Hypogonadism in aged hospitalized male patients: prevalence and clinical outcome

Hypogonadism is frequent in very old men with multimorbidity and is associated with anemia and sarcopenia

BACKGROUND

Clinical data regarding hypogonadism in very old men with multimorbidity are rare. Hypogonadism can contribute to osteoporosis, anemia and sarcopenia and is therefore a relevant problem for geriatric patients.

METHODS

A total of 167 men aged 65-96 years (mean 81 ± 7 years) admitted to an acute geriatric ward were included in a cross-sectional study. Body composition derived from dual-energy X‑ray absorptiometry, bone mineral density, handgrip strength, multimorbidity, polypharmacy and laboratory values were obtained from the routine electronic clinical patient file.

RESULTS

Hypogonadism was present in 62% (n = 104) of the study participants, of whom 83% showed clinical manifestation of hypogonadism (hypogonadism in combination with anemia, sarcopenia and/or low T‑score). The subgroups showed a distribution of 52% primary and 48% secondary hypogonadism. Compared to the eugonadal patients, hypogonadal patients had reduced handgrip strength (p = 0.031) and lower hemoglobin levels (p = 0.043), even after adjustment for age, body mass index and glomerular filtration rate.

CONCLUSION

Hypogonadism is common in geriatric patients. If chronic anemia, sarcopenia, or osteoporosis are diagnosed, testosterone levels should be determined in geriatric settings.

Androgens' Role in Severity and Mortality Rates of COVID-19

By the end of December 2019 new corona virus began to spread from Wuhan, China and caused a worldwide pandemic. COVID-19 deaths and prevalence represented sex discrepant patterns with higher rate of deaths and infection in males than females which could be justified by androgen-mediated mechanisms. This review aimed to assess the role of androgens in COVID-19 severity and mortality. Androgens increase expressions of Type II transmembrane Serine Protease (TMPRSS2) and Angiotensin Converting Enzyme 2 (ACE2), which both facilitate new corona virus entry into host cell and their expression is higher in young males than females. According to observational studies, prevalence of COVID-19 infections and deaths was more in androgenic alopecic patients than patients without androgenic alopecia. The COVID-19 mortality rates in aged men (>60 years) were substantially higher than aged females and even young males caused by high inflammatory activities such as cytokine storm due to hypogonadism in this population. Use of anti-androgen and TMPRSS2 inhibitor drugs considerably modified COVID-19 symptoms. Androgen deprivation therapy also improved COVID-19 symptoms in prostate cancer: overall the role of androgens in severity of COVID-19 and its associated mortality seemed to be very important. So, more studies in variety of populations are required to define the absolute role of androgens.

Examining Male Predominance of Severe COVID-19 Outcomes: A Systematic Review

Although not universal, many epidemiological data sources signal that a higher proportion of males than females with confirmed Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infections have adverse outcomes, such as intensive care unit (ICU) admission and death. Though likely multifactorial, the various hypotheses that have been proposed as underlying factors behind this trend are related to greater smoking prevalence among males, testosterone (T) deficiency causing an inflammatory storm, androgen-driven pathogenesis of SARS-CoV-2, a protective effect of estrogen in females, and inborn errors of cytokine immunity. This review aims at examining the evidence and at assessing the likelihood that the factors being investigated are contributory to the reported trend of male predominance of severe COVID-19 cases. Sources were obtained using the PubMed database and were selected based on their relevance to one of the primary hypotheses attempting to explain the strong male sex bias of severe SARS-CoV-2 infections. Emphasis was placed on meta-analyses and population-based studies. Sources are current through February 22, 2022. A severe COVID-19 case or outcome is defined in this review as a progression of the SARS-CoV-2 virus that results in either admission to an ICU for management of symptoms and clinical stabilization or which leads to death. Although the trend of male predominance of severe COVID-19 cases is likely multifactorial, the hypothesis of T deficiency causing an inflammatory storm has support from many studies with limited conflicting evidence. An inborn error in cytokine immunity is also well supported, but it needs more studies to add support to the hypothesis. The immunologic protective effect of estrogen is supported by multiple studies, but it also has conflicting evidence. It appears less likely that the trend is caused solely by an increased prevalence of smoking among males or an androgen-driven pathogenesis, based on the extent of conflicting evidence.

Low testosterone predicts hypoxemic respiratory insufficiency and mortality in patients with COVID-19 disease: another piece in the COVID puzzle

PURPOSE

Hypogonadism was described in high number of male subjects with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this study, we investigated whether low testosterone (T) values may influence the clinical presentation and outcome of SARS-CoV-2-related pneumonia in a large population of adult males with coronavirus disease 19 (COVID-19).

METHODS

Two hundred twenty one adult males hospitalized for COVID-19 at the IRCCS Humanitas Research Hospital, Rozzano-Milan (Italy) were consecutively evaluated for arterial partial pressure oxygen (PaO₂)/fraction of inspired oxygen (FiO₂) ratio, serum T and inflammatory parameters at study entry, need of ventilation during hospital stay and in-hospital mortality.

