Thyroid dysfunction in COVID-19 patients

PURPOSE

"Non thyroidal illness syndrome" (NTIS) or "euthyroid sick syndrome" (ESS) is a possible biochemical finding in euthyroid patients with severe diseases. It is characterized by a reduction of serum T₃ (fT3), sometimes followed by reduction of serum T₄ (fT4). The relationship between thyroid hormones levels and mortality is well known and different studies showed a direct association between NTIS and mortality. The sudden spread of the 2019 novel coronavirus (SARS-CoV 2) infection (COVID-19) and its high mortality become a world healthcare problem. Our aim in this paper was to investigate if patients affected by COVID-19 presented NTIS and the relationship between thyroid function and severity of this infection.

METHODS

We evaluated the thyroid function in two different groups of consecutive patients affected by COVID-19 with respect to a control group of euthyroid patients. Group A included patients hospitalized for COVID-19 pneumonia while patients requiring intensive care unit (ICU) for acute respiratory syndrome formed the group B. Group C identified the control group of euthyroid patients.

RESULTS

Patients from group A and group B showed a statistically significant reduction in fT3 and TSH compared to group C. In group B, compared to group A, a further statistically significant reduction of fT3 and TSH was found.

CONCLUSIONS

COVID-19 in-patients can present NTIS. FT3 and TSH serum levels are lower in patients with more severe symptoms.

Expected and paradoxical effects of obesity on cancer treatment response

Obesity, whose prevalence is pandemic and continuing to increase, is a major preventable and modifiable risk factor for diabetes and cardiovascular diseases, as well as for cancer. Furthermore, epidemiological studies have shown that obesity is a negative independent prognostic factor for several oncological outcomes, including overall and cancer-specific survival, for several site-specific cancers as well as for all cancers combined. Yet, a recently growing body of evidence suggests that sometimes overweight and obesity may associate with better outcomes, and that immunotherapy may show improved response among obese patients compared with patients with a normal weight. The so-called 'obesity paradox' has been reported in several advanced cancer as well as in other diseases, albeit the mechanisms behind this unexpected relationship are still not clear. Aim of this review is to explore the expected as well as the paradoxical relationship between obesity and cancer prognosis, with a particular emphasis on the effects of cancer therapies in obese people.

Everolimus is a new anti-cancer molecule: Metabolic side effects as lipid disorders and hyperglycemia

In the last few years, molecular targeted therapies have replaced traditional cytotoxic chemotherapy in the fight against many cancers to the extent that our understanding of tumor biology has become more sophisticated. This shift has markedly changed adverse event profiles, compared to cytotoxic chemotherapy, affecting a diverse range of organ systems. Everolimus was approved by the FDA in 2011 for the treatment of progressive pancreatic NE tumors. It is an inhibitor of mammalian target of rapamycin (mTOR) and exhibits antitumor activity via disruption of various signaling pathways and it's used in the treatment of advanced renal cell cancer, breast cancer and neuroendocrine tumors (NET); it's used also as anti-rejection agent for transplantation but with lower doses for anti-rejection (1.5-3.0 mg/day) than for anti-cancer (5-10 mg/day) treatment. Metabolic side effects are the most frequent reported and will be discussed in this review.

Somatostatin analogs therapy in gastroenteropancreatic neuroendocrine tumors: current aspects and new perspectives

Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are rare tumors that present many clinical features secreting peptides and neuroamines that cause distinct clinical syndromes such as carcinoid syndrome. However most of them are clinically silent until late presentation with mass effects. Surgical resection is the first line treatment for a patient with a GEP-NET while in metastatic disease multiple therapeutic approaches are possible. GEP-NETs are able to express somatostatin receptors (SSTRs) bounded by somatostatin (SST) or its synthetic analogs, although the subtypes and number of SSTRs expressed are very variable. In particular, SST analogs are used frequently to control hormone-related symptoms while their anti-neoplastic activity seems to result prevalently in tumor stabilization. Patients who fail to respond or cease to respond to standard SST analogs treatment seem to have a response to higher doses of these drugs. For this reason, the use of higher doses of SST analogs will probably improve the clinical management of these patients.

