Hypocalcemia in COVID-19: Prevalence, clinical significance and therapeutic implications

Vitamin D and hip protectors in osteosarcopenia: a combined hip fracture preventing approach

Osteosarcopenia is an emerging clinical condition highly prevalent in the older people. Affected subjects due to their intrinsic skeletal fragility and propensity to falls are at elevated risk of hip fractures which can increase morbidity and mortality. Strategies for attenuating the impact of predisposing factors on hip fractures are not yet well defined and should derive from multidisciplinary care and collaborations. Our aim was to narratively review available data on the preventive role of vitamin D and hip protectors on hip fractures in older patients with sarcopenia. Older subjects are at high risk of vitamin D deficiency and of falls due to several concomitant factors besides osteosarcopenia. Vitamin D protective actions against hip fractures may be mediated by both skeletal (increased mineralization) and extra-skeletal (reduced risk of falls) actions. Hip protectors may act downstream attenuating the effects of falls although their use is still not yet enough widespread due to the suboptimal compliance obtained by traditional hard devices. Concomitant use of vitamin D and hip protectors may represent an effective strategy in the prevention of hip fractures which need to be tested in ad hoc designed clinical trials.

Establishment and evaluation of nomogram for predicting acute respiratory distress syndrome in meconium-stained amniotic fluid neonates

OBJECTIVE

To delineate risk factors and develop a predictive nomogram for acute respiratory distress syndrome (ARDS) in neonates exposed to meconium-stained amniotic fluid (MSAF).

METHODS

We conducted a comprehensive retrospective analysis of neonates with MSAF, classifying them into ARDS and non-ARDS groups based on the onset of ARDS within the first week after birth. Clinical and laboratory data are collected to screen the risk factors for ARDS in MSAF neonates, multivariate logistic regression was performed to identify independent predictors and establish a nomogram to predict the occurrence of neonatal ARDS.

RESULTS

We recognized five variables as independent risk factors for ARDS with MSAF neonates via logistic regression analysis, consisting of 1-min Apgar score (Apgar 1 min), white blood cell (WBC), platelet (PLT), red cell distribution width (RDW) and serum calcium (Ca). These predictors were integrated into a nomogram designed to estimate the individual risk of ARDS development in neonates. The predictive model achieved a C-index of 0.942 (95% CI: 0.915-0.970), indicating high predictive accuracy. Additionally, the nomogram was internally validated, demonstrating excellent calibration and practical utility for clinical decision-making.

CONCLUSIONS

The validated nomogram, based on five pivotal factors, provides clinicians with a reliable tool for early identification and management of ARDS in MSAF neonates, potentially improving outcomes by facilitating timely and appropriate therapeutic interventions.

Syndrome of inappropriate antidiuresis/hyponatremia in COVID-19

Hyponatremia is the most frequent electrolyte alteration among hospitalized patients and it has been reported in 20-40% of patients with SARS-CoV-2 (COVID-19) infection. Multiple causes of hyponatremia have been hypothesized in these patients. The syndrome of inappropriate antidiuresis (SIAD) has been considered one of the main reasons leading to hyponatremia in this condition. SIAD can be secondary to cytokines release, in particular IL-6. Positive pressure ventilation can be another cause of hyponatremia due to SIAD. Other possible etiologies of hyponatremia in COVID-19 patients can be related to secondary hypocortisolism, nausea, vomiting, heart and kidney damage. Similar to many other clinical conditions, there is strong evidence that hyponatremia is associated with a worse prognosis also in patients with COVID-19 infection. In particular, hyponatremia has been identified as an independent risk of ICU transfer, need of non-invasive ventilation and death. Hyponatremia in COVID-19 patients is in principle acute and symptomatic and should be treated as such, according to the published guidelines. Therefore, patients should be initially treated with i.v. hypertonic saline (3% NaCl) infusion and serum [Na+] should be frequently monitored, in order to remain within a safe rate of correction. There is evidence showing that serum [Na+] correction is associated with a better outcome in different pathologies, including COVID-19 infection.

Hypophysitis in COVID-19: a systematic review

PURPOSE

This systematic review aims to collect and examine recent research findings regarding hypophysitis in COVID-19 patients.

METHOD

We conducted a comprehensive literature review in English on the topic "Hypophysitis in COVID-19," using the MEDLINE (PubMed) database in July 2024. The selected articles were systematically tabulated and we have assessed in this review patient demographics, symptom presentation, imaging results, diagnosis, clinical management, and outcomes.

RESULTS

Seven reported cases of post-COVID-19 hypophysitis were identified, comprising 4 (57%) females and 3 (43%) males, with a median age of 37 years. The interval between COVID-19 infection symptoms and the onset of hypophysitis ranged from 2 to 3 weeks. Initial symptoms included frontal headache in 4 (57%) cases and polyuria and polydipsia in 3 (43%) cases. Anterior or posterior hypopituitarism was observed in 6 (85%) patients. Radiological findings varied: 2 (28.5%) cases showed panhypophysitis, 3 (43%) cases exhibited gland enlargement with homogeneous contrast enhancement on magnetic resonance imaging (MRI), 1 case involved the loss of the posterior pituitary bright spot, and 1 case involved pituitary apoplexy/enlargement of the gland and infundibulum. No pituitary biopsies were performed. Four (57%) patients received glucocorticoid (GC) treatment. Long-term follow-up was documented in only one case, a 16-year-old female followed for 2 years reporting complete clinical and radiological resolution.

CONCLUSION

Although rare, hypophysitis related to COVID-19 is documented in the literature exhibiting distinct characteristics such as a homogeneous gender prevalence, an average age of onset around 35 years, and primary symptoms of headache, polyuria, and polydipsia which are indicative of angiotensin-vasopressin deficiency. This is in contrast with primary autoimmune hypophysitis characterized by a female prevalence and typical symptoms with headache and visual impairment. Longer-term follow-up of these patients is needed to better understand the potential lasting impact on pituitary function and radiological improvement. Future research should also explore the presence of anti-pituitary antibodies and the other possible pathophysiological mechanisms potentially involved in these cases.

Prevalence of Acute Renal Failure, Para-Clinical Outcomes, and Mortality in COVID-19 Patients

Objectives: Although acute respiratory syndrome is the main manifestation of COVID-19 disease, one of the characteristics of the disease is acute kidney injury (AKI). This study aimed to assess the prevalence of kidney dysfunction and para-clinical outcomes in hospitalized COVID-19 patients and its relationship with mortality.Methods: This cross-sectional analytical study was carried out on 715 patients aged older than 16-years with a diagnosis of COVID-19 admitted to the tertiary teaching Imam Reza Hospital, Mashhad, Iran from February 2020 to February 2021. During hospitalization, these patients were evaluated for AKI based on the Kidney Disease Improving Global Outcomes classification and mortality. Demographic variables and laboratory data were extracted from the hospital information systems electronic database. The significant risk factors for the incidence of AKI were analyzed using SPSS software in the present study.Results: The mortality rate of the included patients was 18.9%, which expired during hospitalization. Mortality was higher among patients with stage 1-2 AKI (34.1%) and stage 3 AKI (44.9%) compared to patients without AKI (8.7%). Individuals in different stages of AKI were significantly older relative to the non-AKI patients; hence, aging could be considered as the predictor of AKI. Leukocytosis, lactate dehydrogenase (LDH), and blood urea nitrogen (BUN) were indicated as significant risk factors for the incidence of AKI.Conclusions: It was found that the prevalence of AKI was 37.2% in hospitalized COVID-19 patients, and there was an association between mortality and the incidence of AKI.

Long COVID and pituitary dysfunctions: a bidirectional relationship?

Long COVID is a novel emerging syndrome known to affect multiple health areas in patients previously infected by SARS-CoV-2 markedly impairing their quality of life. The pathophysiology of Long COVID is still largely poorly understood and multiple mechanisms were proposed to underlie its occurrence, including alterations in the hormonal hypothalamic-pituitary axes. Aim of this review is to present and discuss the potential negative implications of these hormonal dysfunctions in promoting and influencing the Long COVID syndrome. To date, the hypothalamic-pituitary-adrenal axis is the mostly investigated and several studies have reported a prolonged impairment leading to mild and subclinical forms of central adrenal insufficiency. Few data are also available regarding central hypogonadism, central hypothyroidism and growth hormone (GH) deficiency. A high prevalence of central hypogonadism in COVID-19 survivors several months after recovery was consistently reported in different cohorts. Conversely, very few data are available on the hypothalamic-pituitary-thyroid axis function that was mainly shown to be preserved in COVID-19 survivors. Finally, a potential impairment of the hypothalamic-GH axis in Long COVID has also been reported. These data altogether may suggest a novel possible pituitary-centred pathophysiological view of Long COVID syndrome which if confirmed by large clinical studies may have relevant implication for the diagnostic and therapeutic approach at least in a subset of patients with the syndrome.

