ENDOCRINOLOGY IN THE TIME OF COVID-19: Management of diabetes insipidus and hyponatraemia

From Emergence to Endemicity: A Comprehensive Review of COVID-19

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), later renamed coronavirus disease 2019 (COVID-19), was first identified in Wuhan, China, in early December 2019. Initially, the China office of the World Health Organization was informed of numerous cases of pneumonia of unidentified etiology in Wuhan, Hubei Province at the end of 2019. This would subsequently result in a global pandemic with millions of confirmed cases of COVID-19 and millions of deaths reported to the WHO. We have analyzed most of the data published since the beginning of the pandemic to compile this comprehensive review of SARS-CoV-2. We looked at the core ideas, such as the etiology, epidemiology, pathogenesis, clinical symptoms, diagnostics, histopathologic findings, consequences, therapies, and vaccines. We have also included the long-term effects and myths associated with some therapeutics of COVID-19. This study presents a comprehensive assessment of the SARS-CoV-2 virology, vaccines, medicines, and significant variants identified during the course of the pandemic. Our review article is intended to provide medical practitioners with a better understanding of the fundamental sciences, clinical treatment, and prevention of COVID-19. As of May 2023, this paper contains the most recent data made accessible.

Pediatric endocrinopathies related to COVID-19: an update

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the seventh coronavirus to be linked to human disease. The SARS-CoV-2 virus may have several pathophysiologic interactions with endocrine systems, resulting in disruptions in glucose metabolism, hypothalamus and pituitary function, adrenal function, and mineral metabolism. An increasing amount of evidence demonstrates both the influence of underlying endocrine abnormalities on the outcome of COVID-19 and the effect of the SARS-CoV-2 virus on endocrine systems. However, a systematic examination of the link to pediatric endocrine diseases has been missing.

DATA SOURCES

The purpose of this review is to discuss the impact of SARS-CoV-2 infection on endocrine systems and to summarize the available knowledge on COVID-19 consequences in children with underlying endocrine abnormalities. For this purpose, a literature search was conducted in EMBASE, and data that were discussed about the effects of COVID-19 on endocrine systems were used in the current study.

RESULTS

Treatment suggestions were provided for endocrinopathies associated with SARS-CoV-2 infection.

CONCLUSIONS

With the global outbreak of COVID-19, it is critical for pediatric endocrinologists to understand how SARS-CoV-2 interacts with the endocrine system and the therapeutic concerns for children with underlying problems who develop COVID-19. While children and adults share certain risk factors for SARS-CoV-2 infection sequelae, it is becoming obvious that pediatric responses are different and that adult study results cannot be generalized. While pediatric research gives some insight, it also shows the need for more study in this area.

Inappropriate therapy of euvolemic hyponatremia, the most frequent type of hyponatremia in SARS-CoV-2 infection, is associated with increased mortality in COVID-19 patients

Introduction

Admission hyponatremia, frequent in patients hospitalized for COVID-19, has been associated with increased mortality. However, although euvolemic hyponatremia secondary to the Syndrome of Inappropriate Antidiuresis (SIAD) is the single most common cause of hyponatremia in community-acquired pneumonia (CAP), a thorough and rigorous assessment of the volemia of hyponatremic COVID-19 subjects has yet to be described. We sought to identify factors contributing to mortality and hospital length-of-stay (LOS) in hospitalized COVID-19 patients admitted with hyponatremia, taking volemia into account.

Method

Retrospective study of 247 patients admitted with COVID-19 to a tertiary hospital in Madrid, Spain from March 1st through March 30th, 2020, with a glycemia-corrected serum sodium level (SNa) < 135 mmol/L. Variables were collected at admission, at 2nd-3rd day of hospitalization, and ensuing days when hyponatremia persisted. Admission volemia (based on both physical and analytical parameters), therapy, and its adequacy as a function of volemia, were determined.

Results

Age: 68 years [56-81]; 39.9% were female. Median admission SNa was 133 mmol/L [131- 134]. Hyponatremia was mild (SNa 131-134 mmol/L) in 188/247 (76%). Volemia was available in 208/247 patients; 57.2% were euvolemic and the rest (42.8%) hypovolemic. Hyponatremia was left untreated in 154/247 (62.3%) patients. Admission therapy was not concordant with volemia in 43/84 (51.2%). In fact, the majority of treated euvolemic patients received incorrect therapy with isotonic saline (37/41, 90.2%), whereas hypovolemics did not (p=0.001). The latter showed higher mortality rates than those receiving adequate or no therapy (36.7% vs. 19% respectively, p=0.023). The administration of isotonic saline to euvolemic hyponatremic subjects was independently associated with an elevation of in-hospital mortality (Odds Ratio: 3.877, 95%; Confidence Interval: 1.25-12.03).

Conclusion

Hyponatremia in COVID-19 is predominantly euvolemic. Isotonic saline infusion therapy in euvolemic hyponatremic COVID-19 patients can lead to an increased mortality rate. Thus, an exhaustive and precise volemic assessment of the hyponatremic patient with CAP, particularly when due to COVID-19, is mandatory before instauration of therapy, even when hyponatremia is mild.

Pituitary and SARS CoV-2: An unremitting conundrum

There is increased interest related to the impact of coronavirus disease 19 (COVID-19) on the endocrine system and in particular on the pituitary gland. Over the course of the severe infection with acute respiratory syndrome coronavirus 2 (SARS-CoV-2), there are both acute and delayed effects on the pituitary, related to infection and/or treatment. Hypopituitarism, pituitary apoplexy and hypophysitis have been all reported, as well as arginine vasopressin deficiency (diabetes insipidus) and syndrome of inappropriate antidiuretic hormone secretion. Furthermore, patients with acromegaly, Cushing's disease and hypopituitarism are theoretically at increased risk of complications with COVID-19 and require close monitoring. Evidence regarding pituitary dysfunction in patients with COVID-19 continues to be gathered, as the breadth and depth of knowledge also continues to rapidly evolve. This review summarizes data analysis to date on the possible effects of COVID-19 and COVID-19 vaccination on patients with normal pituitary function and patients with known pituitary pathology. Though clinical systems were significantly affected, it seems there is no overall loss of biochemical control in patients with certain pituitary pathologies.

The effect of COVID-19 process on patients with endocrinological disease in a pandemic hospital: What happened to the others?

Objective

To evaluate the effects of the pandemic process on those with an endocrinological disease that will require close follow-up from the last visit before the pandemic.

Materials and Methods

Patients of 3,903 with thyroid, calcium-bone metabolism, adrenal gland, pituitary diseases, and neuroendocrine tumor (NET) were retrospectively scanned. The remaining 855 (656 females and 199 males) patients with active disease or who still needed multidisciplinary approaches were included. The number of patients who continued the disease-related medical procedures and could complete these procedures on time in the pandemic period was determined, and medical deprivation rate (MDR) was calculated.