RESULTS

Subjects low T values (< 8 nmol/L; 176 cases) were significantly older (P = 0.001) and had higher serum interleukin-6 (P = 0.001), C-reactive protein (P < 0.001), lactate dehydrogenase (P < 0.001), ferritin (P = 0.012), lower P/F ratio (P = 0.001), increased prevalence of low T3 syndrome (P = 0.041), acute respiratory insufficiency (P < 0.001), more frequently need of ventilation (P < 0.001) and higher mortality rate (P = 0.009) compared to subjects with higher T values. In the multivariable regression analyses, T values maintained significant associations with acute respiratory insufficiency (odds ratio [OR] 0.85, 95% confidence interval [CI] 0.79-0.94; P < 0.001 and in-hospital mortality (OR 0.80, 95% CI 0.69-0.95; P = 0.009), independently of age, comorbidities, thyroid function and inflammation.

CONCLUSION

Low T levels values are associated with unfavorable outcome of COVID-19. Prospective studies are needed to evaluate the long-term outcomes of hypogonadism related to COVID-19 and the clinical impact of T replacement during and after acute illness.

Serum level of testosterone predicts disease severity of male COVID-19 patients and is related to T-cell immune modulation by transcriptome analysis

Background

Severe disease of COVID-19 and mortality occur more frequently in male patients than that in female patients may be related to testosterone level. However, the diagnostic value of changes in the level of testosterone in predicting severe disease of male COVID-19 patients has not been determined yet.

Methods

Sixty-one male COVID-19 patients admitted to the First Affiliated Hospital of Zhejiang University School of Medicine were enrolled. Serum samples at different stages of the patients after admission were collected and testosterone levels were detected to analyze the correlation between testosterone level and disease severity. Transcriptome analysis of PBMC was performed in 34 patients.

Results

Testosterone levels at admission in male non-ICU COVID-19 patients (3.7 nmol/L, IQR: 1.5 ∼ 4.7) were significantly lower than those in male ICU COVID-19 patients (6.7 nmol/L, IQR: 4.2 ∼ 8.7). Testosterone levels in the non-ICU group increased gradually during the progression of the disease, while those in the ICU group remained low. In addition, testosterone level of enrolled patients in the second week after onset was significantly correlated with the severity of pneumonia, and ROC curve showed that testosterone level in the second week after onset was highly effective in predicting the severity of COVID-19. Transcriptome studies have found that testosterone levels of COVID-19 patients were associated with immune response, including T cell activation and regulation of lymphocyte activation. In addition, CD28 and Inositol Polyphosphate-4-Phosphatase Type II B (INPP4B) were found positively correlated with testosterone.

Conclusions

Serum testosterone is an independent risk factor for predicting the severity of COVID-19 in male patients, and the level of serum testosterone in the second week after onset is valuable for evaluating the severity of COVID-19. Testosterone level is associated with T cell immune activation. The monitoring of serum testosterone should be highlighted in clinical treatment and the related mechanism should be further studied.

Testosterone Deficiency Is a Risk Factor for Severe COVID-19

Background

Male sex is related to increased COVID-19 severity and fatality although confirmed infections are similarly distributed between men and women. The aim of this retrospective analysis was to investigate the impact of sex hormones on disease progression and immune activation in men with COVID-19.

Patients and Methods

We studied for effects of sex hormones on disease severity and immune activation in 377 patients (230 men, 147 women) with PCR-confirmed SARS-CoV-2 infections hospitalized at the Innsbruck University Hospital between February and December 2020.

Results

Men had more severe COVID-19 with concomitant higher immune system activation upon hospital admission when compared to women. Men with a severe course of infection had lower serum total testosterone (tT) levels whereas luteinizing hormone (LH) and estradiol (E2) levels were within the normal range. tT deficiency was associated with elevated CRP (rs = - 0.567, p < 0.001), IL-6 levels (rs = - 0.563, p < 0.001), lower cholesterol levels (rs = 0.407, p < 0.001) and an increased morbidity and mortality. Men with tT levels < 100 ng/dL had a more than eighteen-fold higher in-hospital mortality risk (OR 18.243 [95%CI 2.301 - 144.639], p = 0.006) compared to men with tT levels > 230 ng/dL. Moreover, while morbidity and mortality showed a positive correlation with E2 levels at admission, we detected a negative correlation with the tT/E2 ratio upon hospital admission.

Conclusion

Hospitalized men with COVID-19 present with rather low testosterone levels linked to more advanced immune activation, severe clinical manifestations translating into an increased risk for ICU admission or death. The underlying mechanisms remain elusive but may include infection driven hypogonadism as well as inflammation mediated cholesterol reduction causing gonadotropin suppression and impaired androgen formation. Finally, in elderly late onset hypogonadism might also contribute to lower testosterone levels.