Appropriate use of stimulation tests and insulin-like growth factor-I in obesity

Obesity is characterized by abnormal GH secretion, with GH levels reduced up to levels that are comparable to those found in adult patients with organic GH deficiency (GHD). Despite the marked GH insufficiency, obese patients with no evidence of pituitary disease have generally normal levels of total IGF-I but increased levels of free IGF-I. Although the mechanism of the low GH in obesity is not completely understood nor is it clear whether its relationship with visceral adiposity is causal, it is widely accepted that the low GH secretory state in obesity is reversible since it is completely reversed by the normalization of body weight. Since overweight and obesity might affect the GH response to all provocative stimuli, particular attention has been recently paid to the confounding effect of body weight on the interpretation of GH stimulating tests and appropriate cut-offs for lean, overweight, and obese subjects must be used in order to avoid false-positive diagnoses of severe GHD in obese adults. As the definition of appropriate criteria for the correct diagnosis of GHD in obesity is still debated, and the beneficial effects of chronic recombinant human GH replacement on obese individuals have not been definitely proved yet, further studies are therefore mandatory to confirm the real effectiveness of GH supplementation in conditions associated with a blunted GH secretion without organic hypopituitarism and to understand the physiological relevance of "functional" GHD on the pathogenesis of the multiple maladaptative endocrine changes involved in the pathogenesis of obesity.

Bone density and turnover in young adult patients with growth hormone deficiency after 2-year growth hormone replacement according with gender

GH deficiency (GHD) in adults is accompanied by reduced bone mass that may revert only after 2 yr of GH replacement. However, it is unclear whether the gender may modify bone responsiveness to GH replacement in adults. In this study we have evaluated whether bone mineral density (BMD) and turnover improve after GH replacement according to patients' gender. BMD at lumbar spine (LS) and femoral neck (FN), serum osteocalcin (OC), and urinary cross-linked N-telopeptides of type I collagen (Ntx) were assessed in 64 hypopituitaric patients (35 men, 30-50 yr) before and 2 yr after the beginning of GH replacement. Values of IGF-I and BMD at LS and at FN were expressed as Zscores. At study entry, IGF-I and BMD resulted similar among men and women with GHD. During GH replacement, IGF-I levels increased in both men and women without any difference in the percentage of IGF-I increase between the genders (p=0.47). In women receiving estrogen replacement, however, the percentage of IGF-I increase (p<0.05), and the Z IGF-I score (p<0.001) were significant lower than estrogen untreated women, although IGF-I levels were similar in the 2 groups (p=0.53). The GH dose adjusted for body weight required to restore normal age- and sex- matched IGF-I levels was lower in men than in women (p<0.001), and was higher in women receiving than in those not receiving estrogen replacement (p<0.05). In contrast, hypogonadal men treated with testosterone and eugonadal men received a similar GH dose (p=0.97). Also OC, Ntx levels, lumbar and femoral BMD improved (p<0.001) in all patients. Nevertheless, a greater increase in lumbar BMD increase was observed in men than in women (8.0+/-2.1 vs 2.6+/-0.4%; p<0.05). No significant difference was revealed in bone parameters in women treated or untreated with estrogen replacement and in men treated or not with testosterone replacement for concomitant hypogonadism. At the multiple correlation analysis, gender was a stronger predictor for the required GH dose than the age (p<0.001 and p=0.02, respectively). In conclusion, a 2-yr GH replacement normalizes IGF-I levels, increases bone mass and improves bone turnover both in men and in women with GHD without any difference between the 2 groups, provided that the dose of GH was modulated on the basis of IGF-I levels. Women receiving oral estrogens should receive a GH dose approximately doubled, as compared to men and women not receiving oral estrogens, to achieve similar effects on bone density and turnover. In particular, GH replacement dose, to be successful on bone mass and turnover, depends on gender in hypopituitary patients aged below 50 yr.

Ulcerative colitis masked by giant urticaria

The occurrence of giant urticaria and ulcerative colitis is very infrequent. A 23 year-old female reported the initial eruption of short-lived cutaneous itchy weals on her arms. Then lesions ran together and became confluent, extending to her legs, followed by undefined abdominal pain and a slight increase of body temperature. Exams showed hystologically confirmed ulcerative colitis, with perinuclear anti-neutrophil cytoplasmic antibody positivity. Ulcerative colitis therapy led not only to the remission of the colitic symptoms, but also to the prompt recovery of skin manifestations. Urticaria was the epiphenomenon of ulcerative colitis.

