosis of Parkinson's Disease Based on Searching Blood Markers in Patients and Experimental Models

Numerous attempts to develop an early diagnosis of Parkinson's disease (PD) by searching biomarkers in biological fluids were unsuccessful. The drawback of this methodology is searching markers in patients at the clinical stage without guarantee that they are also characteristic of either preclinical stage or prodromal stage (preclinical-prodromal stage). We attempted to upgrade this methodology by selecting only markers that are found both in patients and in PD animal models. HPLC and RT-PCR were used to estimate the concentration of amino acids, catecholamines/metabolites in plasma and gene expression in lymphocytes in 36 untreated early-stage PD patients and 52 controls, and in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-treated mice at modeling the clinical ("symptomatic") stage and preclinical-prodromal ("presymptomatic") stage of PD. It was shown that among 13 blood markers found in patients, 7 markers are characteristic of parkinsonian symptomatic mice and 3 markers of both symptomatic and presymptomatic mice. According to our suggestion, the detection of the same marker in patients and symptomatic animals indicates adequate reproduction of pathogenesis along the corresponding metabolic pathway, whereas the detection of the same marker in presymptomatic animals indicates its specificity for preclinical-prodromal stage. This means that the minority of markers found in patients-decreased concentration of L-3,4-dihydroxyphenylalanine (L-DOPA) and dihydroxyphenylacetic acid (DOPAC) and increased dopamine D3 receptor gene expression-are specific for preclinical-prodromal stage and are suitable for early diagnosis of PD. Thus, we upgraded a current methodology for development of early diagnosis of PD by searching blood markers not only in patients but also in parkinsonian animals.

Molecular genetic analysis of the Influenza A(H1N1)pdm09 virus from lethal and recovered cases in Russia from 2009 to 2014: Deletions in the nucleoprotein

Influenza A(H1N1)pdm09 virus caused about 2000 laboratory confirmed lethal cases in Russia during 2009-2010 and 1302, 135 and 29 cases in the 2010-2011, 2012-2013 and 2013-2014 seasons respectively. The on average short duration (7.8±5 days) of lethal cases of Influenza A(H1N1)pdm09 infections in Russia suggests primary viral rather than secondary bacterial pneumonia. Hemorrhagic syndrome was recorded in 36.6% of patients. An examination of 221 lung samples from lethal influenza cases for the presence of bacterial DNA that could cause pneumonia did not reveal bacterial superinfections in 86% of cases. Molecular-genetic analyses of Influenza A(H1N1)pdm09 viruses from lethal and recovered cases were performed. Amino acids G and N at position 222 of the influenza virus hemagglutinin, which increase the affinity for the lower respiratory tract receptors, were detected more often in the lungs of patients who died than in respiratory swabs collected from recovered patients (p<0.0001 and p=0.007). Viruses harboring various mutations (222D/G/N/S) was significantly associated with lung samples compared with respiratory swabs from recovered patients (p<0.0001). Amino acid 222E, which increases the affinity for upper respiratory tract receptors, was found more frequently in recovered patients than in patients with lethal disease (27% versus 3%, p=0.005). Phylogenetic analysis identified an isolated cluster of viruses in the 2009-2010 season that harbored amino acid 222E, which could explain the high transmissibility of the virus at the beginning of the pandemic. Bayesian skyline plot implied a decline in the effective population size of Influenza A(H1N1)pdm09 viruses in Russia from 2010-2011 to 2011-2012, followed by an increase in 2012-2013; this trend was accompanied by the increased genetic diversity of the hemagglutinin antigenic sites. Mutations of viral RNA leading to oseltamivir resistance were found in 2.8% of tested patients during only 2010-2011 season. Deletions in the nucleoprotein cDNA were found in influenza viruses from two patients.

The DUBm subunit Sgf11 is required for mRNA export and interacts with Cbp80 in Drosophila

SAGA/TFTC is a histone acetyltransferase complex that has a second enzymatic activity because of the presence of a deubiquitination module (DUBm). Drosophila DUBm consists of Sgf11, ENY2 and Nonstop proteins. We show that Sgf11 has other DUBm-independent functions. It associates with Cbp80 component of the cap-binding complex and is thereby recruited onto growing messenger ribonucleic acid (mRNA); it also interacts with the AMEX mRNA export complex and is essential for hsp70 mRNA export, as well as for general mRNA export from the nucleus. Thus, Sgf11 functions as a component of both SAGA DUBm and the mRNA biogenesis machinery.

Localization of HTLV-1 and HIV-1 proviral sequences in chromosomes of persistently infected cells

Integration sites for HTLV-1 and HIV-1proviruses were detected by FISH on the chromosomes of HTHIV27 cells persistently infected by HIV-1 (strain IIIB). HTLV-1 signals were found on 9 loci of chromosomes 4, 6, 9, 15 and 16. Integration sites of GC-rich HTLV-1 provirus are located in GC-rich isochores, confirming an 'isopycnic' integration, namely an integration in which the GC level of the host sequences around the integration site match the GC level of the provirus. This conclusion is not only derived from the compositional map of human chromosomes, but also from HTLV-1 hybridization on compositional fractions of human DNA. Integration of GC-poor HIV-1 provirus was found on 4 loci of chromosomes 2, 7, 17 and 19. One copy of a complete HIV-1 provirus, which is active, was integrated in H1 isochores, whereas other defective copies were located in GC-poor L isochores. These results are discussed in terms of regional integration of retroviral sequences.

Crystal structure of Escherichia coli inorganic pyrophosphatase complexed with SO4(2-). Ligand-induced molecular asymmetry

The three-dimensional structure of inorganic pyrophosphatase from Escherichia coli complexed with sulfate was determined at 2.2 A resolution using Patterson's search technique and refmed to an R-factor of 19.2%. Sulfate may be regarded as a structural analog of phosphate, the product of the enzyme reaction, and as a structural analog of methyl phosphate, the irreversible inhibitor. Sulfate binds to the pyrophosphatase active site cavity as does phosphate and this diminishes molecular symmetry, converting the homohexamer structure form (alpha3)2 into alpha3'alpha3". The asymmetry of the molecule is manifested in displacements of protein functional groups and some parts of the polypeptide chain and reflects the interaction of subunits and their cooperation. The significance of re-arrangements for pyrophosphatase function is discussed.

Escherichia coli inorganic pyrophosphatase: site-directed mutagenesis of the metal binding sites

Aspartic acids 65, 67, 70, 97 and 102 in the inorganic pyrophosphatase of Escherichia coli, identified as evolutionarily conserved residues of the active site, have been replaced by asparagine. Each mutation was found to decrease the k(app) value by approx. 2-3 orders of magnitude. At the same time, the Km values changed only slightly. Only minor changes take place in the pK values of the residues essential for both substrate binding and catalysis. All mutant variants have practically the same affinity to Mg2+ as the wild-type pyrophosphatase.