Novel protective circulating miRNA are associated with preserved vitamin D levels in patients with mild COVID-19 presentation at hospital admission not progressing into severe disease

PURPOSE

Low vitamin D levels were reported to negatively influence the outcomes of acute COVID-19, as well as other biochemical markers were linked to COVID-19, including microRNAs (miRNAs). This study aimed to prospectively evaluate miRNAs and vitamin D relationship in predicting COVID-19 outcomes.

METHODS

COVID-19 patients were part of a previously reported cohort and enrolled in a matched-ratio based on the presence/or not of severe disease at hospital admission. 25(OH) vitamin D levels and miRNAs expression were evaluated.

RESULTS

Patients affected by non-severe COVID-19 were characterized by a higher expression of miRNAs hsa-miR-3115 and hsa-miR-7151-3p, as compared to those affected by severe disease. In non-severe patients, these miRNAs were more frequently expressed in those who subsequently did not develop worsening outcomes. In addition, patients with miRNA-7151 expression and without worsening disease were characterized by higher 25(OH) vitamin D levels and lower prevalence of vitamin D deficiency.

CONCLUSIONS

The expression of two novel miRNAs was reported for the first-time to be associated with a less severe COVID-19 form and to prospectively predict the occurrence of disease outcome. Furthermore, the association observed between vitamin D deficiency and lack of miRNA-7151 expression in COVID-19 patients with worse outcomes may support the hypothesis that the co-existence of these two conditions may have a strong negative prognostic role.

COVID-19-Induced Refractory Symptomatic Hypocalcemia in a Patient With Parathyroid Gland Reimplantation

Background: Several cases of severe hypocalcemia in the setting of COVID-19 have been reported. The proposed mechanisms include direct viral interaction with ACE2 receptors in the parathyroid gland, viral chelation of calcium, worsening hypovitaminosis D, critical illness leading to unbound fatty acids binding calcium, and inflammatory cytokines leading to PTH resistance. Given the life-threatening nature of hypocalcemia, this underrecognized phenomenon should be on the forefront of the clinician's attention. This case highlights a rare manifestation of COVID-19 and further complicated by the patient's reimplanted parathyroid gland. Presentation: A 73-year-old female with primary hyperparathyroidism status post parathyroidectomy with reimplantation in the left forearm presented with 4 days of viral syndrome, found to have tetany and Chvostek's sign on physical exam. Pertinent laboratory abnormalities included calcium 5.3 mg/dL, ionized calcium 0.44 mmol/L, magnesium 1.4 mg/dL, phosphorous 5.5 mg/dL, PTH 242 pg/mL, and 25-OH vitamin D 56 ng/mL. Chest CT revealed multifocal pneumonia consistent with positive COVID-19 testing. She was subsequently admitted to the ICU for severe, symptomatic hypocalcemia and was initiated on a continuous calcium infusion, remdesivir, baricitinib, and steroids. Tetany resolved after 9 g calcium repletion, and she was transferred to the medical floor with an ionized calcium of 0.83 mmol/L. On hospital day 3, repeat ionized calcium was 0.78 mmol/L despite ongoing repletion. Given the persistence of hypocalcemia, a repeat PTH level was obtained which remained high at 487 pg/mL, suggesting ongoing PTH interference in the setting of COVID-19. PTH was obtained from the right (nonimplanted) arm which was normal at 74 pg/mL. This indicated an appropriate PTH response from the reimplanted gland, and that ongoing hypocalcemia may be due to insufficient PTH function to maintain systemic calcium levels or a peripheral interference with PTH level. With continued calcium supplementation and treatment of COVID-19, the patient's calcium stabilized at 8.6 mg/dL. She was discharged on oral calcium supplementation with endocrinology follow-up. Conclusion: Acute hypocalcemia strongly correlates with a profound inflammatory response in COVID-19 patients. This case corroborates the cytokine/PTH hypothesis. This patient had a high PTH sampled near the reimplanted gland but an inappropriately normal PTH from the nonimplanted arm, indicating that direct viral interaction interfering with PTH release is an unlikely mechanism. This case represents a scenario where PTH can be sampled directly from the source and this type of model could aid in the process of determining the etiology of hypocalcemia in COVID-19.

Hypocalcemia Following Thyroidectomy in a Patient With COVID-19: A Case Report and Literature Review

COVID-19 can lead to various complications, including severe respiratory symptoms. Both viral infections and total thyroidectomy are known to cause hypocalcemia, making a history of thyroidectomy a potential risk factor for hypocalcemia in COVID-19 patients. We present the case of a 34-year-old woman with Graves' disease who developed hypocalcemia due to COVID-19 following a total thyroidectomy. The patient underwent an uneventful total thyroidectomy, with preservation of at least three of the four parathyroid glands. Postoperatively, her parathyroid hormone (PTH) levels were normal, and she was discharged without tetany. However, on postoperative day 90, she experienced mild hypocalcemia during a COVID-19 infection, although it was asymptomatic. By postoperative day 127, she presented with severe tetany and general malaise. Testing confirmed a reinfection with SARS-CoV-2 and hypocalcemia, while PTH levels remained normal. Treatment with intravenous calcium gluconate, oral calcium lactate, and alfacalcidol effectively resolved the hypocalcemia and tetany. The patient was subsequently discharged without tetany and has since been monitored without the need for calcium or vitamin D supplementation. This case highlights that the COVID-19 infection following a total thyroidectomy can cause hypocalcemia. Postoperative hypocalcemia is a common issue in head and neck surgery, and viral infections like COVID-19 should be considered in the differential diagnosis of hypocalcemia.

Characteristics and Differences in Mpox Patients with and without HIV Infection: A Retrospective Cross-Sectional Study in Chengdu, China

PURPOSE

To date, there are few reports about mpox case series in China, and scarce information is available about the in-vivo kinetics of T-cell responses in the early stage of mpox infection. This study aims to investigate the clinical difference among mpox patients with and without human immunodeficiency virus (HIV) infection.

PATIENTS AND METHODS

A total of 56 patients diagnosed with mpox by Chengdu Center for Disease Control and Prevention (CDC) and hospitalized in Public Health Clinical Center of Chengdu were retrospectively included and divided into an HIV-infected group (n=23) and a non-HIV-infected group (n=33). Clinical characteristics and serum chemistry findings of mpox patients were collected in order to analyze the differences between the HIV-infected group and the non-HIV-infected group.

RESULTS

Multiple laboratory abnormalities, including elevated C-reactive protein (69.1%), hypocalcemia (50.9%), elevated CD3+CD8+T counts (47.0%) and inverted ratio of CD3+CD4+T to CD3+CD8+T (64.7%) were common in mpox cases. There were statistically significant differences (all P < 0.05) in age, serum calcium levels, CD3+CD4+T counts, the ratio of CD3+CD4+T to CD3+CD8+T, proportion with >10 rashes, incidence of proctitis anus and time from rash growth to rash scab shedding between HIV-infected group and non-HIV-infected group. In the early stage of mpox infection, the median of CD3+CD8+T counts in the non-HIV-infected group was significantly higher than that in healthy donors (P<0.001), and the median of CD3+CD4+T/CD3+CD8+T ratio was significantly lower (P<0.001). The median of CD3+CD4+T counts in mpox patients co-infected with HIV significantly decreased compared to the pre-infection level (p =0.033).

CONCLUSION

Our study indicates that mpox co-infected with HIV patients have longer lasting rash lesions and a higher incidence of proctitis anus. T-cell responses may be different between HIV-infected and non-HIV-infected individuals in the early stage of mpox infection.

The abortive SARS-CoV-2 infection of osteoclast precursors promotes their differentiation into osteoclasts

The Coronavirus Disease 2019 (COVID-19) pandemic has resulted in the loss of millions of lives, although a majority of those infected have managed to survive. Consequently, a set of outcomes, identified as long COVID, is now emerging. While the primary target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the respiratory system, the impact of COVID-19 extends to various body parts, including the bone. This study aims to investigate the effects of acute SARS-CoV-2 infection on osteoclastogenesis, utilizing both ancestral and Omicron viral strains. Monocyte-derived macrophages, which serve as precursors to osteoclasts, were exposed to both viral variants. However, the infection proved abortive, even though ACE2 receptor expression increased postinfection, with no significant impact on cellular viability and redox balance. Both SARS-CoV-2 strains heightened osteoclast formation in a dose-dependent manner, as well as CD51/61 expression and bone resorptive ability. Notably, SARS-CoV-2 induced early pro-inflammatory M1 macrophage polarization, shifting toward an M2-like profile. Osteoclastogenesis-related genes (RANK, NFATc1, DC-STAMP, MMP9) were upregulated, and surprisingly, SARS-CoV-2 variants promoted RANKL-independent osteoclast formation. This thorough investigation illuminates the intricate interplay between SARS-CoV-2 and osteoclast precursors, suggesting potential implications for bone homeostasis and opening new avenues for therapeutic exploration in COVID-19.