COVID-19 Pandemic and Male Fertility: Clinical Manifestations and Pathogenic Mechanisms

The novel coronavirus disease-2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been a major public health emergency worldwide with over 118.27-million confirmed COVID-19 cases and 2.62-million deaths recorded, as of March 12, 2021. Although this disease primarily targets lungs, damages in other organs, such as heart, kidney, liver, and testis, may occur. Testis is the cornerstone of male reproduction, while reproductive health is the most valuable resource for continuity of the human race. Given the unique nature of SARS-CoV-2, the mechanisms of its impact on the testes have yet to be fully explored. Notably, coronaviruses have been found to invade target cells through the angiotensin-converting enzyme 2 receptor, which can be found in the respiratory, gastrointestinal, cardiovascular, urinary tract, and reproductive organs, such as testes. Coronavirus studies have suggested that testes might be a potential target for SARS-CoV-2 infection. The first etiopathogenic concept proposed by current hypotheses indicates that the virus can invade testes through the angiotensin-converting enzyme 2 receptor. Next, the activated inflammatory response in the testes, disease-associated fever, and COVID-19 medications might be implicated in testicular alterations. Although evidence regarding the presence of SARS-CoV-2 mRNA in semen remains controversial, this emphasizes the need for researchers to pay closer attention to sexually transmitted diseases and male fertility after recovering from COVID-19. In this review the latest updates regarding COVID-19-associated testicular dysfunction are summarized and possible pathogenic mechanisms are discussed.

Insights into the possible impact of COVID-19 on the endocrine system

The novel 2019 coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a highly transmissible and pathogenic coronavirus. Because of the novelty of the COVID-19 pandemic, few data are available on the impact of the SARS-CoV-2 on the different endocrine glands. Previous studies of severe acute respiratory syndrome (SARS) have shown a harmful effect on endocrine function. Notably, the angiotensin-converting enzyme-2 receptor, which is the entry route of coronaviruses to the host cell, is widely expressed in the endocrine organs including testis, endocrine pancreas, thyroid, and adrenal, and pituitary glands. Clinical and biochemical manifestations have been recorded in COVID-19 patients resulting in changes in endocrine activities, which were also recorded during the SARS outbreak in 2003. This review aims to explore the impact of SARS-CoV-2 infection on the function of endocrine glands, based on the latest research in the field.

SARS-CoV-2 Pneumonia Affects Male Reproductive Hormone Levels: A Prospective, Cohort Study

BACKGROUND

SARS-CoV-2 which causes coronavirus disease 2019 (COVID-19) binds to angiotensin-converting enyzme 2 (ACE2) and enters the host cell. ACE2 protein is expressed highly in the testis.

AIM

The aim of this study was to compare male reproductive hormones such as total testosterone (TT), luteinizing hormone (LH), follicular stimulant hormone (FSH), and prolactin between patients with COVID-19, age-matched cases with non-COVID-19 respiratory tract infection, and age-matched controls.

METHODS

This was a prospective cohort study and included 262 men aged between 20 and 65 years. The study comprised 3 groups including patients with COVID-19 (n = 89), cases with non-COVID-19 respiratory tract infection (n = 30), and age-matched controls (n = 143). All cases were evaluated using TT, LH, FSH, and prolactin. Correlations between TT and clinical parameters of patient groups were investigated using Pearson's correlation test.

OUTCOMES

The primary outcome of the study was detection of the difference of TT, FSH, LH, and prolactin levels between the groups. Secondary outcome was to correlate TT and hospitalization time and oxygen saturation on hospital admission (SpO2) of patients.

RESULTS

The mean age of study groups was 49.9 ± 12.5 years, 52.7 ± 9.6 years, and 50 ± 7.8 years, respectively (P = .06). Serum TT levels was median 185.52 ng/dL in patients with COVID-19, median 288.67 ng/dL in patients with non-COVID-19 respiratory tract infection and median 332 ng/dL in control cases, (P < .0001). The proportion of patients with testosterone deficiency in group 1, group 2, and group 3 was 74.2%, 53.3%, and 37.8%, respectively (P < .0001). Serum LH levels (P = 0.0003) and serum prolactin levels (P = .0007) were higher in patients with COVID-19 and patients with non-COVID-19 respiratory tract infection than control cases. Correlation analysis revealed significant negative correlation between serum TT levels and hospitalization time of patients with COVID-19 (r = -0.45, P < .0001). In addition, a significant positive correlation was observed between SpO2 and serum TT levels in patients with COVID-19 ( r = 0.32, P = .0028).

CLINICAL IMPLICATIONS

Physicians may consider to evaluate male patients with COVID-19 for concomitant androgen deficiency.

STRENGTHS & LIMITATIONS

Strengths include the evidence about the alteration of male reproductive hormones under COVID-19. Limitations include the analysis limited to one general hospital, only a single measurement of TT was available, free and bioavailable testosterone levels were not evaluated.

CONCLUSION

This study demonstrates COVID-19 is associated with decreased level of TT and increased level of LH and prolactin. More serious COVID-19 causes more reduction in TT levels and prolongs hospitalization period. Kadihasanoglu M, Aktas S, Yardimci E, et al. SARS-CoV-2 Pneumonia Affects Male Reproductive Hormone Levels: A Prospective, Cohort Study. J Sex Med 2021;18:256-264.