Growth hormone status in morbidly obese subjects and correlation with body composition

Morbidly obese subjects are characterized by multiple endocrine abnormalities and these are paralleled by unfavorable changes in body composition. In obese individuals, either 24-h spontaneous or stimulated GH secretion is impaired without an organic pituitary disease and the severity of the secretory defect is proportional to the degree of obesity. The GHRH+arginine (GHRH+ARG) test is likely to be the overall test of choice in clinical practice to differentiate GH deficiency (GHD) patients. Similarly to other provocative tests, GHRH+ARG is influenced by obesity per se. Therefore, a new cut-off limit of peak GH response of 4.2 microg/l in obese subjects has been recently assumed. The aim of the present study was to investigate the reciprocal influence between decreased GH secretion and body composition in a group of 110 morbidly obese subjects, using the new cut-off limit of peak GH response to GHRH+ARG test for these subjects. In our study, GHD was identified in 27.3% of the obese subjects, without gender difference. In GDH obese subjects body mass index (BMI), waist circumference, waist-to-hip ratio (WHR), fat mass (FM), and resistance (R) were higher while reactance (Xc), phase angle, body cell mass (BCM), IGF-I, or IGF-I z-scores were lower than in normal responders (p<0.001). In all obese subjects, GH peak levels showed a negative correlation with age, BMI, waist circumference and FM, and a positive correlation with IGF-I. In the stepwise multiple linear regression, waist circumference and FM were the major determinants of GH peak levels and IGF-I. In conclusion, using the new cut-off limit of peak GH response to GHRH+ARG test for obese subjects, about 1/3 morbidly obese subjects were GHD. GHD subjects showed a significantly different body composition compared with normal responders, and the secretory defect was correlated to different anthropometric variables with waist circumference and FM as the major determinants.

A structure-activity study for the inhibition of metalloproteinase-9 activity and gene expression by analogues of gallocatechin-3-gallate

Catechins are able to modulate the gelatinolytic activity of matrix metalloproteinase-9 (MMP-9) by reducing its release from macrophages. Gallocatechins decrease MMP-9 secretion by lowering MMP-9 promoter activity and mRNA levels. The effect appears to be dependent on some structural and stereochemical requirements. In this study, the relationship between chemical structure and activity was studied by testing the effect of analogues of (+/-)-gallocatechin-3-gallate (+/-)-GCG, selectively deprived of hydroxyl groups, on MMP-9 activity, transcription, and secretion. Our results indicate that (+/-)-GCG and (+/-)-catechin-3-gallate are characterized by a substitution pattern compatible with direct inhibition of MMP-9 activity. Conversely, when transcription was the target, (+/-)-trans-3-flavanol-3-benzoate, lacking all the hydroxyl groups, was the most effective both in lowering MMP-9 promoter activity and consequently protein secretion, and in inhibiting nuclear-factor-kappaB-driven transcription. Our results suggest that the structural requirements for enzyme inhibition are different from those necessary for targeting gene expression.

Circulating insulin-like growth factor-I levels are correlated with the atherosclerotic profile in healthy subjects independently of age

To investigate the relationships between the GH-IGF-I axis and the atherosclerotic profile, we designed this open, observational, prospective study. Peak GH after GHRH+arginine (ARG) test, serum IGF-I and IGF binding protein-3 (IGFBP-3), lipid profile, homeostasis model assessment (HOMA) index and intima-media thickness (IMT) at common carotid arteries were measured in 174 healthy individuals (92 women, 82 men, aged 18-80 yr). Exclusion criteria for this study were: 1) body mass index (BMI) > or = 30 kg/m2; 2) personal history of cardiovascular diseases; 3) previous or current treatments of diabetes or hypertension; 4) previous corticosteroids treatment for longer than 2 weeks or estrogens for longer than 3 months; 5) smoking of more than 15 cigarettes/day and alcohol abuse. Subjects were divided according to age in decade groups from < 20 to > 70 yr. BMI increased with age, as did systolic and diastolic blood pressures, although they remained in the normal range. The GH peak after GHRH+ARG test was significantly higher in the subjects aged < 20 yr than in all the other groups (p < 0.01), but was similar in the remaining groups. An inverse correlation was found between the IGF-I z-score and total/HDL-cholesterol ratio (p = 0.02) and mean IMT (p = 0.0009); IGFBP-3 z-score and mean IMT (p = 0.043); IGF: IGFBP-3 molar ratio and total/HDL-cholesterol ratio (p < 0.0001) and mean IMT (p < 0.0001). Atherosclerotic plaques were found in 7 out of 12 subjects (53.8%) with a z-IGF-I score from < or = -2 to -1, in 4 out of 63 (6.3%) with a z-IGF-I score from -0.99 to 0.1 out of 66 (1.5%) with a z-IGF-I score from 0.1 to 1 and none of the 33 subjects with an IGF-I z-score >1 (p = 0.006). At multi-step regression analysis, age was the best predictor of HDL-cholesterol levels and mean IMT, IGF-I level was the best predictor of total cholesterol and total/HDL-cholesterol ratio, the IGF-I/IGFBP-3 molar ratio was the best predictor of triglycerides levels. The z-scores of IGF-I and IGFBP-3 were the second best predictors of mean IMT after age. In conclusion, IGF-I and IGFBP-3 were negatively correlated with common cardiovascular risk factors, studied as total/HDL-cholesterol ratio, and/or early atherosclerosis, studied as IMT at common carotid arteries. The prevalence of atherosclerotic plaques, though not hemodinamically significant, was higher in the subjects having a z-score of IGF-I of < or = -2 to -1. Our results support a role of the IGF/IGFBP-3 axis in the pathogenesis of atherosclerosis.