Precision nutrition to reset virus-induced human metabolic reprogramming and dysregulation (HMRD) in long-COVID

SARS-CoV-2, the etiological agent of COVID-19, is devoid of any metabolic capacity; therefore, it is critical for the viral pathogen to hijack host cellular metabolic machinery for its replication and propagation. This single-stranded RNA virus with a 29.9 kb genome encodes 14 open reading frames (ORFs) and initiates a plethora of virus-host protein-protein interactions in the human body. These extensive viral protein interactions with host-specific cellular targets could trigger severe human metabolic reprogramming/dysregulation (HMRD), a rewiring of sugar-, amino acid-, lipid-, and nucleotide-metabolism(s), as well as altered or impaired bioenergetics, immune dysfunction, and redox imbalance in the body. In the infectious process, the viral pathogen hijacks two major human receptors, angiotensin-converting enzyme (ACE)-2 and/or neuropilin (NRP)-1, for initial adhesion to cell surface; then utilizes two major host proteases, TMPRSS2 and/or furin, to gain cellular entry; and finally employs an endosomal enzyme, cathepsin L (CTSL) for fusogenic release of its viral genome. The virus-induced HMRD results in 5 possible infectious outcomes: asymptomatic, mild, moderate, severe to fatal episodes; while the symptomatic acute COVID-19 condition could manifest into 3 clinical phases: (i) hypoxia and hypoxemia (Warburg effect), (ii) hyperferritinemia ('cytokine storm'), and (iii) thrombocytosis (coagulopathy). The mean incubation period for COVID-19 onset was estimated to be 5.1 days, and most cases develop symptoms after 14 days. The mean viral clearance times were 24, 30, and 39 days for acute, severe, and ICU-admitted COVID-19 patients, respectively. However, about 25-70% of virus-free COVID-19 survivors continue to sustain virus-induced HMRD and exhibit a wide range of symptoms that are persistent, exacerbated, or new 'onset' clinical incidents, collectively termed as post-acute sequelae of COVID-19 (PASC) or long COVID. PASC patients experience several debilitating clinical condition(s) with >200 different and overlapping symptoms that may last for weeks to months. Chronic PASC is a cumulative outcome of at least 10 different HMRD-related pathophysiological mechanisms involving both virus-derived virulence factors and a multitude of innate host responses. Based on HMRD and virus-free clinical impairments of different human organs/systems, PASC patients can be categorized into 4 different clusters or sub-phenotypes: sub-phenotype-1 (33.8%) with cardiac and renal manifestations; sub-phenotype-2 (32.8%) with respiratory, sleep and anxiety disorders; sub-phenotype-3 (23.4%) with skeleto-muscular and nervous disorders; and sub-phenotype-4 (10.1%) with digestive and pulmonary dysfunctions. This narrative review elucidates the effects of viral hijack on host cellular machinery during SARS-CoV-2 infection, ensuing detrimental effect(s) of virus-induced HMRD on human metabolism, consequential symptomatic clinical implications, and damage to multiple organ systems; as well as chronic pathophysiological sequelae in virus-free PASC patients. We have also provided a few evidence-based, human randomized controlled trial (RCT)-tested, precision nutrients to reset HMRD for health recovery of PASC patients.

Unmasking the complex roles of hypocalcemia in cancer, COVID-19, and sepsis: Engineered nanodelivery and diagnosis

Calcium (Ca2+) homeostasis is essential for maintaining physiological processes in the body. Disruptions in Ca2+ signaling can lead to various pathological conditions including inflammation, fibrosis, impaired immune function, and accelerated senescence. Hypocalcemia, a common symptom in diseases such as acute respiratory distress syndrome (ARDS), cancer, septic shock, and COVID-19, can have both potential protective and detrimental effects. This article explores the multifaceted role of Ca2+ dysregulation in inflammation, fibrosis, impaired immune function, and accelerated senescence, contributing to disease severity. Targeting Ca2+ signaling pathways may provide opportunities to develop novel therapeutics for age-related diseases and combat viral infections. However, the role of Ca2+ in viral infections is complex, and evidence suggests that hypocalcemia may have a protective effect against certain viruses, while changes in Ca2+ homeostasis can influence susceptibility to viral infections. The effectiveness and safety of Ca2+ supplements in COVID-19 patients remain a subject of ongoing research and debate. Further investigations are needed to understand the intricate interplay between Ca2+ signaling and disease pathogenesis.

Bovine colostrum and its potential contributions for treatment and prevention of COVID-19

Bovine colostrum (BC) is the initial milk an animal produces after giving birth, particularly in the first few days. Numerous bioactive substances found in BC, including proteins, enzymes, growth factors, immunoglobulins, etc., are beneficial to human health. BC has a significant role to play as part of a healthy diet, with well-documented health and nutritional advantages for people. Therefore, the use of BC and its crucial derivatives in the development of functional food and pharmaceuticals for the prevention of several diseases such as gastrointestinal and respiratory system disorders is becoming increasingly popular around the world. A novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified as the cause of a cluster of pneumonia cases that is called Coronavirus Disease 2019 (COVID-19) in China. After the first SARS-CoV-2 virus-related fatality was announced, the illness quickly spread throughout China and to other continents, causing a pandemic. Since then, numerous studies have been initiated to develop safe and efficient treatments. To prevent viral infection and potential lingering effects, it is important to investigate alternative treatments for COVID-19. Due to its effective bioactive profile and its immunomodulatory roles in biological processes, BC might be considered a promising approach to assist in combating people affected by the SARS-CoV-2 or prevention from the virus. BC has immunomodulatory effects because to its high concentration of bioactive components such as immunoglobulins, lactoferrin, cytokines, and growth factors, etc., which might help control immunological responses, potentially fostering a balanced immune response. Furthermore, its bioactive components have a potential cross-reactivity against SARS-CoV-2, aiding in virus neutralization and its comprehensive food profile also supplies important vitamins, minerals, and amino acids, fostering a healthy immune system. Hence, the possible contributions of BC to the management of COVID-19 were reviewed in this article based on the most recent research on the subject. Additionally, the key BC components that influence immune system modulation were evaluated. These components may serve as potential mediators or therapeutic advantages in COVID-19.

Low Vitamin D Levels Are Associated With Long COVID Syndrome in COVID-19 Survivors

CONTEXT

Long COVID is an emerging syndrome affecting 50% to 70% of COVID-19 survivors that still lacks predicting factors.

OBJECTIVE

Due to the extraskeletal effects of vitamin D, we retrospectively assessed the association between 25(OH) vitamin D levels and long COVID in COVID-19 survivors 6 months after hospitalization.

METHODS

Long COVID was defined according to NICE guidelines. Fifty long COVID and 50 non-long-COVID subjects matched on a 1:1 basis were enrolled from an outpatient clinic post-COVID cohort seen from August to November 2020. Therapies/comorbidities affecting calcium/vitamin D/bone metabolism, and/or admission to the intensive care unit during hospitalization were exclusion criteria. 25(OH) Vitamin D was measured at hospital admission and 6 months after discharge.

RESULTS

We observed lower 25(OH) vitamin D levels, evaluated at follow-up, in subjects with long COVID than those without (20.1 vs 23.2 ng/mL, P = .03). Regarding the affected health areas evaluated in the entire cohort, we observed lower 25(OH) vitamin D levels in those with neurocognitive symptoms at follow-up (n = 7) than those without (n = 93) (14.6 vs 20.6 ng/mL, P = .042). In patients presenting vitamin D deficiency (<20 ng/mL), both at admission and at follow-up (n = 42), those affected by long COVID (n = 22) presented lower 25(OH) vitamin D levels at follow-up than those not affected (n = 20) (12.7 vs 15.2 ng/mL, P = .041). In multiple regression analyses, lower 25(OH) vitamin D levels at follow-up were the only variable significantly associated with long COVID in our cohort (P = .008, OR 1.09, CI 1.01-1.16).

CONCLUSION

COVID-19 survivors with long COVID have lower 25(OH) vitamin D levels than matched patients without long COVID. Our data suggest that vitamin D levels should be evaluated in COVID-19 patients after hospital discharge. The role of vitamin D supplementation as a preventive strategy of COVID-19 sequelae should be tested in randomized controlled trials.