Interpretation of the endocrinology of hospital inpatients

Blood tests to assess the endocrine system are commonly performed in patients admitted to hospital. This may be because an endocrinopathy is thought to be aetiological in the presenting disease or suspected as an incidental occurrence by the clinician. Many patients, in addition to the pathology leading to admission, frequently have one or more comorbidities, a change in nutritional status and polypharmacy. Added to this, presentation with acute illness is a major life stress. All of these are likely to impact on one or more endocrine axes, although often only transiently. Endocrine evaluation in the vast majority of cases can be safely deferred to the outpatient setting. This article considers the most common endocrine anomalies discovered in hospital, the confounders, and provides guidance on how to investigate these further.

Role of anabolic testosterone agents and structured exercise to promote recovery in ICU survivors

PURPOSE OF REVIEW

ICU survivors frequently suffer significant, prolonged physical disability. 'ICU Survivorship', or addressing quality-of-life impairments post-ICU care, is a defining challenge, and existing standards of care fail to successfully address these disabilities. We suggest addressing persistent catabolism by treatment with testosterone analogues combined with structured exercise is a promising novel intervention to improve 'ICU Survivorship'.

RECENT FINDINGS

One explanation for lack of success in addressing post-ICU physical disability is most ICU patients exhibit severe testosterone deficiencies early in ICU that drives persistent catabolism despite rehabilitation efforts. Oxandrolone is an FDA-approved testosterone analogue for treating muscle weakness in ICU patients. A growing number of trials with this agent combined with structured exercise show clinical benefit, including improved physical function and safety in burns and other catabolic states. However, no trials of oxandrolone/testosterone and exercise in nonburn ICU populations have been conducted.

SUMMARY

Critical illness leads to a catabolic state, including severe testosterone deficiency that persists throughout hospital stay, and results in persistent muscle weakness and physical dysfunction. The combination of an anabolic agent with adequate nutrition and structured exercise is likely essential to optimize muscle mass/strength and physical function in ICU survivors. Further research in ICU populations is needed.

Effect of serum total testosterone and its relationship with other laboratory parameters on the prognosis of coronavirus disease 2019 (COVID-19) in SARS-CoV-2 infected male patients: a cohort study

OBJECTIVE

To investigate effect of serum total testosterone and its relationship with other laboratory parameters on the prognosis of coronavirus disease 2019 (COVID-19) in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected male patients.

METHODS

This prospective cohort study included 221 consecutive male patients (>18 years old) with laboratory confirmed SARS-CoV-2 who had been hospitalized due to COVID-19. The patients were divided into 3 groups: Asymptomatic patients (n: 46), symptomatic patients who were hospitalized in the internal medicine unit (IMU) (n: 129), and patients who were hospitalized in the intensive care unit (ICU) (n: 46).

RESULTS

As serum total testosterone level at baseline decreases, probability (%) to be in the ICU significantly increases (p = 0.001). As serum total testosterone level at baseline decreases, probability (%) of mortality significantly increases (p = 0.002). In the patients who had pre-COVID-19 serum gonadal hormones test (n: 24), serum total testosterone level significantly decreased from pre-COVID-19 level of 458 ± 198 ng/dl to 315 ± 120 ng/dl at the time of COVID-19 in the patients (p = 0.003).

CONCLUSIONS

COVID-19 might deteriorate serum testosterone level in SARS-CoV-2 infected male patients. Low serum total testosterone level at baseline has a significant increased risk for the ICU and mortality in patients with COVID-19.

Role of testosterone in COVID-19 patients - A double-edged sword?

COVID-19 affects males twice as frequently as females with significantly increased severity and mortality. Current data suggest a direct correlation between the lower level of serum testosterone, inflammatory cytokines, disease severity, and poor clinical outcomes among male patients with COVID-19. The gradual decline in total and free testosterone levels has a direct correlation with serious pulmonary complications requiring advanced care (ICU, ventilators, ECMO, etc.). SARS-CoV-2 utilizes Angiotensin-Converting Enzyme II (ACE2) for entry in the host cell, and Transmembrane Protease, Serine 2 (TMPRSS2) to prime spike protein of SARS-CoV-2. Testosterone induces ACE-2 expression, a critical pulmonary protective enzyme. Low testosterone levels in males have a direct correlation with the high probability of ICU admission and the worse disease outcome (ARDS, duration of ICU stay, mortality). On the contrary, however, high testosterone levels can lead to thrombosis which is also one of the fatal manifestations in COVID-19 patients. A critical evaluation of the serum testosterone and its relevance to COVID-19 is warranted to re-evaluate strategies to effectively triage, prioritize, and manage high-risk patients for ICU admission, survival outcomes, targeted solutions, and operational algorithms.

Why does COVID-19 kill more elderly men than women? Is there a role for testosterone?

Background

Recent epidemiological data indicate that there may be a gender predisposition to COVID‐19, with men predisposed to being most severely affected, and older men accounting for most deaths.