Somatopause: dismetabolic and bone effects

The physiological changes that the human body undergoes during aging are similar to those observed in GH deficiency (GHD). Early changes of aging are represented by increased fat mass, increased cardiovascular risk, reduced muscle mass and strength, reduced exercise tolerance, thinned skin, decreased strength and impaired quality of life. These observations led to hypothesize that the elderly could be GH deficient and would benefit from GH treatment. However, the effects of GH treatment in healthy elderly subjects by randomized and controlled studies are less promising than initially hypothesized. The etiopathology of age-related bone loss is multifactorial including menopause, andropause, somatopause and secondary hyperparathyroidism. GH has multiple effects on bone, either direct or mediated by IGF-I, stimulating osteoblast proliferation as well as osteoclast differentiation. Consequently, decline in GH secretion reduces bone turnover that causes osteopenia in young adults, but it has been hypothesized that it could protect against fractures in elderly subjects. The increase of bone remodeling achieved by GH therapy may be helpful in elderly men and women who have severely decreased bone turnover and impaired osteoblastic function. In conclusion, the endocrine pattern of aging is distinct from the decrease of GH/IGF-I levels associated with hypopituitarism. However, GH plays a role in metabolism and bone physiology throughout the human life span, although there is insufficient evidence for a clear therapeutic role of rhGH in aging. Thus, more data are needed to define the effects of somatopause to identify who could potentially benefit from the effects of somatotropic treatment.

Associated hormonal decline in aging: is there a role for GH therapy in aging men?

Aging is associated with decline in the somatotroph axis, a decline that has been considered to cause many of the catabolic sequelae of normal aging. Consequently, IGF-I levels decline progressively: this mainly reflects the impaired GH secretion, but decline in gonadal sex steroids and malnutrition also play a role. Decreases in GH secretion may partially explain the age-related changes in metabolism, bones, muscles, cardiovascular system, central nervous system, the immune system and sense of well-being. Normal aging and GH deficiency (GHD) share several clinical signs and symptoms: the endocrine pattern of aging is, however, distinct from the decrease of GH and/or IGF-I levels associated with hypopituitarism. Owing to clinical similarities between aging and GHD, the relative GH insufficiency of elderly subjects has been postulated as one important factor contributing to their frailty. However, it is currently unclear whether treatment with exogenous GH, or IGF-I can retard or reverse age-related changes in body structure and function. Several studies enrolling healthy elderly subjects showed that GH treatment was followed by increase of lean mass, decrease of fat mass and improvement of bone turnover, but other studies failed to confirm these data. The treatment with natural or synthetic GH secretagogues, that could represent a physiological approach to restore the GH and IGF-I secretion, requires further investigations. In conclusion, there is not sufficient evidence for a clear therapeutic role of rhGH, IGF-I, and secretagogues in aging. Further studies are needed to evaluate the real benefit of somatotropic treatment in aging men.

[Videolaparoscopic oncologic surgery of the right colon: our experience]

The authors present their experience in videolaparoscopic surgery for right colon cancer after two years of videolaparoscopic surgery for approach to colorectal cancer. In the period between March 2002 and March 2003 they have practiced 11 right emicolectomy by videolaparoscopic technique for neoplasms: 7 were males and 4 were females with age of about 70 years old. These case included: 7 right colon's cancers, 2 cecal cancers and two hepatic flexure cancers. One postoperative complications has been observed (9%) for bowel's occlusion for early adhesion syndrome. On the base of their experience the authors perform usually videolaparoscopic surgery (M.I.S.) for the approach to right colon cancer.

[Videolaparoscopic oncologic surgery of the left and right colon: our experience]

The authors present their experience in videolaparoscopic surgery for colorectal cancer. In the period between November 2000 and march 2003 they have treated 31 patients by videolaparoscopic surgery for colorectal cancer: 17 were males and 14 were females with age included between 41 and 93 y.o. These case included: 15 rectal cancers, 12 sigmoid cancer, 3 cases of lineal flexura's cancers and I case of transverse cancer. Postoperative complications has been observed in three cases (9.6%) in the first 14 operations practiced, then confirming the learning curve. The authors perform usually mini-invasive surgery (MIS) for the approach to colorectal cancer surgery.