Factors contributing to poor COVID-19 outcomes in diabetic patients: Findings from a single-center cohort study

Diabetes Mellitus (DM) is a frequent comorbidity in patients infected with the SARS-CoV-2 virus. The risk of developing severe or critical COVID-19 and higher mortality was observed to be increased in diabetic patients hospitalized due to COVID-19. In this study we aimed to find out the impact of clinical characteristics, comorbidities, laboratory results, and complications on the outcomes of diabetic patients hospitalized due to COVID-19. This article is a retrospective cohort study that include diabetic patients hospitalized with COVID-19 infection. A definition of diabetes was based on the past history of diabetes or if the HbA1c was 6.5% or higher. Demographics, clinical characteristics, comorbidities, laboratory results, and complications were extracted from the electronic medical records. The mortality rate increased with increasing age (from 5.56% in younger patients to 46% in the elderly) and with severity (from 25.71% in moderate cases to 43.77% in critical cases). We found that a critical severity on admission (OR: 5.26, 95% CI: 1.28-21.66, p = 0.0214), a history of stroke (OR: 8.37, 95% CI: 2.2-31.88, p = 0.0018), and low calcium levels on admission (OR: 2.23, 95% CI: 1.01-4.91, p = 0.0475) were significant risk factors predicting higher COVID-19 mortality in diabetic patients. The findings of this study suggest that reduced calcium levels could potentially indicate higher mortality due to COVID-19 in patients with DM. Furthermore, careful monitoring of diabetic patients hospitalized due to COVID-19 infection, especially those with critical disease severity or those with a history of stroke, may improve their outcome and lessen mortality.

Low vitamin D levels predict outcomes of COVID-19 in patients with both severe and non-severe disease at hospitalization

PURPOSE

Low vitamin D in COVID-19 have been related to worse outcomes. However, most of the studies conducted so far were not-controlled and retrospective, including biases potentially influencing this association. We evaluated 25(OH)vitamin D levels of patients with both severe and non-severe disease at hospital-admission, and in a cohort of control subjects. Moreover, we evaluated sACE-2 levels to investigate the mechanisms underlying the association between vitamin D and COVID-19.

METHODS

COVID-19 patients were enrolled in a matched for age, sex and comorbidities 1:1-ratio based on the presence/or not of respiratory-distress/severe-disease at hospital-admission. Control matched subjects were enrolled from an outpatient-setting.

RESULTS

Seventy-three COVID-19 patients (36 severe and 37 non-severe) and 30 control subjects were included. We observed a higher vitamin D deficiency (<20 ng/mL) prevalence in COVID-19 patients than control subjects (75% vs 43%). No differences were found regarding 25(OH)vitamin D and sACE-2 levels between patients with and without severe-disease at study entry. During the disease-course, in the severe group a life-threatening disease occurred in 17 patients (47.2%), and, in the non-severe group, a worsening disease occurred in 10 (27%). 25(OH)vitamin D levels, at admission, were negatively correlated with sACE-2 levels, and were lower in patients whose disease worsened as compared to those in whom it did not, independently from the disease severity at admission. In multivariate-analysis, lower 25(OH)vitamin D resulted as an independent risk factor for disease worsening.

CONCLUSIONS

25(OH)vitamin D levels at hospital-admission strongly predicted the occurrence of worsening outcomes in COVID-19 independently of the disease severity at presentation.

Hypocalcemia on Admission Is a Predictor of Disease Progression in COVID-19 Patients with Cirrhosis: A Multicenter Study in Hungary

Hypocalcemia is a common condition in liver cirrhosis and is associated with the severity of SARS-CoV-2 infection. However, there is a lack of data demonstrating the prognostic value of hypocalcemia in COVID-19 patients with cirrhosis. This study aimed to evaluate the prognostic value of hypocalcemia for COVID-19 severity, mortality and its associations with abnormal liver function parameters. We selected 451 COVID-19 patients in this retrospective study and compared the laboratory findings of 52 COVID-19 patients with cirrhosis to those of 399 COVID-19 patients without cirrhosis. Laboratory tests measuring albumin-corrected total serum calcium were performed on admission, and the levels were monitored during hospitalization. The total serum calcium levels were significantly lower in cirrhosis cases (2.16 mmol/L) compared to those without cirrhosis (2.32 mmol/L). Multivariate analysis showed that hypocalcemia in COVID-19 patients with cirrhosis was a significant predictor of in-hospital mortality, with an OR of 4.871 (p < 0.05; 95% CI 1.566-15.146). ROC analysis showed the AUC value of total serum calcium was 0.818 (95% CI 0.683-0.953, p < 0.05), with a sensitivity of 88.3% and a specificity of 75%. The total serum calcium levels showed a significant negative correlation with the Child-Turcette-Pugh score (r = -0.400, p < 0.05). Hypocalcemia on admission was a significant prognostic factor of disease progression in COVID-19 patients with cirrhosis.

Hypocalcemia is associated with adverse outcomes in patients hospitalized with COVID-19

PURPOSE

Calcium ions are involved in the regulation of several cellular processes and may also influence viral replication. Hypocalcemia has been frequently reported during infectious diseases and in critically ill patients, including also COVID-19 patients, significantly related with the pro-inflammatory state and mortality. The aim of this study is to investigate the prevalence of hypocalcemia at admission in patients hospitalized for COVID-19 (Coronavirus disease 2019) and to evaluate association of hypocalcemia with in-hospital COVID-19 outcomes.

METHODS

Retrospective analysis on 118 consecutive patients, hospitalized for COVID-19 between March and May 2020. Clinical characteristics, inflammation markers, biochemical routine and mineral metabolism parameters at admission were collected. Hypocalcemia was defined as total serum calcium <2.2 mmol/L. Population was stratified by tertiles of total serum calcium. Primary outcome was the composite of in-hospital death or admission to intensive care unit (ICU). Secondary outcomes included in-hospital death, admission to ICU and need for non-invasive ventilation as separate events. Associations were tested by logistic regression and Cox-regression analysis with survival curves.

RESULTS

Overall prevalence of hypocalcemia was 76.6%, with just 6.7% of patients reporting levels of 25-(OH)-vitamin D > 30 ng/ml. Total serum calcium was inversely related with selected inflammatory biomarkers (p < 0.05) and poorer outcome of COVID-19 during hospitalization. Lower tertile of total calcium (≤2.02 mmol/L) had increased risk of in-hospital mortality (HR 2.77; 1.28-6.03, p = 0.01) compared with other groups.

CONCLUSION

Total serum calcium detected on admission is inversely related with proinflammatory biomarkers of severe COVID-19 and is useful to better define risk stratification for adverse in-hospital outcome.

Eucalcemia during lipopolysaccharide challenge in postpartum dairy cows: II. Calcium dynamics

Hypocalcemia induced by immune activation is a conserved response among mammals. Early postpartum cows will experience decreased circulating Ca concentrations following acute immune activation; however, the cause for decreased Ca concentration is unknown. Our objectives were to (1) describe Ca dynamics following an intravenous (IV) LPS challenge in early postpartum cows, and (2) compare inflammatory-induced changes in Ca dynamics between IV Ca-treated cows and control cows. Cows (n = 14, 8 ± 1 d in milk) were enrolled in a matched-pair randomized controlled design to receive IV Ca (IVCa) in a eucalcemic clamp for 12 h, or 0.9% NaCl (CTRL) following an IV LPS infusion (0.040 or 0.045 µg of LPS/kg of body weight over 1 h). During the 24 h following LPS infusion, circulating concentrations of parathyroid hormone and serotonin were measured, serum and urine samples were collected to calculate urinary fractional excretion of Ca (FECa), and fecal samples were collected to calculate Ca apparent digestibility (ADCa) using amylase-treated and ash-corrected undigested neutral detergent fiber after 240 h (uNDFom₂₄₀) as an internal marker. Changes in Ca intake and milk Ca secretion were also quantified and compared with baseline values. Cows were fasted during challenge and dry matter intake was 20 ± 5% less than baseline values on the day of challenge and did not differ between groups. On the day of challenge, milk Ca concentration increased, but milk yield decreased such that total Ca secreted in milk did not change from baseline. Urine FECa was low overall, but an interaction of treatment and time was identified such that FECa increased in IVCa but decreased in CTRL. Concentrations of parathyroid hormone increased and serotonin decreased following challenge. Fecal dry matter decreased from baseline, but did not differ between 6, 12, and 24 h, and did not differ between groups. An interaction of treatment and time was identified for ADCa and apparent digestibility of dry matter such that digestibility was decreased in CTRL but not IVCa at 6 h. Acute immune activation induced hypocalcemia in CTRL, and although urinary Ca excretion was not a primary cause, it is unclear to what degree hypocalcemia was due to altered ADCa. Eucalcemia appeared to alter adaptations in Ca homeostasis during immune activation as FECa was increased in IVCa animals.