Results

The prepandemic period of our patients with thyroid disease (n = 594), calcium-bone metabolism disorder (n = 130), adrenal disease (n = 85), pituitary disease, and NET (n = 46) had MDRs of 85%, 56%, 81%, and 89%, respectively. For each subgroup of patients, the lowest MDR (67%) was in medullary thyroid carcinoma, the highest MDR (89%) was in differentiated thyroid carcinoma; the lowest MDR (6%) was in osteoporosis, the highest MDR (100%) was in the active Paget's disease; the lowest MDR (0%) was in primary adrenocortical insufficiency, the highest MDR (100%) was in hyperfunctional adrenal adenomas; the lowest MDR (81%) was in pituitary nonfunctional adenomas, and the highest MDR (100%) was in Cushing's disease, active prolactinoma, TSHoma, and NET, respectively.

Conclusion

This study showed that not only those who had COVID-19 but also those who had medical deprivation due to their current endocrinological disease were not to be underestimated during the pandemic period.

SIADH & Diabetes insipidus: Neues zu Diagnosestellung und Therapie

COVID-19 und Störungen der Wasser- und Natriumhomöostase Eine Dysnatriämie tritt bei hospitalisierten Patient*innen mit COVID-19 gehäuft auf und ist mit einer erhöhten Mortalität und vermehrt septischen Verläufen assoziiert. Insbesondere eine profunde Hyponatriämie kann auch Ausdruck für ein zugrunde liegendes Syndrom der inadäquaten AVP-Sekretion (SIADH) oder einen Cortisolmangel unter COVID-19-Infektion sein. Patient*innen mit bereits bekannten Störungen des AVP-Systems – wie dem SIADH oder Diabetes insipidus – sind einem erhöhten Risiko einer mitunter schwerwiegenden Elektrolyt-Entgleisung unter COVID-19-Infektion ausgesetzt und sollten engmaschig kontrolliert werden.

Hyponatriämie unter Immun-Checkpoint-Blockade – nicht immer SIADH Der wachsende Einsatz von Immun-Checkpoint-Inhibitoren (ICI) in der Tumortherapie hat auch zu einem Zuwachs von immunvermittelten endokrinen Nebenwirkungen geführt. Diese können zeitlich sehr variabel, auch noch nach Beendigung einer ICI-Therapie, auftreten und initial eine unspezifische Klinik aufweisen. Als ein einfacher, allgemein verfügbarer Biomarker und zugleich sensitives Warnsignal für mögliche endokrine Nebenwirkungen kann die Hyponatriämie dienen. Eine unklare und neu aufgetretene Hyponatriämie unter ICI-Therapie sollte vor Diagnose eines SIADH stets abgeklärt und endokrine Nebenwirkungen sollten ausgeschlossen werden.

Neue Evidenz in der Behandlung der akuten und chronischen Hyponatriämie In der Behandlung der akuten symptomatischen Hyponatriämie eignen sich sowohl die rasche intermittierende Bolusgabe als auch die langsam kontinuierliche Infusion von 3 % NaCl zur Akuttherapie. Die Bolusgabe bietet eine geringe Überlegenheit im Sicherheitsprofil und wird in den Empfehlungen der Europäischen Praxisleitlinie favorisiert. In der Behandlung der chronischen Hyponatriämie bei SIADH ist die Flüssigkeitsrestriktion als Erstlinientherapie ein probates Mittel zur Elektrolyt-Korrektur. Die additive Gabe von Furosemid und NaCl-Kapseln zeigt keine gesteigerte Wirkeffizienz, jedoch eine schlechtere Verträglichkeit.

Copeptin-basierte Diagnostik in der Abklärung des Polyurie-Polydipsie-Syndroms Bei der Abklärung des Polyurie-Polydipsie-Syndroms ist die Sicherung einer hypotonen Polyurie vor der erweiterten diagnostischen Differenzierung essenziell. Copeptin-basierte Testverfahren zeigen eine deutliche Überlegenheit gegenüber dem indirekten Durstversuch in der Differenzierung zwischen Patient*innen mit einem Diabetes insipidus und einer Primären Polydipsie. Das eskalierende Vorgehen der diagnostischen Verfahren ist ebenso zielführend wie ressourceneffizient.

Current evidence on the impact of the COVID-19 pandemic on paediatric endocrine conditions

Severe acute respiratory coronavirus 2 (SARS-CoV-2) interacts with the host cells through its spike protein by binding to the membrane enzyme angiotensin-converting enzyme 2 (ACE2) and it can have a direct effect on endocrine function as ACE2 is expressed in many glands and organs with endocrine function. Furthermore, several endocrine conditions have features that might increase the risk of SARS-CoV-2 infection and the severity and course of the infection, as obesity for the underlying chronic increased inflammatory status and metabolic derangement, and for the possible changes in thyroid function. Vitamin D has immunomodulatory effects, and its deficiency has negative effects. Adrenal insufficiency and excess glucocorticoids affect immune conditions also besides metabolism. This review aims to analyze the rationale for the fear of direct effects of SARS-Cov-2 on endocrinological disorders, to study the influence of pre-existing endocrine disorders on the course of the infection, and the actual data in childhood. Currently, data concerning endocrine function during the pandemic are scarce in childhood and for many aspects definite conclusions cannot be drawn, however, data on properly managed patients with adrenal insufficiency at present are re-assuring. Too little attention has been paid to thyroid function and further studies may be helpful. The available data support a need for adequate vitamin D supplementation, caution in obese patients, monitoring of thyroid function in hospitalized patients, and confirm the need for an awareness campaign for the increased frequency of precocious puberty, rapidly progressive puberty and precocious menarche. The changes in lifestyle, the increased incidence of overweight and the change in the timing of puberty lead also to hypothesize that there might be an increase in ovarian dysfunction, as for example polycystic ovarian disease, and metabolic derangements in the next years, and in the future we might be facing fertility problems. This prompts to be cautious and maintain further surveillance.

[Pituitary and COVID-19: review]

A severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rapidly spread around the world since was first scientifically described in December 2019. At present approximately 400 million people have suffered from the disease, almost 6 million people have died.SARS-CoV-2 uses the angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 for S protein priming. ACE2 and TMPRSS2 are expressed in several endocrine glands, including the pituitary, pancreas, thyroid, ovaries, and testes. Thus, the endocrine glands may be a direct target for SARS-CoV-2. The main risk factors for severity of the COVID-19 are obesity, arterial hypertension, diabetes mellitus (DM), vertebral fractures, which potentially predisposes patients to a severe course of COVID-19.In this review, we present current data on the course of COVID-19 in patients with hypothalamic-pituitary diseases, and also discuss treatment for endocrinopathies during to COVID-19.

A retrospective cohort study of risk factors and outcomes in older patients admitted to an inner-city geriatric unit in London during first peak of COVID-19 pandemic

PURPOSE

Compared to younger patients, coronavirus disease 2019 (COVID-19) clinical presentation in older people can be more heterogeneous and fatal. We aim to describe a cohort of older adults admitted in an inner-city London hospital during the first peak of the pandemic.