Objectives

Provide a review of the research literature, propose hypotheses, and therapies based on the potential link between testosterone (T) and COVID‐19 induced mortality in elderly men.

Materials and Methods

A search of publications in academic electronic databases, and government and public health organization web sites on T, aging, inflammation, severe acute respiratory syndrome (SARS) due to coronavirus (CoV) 2 (SARS‐CoV‐2) infection, and COVID‐19 disease state and outcomes was performed.

Results

The link between T, the immune system, and male aging is well‐established, as is the progressive decline in T levels with aging. In women, T levels drop before menopause and variably increase with advanced age. Elevated IL‐6 is a characteristic biomarker of patients infected with COVID‐19 and has been linked to the development of the acute respiratory distress syndrome (ARDS). Thus far, half of the admitted COVID‐19 patients developed ARDS, half of these patients died, and elderly male patients have been more likely to develop ARDS and die. Low T is associated with ARDS. These data suggest that low T levels may exacerbate the severity of COVID‐19 infection in elderly men. It may also stand to reason that normal T levels may offer some protection against COVID‐19. SARS‐CoV‐2 binds to the angiotensin‐converting enzyme 2, present in high levels in the testis.

Conclusion

At present, it is not known whether low T levels in aging hypogonadal males create a permissive environment for severe responses to COVID‐19 infection or if the virus inhibits androgen formation. Given the preponderance of COVID‐19 related mortality in elderly males, additional testing for gonadal function and treatment with T may be merited.

Worse progression of COVID-19 in men: Is testosterone a key factor?

Background

The novel severe acute respiratory syndrome coronavirus (SARS‐CoV‐2) disease 2019 (COVID‐19) seems to have a worse clinical course among infected men compared with women, thus highlighting concerns about gender predisposition to serious prognosis. Therefore, androgens, particularly testosterone (T), could be suspected as playing a critical role in driving this excess of risk. However, gonadal function in critically ill men is actually unknown, mainly because serum T concentration is not routinely measured in clinical practice, even more in this clinical context.

Objective

To overview on possible mechanisms by which serum T levels could affect the progression of COVID‐19 in men.

Methods

Authors searched PubMed/MEDLINE, Web of Science, EMBASE, Cochrane Library, Google, and institutional websites for medical subject headings terms and free text words referred to “SARS‐CoV‐2,” “COVID‐19,” “testosterone,” “male hypogonadism,” “gender” “immune system,” “obesity,” “thrombosis” until May 19th 2020.

Results

T, co‐regulating the expression of angiotensin‐converting enzyme 2 and transmembrane protease serine 2 in host cells, may facilitate SARS‐CoV‐2 internalization. Instead, low serum T levels may predispose to endothelial dysfunction, thrombosis and defective immune response, leading to both impaired viral clearance and systemic inflammation. Obesity, one of the leading causes of severe prognosis in infected patients, is strictly associated with functional hypogonadism, and may consistently strengthen the aforementioned alterations, ultimately predisposing to serious respiratory and systemic consequences.

Discussion and conclusion

T in comparison to estrogen may predispose men to a widespread COVID‐19 infection. Low serum levels of T, which should be supposed to characterize the hormonal milieu in seriously ill individuals, may predispose men, especially elderly men, to poor prognosis or death. Further studies are needed to confirm these pathophysiological assumptions and to promptly identify adequate therapeutic strategies.

Low testosterone levels predict clinical adverse outcomes in SARS-CoV-2 pneumonia patients

BACKGROUND

The pandemic of new severe acute respiratory syndrome (SARS) due to coronavirus (CoV) 2 (SARS-CoV-2) has stressed the importance of effective diagnostic and prognostic biomarkers of clinical worsening and mortality. Epidemiological data showing a differential impact of SARS-CoV-2 infection on women and men have suggested a potential role for testosterone (T) in determining gender disparity in the SARS-CoV-2 clinical outcomes.

OBJECTIVES

To estimate the association between T level and SARS-CoV-2 clinical outcomes (defined as conditions requiring transfer to higher or lower intensity of care or death) in a cohort of patients admitted in the respiratory intensive care unit (RICU).

MATERIALS AND METHODS

A consecutive series of 31 male patients affected by SARS-CoV-2 pneumonia and recovered in the respiratory intensive care unit (RICU) of the "Carlo Poma" Hospital in Mantua were analyzed. Several biochemical risk factors (ie, blood count and leukocyte formula, C-reactive protein (CRP), procalcitonin (PCT), lactate dehydrogenase (LDH), ferritin, D-dimer, fibrinogen, interleukin 6 (IL-6)) as well as total testosterone (TT), calculated free T (cFT), sex hormone-binding globulin (SHBG), and luteinizing hormone (LH) were determined.

RESULTS

Lower TT and cFT were found in the transferred to ICU/deceased in RICU group vs groups of patients transferred to IM or maintained in the RICU in stable condition. Both TT and cFT showed a negative significant correlation with biochemical risk factors (ie, the neutrophil count, LDH, and PCT) but a positive association with the lymphocyte count. Likewise, TT was also negatively associated with CRP and ferritin levels. A steep increase in both ICU transfer and mortality risk was observed in men with TT < 5 nmol/L or cFT < 100 pmol/L.