Endocrine Disorders and COVID-19

The multifaceted interaction between coronavirus disease 2019 (COVID-19) and the endocrine system has been a major area of scientific research over the past two years. While common endocrine/metabolic disorders such as obesity and diabetes have been recognized among significant risk factors for COVID-19 severity, several endocrine organs were identified to be targeted by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). New-onset endocrine disorders related to COVID-19 were reported while long-term effects, if any, are yet to be determined. Meanwhile, the "stay home" measures during the pandemic caused interruption in the care of patients with pre-existing endocrine disorders and may have impeded the diagnosis and treatment of new ones. This review aims to outline this complex interaction between COVID-19 and endocrine disorders by synthesizing the current scientific knowledge obtained from clinical and pathophysiological studies, and to emphasize considerations for future research.

Association of hypocalcemia with in-hospital mortality in critically ill patients with intracerebral hemorrhage: A retrospective cohort study

Background and purpose

There was little evidence to study the relationship between hypocalcemia and mortality among critically ill patients with intracerebral hemorrhage (ICH) aged ≥16 years. This study aimed to determine the potential association between hypocalcemia and in-hospital and ICU mortality in patients with ICH in the United States.

Methods

We analyzed 1,954 patients with ICH from the e-Intensive Care Unit Collaborative Research Database and divided them into hypocalcemia and non-hypocalcemia groups. Hypocalcemia was defined as albumin-adjusted total calcium below 8.4 mg/dl. The primary and secondary outcomes were hospital and ICU mortality, respectively. We performed multivariable regression and subgroup analyses to evaluate the association of hypocalcemia with hospital and ICU mortality. Cumulative survival rate analysis was performed using Kaplan-Meier curves with log-rank statistics.

Results

We enrolled 1,954 patients with ICH who had been hospitalized in ICU for >24 h and were older than 16 years (average age, 61.8 years; men, 56.7%). We noted that 373 (19%) hospital mortality occurred, including 235 (12%) ICU mortality. In this sample, 195 patients had hypocalcemia. Multivariable logistic regression analyses showed that hypocalcemia was associated with a 67% increased risk of in-hospital and a 72% increased risk of ICU mortality. This association was consistent across subgroup analyses.

Conclusions

Hypocalcemia was associated with a high risk of hospital and ICU mortality among critically ill patients with ICH. Future prospective, randomized, controlled studies are needed to confirm our results.

Serum Calcium, Magnesium, and Phosphorus Levels in Patients with COVID-19: Relationships with Poor Outcome and Mortality

In this retrospective study to assess the impact of serum corrected calcium (CorrCa), magnesium (Mg) and phosphorus (P) levels, all adult patients with laboratory-confirmed COVID-19 hospitalized during 2020 were included. Poor outcome was considered in patients who presented need for mechanical ventilation, intensive care unit (ICU) admission, or in-hospital mortality. We analyzed 2473 patients (956 females) aged (mean±SD) 63.4±15.9 years. During admission, 169 patients (6.8%) required mechanical ventilation, 205 (8.3%) were admitted to the ICU, and 270 (10.9%) died. Composite variable of poor outcome, defined as need for mechanical ventilation, ICU admission or death, was present in 434 (17.5%) patients. In univariate analysis, the need for mechanical ventilation was positively related to Mg levels (OR 8.37, 95% CI 3.62-19.33; p<0.001); ICU admission was related to CorrCa (OR 0.49, 95% CI 0.25-0.99; p=0.049) and Mg levels (OR 5.81, 95% CI 2.74-12.35; p<0.001); and in-hospital mortality was related to CorrCa (OR 1.73, 95% CI 1.14-2.64; p=0.011). The composite variable of poor outcome was only related to Mg (OR 2.68, 95% CI 1.54-4.68; p=0.001). However, in multivariate analysis only CorrCa was significantly related to the need for mechanical ventilation (OR 0.19, 95% CI 0.05-0.72; p=0.014) and ICU admission (OR 0.25; 95% CI 0.09-0.66; p=0.005), but not with in-hospital mortality or the composite variable. In conclusion, CorrCa can be used as a simple and reliable marker of poor outcome in patients with COVID-19, although not to predict the risk of in-hospital mortality.

Baseline electrolyte disorders predict disease severity and mortality in patients with COVID-19

Distinguishing critical laboratory biomarkers for disease severity at the time of hospital presentation is important for early identification of patients who are most likely to have poor outcomes and effective use of health resources. This study aimed to evaluate whether electrolyte imbalances on hospital admission predict severe disease and mortality in patients with coronavirus disease 2019 (COVID-19). We retrospectively collected data on the blood electrolyte concentrations of 286 COVID-19 patients at admission. The correlations between electrolyte imbalances, inflammation, and thrombosis markers in COVID-19 patients were also evaluated. We assessed the predictive performance of baseline blood electrolyte concentrations for severe disease and death using receiver operating characteristic curve analysis and multivariate logistic regression methods. Abnormalities in serum sodium, calcium, and potassium levels at admission were found at 20.6%, 14%, and 4.2%, respectively in this study. In the receiver operating characteristic curve analyses, hypocalcemia and hyponatremia effectively predicted disease progression to hospitalization (area under the curve 0.82, P < .001 and 0.81, P < .001, respectively) and 30-day mortality (area under the curve 0.85, P < .001 and 0.91, P < .001, respectively). In the multivariate logistic regression analysis, baseline hypocalcemia was identified as an independent risk factor associated with the risk of hospitalization (β = 2.019, P = .01; odds ratio: 7.53). Baseline hypocalcemia and hyponatremia effectively predicted disease progression toward hospitalization and 30-day mortality in patients with COVID-19. Clinicians should closely follow up or reevaluate COVID-19 patients with baseline electrolyte disorders.

Consensus and Controversial Aspects of Vitamin D and COVID-19

OBJECTIVES

This work aims to review and discuss controversial topics in the field of vitamin D, SARS-CoV-2 infection, and COVID-19.

PARTICIPANTS

The International Conferences "Controversies in Vitamin D" are a series of workshops that started in 2017 featuring international experts and leaders in vitamin D research and clinical practice. The 5th annual conference was held in Stresa, Italy, from 15 to 18 September 2021.

EVIDENCE

Before the event, participants reviewed available studies on their assigned topic, drafted a related abstract, and presented their findings at the time of the conference. Relevant literature that became available since was also discussed within the panel and updated accordingly.

CONSENSUS

Before the event, the drafted abstracts had been merged to prepare a preliminary document. After the conference presentations, in-depth discussions in open sessions led to consensus. The document was subsequently modified according to discussions and up-to-date literature inclusion.

CONCLUSIONS

There is quite consistent evidence for an association between low 25 OH vitamin D (25(OH)D) levels and poor COVID-19 outcomes, despite heterogeneous publications of variable quality. However, the low vitamin D status in COVID-19 patients might also reflect reverse causality. Vitamin D supplementation might have a positive role in COVID-19 prevention. The evidence supporting a beneficial effect of vitamin D treatment in decreasing the risk of COVID-19 complications is conflicting. Conclusive statement regarding the beneficial effect of vitamin D in this context await high-quality randomized controlled trials.

Bone mineral density changes in osteoporotic and osteopenic patients after COVID-19 infection

Background

Coronavirus disease 2019 (COVID-19) infection is linked to high levels of inflammatory cytokines and prolonged immobilization; furthermore, corticosteroid treatment leads to increased bone loss and resorption. We aimed to study the change in bone mineral density (BMD) after COVID-19 infection in osteoporotic and osteopenic patients. One hundred osteoporotic or osteopenic patients were selected in this single-center retrospective study; the patients were divided into two groups. Group 1 included 56 patients who got COVID-19 infection. Group 2 included 44 patients who did not get COVID-19 infection. BMD was assessed at baseline, after 9 months of COVID infection, and then after 1 year follow-up using dual energy x-ray absorptiometry (DXA) scan.

Results

There was no significant difference between two groups regarding demographic data (p > 0.05); there was a significant decrease in BMD of the lumbar region and femur at 9 months as compared to baseline in group1 (p < 0.001), while there was a significant increase in the lumbar BMD of osteoporotic patients who did not get COVID infection after 21 months. Concerning activity of COVID infection, there was a significant difference between the three subgroups of COVID patients regarding percentage of change in BMD after 9 months, the severe group having the highest decrease in BMD (p < 0.001).

Conclusions

COVID-19 may have deleterious effect on BMD in osteoporotic patients. It is recommended to assess BMD in osteoporotic/osteopenic patients who got COVID infection to detect if there is an increased risk of fracture which may necessitate post-COVID change in the therapeutic intervention plan.