METHODS

A retrospective observational study that enrolled older adults consecutively admitted into two geriatric wards with suspected or confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We collected socio-demographic data, comorbidities, symptoms at presentation and/or during admission, biochemical and radiological data and outcomes at 28 days.

RESULTS

One hundred twenty-four patients were included, and 75% were > 80 years old. 19.5% of COVID-19 cases were judged to be hospital-acquired. More than half presented or developed typical symptoms, respiratory failure or fatigue. 46.8% were diagnosed with delirium, 24.2% with falls and dysphagia was present in 13.7%. The mortality rate was 29.8% and was higher among males, those > 80 years, patients with a higher grade of frailty, a history of dementia or chronic kidney disease, as well as those diagnosed with respiratory failure, acute kidney injury or hypernatremia. Independent predictors of mortality were male sex, age > 80 years, respiratory failure and hypernatremia.

CONCLUSION

We have described a cohort of patients with SARS-CoV-2 infection in the first UK peak of the global pandemic. We found that these patients had significant frailty with multiple comorbidities. There was a high mortality and increased dependency and greater social care need in survivors.

COVID-19 and hypopituitarism

Besides the pulmonary manifestations caused by severe acute respiratory syndrome (SARS) coronavirus 2 (SARS-CoV-2), an emerging endocrine phenotype, which can heavily impact on the severity of the syndrome, has been recently associated with coronavirus disease 2019 (COVID-19). Patients with pituitary diseases or the pituitary gland itself may also be involved in COVID-19 clinical presentation and/or severity, causing pituitary apoplexy.Moreover, hypopituitarism is frequently burdened by several metabolic complications, including arterial hypertension, hyperglycemia, obesity and vertebral fractures, which have all been associated with poor outcomes and increased mortality in patients infected by SARS-CoV-2.This review will discuss hypopituitarism as a condition that might have a bidirectional relationship with COVID-19 due to the frequent presence of metabolic comorbidities, to the direct or indirect pituitary damage or being per se a potential risk factor for COVID-19. Finally, we will address the current recommendations for the clinical management of vaccines in patients with hypopituitarism and adrenal insufficiency.

Remote management of osteoporosis in the first wave of the COVID-19 pandemic

We conducted a survey during the first pandemic wave of coronavirus disease 2019 (COVID-19) on a large group of osteoporotic patients to evaluate the general conditions of osteoporotic patients and the impact of the pandemic on the management of osteoporosis, finding high compliance to treatments and low COVID-19 lethality.

INTRODUCTION

During the first pandemic wave of coronavirus disease 2019 (COVID-19), 209,254 cases were diagnosed in Italy; fatalities were 26,892 and were overwhelmingly older patients. The high prevalence of osteoporosis in this age group suggests a potential relationship between SARS-CoV-2 infection and bone metabolism.

METHODS

In a telephone survey conducted from April to May 2020, patients from the Osteoporosis Center, Clinic of Endocrinology and Metabolic Diseases of Umberto I Hospital (Ancona, Italy), were interviewed to evaluate the general clinical conditions of osteoporotic patients, compliance with osteoporosis medications, COVID-19 prevalence, hospitalization rate, COVID-19 mortality, and lethality.

RESULTS

Among the 892 patients interviewed, 77.9% were taking osteoporosis treatment and 94.6% vitamin D supplementation as prescribed at the last visit. COVID-19-like symptoms were reported by 5.1%, whereas confirmed cases were 1.2%. A total number of 33 patients had been in hospital and the hospitalization rate of those who had not discontinued vitamin D supplementation was less than 4%. There were eight deaths, two with a concomitant COVID-19 diagnosis. The prevalence of severe osteoporosis was 50% in total COVID-19 patients and 87.5% in deceased COVID-19 patients. The overall COVID-19 mortality was 0.2%; lethality was 20%, lower than the national rate of the same age group.

CONCLUSIONS

This large group of osteoporotic patients showed high compliance and lower COVID-19 lethality compared to patients of the same age. Novel approaches such as telemedicine can provide critical support for the remote follow-up of patients with chronic diseases also in the setting of routine care.

Challenges and improvement needs in the care of patients with central diabetes insipidus

Central diabetes insipidus (CDI) is a rare condition, with significant impact on patient health and well-being. It is a chronic condition which usually requires meticulous long-term care. It can affect both children and adults. There is limited literature considering the needs and challenges inherent in providing high quality care to patients with CDI, across the care pathway. This paper seeks to address this gap by providing a unique and well-rounded understanding of clinical and healthcare systems-related challenges. It draws on insights from the literature, from direct clinical experience contributed by five clinicians as co-authors (providing insights from France, Ireland, Italy, Spain and the United Kingdom), and from patient perspectives provided through interviews with patient representatives from three patient organisations. We identify clinical challenges related to the diagnosis of CDI, including differentiating between other similar conditions and determining the underlying aetiology. Treatment is challenging, given the need to tailor medication to each patient’s needs and ongoing management is required to ensure that patients continue to respond adequately to treatment. Ongoing support is required when patients switch between formulations. We also identify healthcare systems challenges related to limited awareness of CDI amongst primary care physicians and general paediatricians, and the need for highly skilled specialist care and appropriate workforce capacity. There is also a significant need for raising awareness and for the education of both healthcare professionals and patients about different aspects of CDI, with the aim of supporting improved care and effective patient engagement with healthcare professionals. We reflect on this information and highlight improvement opportunities. These relate to developing guidance to support patients, carers, primary care physicians and general paediatricians to identify clinical features earlier, and to consider CDI as a possible diagnosis when a patient presents with suggestive symptoms.

Prevalence, prognostic value, pathophysiology, and management of hyponatraemia in children and adolescents with COVID-19

Hyponatraemia is frequently encountered in adults with coronavirus disease 2019 (COVID-19) and is associated with poor prognosis. This review aims to describe for the first time the prevalence, aetiology, prognostic value, pathophysiology, and management of hyponatraemia in children and adolescents with COVID-19, taking into account all relevant studies published in PubMed and Cochrane Library studies until 26th September 2021. Literature search did not detect any studies evaluating the prevalence and prognostic value of sodium disorders in paediatric patients with COVID-19. A broader literature review showed a high prevalence of hyponatraemia in children with bacterial pneumonia, while some studies have reported that hyponatraemia is relatively common in Multisystem Inflammatory Syndrome in Children (MIS-C). In adults with COVID-19, an inverse association between sodium and interleukin-6 levels has been found, indicating that hyponatraemia could be used as a surrogate marker for the risk of cytokine storm and may facilitate the identification of patients who could benefit from immunomodulatory agents. Studies are urgently needed to evaluate the frequency and prognostic impact of electrolyte abnormalities in children with COVID-19. In the meantime, clinicians are urged to consider hyponatraemia in children with COVID-19 as a potential red flag, investigate the cause and administer fluids and other therapies accordingly.