An evaluation of patients with hyperprolactinemia: have dynamic tests had their day?

Except for a few particular conditions, the diagnostic evaluation of hyperprolactinemia is easy since the routine use of magnetic resonance imaging (MRI) scan has permitted to identify even small microadenomas. Other conditions include the identification of large PRL molecular complex, dimers, trimers or polymers of PRL, called "big or big-big PRL", and of PRL autoantibodies and the biochemical finding of "high dose PRL hook effect". Finding elevated serum PRL levels should be considered as the beginning and not the conclusion of a diagnostic evaluation: first, a careful anamnesis should exclude possible physiologic, pharmacologic and organic causes of hyperprolactinemia; second, possibly one laboratory only, undergoing regularly quality controls, should analyze blood samples; serial serum PRL measurements at 0, 30, 60 min is a valuable and simple measure to identify stress-related hyperprolactinemia. In the past two decades several pharmacological tests were used in order to distinguish between small microprolactinomas and "non-tumoral hyperprolactinemia": the controversial results of these tests together with the availability of MRI has excluded all pharmacological tests in the work-up of hyperprolactinemia. MRI is preferred to computed tomography (CT) due to its better definition of very small lesions in the pituitary sella and better anatomical definition prior to surgery. Finally, once the diagnosis of prolactinoma is suspected, patients should be referred to a specialist centre for further assessment and treatment.

Amniotic fluid nitric oxide metabolite levels and nitric oxide synthase localization in feto-placental tissues are modified in association with human labor

Nitric oxide (NO) has a relaxant effect on uterine smooth muscle and may be implicated in maintaining uterine quiescence during pregnancy. In order to investigate the role of nitric oxide in human parturition, we have measured NO metabolite levels in maternal and fetal compartments in association with labor, both at term and preterm. We have also examined the localization and distribution of NO synthase (NOS) isoforms in placentas and fetal membranes after term and preterm delivery by means of immunohistochemistry. Although no differences were present in maternal and fetal blood and in maternal urine among groups, we found that NO metabolite concentrations were higher in amniotic fluid collected from women in labor than in non-laboring patients, both at term (15.4+/-1.6 vs. 6.8+/-0.6 microM/mg creatinine) and preterm (16.7+/-2.0 vs. 7.0+/-0.8 microM/mg creatinine). Ir-bNOS staining appeared to be decreased in fetal membranes collected after spontaneous labor at term and preterm. In contrast, a stronger staining for iNOS was detected in trophoblast cells of fetal membranes from women in labor than in those from non-laboring women. We suggest that NOS isoenzymes in fetal placental tissues are differently regulated and might play different roles during pregnancy.

Correlation between cervical intraepithelial neoplasia and human papillomavirus male infections: a longitudinal study

BACKGROUND

Genital HPV infection is one of the most common sexually-transmitted diseases. The aim of the study was to evaluate the correlation between HPV-associated lesions in male partners of women affected by CIN.

METHODS

210 male partners of women affected by CIN were examined in a long-term follow-up (from 5 to 13 years). The diagnosis in females was performed by cytology, colposcopy and histology. Male partners were submitted to clinical examination, peniscopy and biopsy.

RESULTS

111/210 (53%) females had CIN I, 53/210 (25%) and 46/210 (22%) had CIN III. Subclinical lesions were associated with 18%, 28% and 24% of male partners of women with CIN I, CIN II and CIN III, respectively. Clinical lesions were observed in 7% and 10% of sexual partners of women with CIN I and CIN II, respectively. Mixed lesions affected only 3% of sexual partners of women with CIN I.

CONCLUSIONS

Our data show that the transmissibility of HPV infection to the male partners of women affected by CIN was easier when there was a lower grade of CIN. In fact, male partners of women with CIN III had a lower percentage (26%) of clinical or subclinical HPV skin lesions.

[An uncommon complication: cryptorchidism in an adult]

This unusual pathology has not been described in the medical literature of the last ten years. A 39-year-old patient, affected by unilateral cryptorchidism, on the right side, and congenital inguinal hernia, reached the operating theatre suffering from occlusive intestinal syndrome, due to a clogged hernial sac. This clog was caused by a retracting testicle which in turn stopped the ileal ansa from slipping back in to the peritoneum. Through this case we can underline the excursus of such pathology, which isn't very frequent in the adult but can, nevertheless create a fairly serious pathology, often leading to neoplan.