DISCUSSION AND CONCLUSION

Our study demonstrates for the first time that lower baseline levels of TT and cFT levels predict poor prognosis and mortality in SARS-CoV-2-infected men admitted to RICU.

Cross-Sectional, Primary Care-Based Study of the Prevalence of Hypoandrogenemia in Nondiabetic Young Men with Obesity

OBJECTIVE

Obesity-associated hypoandrogenemia is increasing in parallel to the obesity epidemic. The prevalence of hypoandrogenemia in nondiabetic young men with obesity is not known. This study aimed to evaluate the prevalence of hypoandrogenemia and associated risk factors in this population.

METHODS

This cross-sectional study included 266 nondiabetic men < 50 years of age with obesity who were referred from primary care. Total testosterone (high-performance liquid chromatography mass spectrometry), sex hormone-binding globulin, free testosterone (FT), luteinizing hormone (LH), high-sensitivity C-reactive protein, and homeostatic model assessment of insulin resistance were determined. Body composition and erectile function were also assessed. Hypoandrogenemia was defined as FT level < 70 pg/mL.

RESULTS

Subnormal FT concentrations were found in 25.6% of participants. Hypoandrogenemia prevalence was different along the BMI continuum, being > 75% in individuals with BMI ≥ 50 kg/m² . A multivariate regression analysis indicated that increasing BMI (P < 0.001), age (P = 0.049), and reduced LH levels (P = 0.003) were independent risk factors for hypoandrogenemia.

CONCLUSIONS

In a primary care-based cohort of nondiabetic young men with obesity, hypoandrogenemia was a very prevalent finding and was directly associated with adiposity. Obesity, age, and reduced LH levels were independent risk factors associated with hypoandrogenemia. Further prospective studies are needed to evaluate the long-term consequences of hypoandrogenemia in this population.

The relationship of depression in asthma-chronic obstructive pulmonary disease overlap syndrome

Purpose

To clarify the relationship between asthma–chronic obstructive pulmonary disease overlap syndrome (ACOS) and depression.

Methods

We identified 10,911 patients who received an ACOS diagnosis and concurrent treatment between January 2000 and December 2009. Subjects without ACOS were included in the non-ACOS cohort (n = 10,911). Cox proportional hazard regression analysis was performed to compare the risk of depression between the ACOS and non-ACOS cohorts.

Results

The risk of depression was higher in the ACOS cohort than in the non-ACOS cohort (adjusted hazard ratios (aHRs) = 1.67, 95% confidence interval [CI] = 1.48–1.88). In the ACOS cohort, the aHRs for depression were [2.44 (95% CI = 1.45–4.11); 2.36 (95% CI = 1.58–3.52)] in patients [aged 20–39 years; without comorbidity]. In the ACOS cohort, the aHRs for depression were 1.70 (95% CI = 1.51–1.93) and 1.84 (95% CI = 1.55–2.19) in patients without inhaled corticosteroids (ICSs) and oral steroids (OSs) use, respectively. Moreover, the aHRs for the risk of depression were 1.16 (95% CI = 0.95–1.41) and 1.12 (95% CI = 0.96–1.29) in patients with ICSs and OSs use, respectively.

Conclusion

The risk of depression is higher in ACOS patients, even in those without comorbidities or in young adults. The events of the depression were not significant difference in patients receiving the ICSs/OSs between the ACOS and the non-ACOS cohorts.

Associations Between Low Serum Testosterone and All-Cause Mortality and Infection-Related Hospitalization in Male Hemodialysis Patients: A Prospective Cohort Study

Introduction

Infectious diseases are the second highest cause of death in patients on dialysis. In addition, testosterone deficiency or hypogonadism is prevalent in dialysis patients. However, to our knowledge, no studies have investigated the association between testosterone levels and infectious events. We aimed to evaluate whether serum testosterone levels are associated with infection-related hospitalization in male hemodialysis patients in a prospective cohort study.

Methods

We divided the study population into 3 groups based on serum testosterone levels. Associations between testosterone levels and clinical outcomes of infection-related hospitalization, all-cause mortality, and cardiovascular disease (CVD) events were analyzed using the Cox proportional hazard model.

Results

Nine hundred two male patients were enrolled and followed up for a median of 24.7 months. Their mean ± SD age was 63.4 ± 11.8 years, and their median (interquartile range) of total testosterone was 11.7 nmol/l (7.9–14.9 nmol/l). During follow-up, 123 participants died. Infection-related hospitalization and CVD events occurred in 116 and 151 patients, respectively. Infection-related hospitalization was more frequent in the lower testosterone tertile than in the higher testosterone tertile (hazard ratio [HR]: 2.12; 95% confidence interval [CI]: 1.18–3.79; P = 0.01) in adjusted models. Moreover, all-cause mortality was significantly greater in the lower testosterone tertile than in the higher testosterone tertile in adjusted analysis (HR: 2.26; 95% CI: 1.21–4.23; P = 0.01). In contrast, there were no significant differences in CVD events by testosterone level.