MANAGEMENT OF ENDOCRINE DISEASE: Dysnatraemia in COVID-19: prevalence, prognostic impact, pathophysiology, and management

This review examines the prevalence, aetiology, pathophysiology, prognostic value, and investigation of dysnatraemia in hospitalised COVID-19 patients, taking into account all relevant studies published in PubMed and Cochrane Library studies until March 2021. Hyponatraemia is commonly observed in patients with bacterial pneumonia and is an independent predictor for excess mortality and morbidity. However, it remains unknown whether this association applies to coronavirus disease-2019 (COVID-19). Several studies reported a 20-35% prevalence for hyponatraemia and 2-5% for hypernatraemia in patients admitted with COVID-19. In addition, hyponatraemia on admission was a risk factor for progression to severe disease, being associated with an increased likelihood for the need for invasive mechanical ventilation, with an odds ratio (OR) of 1.83-3.30. Hyponatraemia seems to be an independent risk factor for mortality, with an OR of 1.40-1.50 compared to normonatraemia, while hypernatraemia is related to even worse outcomes than hyponatraemia. Furthermore, preliminary data show an inverse association between serum sodium and interleukin-6 levels, suggesting that hyponatraemia might be used as a surrogate marker for the risk of a cytokine storm and the need for treatment with interleukin antagonists. In conclusion, dysnatraemia is common and carries a poor prognosis in COVID-19 patients, indicating that it may play a future role in risk stratification and individualising therapy.

Interplay between endocrinology, metabolism and COVID-19 infection

There are more than 170 million confirmed cases of COVID-19 worldwide, yet its effects on the endocrine system remain under-reported due to lack of awareness by the public, primary care givers and specialists. This is a narrative review using up-to-date literature discussing the consequences that infection with SARS-CoV-2 can have on diabetes and the endocrine glands including the adrenals, thyroid and pituitary, as well as hyponatremia and hypogonadism. Endocrinologists, internists and primary care physicians need to be aware of the involvement of the endocrine organs when dealing with people recovering from COVID-19 and actively manage any complications to reduce mortality and improve the quality of life of those affected.

ENDOCRINOLOGY IN THE TIME OF COVID-19-2021 UPDATES: The management of diabetes insipidus and hyponatraemia

COVID-19 has changed the nature of medical consultations, emphasizing virtual patient counselling, with relevance for patients with diabetes insipidus (DI) or hyponatraemia. The main complication of desmopressin treatment in DI is dilutional hyponatraemia. Since plasma sodium monitoring is not always possible in times of COVID-19, we recommend to delay the desmopressin dose once a week until aquaresis occurs allowing excess retained water to be excreted. Patients should measure their body weight daily. Patients with DI admitted to the hospital with COVID-19 have a high risk for mortality due to volume depletion. Specialists must supervise fluid replacement and dosing of desmopressin. Patients after pituitary surgery should drink to thirst and measure their body weight daily to early recognize the development of postoperative SIAD. They should know hyponatraemia symptoms. Hyponatraemia in COVID-19 is common with a prevalence of 20-30% and is mostly due to SIAD or hypovolaemia. It mirrors disease severity and is an early predictor of mortality. Hypernatraemia may also develop in COVID-19 patients, with a prevalence of 3-5%, especially in ICU, and derives from different multifactorial reasons, for example, due to insensible water losses from pyrexia, increased respiration rate and use of diuretics. Hypernatraemic dehydration may contribute to the high risk of acute kidney injury in COVID-19. IV fluid replacement should be administered with caution in severe cases of COVID-19 because of the risk of pulmonary oedema.

Higher admission activated partial thromboplastin time, neutrophil-lymphocyte ratio, serum sodium, and anticoagulant use predict in-hospital COVID-19 mortality in people with Diabetes: Findings from Two University Hospitals in the U.K

AIMS

To create and compare survival models from admission laboratory indices in people hospitalized with coronavirus disease 2019 (COVID-19) with and without diabetes.

METHODS

Retrospective observational study of patients with COVID-19 with or without diabetes admitted to Sheffield Teaching Hospitals from 29 February to 01 May 2020. Predictive variables for in-hospital mortality from COVID-19 were explored using Cox proportional hazard models.

RESULTS

Out of 505 patients, 156 (30.8%) had diabetes mellitus (DM) of which 143 (91.7%) had type 2 diabetes. There were significantly higher in-hospital COVID-19 deaths in those with DM [DM COVID-19 deaths 54 (34.6%) vs. non-DM COVID-19 deaths 88 (25.2%): P < 0.05]. Activated partial thromboplastin time (APPT) > 24 s without anticoagulants (HR 6.38, 95% CI: 1.07-37.87: P = 0.04), APTT > 24 s with anticoagulants (HR 24.01, 95% CI: 3.63-159.01: P < 0.001), neutrophil-lymphocyte ratio > 8 (HR 6.18, 95% CI: 2.36-16.16: P < 0.001), and sodium > 136 mmol/L (HR 3.27, 95% CI: 1.12-9.56: P = 0.03) at admission, were only associated with in-hospital COVID-19 mortality for those with diabetes.

CONCLUSIONS

At admission, elevated APTT with or without anticoagulants, neutrophil-lymphocyte ratio and serum sodium are unique factors that predict in-hospital COVID-19 mortality in patients with diabetes compared to those without. This novel finding may lead to research into haematological and biochemical mechanisms to understand why those with diabetes are more susceptible to poor outcomes when infected with Covid-19, and contribute to identification of those most at risk when admitted to hospital.

COVID-19 and endocrine and metabolic disorders: critical points and suggestions for a correct therapeutic management from a tertiary endocrine center in Italy

The Coronavirus-19 (COVID-19) pandemic, which began in December 2019 in Wuhan, China, has spread rapidly worldwide, affecting mostly frail individuals and resulting in high lethality among people with chronic conditions. The management of chronic endocrine disorders during the pandemic period proved particularly challenging, as they require close physician-patient contact for proper long-term management. In addition, acute endocrinologic conditions that presented during the COVID-19 period required timely management in an unusual clinical setting, providing an ongoing challenge for clinicians. This article summarizes the most recent guidance on the management and therapy of frequent conditions such as diabetes and osteoporosis and less common endocrine disorders (e.g., adrenal insufficiency) in this setting.

