Systemic illness

Involvement of prolactin in the meloxicam-dependent inflammatory response of the gonadotropic axis to prolonged lipopolysaccharide treatment in anoestrous ewes

An immune challenge can affect the reproductive process in females. Peripheral administration of bacterial endotoxin (lipopolysaccharide; LPS) decreases LH secretion and disrupts ovarian cyclicity. The aim of the present study was to determine the effects of a cyclo-oxygenase (COX)-2 inhibitor (meloxicam) on gonadotropin-releasing hormone (GnRH) and LH secretion in anoestrous ewes during systemic inflammation induced by LPS. LPS (400ngkg^-1 per day) suppressed LH release. In three individuals, meloxicam (500μgkg^-1, i.v.) abolished LPS-induced LH suppression. In another three ewes LH was ineffective. Similar changes were observed in hypothalamic GnRH expression. The effect of meloxicam depended on the circulating level of prolactin: meloxicam abolished inflammatory-dependent suppression of GnRH and LH secretion when plasma prolactin levels were similar to those in untreated animals, but was ineffective in those with elevated levels of prolactin. We conclude that COX-2 inhibitors minimise the negative effect of inflammation on the reproductive system but that this effect may be antagonised by prolactin.

Interrelation between Neuroendocrine Disturbances and Medical Complications Encountered during Rehabilitation after TBI

Traumatic brain injury is not a discrete event but an unfolding sequence of damage to the central nervous system. Not only the acute phase but also the subacute and chronic period after injury, i.e., during inpatient rehabilitation, is characterized by multiple neurotransmitter alterations, cellular dysfunction, and medical complications causing additional secondary injury. Neuroendocrine disturbances also influence neurological outcome and are easily overlooked as they often present with diffuse symptoms such as fatigue, depression, poor concentration, or a decline in overall cognitive function; these are also typical sequelae of traumatic brain injury. Furthermore, neurological complications such as hydrocephalus, epilepsy, fatigue, disorders of consciousness, paroxysmal sympathetic hyperactivity, or psychiatric-behavioural symptoms may mask and/or complicate the diagnosis of neuroendocrine disturbances, delay appropriate treatment and impede neurorehabilitation. The present review seeks to examine the interrelation between neuroendocrine disturbances with neurological complications frequently encountered after moderate to severe TBI during rehabilitation. Common neuroendocrine disturbances and medical complications and their clinical implications are discussed.

Risk factors for development of atypical femoral fractures in patients on long-term oral bisphosphonate therapy

Bisphosphonates (BPs) are the first-line therapy for osteoporosis. In recent years, atypical femoral fractures (AFF) have been described in patients on BPs therapy. However, the relationship between BPs and AFF remains to be clarified. We evaluated clinical and hormonal characteristics of AFF patients, in order to determine AFF risk factors. We studied 11 females with AFF and 58 females with typical femoral fractures (TFF), admitted to our Department for surgical repair between January 2008 and December 2011. All AFF patients received BPs therapy for 6 to 13 yrs, whereas 36.2% (p<0.0001) of TFF patients received BPs for shorter period (TFF, 6.1±1.8 yr vs. AFF, 8.6±1.9 yr, p<0.0001). A higher prevalence of hypocalcemia was observed in AFF patients compared with TFF (p<0.02), with significantly (p<0.05) lower corrected calcium levels in AFF patients. By contrast a reduced prevalence of elevated PTH levels (p<0.05) was found in AFF patients. No significant difference in prevalence of vitamin D defect was observed between the two groups. Younger age (p<0.004), higher BMI (>30 kg/m2, p<0.03) and early menopausal age (p<0.05) were observed in AFF patients. At time of fracture, prevalence of osteopenia/osteoporosis and levels of bone turnover markers were significantly (p<0.01) lower in AFF compared with TFF patients. By multivariate analysis hypocalcemia, obesity, and younger age (<70 yr) were confirmed to be independent predictors of AFF; elevated PTH level was the predominant independent protective factor (p<0.004). In conclusion, our data indicate that clinical characteristics and metabolic factors may favor the development of AFF in BP treated patients. We identified hypocalcemia due to latent hypoparathyroidism as primary risk factor for AFF; age, obesity, early menopause, and BMD may also influence the development of AFF. An adequate clinical and metabolic assessment is suggested to prevent the development of AFF in BP treated patients.

Insulin-like Growth Factor I and its binding protein 3 in sepsis

OBJECTIVE

To investigate the Growth Hormone (GH)/Insulin-like Growth Factor-I (IGF-I) axis and identify the factors that determine IGF-I levels in adult septic patients of variable severity, i.e., with sepsis, severe sepsis or septic shock, in the acute phase of disease.

DESIGN

In 107 consecutive septic patients (44 with sepsis, 13 with severe sepsis, and 50 with septic shock), GH, IGF-I, Insulin-like Growth Factor Binding Protein-3 (IGFBP-3), insulin, cortisol, albumin, thyroid hormones, C-reactive protein and interleukin-6 serum levels were measured once within 48 h after onset of a septic episode. Twenty-nine healthy volunteers served as controls.

RESULTS

IGF-I and IGFBP-3 levels were decreased in patients with sepsis and severe sepsis (versus controls), decreasing further in patients with septic shock (versus sepsis). IGF-I levels were positively related to IGFBP-3, albumin, triiodothyronine and thyroxine, and inversely related to cortisol, sepsis severity, C-reactive protein, interleukin-6 and age. In multiple regression analysis, IGF-I levels were independently related to IGFBP-3 and albumin (lower in patients with decreased IGFBP-3 and albumin levels) (p<0.001 and p=0.01, respectively), and cortisol (lower in patients with increased cortisol levels) (p=0.04). IGFBP-3 accounted for most of the variance explained by the model (R(2)=0.519). GH levels were not related to IGF-I levels or mortality. IGF-I and IGFBP-3 levels were not associated with mortality.