Discussion

Low levels of testosterone may be associated with higher rates of infection-related hospitalization and all-cause mortality in male hemodialysis patients.

Testosterone supplementation and body composition: results from a meta-analysis of observational studies

PURPOSE

The concept of testosterone (T) supplementation (TS) as a new anti-obesity medication in men with testosterone deficiency syndrome (TDS) is emerging. Data from placebo-controlled trials are more conflicting. The aim of this study is to systematically review and meta-analyze available observational and register studies reporting data on body composition in studies on TS in TDS.

METHODS

An extensive MEDLINE, Embase, and Cochrane search was performed including the following words: "testosterone" and "body composition." All observational studies comparing the effect of TS on body weight and other body composition and metabolic endpoints were considered.

RESULTS

Out of 824 retrieved articles, 32 were included in the study enrolling 4513 patients (mean age 51.7 ± 6.1 years). TS was associated with a time-dependent reduction in body weight and waist circumference (WC). The estimated weight loss and WC reduction at 24 months were -3.50 [-5.21; -1.80] kg and -6.23 [-7.94; -4.76] cm, respectively. TS was also associated with a significant reduction in fat and with an increase in lean mass as well as with a reduction in fasting glycemia and insulin resistance. In addition, an improvement of lipid profile (reduction in total cholesterol as well as of triglyceride levels and an improvement in HDL cholesterol levels) and in both systolic and diastolic blood pressure was observed.

CONCLUSIONS

Present data support the view of a positive effect of TS on body composition and on glucose and lipid metabolism. In addition, a significant effect on body weight loss was observed, which should be confirmed by a specifically designed RCT.

Testosterone and Cardiovascular Disease

Testosterone (T) is the principal male sex hormone. As men age, T levels typically fall. Symptoms of low T include decreased libido, vasomotor instability, and decreased bone mineral density. Other symptoms may include depression, fatigue, erectile dysfunction, and reduced muscle strength/mass. Epidemiology studies show that low levels of T are associated with more atherosclerosis, coronary artery disease, and cardiovascular events. However, treating hypogonadism in the aging male has resulted in discrepant results in regard to its effect on cardiovascular events. Emerging studies suggest that T may have a future role in treating heart failure, angina, and myocardial ischemia. A large, prospective, long-term study of T replacement, with a primary endpoint of a composite of adverse cardiovascular events including myocardial infarction, stroke, and/or cardiovascular death, is needed. The Food and Drug Administration recently put additional restrictions on T replacement therapy labeling and called for additional studies to determine its cardiac safety.

How to define hypogonadism? Results from a population of men consulting for sexual dysfunction

PURPOSE

The thresholds for testost erone (T) and the symptoms required for defining late onset hypogonadism (LOH) are under debate. The aims of the study are: (1) to verify the association between total and calculated free T (cfT) and sexual symptoms and (2) to identify thresholds for total and calculated free T to discriminate symptomatic from asymptomatic men.

METHODS

A consecutive series of 4890 men attending the outpatient clinic for sexual dysfunction was retrospectively studied. Biochemical parameters were collected. The relationships between symptoms and total or calculated free T were evaluated as LOESS curves.

RESULTS

Severe impairment in morning erections, low libido and ED were reported by 14.6, 2.7 and 60.2 %, respectively. Simultaneous presence of severe ED and impaired morning erections or low desire was reported by 12.7 and 1.9 %, respectively. Severely reduced desire and morning erections were complained of by 1.0 %. The simultaneous presence of the three severe sexual symptoms was reported by 0.8 %. Receiver operating characteristic (ROC) curve analysis showed that the highest accuracy for total T and cfT in detecting subjects with two symptoms was observed for reduced morning erections and desire (area under the ROC curve [AUC] = 0.670 ± 0.04 and 0.747 ± 0.04, for total T and cfT, respectively, both p < 0.0001). The addition of the third symptom, ED, further improved the accuracy (AUC = 0.681 ± 0.05 and 0.784 ± 0.04, for total T and cfT, respectively, both p < 0.0001). The assessment of the Youden index showed that the best thresholds for detecting men with androgen deficiency-related symptoms are 10.4 nmol/L for total T and ranges 225-260 pmol/L for cfT.

CONCLUSIONS

The simultaneous presence of reduced morning erections and desire is the cluster of symptoms that, along with total T < 10.4 nmol/L or cfT <225 pmol/L, defines LOH in a specific, evidence-based manner.