Sodium Toxicity in the Nutritional Epidemiology and Nutritional Immunology of COVID-19

Dietary factors in the etiology of COVID-19 are understudied. High dietary sodium intake leading to sodium toxicity is associated with comorbid conditions of COVID-19 such as hypertension, kidney disease, stroke, pneumonia, obesity, diabetes, hepatic disease, cardiac arrhythmias, thrombosis, migraine, tinnitus, Bell's palsy, multiple sclerosis, systemic sclerosis, and polycystic ovary syndrome. This article synthesizes evidence from epidemiology, pathophysiology, immunology, and virology literature linking sodium toxicological mechanisms to COVID-19 and SARS-CoV-2 infection. Sodium toxicity is a modifiable disease determinant that impairs the mucociliary clearance of virion aggregates in nasal sinuses of the mucosal immune system, which may lead to SARS-CoV-2 infection and viral sepsis. In addition, sodium toxicity causes pulmonary edema associated with severe acute respiratory syndrome, as well as inflammatory immune responses and other symptoms of COVID-19 such as fever and nasal sinus congestion. Consequently, sodium toxicity potentially mediates the association of COVID-19 pathophysiology with SARS-CoV-2 infection. Sodium dietary intake also increases in the winter, when sodium losses through sweating are reduced, correlating with influenza-like illness outbreaks. Increased SARS-CoV-2 infections in lower socioeconomic classes and among people in government institutions are linked to the consumption of foods highly processed with sodium. Interventions to reduce COVID-19 morbidity and mortality through reduced-sodium diets should be explored further.

Diagnosis and management of diabetes insipidus for the internist: an update

Diabetes insipidus is a disorder characterized by excretion of large amounts of hypotonic urine. Four entities have to be differentiated: central diabetes insipidus resulting from a deficiency of the hormone arginine vasopressin (AVP) in the pituitary gland or the hypothalamus, nephrogenic diabetes insipidus resulting from resistance to AVP in the kidneys, gestational diabetes insipidus resulting from an increase in placental vasopressinase and finally primary polydipsia, which involves excessive intake of large amounts of water despite normal AVP secretion and action. Distinguishing between the different types of diabetes insipidus can be challenging. A detailed medical history, physical examination and imaging studies are needed to detect the aetiology of diabetes insipidus. Differentiation between the various forms of hypotonic polyuria is then done by the classical water deprivation test or the more recently developed hypertonic saline or arginine stimulation together with copeptin (or AVP) measurement. In patients with idiopathic central DI, a close follow-up is needed since central DI can be the first sign of an underlying pathology. Treatment of diabetes insipidus or primary polydipsia depends on the underlying aetiology and differs in central diabetes insipidus, nephrogenic diabetes insipidus and primary polydipsia. This review will discuss issues and newest developments in diagnosis, differential diagnosis and treatment, with a focus on central diabetes insipidus.

SARS-CoV-2 infection and paediatric endocrine disorders: Risks and management considerations

Background

Coronavirus-19 (COVID-19) is a disease caused by the SARS-CoV-2 virus, the seventh coronavirus identified as causing disease in humans. The SARS-CoV-2 virus has multiple potential pathophysiologic interconnections with endocrine systems, potentially causing disturbances in glucose metabolism, hypothalamic and pituitary function, adrenal function and mineral metabolism. A growing body of data is revealing both the effects of underlying endocrine disorders on COVID-19 disease outcome and the effects of the SARS-CoV-2 virus on endocrine systems. However, comprehensive assessment of the relationship to endocrine disorders in children has been lacking.

Content

In this review, we present the effects of SARS-CoV-2 infection on endocrine systems and review the current literature on complications of COVID-19 disease in underlying paediatric endocrine disorders. We provide recommendations on management of endocrinopathies related to SARS-CoV-2 infection in this population.

Summary and outlook

With the surge in COVID-19 cases worldwide, it is important for paediatric endocrinologists to be aware of the interaction of SARS-CoV-2 with the endocrine system and management considerations for patients with underlying disorders who develop COVID-19 disease. While children and adults share some risk factors that influence risk of complications in SARS-CoV-2 infection, it is becoming clear that responses in the paediatric population are distinct and outcomes from adult studies cannot be extrapolated. Evidence emerging from paediatric studies provides some guidance but highlights the need for more research in this area.

COVID-19 and the Endocrine System: A Comprehensive Review on the Theme

Background and aim. The review aimed to summarize advances in the topic of endocrine diseases and coronavirus disease 2019 (COVID-19). Methods. Scientific and institutional websites and databases were searched and data were collected and organized, when plausible, to angle the discussion toward the following clinical issues. (1) Are patients with COVID-19 at higher risk of developing acute or late-onset endocrine diseases or dysfunction? (2) May the underlying endocrine diseases or dysfunctions be considered risk factors for poor prognosis once the infection has occurred? (3) Are there defined strategies to manage endocrine diseases despite pandemic-related constraints? Herein, the authors considered only relevant and more frequently observed endocrine diseases and disorders related to the hypothalamic-pituitary region, thyroid and parathyroid glands, calcium-phosphorus homeostasis and osteoporosis, adrenal glands, and gonads. Main. Data highlight the basis of some pathophysiological mechanisms and anatomical alterations of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)-induced endocrine dysfunctions. Some conditions, such as adrenal insufficiency and cortisol excess, may be risk factors of worse clinical progression once the infection has occurred. These at-risk populations may require adequate education to avoid the SARS-CoV-2 infection and adequately manage medical therapy during the pandemic, even in emergencies. Endocrine disease management underwent a palpable restraint, especially procedures requiring obligate access to healthcare facilities for diagnostic and therapeutic purposes. Strategies of clinical triage to prioritize medical consultations, laboratory, instrumental evaluations, and digital telehealth solutions should be implemented to better deal with this probably long-term situation.

Pulmonary Edema in COVID-19 Patients: Mechanisms and Treatment Potential

COVID-19 mortality is primarily driven by abnormal alveolar fluid metabolism of the lung, leading to fluid accumulation in the alveolar airspace. This condition is generally referred to as pulmonary edema and is a direct consequence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. There are multiple potential mechanisms leading to pulmonary edema in severe Coronavirus Disease (COVID-19) patients and understanding of those mechanisms may enable proper management of this condition. Here, we provide a perspective on abnormal lung humoral metabolism of pulmonary edema in COVID-19 patients, review the mechanisms by which pulmonary edema may be induced in COVID-19 patients, and propose putative drug targets that may be of use in treating COVID-19. Among the currently pursued therapeutic strategies against COVID-19, little attention has been paid to abnormal lung humoral metabolism. Perplexingly, successful balance of lung humoral metabolism may lead to the reduction of the number of COVID-19 death limiting the possibility of healthcare services with insufficient capacity to provide ventilator-assisted respiration.

Management of hyponatraemia and hypernatraemia during the Covid-19 pandemic: a consensus statement of the Spanish Society for Endocrinology (Acqua Neuroendocrinology Group)

SARS-COV2 infection has swiftly become a pandemic disease of historic relevance and widely variable outcomes. This variable prognosis is related both to uneven damage, among others, to lungs, heart and kidneys, and to a multisystemic inflammatory reaction. All these factors are known to disrupt water balance and potentially induce hyponatraemia or hypernatraemia. Water balance disorders are known mortality and morbidity risk factors in several clinical scenarios and their proper management, though often complex and hazardous, can reduce mortality and length of hospitalization. Clinical uncertainty over COVID-19 outcome, the variety of organs involved in both the infection and water balance and difficulties in clinical examination due to risk of contagion might obstruct proper management of dysnatremic disorders. Thus, the Acqua Neuroendocrinology Group of the Spanish Society for Endocrinology (SEEN) has endeavoured to provide evidence and expert based recommendations on the management of hyponatraemia and hypernatraemia in COVID-19 patients.