The calcium-sensing receptor in inflammation: Recent updates

The Calcium-Sensing Receptor (CaSR) is a member of the class C of G-proteins coupled receptors (GPCRs), it plays a pivotal role in calcium homeostasis by directly controlling calcium excretion in the kidneys and indirectly by regulating parathyroid hormone (PTH) release from the parathyroid glands. The CaSR is found to be ubiquitously expressed in the body, playing a plethora of additional functions spanning from fluid secretion, insulin release, neuronal development, vessel tone to cell proliferation and apoptosis, to name but a few. The present review aims to elucidate and clarify the emerging regulatory effects that the CaSR plays in inflammation in several tissues, where it mostly promotes pro-inflammatory responses, with the exception of the large intestine, where contradictory roles have been recently reported. The CaSR has been found to be expressed even in immune cells, where it stimulates immune response and chemokinesis. On the other hand, CaSR expression seems to be boosted under inflammatory stimulus, in particular, by pro-inflammatory cytokines. Because of this, the CaSR has been addressed as a key factor responsible for hypocalcemia and low levels of PTH that are commonly found in critically ill patients under sepsis or after burn injury. Moreover, the CaSR has been found to be implicated in autoimmune-hypoparathyroidism, recently found also in patients treated with immune-checkpoint inhibitors. Given the tight bound between the CaSR, calcium and vitamin D metabolism, we also speculate about their roles in the pathogenesis of severe acute respiratory syndrome coronavirus-19 (SARS-COVID-19) infection and their impact on patients' prognosis. We will further explore the therapeutic potential of pharmacological targeting of the CaSR for the treatment and management of aberrant inflammatory responses.

The osteo-metabolic phenotype of COVID-19: an update

CONTEXT

In the multifaceted COVID-19 clinical scenario characterized by a multi-system disorder with negative implications not only on respiratory function but also on cardiac, hematological, neurological and endocrine-metabolic systems, a distinctive osteo-metabolic phenotype with an independent influence on disease severity and recovery of patients affected was early reported.

AIM

To summarize and update the main evidences regarding the distinct components of this phenotype in acute and Long COVID-19, reinforcing its clinical relevance and discussing the main pathophysiological and clinical-therapeutic implications of the most recent reported findings.

RESULTS

This emerging phenotype is characterized by a widespread acute hypocalcemia and hypovitaminosis D with an impaired compensatory parathyroid hormone response, and a high prevalence of skeletal complications such as vertebral fractures. The clinical relevance of this osteo-metabolic phenotype on acute COVID-19 is well characterized, and novel seminal evidences are progressively highlighting its importance also in predicting patient's long-term outcomes and Long COVID-19 occurrence.

CONCLUSIONS

These findings reinforced the central role of a multidisciplinary team, including endocrinologists, in evaluating these patients for a proactive search of each aspect of the osteo-metabolic phenotype components since they may represent suitable therapeutic targets to prevent SARS-CoV-2 infection, poor COVID-19 outcomes, Long COVID-19 occurrence and even possibly better responses to COVID-19 vaccination.

Osteosarcopenia and Long-COVID: a dangerous combination

SARS-CoV-2 has caused a global pandemic and an unprecedented public health crisis, infecting more than 580 million people worldwide. Moreover, recent evidence has suggested the emergence of a new syndrome known as Long-COVID, a term used to describe a diverse set of physical and mental symptoms that persist after a diagnosed SARS-CoV-2 infection. Epidemiological data have identified myalgias, muscle and joint dysfunction, and bone fragility as common sequelae in patients with moderate and severe forms of this disease. Significant musculoskeletal dysfunction has also been detected in some healed patients, although knowledge about pathophysiological mechanisms of Long-COVID is still rather scarce. In this context, SARS-CoV-2 infection has been suggested to amplify the effects of aging on the musculoskeletal system by aggravating the osteosarcopenic state. Based on this evidence, our review focused on the muscle and bone tissue alterations induced by SARS-CoV-2 infection and Long-COVID, summarizing the current knowledge on the underlying biological mechanisms and highlighting the need for a multidisciplinary approach to predict the musculoskeletal targets and long-term consequences of COVID-19 disease.

Hypocalcemia: a key biomarker in hospitalized COVID-19 patients

Background

At the end of 2019 a new respiratory syndrome emerged in China named Coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 infection. Considering the severity of the disease in adult subjects with one or more chronic pathologies, it was mandatory to find simple and effective biomarkers for negative prognosis of the disease easily available at the admission to the hospital.

Methods

To identify possible parameters showing association with the outcome in COVID-19 patients with pre-existing chronic diseases, blood biochemical profiles of 511 patients, enrolled from March to June 2020, were retrospectively evaluated. The pathological conditions taken into consideration were diabetes, arterial hypertension, chronic kidney disease, cardiovascular diseases, chronic obstructive pulmonary disease, obesity, and cancer. All the data were collected upon admission to the emergency room (ER) during the indicated period.

Results

We observed that serum and ionized calcium were prevalently altered in our cohort. We determined that hypocalcemia was a major parameter associated with mechanical ventilation and poor prognosis, correlating also with the presence of comorbidities such as cardiovascular diseases, chronic kidney disease, and cancer. In addition, we found a positive correlation between hypocalcemia and clinical complications during hospitalizations.

Conclusions

Our results strengthen the relevance of serum calcium concentration as a useful prognostic biomarker in hospitalized COVID-19 patients.

Correlation of clinical characteristics between patients with seasonal influenza and patients infected by the wild type or delta variant of SARS-CoV-2

Background

We compared the clinical characteristics of the patients with COVID-19, infected by the wild type or delta variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in connection with those of patients with seasonal influenza, all in mild cases.

Methods

We retrospectively studied 245 and 115 patients with mild COVID-19 infected by the wild type and the delta variant of SARS-CoV-2, respectively, with their demographic information, medical history, and laboratory data from hospital records, individually compared to 377 patients with mild seasonal influenza, before and after individual treatment.

Results

Compared to the influenza cohort, the COVID-19 cohort or the COVID-19 delta variant cohort demonstrated younger median age, lower male ratio, and shorter duration from disease onset to hospitalization. Hypertension remained the top comorbidity among all cohorts. Based on patients' data upon hospitalization, the correlation of clinical characteristics between patients with influenza and those with the wild-type COVID-19 is greater than that between patients with influenza and those with the delta variant COVID-19. Individual treatment in each viral disease alleviated most hematological parameters, but some compromised biomarkers at the time of hospital discharge revealed persistent renal or myocardial impairment among patients with COVID-19 and influenza in recovery.

Conclusion

Timely and proper treatment using broad-spectrum antibiotics and antiviral drugs could moderately alleviate the acute viremia and possible bacterial co-infection in patients with mild COVID-19 and influenza, followed by compromised recovery. To prepare for the flu season amid the COVID-19 pandemic, preventive and adequate immunizations of both flu and COVID-19 vaccines, as well as specific therapeutics to effectively reverse viral impairments, are in urgent need.

Vertebral fractures at hospitalization predict impaired respiratory function during follow-up of COVID-19 survivors

PURPOSE

Morphometric vertebral fractures (VFs) have been recently reported as an important component of the endocrine phenotype of COVID-19 and emerging data show negative respiratory sequelae at long-term follow-up in COVID-19 survivors. The aim of this study was to evaluate the impact of VFs on respiratory function in COVID-19 survivors.

METHODS

We included patients referred to our Hospital Emergency Department and re-evaluated during follow-up. VFs were detected on lateral chest X-rays on admission using a qualitative and semiquantitative assessment and pulmonary function tests were obtained by Jaeger-MasterScreen-Analyzer Unit 6 months after discharge.

RESULTS

Fifty patients were included. Median age was 66 years and 66% were males. No respiratory function data were available at COVID-19 diagnosis. VFs were detected in 16 (32%) patients. No differences between fractured and non-fractured patients regarding age and sex were observed. Although no difference was observed between VF and non-VF patient groups in the severity of pneumonia as assessed by Radiological-Assessment-of-Lung-Edema score at admission, (5 vs. 6, p = 0.69), patients with VFs were characterized as compared to those without VFs by lower Forced Vital Capacity (FVC, 2.9 vs. 3.6 L, p = 0.006; 85% vs. 110% of predicted, respectively, p = 0.001), Forced Expiratory Volume 1st s (FEV1, 2.2 vs. 2.8 L, p = 0.005; 92% vs. 110% of predicted, respectively, p = 0.001) and Diffusing Capacity of the Lungs for Carbon Monoxide (DLCO 5.83 vs. 6.98 mmol/min/kPa, p = 0.036, 59% vs. 86.3% of predicted, respectively, p = 0.043) at 6-month follow up.

CONCLUSIONS

VFs, expression of the endocrine phenotype of the disease, appear to influence medium-term impaired respiratory function of COVID-19 survivors which may significantly influence their recovery. Therefore, our findings suggest that a VFs assessment at baseline may help in identifying patients needing a more intensive respiratory follow-up and patients showing persistent respiratory impairment without evidence of pulmonary disease may benefit from VFs assessment to preventing the vicious circle of further fractures and respiratory deterioration.