Natural course of hypogonadism diagnosed during hospitalization in aged male patients

Our aim was to assess short-term natural course of hypogonadism diagnosed during hospitalization for acute disease in aged male patients after discharge. A group of 43 hypogonadal males, aged 86.7±5.7 year, was studied. Serum concentrations of testosterone (T) and gonadotropins (follicle-stimulating hormone, FSH, and luteinizing hormone, LH) were measured in every patient both at admission and one month after discharge. Mean serum T at entry was 115.4±48.0 ng/dl. Hypogonadism was hyper-, hypo-, and normogonadotropic in 20 (46.5%), 20 (46.5%), and 3 (7.0%) patients, respectively. One month after discharge serum T concentrations increased significantly (230.9±135.6 ng/dl, p<0.001). At this point, more than half of the patients (n=27, 62.8%) showed normal serum T concentrations. Both gonadotropins, FSH (p<0.001), and LH (p=0.04) also increased one month after discharge. Approximately, half of the patients (13, 48.1%) who normalized serum T concentrations also showed normal serum gonadotropin concentrations. Patients who normalized their serum T concentrations one month after discharge showed significantly higher baseline values of T (134.7±33.9 ng/dl) than those who persisted with hypogonadism (n=16, 32.7%; 82.8±51.6 ng/dl, p<0.001). Lastly, serum T was the only independent predictor for achieving eugonadal status (OR 1.030; CI 95%, 1.010-1.050; p<0.001). In conclusion, about 63% of aged patients hospitalized for acute illness with hypogonadism discovered during hospitalization spontaneously normalize their serum T concentrations one month after discharge. Serum gonadotropin concentrations also increased after discharge. Serum T levels at admission was an independent predictor for the normalization of serum T concentrations.

Low Testosterone Levels are Frequent in Patients with Acute Respiratory Failure and are Associated with Poor Outcomes

OBJECTIVE

Low testosterone level is a common finding in critically ill patients with trauma, shock, and sepsis. However, its prevalence and outcomes in patients with primary acute respiratory failure is unknown; low testosterone could contribute to respiratory muscle weakness and further compromise ventilation in these patients.

METHODS

We aimed to determine the prevalence, severity, and effects of hypotestosteronemia in patients with acute respiratory failure in a 16-bed single academic center medical intensive care unit (ICU). We studied 30 men who required mechanical ventilation for ≥24 hours for a primary diagnosis of acute respiratory failure. Blood samples were drawn on ICU day 1 and day 3 to measure serum levels of total and free testosterone.

RESULTS

Hypotestosteronemia (level below the lower reference limit) was present on day 1 in 93.1% (total testosterone) and 76.7% (free testosterone) of patients and on day 3 in 94.4% (total testosterone) and 100% (free testosterone) of patients. Sex hormone-binding globulin, dehydroepiandrosterone sulfate, follicle-stimulating hormone, luteinizing hormone, and thyroid function levels were all within stated reference ranges. Total and free testosterone levels correlated inversely with ventilator days and ICU length of stay.

CONCLUSION

Hypotestosteronemia is common in mechanically ventilated patients with primary acute respiratory failure and may contribute to longer ICU stay. Further studies are needed to determine the effect of testosterone replacement on short- and long-term outcomes in these patients.

Serum testosterone levels and mortality in men with CKD stages 3-4

BACKGROUND

Hypogonadism in men (total testosterone <350 ng/dL) is associated with higher risk of cardiovascular disease and mortality in men on dialysis therapy. We evaluated the association of hypogonadism with all-cause mortality in men with non-dialysis-dependent chronic kidney disease (CKD).

STUDY DESIGN

Retrospective, cohort study.

SETTING & PARTICIPANTS

2,419 men with CKD stages 3-4 (estimated glomerular filtration rate, 15-59 mL/min/1.73 m2) who had total testosterone measured for cause between January 1, 2005, and October 31, 2011, at a tertiary-care center in Cleveland, OH.

PREDICTORS

Total testosterone measured using an immunoassay measurement in 3 forms: (1) categorized as low or testosterone replacement therapy versus normal, (2) continuous log testosterone, and (3) quintiles (100-226, 227-305, 306-392, 393-511, and 512-3,153 ng/dL).

OUTCOMES

Factors associated with low total testosterone level and the association between low total testosterone level and all-cause mortality were evaluated using logistic regression, Cox proportional hazard models, and Kaplan-Meier survival curves.

RESULTS

Hypogonadism was found in 1,288 of 2,419 (53%) men. In a multivariable logistic regression analysis, African American ethnicity and higher estimated glomerular filtration rate were associated with lower odds of having hypogonadism. Diabetes and higher body mass index were associated with higher odds of having hypogonadism. 357 of 2,419 (15%) patients died during a median follow-up of 2.3 years. In the multivariate Cox model, testosterone level <350 ng/dL or testosterone replacement therapy was not associated with mortality. In a multivariable model also adjusted for testosterone supplementation, higher log testosterone was associated with significantly lower mortality (HR per 1 log unit, 0.70; 95% CI, 0.55-0.89). When compared to the highest quintile, the second lowest quintile of testosterone was associated with higher mortality (HR, 1.53; 95% CI, 1.09-2.16).

LIMITATIONS

Single-center study, timing of testosterone testing, lack of adjustment for proteinuria, and sampling bias.

CONCLUSIONS

Low total testosterone level may be associated with higher mortality in men with CKD stages 3-4, but more studies are needed.