Serum sodium alterations in SARS CoV-2 (COVID-19) infection: impact on patient outcome

OBJECTIVE

Hyponatremia is the most common electrolyte disorder in hospitalized patients and occurs in about 30% of patients with pneumonia. Hyponatremia has been associated with a worse outcome in several pathologic conditions The main objective of this study was to determine whether serum sodium alterations may be independent predictors of the outcome of hospitalized COVID-19 patients.

DESIGN AND METHODS

In this observational study, data from 441 laboratory-confirmed COVID-19 patients admitted to a University Hospital were collected. After excluding 61 patients (no serum sodium at admission available, saline solution infusion before sodium assessment, transfer from another hospital), data from 380 patients were analyzed.

RESULTS

274 (72.1%) patients had normonatremia at admission, 87 (22.9%) patients had hyponatremia and 19 (5%) patients had hypernatremia. We found an inverse correlation between serum sodium and IL-6, whereas a direct correlation between serum sodium and PaO2/FiO2 ratio was observed. Patients with hyponatremia had a higher prevalence of non-invasive ventilation and ICU transfer than those with normonatremia or hypernatremia. Hyponatremia was an independent predictor of in-hospital mortality (2.7-fold increase vs normonatremia) and each mEq/L of serum sodium reduction was associated with a 14.4% increased risk of death.

CONCLUSIONS

These results suggest that serum sodium at admission may be considered as an early prognostic marker of disease severity in hospitalized COVID-19 patients.

COVID-19 and endocrine and metabolic diseases. An updated statement from the European Society of Endocrinology

BACKGROUND

COVID-19 has completely changed our daily clinical practice as well as our social relations. Many organs and biological systems are involved in SARS-Cov-2 infection, either due to direct virus-induced damage or to indirect effects that can have systemic consequences. Endocrine system is not only an exception but its involvement in COVID-19 is so relevant that an "endocrine phenotype" of COVID-19 has progressively acquired clinical relevance.

AIM

We have been appointed by the European Society of Endocrinology (ESE) to update with the current statement ESE members and the whole endocrine community on the emerging endocrine phenotype of COVID-19 and its implication for the prevention and management of the disease.

CONCLUSIONS

Diabetes has a major role in this phenotype since it is one of the most frequent comorbidities associated with severity and mortality of COVID-19. Careful management including treatment modifications may be required for protecting our patients rather with known diabetes from the most dangerous consequences of COVID-19 or hospitalized with COVID-19, but also in patients with SARS-CoV-2 induced newly onset diabetes. Obesity increases susceptibility to SARS-CoV-2 and the risk for COVID-19 adverse outcome. Adequate nutritional management needs to be granted to patients with obesity or undernourishment in order to limit their increased susceptibility and severity of COVID-19 infection. Lack of vitamin D, hypocalcemia and vertebral fractures have also emerged as frequent findings in the hospitalized COVID-19 population and may negatively impact on the outcome of such patients. Also, in patients with adrenal insufficiency prompt adaptation of glucocorticoid doses may be needed. Moreover, in this updated statement role of sex hormones as well as peculiar pituitary and thyroid aspects of COVID-19 have been included. Finally, in view of the mass vaccination, potential implications for endocrine patients should be considered.

Case Report: SARS-CoV-2 Infection in a Child With Suprasellar Tumor and Hypothalamic-Pituitary Failure

In early 2020, a novel coronavirus leading to potentially death was discovered. Since then, the 2019 coronavirus disease (COVID-19) has spread to become a worldwide pandemic. Beyond the risks strictly related to the infection, concerns have been expressed for the endocrinological impact that COVID-19 may have, especially in vulnerable individuals with pre-existing endocrinological health conditions. To date new information is emerging regarding severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) in children but the literature is still scarce concerning this infection in patients with intracranial malignant neoplasms. We report a 9-year-old child infected with SARS-CoV-2 and recent diagnosis of suprasellar non-germinomatous germ cell tumor also suffering from diabetes insipidus and hypothalamic-pituitary failure (hypothyroidism, adrenal insufficiency, hypothalamic obesity and growth hormone deficiency) and its clinical course. The patient remained asymptomatic for the duration of the infection without requiring any change in the replacement therapeutic dosages taken before the infection. We then discuss the proposed approach to treat a pediatric patient with SARS-CoV-2 infection and hypothalamic-pituitary failure and we include a review of the literature. Our report suggests that SARS-CoV-2 infection is usually mild and self-limiting in children even those immunocompromised and with multiple endocrinological deficits. Patients are advised to keep any scheduled appointments unless informed otherwise.

Diuretic-induced hypokalaemia: an updated review

Diuretic-induced hypokalaemia is a common and potentially life-threatening adverse drug reaction in clinical practice. Previous studies revealed a prevalence of 7%-56% of hypokalaemia in patients taking thiazide diuretics. The clinical manifestations of hypokalaemia due to diuretics are non-specific, varying from asymptomatic to fatal arrhythmia. Diagnosis of hypokalaemia is based on the level of serum potassium. ECG is useful in identifying the more severe consequences. A high dosage of diuretics and concomitant use of other drugs that increase the risk of potassium depletion or cardiac arrhythmias can increase the risk of cardiovascular events and mortality. Thiazide-induced potassium depletion may cause dysglycaemia. The risk of thiazide-induced hypokalaemia is higher in women and in black people. Reducing diuretic dose and potassium supplementation are the most direct and effective therapies for hypokalaemia. Combining with a potassium-sparing diuretic or blocker of the renin-angiotensin system also reduces the risk of hypokalaemia. Lowering salt intake and increasing intake of vegetables and fruits help to reduce blood pressure as well as prevent hypokalaemia.

Development and validation of a prognostic COVID-19 severity assessment (COSA) score and machine learning models for patient triage at a tertiary hospital

Background

Clinical risk scores and machine learning models based on routine laboratory values could assist in automated early identification of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients at risk for severe clinical outcomes. They can guide patient triage, inform allocation of health care resources, and contribute to the improvement of clinical outcomes.

Methods

In- and out-patients tested positive for SARS-CoV-2 at the Insel Hospital Group Bern, Switzerland, between February 1st and August 31st (‘first wave’, n = 198) and September 1st through November 16th 2020 (‘second wave’, n = 459) were used as training and prospective validation cohort, respectively. A clinical risk stratification score and machine learning (ML) models were developed using demographic data, medical history, and laboratory values taken up to 3 days before, or 1 day after, positive testing to predict severe outcomes of hospitalization (a composite endpoint of admission to intensive care, or death from any cause). Test accuracy was assessed using the area under the receiver operating characteristic curve (AUROC).