Effects of nutrients on immunomodulation in patients with severe COVID-19: Current knowledge

Recent research has demonstrated that critically ill patients with coronavirus disease 2019 (COVID-19) show significant immune system dysregulation. Due to that, some nutrients that influence immunomodulation have been suggested as a form of treatment against the infection. This review collected the information on the impact of vitamins on the prognosis of COVID-19, with the intention of facilitating treatment and prevention of the disease risk status in patients. The collected information was obtained using the PubMed electronic database by searching for articles that relate COVID-19 and the mechanisms/effects of the nutrients: Proteins, glucose, lipids, vitamin B12, vitamin D, calcium, iron, copper, zinc, and magnesium, including prospective, retrospective, and support articles. The findings reveal an optimal response related mainly to omega-3, eicosapentaenoic acid, docosahexaenoic acid, calcium, and iron that might represent benefits in the treatment of critically ill patients. However, nutrient supplementation should be done with caution due to the limited availability of randomized controlled studies.

Hypocalcemia in hospitalized patients with COVID-19: roles of hypovitaminosis D and functional hypoparathyroidism

INTRODUCTION

Despite the high prevalence of hypocalcemia in patients with COVID-19, very limited studies have been designed to evaluate etiologies of this disorder. This study was designed to evaluate the status of serum parameters involved in calcium metabolism in patients with COVID-19 and hypocalcemia.

MATERIALS AND METHODS

This cross-sectional study was conducted on 123 hospitalized patients with COVID-19. Serum concentrations of PTH, 25 (OH) D, magnesium, phosphate, and albumin were assessed and compared across three groups of moderate/severe hypocalcemia (serum total calcium < 8 mg/dl), mild hypocalcemia (8 mg/dl ≤ serum total calcium < 8.5 mg/dl) and normocalcemia (serum total calcium ≥ 8.5 mg/dl). Multivariate analyses were performed to evaluate the independent roles of serum parameters in hypocalcemia.

RESULTS

In total, 65.9% of the patients had hypocalcemia. Vitamin D deficiency was found in 44.4% and 37.7% of moderate/severe and mild hypocalcemia cases, respectively, compared to 7.1% in the normal serum total calcium group (P = 0.003). In multivariate analysis, vitamin D deficiency was independently associated with 6.2 times higher risk of hypocalcemia (P = 0.001). Only a minority of patients with hypocalcemia had appropriately high PTH (15.1% and 14.3% in mild and moderate/severe hypocalcemia, respectively). Serum PTH was low/low-normal in 40.0% of patients with moderate/severe low-corrected calcium group. Magnesium deficiency was not associated with hypocalcemia in univariate and multivariate analysis.

CONCLUSION

Vitamin D deficiency plays a major role in hypocalcemia among hospitalized patients with COVID-19. Inappropriately low/low-normal serum PTH may be a contributing factor in this disorder.

Natural and genetically-modified animal models to investigate pulmonary and extrapulmonary manifestations of COVID-19

Coronavirus disease-19 (COVID-19), a pandemic caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), is a primarily respiratory tract disease. Suitable animal models for COVID-19 are required to study various aspects of pathogenesis, drug discovery, effective and safe vaccine development. Several laboratory animals including, non-human primates, hamsters, ferrets, transgenic mice, and zebrafish, have been used and proven their significance experimentally. Currently available animal models of SARS-CoV-2 can be broadly classified into two categories 1) natural animal models 2) genetically-modified that exhibit different degrees of susceptibility of SARS-CoV-2, tissue damage in respiratory and other organ systems. Not all the available animal models mimic COVID-19-like phenotype completely. Therefore, understanding various aspects of COVID-19 requires different animal models. In this review article, we provide an update on the immune response and clinical manifestations observed in naturally occurring and genetically-modified animals of COVID-19. We then review the transmission, viral replication, lung pathology, immunological aspects, and extrapulmonary phenotypes observed in various animal models. In the end, we put forth our perspective on the anticipated uses, disadvantages, and limitations of each type of animal model.

Vitamin D for Recovery of COVID-19 in Patients With Chronic Kidney Disease

The severity of coronavirus disease 2019 (COVID-19) is determined not only by viral damage to cells but also by the immune reaction in the host. In addition to therapeutic interventions that target the viral infection, immunoregulation may be helpful in the management of COVID-19. Vitamin D exerts effects on both innate and adaptive immunity and subsequently modulates immune responses to bacteria and viruses. Patients with chronic kidney disease (CKD) frequently have vitamin D deficiency and increased susceptibility to infection, suggesting a potential role of vitamin D in this vulnerable population. In this paper, we review the alterations of the immune system, the risk of COVID-19 infections and mechanisms of vitamin D action in the pathogenesis of COVID-19 in CKD patients. Previous studies have shown that vitamin D deficiency can affect the outcomes of COVID-19. Supplementing vitamin D during treatment may be protective against COVID-19. Future studies, including randomized control trials, are warranted to determine the effect of vitamin D supplementation on the recovery from COVID-19 in CKD patients.

Basic mechanisms of SARS-CoV-2 infection. What endocrine systems could be implicated?

Although SARS-CoV-2 viral attacks starts by the interaction of spike protein (S Protein) to ACE2 receptor located at the cell surface of respiratory tract and digestive system cells, different endocrine targets, endocrine organs and metabolic conditions are of fundamental relevance for understanding disease progression and special outcomes, in particular those of fatal consequences for the patient. During pandemic, moreover, a specific phenotype of COVID-19 metabolic patient has been described, characterized by being at particular risk of worse outcomes. In the present paper we describe the mechanism of viral interaction with endocrine organs, emphasizing the specific endocrine molecules of particular relevance explaining COVID-19 disease evolution and outcomes.

Revisiting the endocrine and metabolic manifestations of COVID-19 two years into the pandemic

An extraordinary effort of the universal endocrine community has led to important insights into endocrine and metabolic aspects of COVID-19. In this Editorial, we introduce a special issue of Reviews in Endocrine and Metabolic Disorders that calls attention, through the efforts of internationally recognized experts in the field, to features that are now widely recognized as endocrine and metabolic manifestations of COVID-19. These advances in our knowledge have seminal implications for how we can prevent and manage these aspects of COVID-19.

Contributing Factors for Calcium Changes During Hospitalization in COVID-19: A Longitudinal Study

BACKGROUND

Hypocalcemia is highly prevalent in Coronavirus disease 2019 (COVID-19). There is limited evidence about the course and roles of different parameters in the occurrence of new or worsening hypocalcemia.

OBJECTIVES

This prospective longitudinal study was conducted on hospitalized COVID-19 patients in Qazvin, Iran, in 2021.

METHODS

Serum levels of calcium, albumin, parathormone (PTH), 25(OH)D (vitamin D), magnesium, and phosphate were assessed on the first day (time one), as well as fourth to sixth days (time two) of hospitalization. Paired t-test, McNemar's test, and multivariate logistic regression test were used to compare data at two times and evaluating the independent roles of different variables in the occurrence or worsening of hypocalcemia.

RESULTS

Out of a total of 123 participants, 102 patients completed the study. The mean serum calcium level significantly decreased from 8.32 ± 0.52 mg/dL to 8.02 ± 0.55 mg/dL at time two compared to time one (P < 0.001). Also, we witnessed new or worsening hypocalcemia at time two in 44 (55%) patients with normal serum calcium or mild hypocalcemia at time one (P < 0.001). The PTH level decreased from 42.17 ± 27.20 pg/mL to 31.28 ± 23.42 pg/mL (P < 0.001). The decrease in albumin and PTH levels was an independent significant factor in the occurrence or worsening of hypocalcemia at time two (OR = 1.27; 95% CI: 1.10 - 1.46; P = 0.001 for each 1 g/L decrement in albumin and OR = 1.29; 95% CI: 1.03 - 1.62; P = 0.026 for each 10 pg/mL decrement in PTH). Vitamin D deficiency or changes during hospitalization did not have a significant role in new or worsening hypocalcemia.

CONCLUSIONS

Decreased PTH secretion and hypoalbuminemia have significant roles in the occurrence of new or worsening hypocalcemia during hospitalization due to COVID-19.

Connections between Orthopedic Conditions and Oxidative Stress: Current Perspective and the Possible Relevance of Other Factors, Such as Metabolic Implications, Antibiotic Resistance, and COVID-19

The general opinion in the literature is that these topics remain clearly understudied and underrated, with many unknown aspects and with controversial results in the respective areas of research. Based on the previous experience of our groups regarding such matters investigated separately, here we attempt a short overview upon their links. Thus, we summarize here the current state of knowledge regarding the connections between oxidative stress and: (a) orthopedic conditions; (b) COVID-19. We also present the reciprocal interferences among them. Oxidative stress is, of course, an interesting and continuously growing area, but what exactly is the impact of COVID-19 in orthopedic patients? In the current paper we also approached some theories on how oxidative stress, metabolism involvement, and even antibiotic resistance might be influenced by either orthopedic conditions or COVID-19. These manifestations could be relevant and of great interest in the context of this current global health threat; therefore, we summarize the current knowledge and/or the lack of sufficient evidence to support the interactions between these conditions.