CONCLUSIONS

The GH/IGF-I axis is severely disrupted in septic patients. IGFBP-3 is the major determinant of IGF-I levels.

Sex hormones and cause-specific mortality in the male veterans: the Vietnam Experience Study

BACKGROUND

Testosterone levels have been linked to life expectancy in men, less is known about the sex hormones follicular stimulating hormone and luteinizing hormone.

AIM

To examine the association of testosterone, follicular stimulating hormone, luteinizing hormone with mortality.

DESIGN

Prospective cohort analysis.

METHODS

Participants were 4255 Vietnam-era US army veterans with a mean age of 38.3 years. From military service files, telephone interviews and a medical examination, socio-demographic and health data were collected. Contemporary morning fasted hormone concentrations were determined. All-cause, cardiovascular, cancer, external and 'other' cause mortality was ascertained over the subsequent 15 years. Hazard ratios were calculated, first with adjustment for age and then, additionally, for a range of confounders.

RESULTS

Individuals within the highest tertiles of follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels were at increased risk of all-cause mortality following adjustment for a range of risk factors. However, with mutual adjustment, neither FSH nor LH significantly predicted mortality. Testosterone levels did not show an association with all-cause mortality, and none of the hormones were significantly associated with CVD, cancer, 'other' or external-cause mortality in fully adjusted models.

CONCLUSION

Greater FSH and LH levels are associated with all-cause mortality, but not independently of one another.

Hormonal status in protracted critical illness and in-hospital mortality

Introduction

The aim of this study was to determine the relationship between hormonal status and mortality in patients with protracted critical illness.

Methods

We conducted a prospective observational study in four medical and surgical intensive care units (ICUs). ICU patients who regained consciousness after 7 days of mechanical ventilation were included. Plasma levels of insulin-like growth factor 1 (IGF-1), prolactin, thyroid-stimulating hormone, follicle-stimulating hormone, luteinizing hormone, estradiol, progesterone, testosterone, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS) and cortisol were measured on the first day patients were awake and cooperative (day 1). Mean blood glucose from admission to day 1 was calculated.

Results

We studied 102 patients: 65 men and 37 women (29 of the women were postmenopausal). Twenty-four patients (24%) died in the hospital. The IGF-1 levels were higher and the cortisol levels were lower in survivors. Mean blood glucose was lower in women who survived, and DHEA and DHEAS were higher in men who survived.

Conclusions

These results suggest that, on the basis of sex, some endocrine or metabolic markers measured in the postacute phase of critical illness might have a prognostic value.

Pituitary insufficiency after infectious meningitis: a prospective study

CONTEXT

Data from previous retrospective studies and case reports have suggested that infectious diseases of the central nervous system could cause pituitary deficiency.

OBJECTIVE

The aim of this prospective study was to investigate pituitary function in patients admitted with infectious meningitis during the acute phase and after 12 months.

DESIGN

Sixteen patients were studied. Basal pituitary function was assessed within 24 h of admission. Twelve of these patients underwent both basal and stimulated (insulin tolerance test) pituitary testing after 12 months.

RESULTS

During the acute phase, five patients (31.25%) showed apparent pituitary hormone deficiencies: two patients with gonadotropic and three patients with somatotropic deficiency. The exact status of corticosteroid sufficiency could not be defined in four patients, because no dynamic test was performed in the acute phase. In addition, seven patients (44%) had probable low T(3) syndrome. At 12 months, five patients (31.25%), two with viral and three with bacterial meningitis, had at least one anterior pituitary hormone deficiency. Two patients had isolated corticotropic and one isolated somatotropic deficiency. Combined corticotropic and somatotropic deficiencies were detected in two patients. New-onset deficiencies accounted for four of those five patients, whereas one patient demonstrated persisting somatotropic deficiency. All cases of low T(3) syndrome resolved at 12 months.

CONCLUSIONS

Isolated or combined pituitary deficiencies, which could present at the acute phase and/or occur at a later stage, can develop in a considerable proportion of patients after acute infectious meningitis.

Hormonal status and ICU-acquired paresis in critically ill patients

BACKGROUND

The pathogenesis of intensive care unit-acquired paresis (ICUAP), a frequent and severe complication of critical illness, is poorly understood. Since ICUAP has been associated with female gender in some studies, we hypothesized that hormonal dysfunction might contribute to ICUAP.

OBJECTIVE

To determine the relationship between hormonal status, ICUAP and mortality in patients with protracted critical illness.

DESIGN

Prospective observational study.

SETTING

Four medical and surgical ICUs.

PATIENTS

ICU patients mechanically ventilated for >7 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Plasma levels of insulin growth factor-1 (IgF1), prolactin, thyroid stimulating hormone (TSH), follicular stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, testosterone, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulphate (DHEAS) and cortisol were measured on the first day patients were awake (day 1). Mean blood glucose from admission to day 1 was calculated. ICUAP was defined as Medical Research Council sum score <48/60 on day 7.

RESULTS

We studied 102 patients (65 men and 37 women, 29 post-menopausal), of whom 24 (24%) died during hospitalization. Among the 86 patients tested at day 7, 39 (49%) had ICUAP, which was more frequent in women (63% versus men 36%, p = 0.02). Mean blood glucose was higher in patients with ICUAP. Estradiol/testosterone ratio was greater in men with ICUAP.

CONCLUSION

ICUAP 7 days after awakening was associated with increased blood glucose and with biological evidence of hypogonadism in men, while an association with hormonal dysfunction was not detected in women.