Results

Sex, C-reactive protein, sodium, hemoglobin, glomerular filtration rate, glucose, and leucocytes around the time of first positive testing (− 3 to + 1 days) were the most predictive parameters. AUROC of the risk stratification score on training data (AUROC = 0.94, positive predictive value (PPV) = 0.97, negative predictive value (NPV) = 0.80) were comparable to the prospective validation cohort (AUROC = 0.85, PPV = 0.91, NPV = 0.81). The most successful ML algorithm with respect to AUROC was support vector machines (median = 0.96, interquartile range = 0.85–0.99, PPV = 0.90, NPV = 0.58).

Conclusion

With a small set of easily obtainable parameters, both the clinical risk stratification score and the ML models were predictive for severe outcomes at our tertiary hospital center, and performed well in prospective validation.

Characteristic of Parkinson's disease with severe COVID-19: a study of 10 cases from Wuhan

Information about Parkinson's disease (PD) patients with severe COVID-19 is scarce. We aimed to analyze the clinical characteristics, outcomes, and risk factors affecting the prognosis of PD patients with severe COVID-19 infection. Clinical data of severe COVID-19 patients admitted at the Union Hospital, Wuhan between 28th January and 29th February 2020 were collected and analyzed. 10 patients (1.96%) had a medical history of PD with a mean (SD) age of 72.10 (± 11.46) years. The clinical characteristics and outcomes of severe COVID-19 with and without PD patients were then compared. There was no significant difference in overall mortality between the PD and non-PD patients with severe COVID-19 (p > 0.05). In PD patients with severe COVID-19, the proportion of patients with critical type, disturbance of consciousness, incidence of complications, white blood cells count and neutrophils counts on admission seem higher in the non-survivors. PD patients with older age, longer PD duration, and late stage PD may be highly susceptible to critical COVID-19 infection and bad outcome. The PD patients with consciousness disorders and complications that progressed rapidly are at increased risk of death.

Early Experience With Methylprednisolone on SARS-CoV-2 Infection in the African American Population, a Retrospective Analysis

BACKGROUND

Coronavirus disease-19 (COVID-19) is associated with acute kidney injury (AKI) and acute respiratory distress syndrome (ARDS) with high mortality rates. In African American (AA) populations, COVID-19 presentations and outcomes are more severe. NIH and Interim WHO guidelines had suggested against the use of corticosteroids unless in clinical trials until the recent publication of the RECOVERY trial. Here, we analyzed the treatment effect of methylprednisolone on patients with AKI and ARDS during the initial 2 months of COVID-19 and detail the learning effect within our institution.

METHODS

Between March 1 and April 30, 2020, 75 AA patients met our inclusion criteria for ARDS and AKI, of which 37 had received corticosteroids. Twenty-eight-day mortality, improvement in PaO2/FiO2 ratio, and renal function were analyzed. The impact of methylprednisolone treatment was assessed with multivariable methods.

RESULTS

Survival in the methylprednisolone group reached 51% at 21 days compared to 29% in the non-corticosteroid group (P < .001). Methylprednisolone improved the likelihood of renal function improvement. PaO2/FiO2 ratio in the methylprednisolone group improved by 73% compared to 45% in the non-corticosteroid group (P = .01). Age, gender, BMI, preexisting conditions, and other treatment factors did not show any impact on renal or PaO2/FiO2 ratio improvement. The use of anticoagulants, the month of treatment, and AKI during hospitalization also influenced outcomes.

CONCLUSION

In AA COVID-19 positive patients with ARDS and AKI, IV methylprednisolone lowered the incidence of mortality and improved the likelihood of renal and lung function recovery. Further investigation with a randomized control trial of corticosteroids is warranted.

Prevalence and Impact of Hyponatremia in Patients With Coronavirus Disease 2019 in New York City

OBJECTIVES

Hyponatremia occurs in up to 30% of patients with pneumonia and is associated with increased morbidity and mortality. The prevalence of hyponatremia associated with coronavirus disease 2019 and the impact on outcome is unknown. We aimed to identify the prevalence, predictors, and impact on outcome of mild, moderate, and severe admission hyponatremia compared with normonatremia among coronavirus disease 2019 patients.

DESIGN

Retrospective, multicenter, observational cohort study.

SETTING

Four New York City hospitals that are part of the same health network.

PATIENTS

Hospitalized, laboratory-confirmed adult coronavirus disease 2019 patients admitted between March 1, 2020, and May 13, 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Hyponatremia was categorized as mild (sodium: 130-134 mmol/L), moderate (sodium: 121-129 mmol/L), or severe (sodium: ≤ 120 mmol/L) versus normonatremia (135-145 mmol/L). The primary outcome was the association of increasing severity of hyponatremia and in-hospital mortality assessed using multivariable logistic regression analysis. Secondary outcomes included encephalopathy, acute renal failure, mechanical ventilation, and discharge home compared across sodium levels using Kruskal-Wallis and chi-square tests. In exploratory analysis, the association of sodium levels and interleukin-6 levels (which has been linked to nonosmotic release of vasopressin) was assessed. Among 4,645 patient encounters, hyponatremia (sodium < 135 mmol/L) occurred in 1,373 (30%) and 374 of 1,373 (27%) required invasive mechanical ventilation. Mild, moderate, and severe hyponatremia occurred in 1,032 (22%), 305 (7%), and 36 (1%) patients, respectively. Each level of worsening hyponatremia conferred 43% increased odds of in-hospital death after adjusting for age, gender, race, body mass index, past medical history, admission laboratory abnormalities, admission Sequential Organ Failure Assessment score, renal failure, encephalopathy, and mechanical ventilation (adjusted odds ratio, 1.43; 95% CI, 1.08-1.88; p = 0.012). Increasing severity of hyponatremia was associated with encephalopathy, mechanical ventilation, and decreased probability of discharge home (all p < 0.001). Higher interleukin-6 levels correlated with lower sodium levels (p = 0.017).

CONCLUSIONS

Hyponatremia occurred in nearly a third of coronavirus disease 2019 patients, was an independent predictor of in-hospital mortality, and was associated with increased risk of encephalopathy and mechanical ventilation.

Endocrine and metabolic aspects of the COVID-19 pandemic

COVID-19 infection has tremendously impacted our daily clinical practice as well as our social living organization. Virtually all organs and biological systems suffer from this new coronavirus infection, either because the virus targets directly specific tissues or because of indirect effects. Endocrine diseases are not an exception and some of endocrine organs are at risk of direct or indirect lesion by COVID-19. Although there is still no evidence of higher predisposition to contract the infection in patients with diabetes and/or obesity, the coexistence of these conditions contributes to a worse prognosis because both conditions confer an impaired immunologic system. Cytokines storm can be amplified by these two latter conditions thereby leading to multisystemic failure and death. Glycaemic control has been demonstrated to be crucial to avoiding long hospital stays, ICU requirement and also prevention of excessive mortality. Endocrine treatment modifications as a consequence of COVID-19 infection are required in a proactive manner, in order to avoid decompensation and eventual hospital admission. This is the case of diabetes and adrenal insufficiency in which prompt increase of insulin dosage and substitutive adrenal steroids through adoption of the sick day's rules should be warranted, as well as easy contact with the health care provider through telematic different modalities. New possible endocrinological targets of COVID-19 have been recently described and warrant a full study in the next future.

The associations between fasting plasma glucose levels and mortality of COVID-19 in patients without diabetes

AIMS

Coronavirus disease 2019 (COVID-19) which is a novel pneumonia can rapidly progress to acute respiratory distress syndrome, septic shock, and multiple organ dysfunction syndrome. It has appeared in 196 countries around the world. We aimed to clarify the associations between fasting plasma glucose levels and mortality of COVID-19 in patients without diabetes.

METHODS

We performed a retrospective, single-center study of 151 patients without diabetes in Tongji Hospital from January 1, 2020 to February 28, 2020. Past medical histories, clinical features and laboratory parameters were collected in these patients.

RESULTS

Compared with survivors, non-survivors were more likely to have underlying medical conditions including hypertension and chronic pulmonary diseases. Non-survivors had higher C-reactive protein (CRP), procalcitonin (PCT), interleukin (IL)-2R, IL-6, IL-8 and, tumor necrosis factor-α (TNF-α) levels, while lower lymphocyte counts as compared with those of survivors (all P<0.05). Besides, patients with higher fasting plasma glucose (FPG) had higher IL-6, IL-8, CRP levels and mortality; while lower lymphocyte counts. After adjusting for age and gender, each tertile increment of FPG levels conferred 3.54-fold higher risks of death (odds ratio, 3.54; 95% confidential interval, 1.25-10.06, P=0.018).

CONCLUSIONS

Non-survivors combined with more comorbidities, more severe infection, and worse liver, kidney and cardiac function in patients without diabetes. Additionally, fasting plasma glucose levels were significantly associated with the risk of death in patients even with normal FPG and HbA1c levels.

The extended autonomic system, dyshomeostasis, and COVID-19

The pandemic viral illness COVID-19 is especially life-threatening in the elderly and in those with any of a variety of chronic medical conditions. This essay explores the possibility that the heightened risk may involve activation of the "extended autonomic system" (EAS). Traditionally, the autonomic nervous system has been viewed as consisting of the sympathetic nervous system, the parasympathetic nervous system, and the enteric nervous system. Over the past century, however, neuroendocrine and neuroimmune systems have come to the fore, justifying expansion of the meaning of "autonomic." Additional facets include the sympathetic adrenergic system, for which adrenaline is the key effector; the hypothalamic-pituitary-adrenocortical axis; arginine vasopressin (synonymous with anti-diuretic hormone); the renin-angiotensin-aldosterone system, with angiotensin II and aldosterone the main effectors; and cholinergic anti-inflammatory and sympathetic inflammasomal pathways. A hierarchical brain network-the "central autonomic network"-regulates these systems; embedded within it are components of the Chrousos/Gold "stress system." Acute, coordinated alterations in homeostatic settings (allostasis) can be crucial for surviving stressors such as traumatic hemorrhage, asphyxiation, and sepsis, which throughout human evolution have threatened homeostasis; however, intense or long-term EAS activation may cause harm. While required for appropriate responses in emergencies, EAS activation in the setting of chronically decreased homeostatic efficiencies (dyshomeostasis) may reduce thresholds for induction of destabilizing, lethal vicious cycles. Testable hypotheses derived from these concepts are that biomarkers of EAS activation correlate with clinical and pathophysiologic data and predict outcome in COVID-19 and that treatments targeting specific abnormalities identified in individual patients may be beneficial.

Fluid Replacement Versus Fluid Restriction in COVID-19 Associated Hyponatremia

Hyponatremia is one of the most frequently observed electrolyte abnormalities in coronavirus disease 2019 (COVID-19). Literature describes syndrome of inappropriate anti diuretic hormone (SIADH) as the mechanism of hyponatremia in COVID-19 requiring fluid restriction for management. However, it is important to rule out other etiologies of hyponatremia in such cases keeping in mind the effect of an alternate etiology on patient management and outcome. We present a case of hypovolemic hyponatremia in a patient with COVID-19, which unlike SIADH, required fluid replacement early in the disease course for its correction. A 52-year-old Filipino gentleman presented with a three-week history of diarrhea and symptomatic hyponatremia. There was no history of fever or respiratory symptoms. Physical examination revealed a dehydrated and confused middle-aged gentleman. Labs revealed lymphopenia, thrombocytopenia, and severe hyponatremia (108 mmol/L). Blood cultures and stool workup were negative. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nasopharyngeal swab was positive. Hyponatremia workup excluded SIADH. The patient had hypovolemic hyponatremia due to gastrointestinal (GI) losses and was managed with saline infusion for correction of hyponatremia with improvement in his clinical status. Hyponatremia in COVID-19 is not only secondary to SIADH but can also be due to other etiologies. Hypovolemic hyponatremia should be distinguished from SIADH as these conditions employ different management strategies, and early diagnosis and management of hypovolemic hyponatremia affects morbidity and mortality.

Endocrinology in the time of COVID-19: Management of pituitary tumours

Patients with pituitary tumours, ensuing hormonal abnormalities and mass effects are usually followed in multidisciplinary pituitary clinics and can represent a management challenge even during the times of non-pandemic. The COVID-19 pandemic has put on hold routine medical care for hundreds of millions of patients around the globe, while many pituitary patients' evaluations cannot be delayed for too long. Furthermore, the majority of patients with pituitary tumours have co-morbidities potentially impacting the course and management of COVID-19 (e.g. hypopituitarism, diabetes mellitus, hypertension, obesity and cardiovascular disease). Here, we summarize some of the diagnostic and management dilemmas encountered, and provide guidance on safe and as effective as possible delivery of care in the COVID-19 era. We also attempt to address how pituitary services should be remodelled in the event of similar crises, while maintaining or even improving patient outcomes. Regular review of these recommendations and further adjustments are needed, depending on the evolution of the COVID-19 pandemic status. We consider that the utilization of successful models of pituitary multidisciplinary care implemented during the COVID-19 pandemic should continue after the crisis is over by using the valuable and exceptional experience gained during these challenging times.

COVID-19: the endocrine opportunity in a pandemic

The 2019 Coronavirus disease (COVID-19) pandemic has disrupted the social, economical and medical system worldwide. Although it is strictly an infectious disease, its intricate bidirectional relationship with various non-communicable metabolic diseases and endocrinological factors has been observed. While diabetes, hypertension, obesity have been found to be independent risk factors for COVID-19 disease severity and mortality, more inclination towards sedentary lifestyle, psychosocial stress at this critical time may be the harbingers of metabolic syndrome. Thus, endocrinologists have a great opportunity to play their role to combat this pandemic. This paper examines how various endocrinological disorders influence the dynamics of COVID-19 and vice versa. Moreover, it also intends to review the clinical guidelines to be adopted in practice of endocrinology in this trying time.