Lower plasma calcium associated with COVID-19, but not with disease severity: a two-centre retrospective cohort study

BACKGROUND

Previous studies indicate hypocalcaemia as a potential diagnostic and prognostic marker of corona-virus disease 2019 (COVID-19). Our aim was to investigate these relations in more detail in a large test cohort and an independent validation cohort.

METHODS

We retrospectively included 2792 COVID-19 suspected patients that presented to the emergency department (ED) of two hospitals. Plasma calcium and ionized plasma calcium levels were compared between COVID-19 positive and negative patients, and between severe and non-severe COVID-19 patients using univariate and multivariate analyses in the first hospital (N = 1363). Severe COVID-19 was defined as intensive care unit (ICU) admission or death within 28 d after admission. The results were validated by repeating the same analyses in the second hospital (N = 1429).

RESULTS

A total of 693 (24.8%) of the enrolled patients were COVID-19 positive, of whom 238 (34.3%) had severe COVID-19. In both hospitals, COVID-19 positive patients had lower plasma calcium levels than COVID-19 negative patients, regardless of correction for albumin, in univariate and multivariate analysis (Δ0.06-0.13 mmol/L, p < .001). Ionized plasma calcium concentrations, with and without correction for pH, were also lower in COVID-19 positive patients in multivariate analyses (Δ0.02-0.05 mmol/L, N = 567, p < .001). However, we did not find a significant association between COVID-19 disease severity and plasma calcium in multivariate analyses.

CONCLUSIONS

Plasma calcium concentrations were lower in COVID-19 positive than COVID-19 negative patients but we found no association with disease severity in multivariate analyses. Further understanding of plasma calcium perturbation may facilitate the development of new preventive and therapeutic modalities for the current pandemic.

COVID-19, Cation Dysmetabolism, Sialic Acid, CD147, ACE2, Viroporins, Hepcidin and Ferroptosis: A Possible Unifying Hypothesis

Background: iron and calcium dysmetabolism, with hyperferritinemia, hypoferremia, hypocalcemia and anemia have been documented in the majority of COVID-19 patients at later/worse stages. Furthermore, complementary to ACE2, both sialic acid (SA) molecules and CD147 proved relevant host receptors for SARS-CoV-2 entry, which explains the viral attack to multiple types of cells, including erythrocytes, endothelium and neural tissue. Several authors advocated that cell ferroptosis may be the core and final cell degenerative mechanism. Methods: a literature research was performed in several scientific search engines, such as PubMed Central, Cochrane Library, Chemical Abstract Service. More than 500 articles were retrieved until mid-December 2021, to highlight the available evidence about the investigated issues. Results: based on COVID-19 literature data, we have highlighted a few pathophysiological mechanisms, associated with virus-based cation dysmetabolism, multi-organ attack, mitochondria degeneration and ferroptosis. Our suggested elucidated pathological sequence is: a) spike protein subunit S1 docking with sialylated membrane glycoproteins/receptors (ACE2, CD147), and S2 subunit fusion with the lipid layer; b) cell membrane morpho-functional changes due to the consequent electro-chemical variations and viroporin action, which induce an altered ion channel function and intracellular cation accumulation; c) additional intracellular iron concentration due to a deregulated hepcidin-ferroportin axis, with higher hepcidin levels. Viral invasion may also affect erythrocytes/erythroid precursors, endothelial cells and macrophages, through SA and CD147 receptors, with relative hemoglobin and iron/calcium dysmetabolism. AB0 blood group, hemochromatosis, or environmental elements may represent possible factors which affect individual susceptibility to COVID-19.     Conclusions: our literature analysis confirms the combined role of SA molecules, ACE2, CD147, viroporins and hepcidin in determining the cation dysmetabolism and final ferroptosis in the cells infected by SARS-CoV-2. The altered ion channels and electrochemical gradients of the cell membrane have a pivotal role in the virus entry and cell dysmetabolism, with subsequent multi-organ immune-inflammatory degeneration and erythrocyte/hemoglobin alterations.

COVID-19, Cation Dysmetabolism, Sialic Acid, CD147, ACE2, Viroporins, Hepcidin and Ferroptosis: A Possible Unifying Hypothesis

Background: iron and calcium dysmetabolism, with hyperferritinemia, hypoferremia, hypocalcemia and anemia have been documented in the majority of COVID-19 patients at later/worse stages. Furthermore, complementary to ACE2, both sialic acid (SA) molecules and CD147 proved relevant host receptors for SARS-CoV-2 entry, which explains the viral attack to multiple types of cells, including erythrocytes, endothelium and neural tissue. Several authors advocated that cell ferroptosis may be the core and final cell degenerative mechanism. Methods: a literature research was performed in several scientific search engines, such as PubMed Central, Cochrane Library, Chemical Abstract Service. More than 500 articles were retrieved until mid-December 2021, to highlight the available evidence about the investigated issues. Results: based on COVID-19 literature data, we have highlighted a few pathophysiological mechanisms, associated with virus-based cation dysmetabolism, multi-organ attack, mitochondria degeneration and ferroptosis. Our suggested elucidated pathological sequence is: a) spike protein subunit S1 docking with sialylated membrane glycoproteins/receptors (ACE2, CD147), and S2 subunit fusion with the lipid layer; b) cell membrane morpho-functional changes due to the consequent electro-chemical variations and viroporin action, which induce an altered ion channel function and intracellular cation accumulation; c) additional intracellular iron concentration due to a deregulated hepcidin-ferroportin axis, with higher hepcidin levels. Viral invasion may also affect erythrocytes/erythroid precursors, endothelial cells and macrophages, through SA and CD147 receptors, with relative hemoglobin and iron/calcium dysmetabolism. AB0 blood group, hemochromatosis, or environmental elements may represent possible factors which affect individual susceptibility to COVID-19.     Conclusions: our literature analysis confirms the combined role of SA molecules, ACE2, CD147, viroporins and hepcidin in determining the cation dysmetabolism and final ferroptosis in the cells infected by SARS-CoV-2. The altered ion channels and electrochemical gradients of the cell membrane have a pivotal role in the virus entry and cell dysmetabolism, with subsequent multi-organ immune-inflammatory degeneration and erythrocyte/hemoglobin alterations.

The Prognostic Role of Metabolic and Endocrine Parameters for the Clinical Severity of COVID-19

OBJECTIVE

An outbreak of coronavirus disease-19 (COVID-19) began in December 2019 and spread globally, overwhelming the entire world. COVID-19 is a public health emergency of international concern. Due to its high morbidity and mortality rate, recognition of its risk and prognostic factors is important. We aimed to understand the relationship between metabolic and endocrine parameters and the prognosis of COVID-19.

METHODS AND MATERIALS

This was a cross-sectional clinical study. A total of 70 patients with severe COVID-19 were enrolled. Laboratory results at the first admission time (including complete blood count, C-reactive protein, lactate dehydrogenase, blood glucose, calcium, phosphate, albumin, creatinine, magnesium, lipid profiles, liver enzymes, thyroid hormones, cortisol, and vitamin D) and outcome data were recorded. We divided patients into (1) intensive care unit- (ICU-) admitted and non-ICU-admitted and (2) survivors and nonsurvivors for estimation of severity and prognosis. We determined the risk factors associated with critical illness and poor prognosis.

RESULTS

Patients with higher white blood cell (WBC) count and phosphate levels had significantly higher ICU admission rates. According to univariate analysis, serum levels of T3, phosphate, and WBC as well as the duration of hospitalization were associated with mortality. Multivariate analysis revealed that only WBC and duration of hospitalization were independent predictors for mortality rate in COVID-19 patients.

CONCLUSION

Our findings suggest that longer duration of hospitalization and higher WBC count are associated with poor outcomes in patients with COVID-19.

COVID-19 in Joint Ageing and Osteoarthritis: Current Status and Perspectives

COVID-19 is a trending topic worldwide due to its immense impact on society. Recent trends have shifted from acute effects towards the long-term morbidity of COVID-19. In this review, we hypothesize that SARS-CoV-2 contributes to age-related perturbations in endothelial and adipose tissue, which are known to characterize the early aging process. This would explain the long-lasting symptoms of SARS-CoV-2 as the result of an accelerated aging process. Connective tissues such as adipose tissue and musculoskeletal tissue are the primary sites of aging. Therefore, current literature was analyzed focusing on the musculoskeletal symptoms in COVID-19 patients. Hypovitaminosis D, increased fragility, and calcium deficiency point towards bone aging, while joint and muscle pain are typical for joint and muscle aging, respectively. These characteristics could be classified as early osteoarthritis-like phenotype. Exploration of the impact of SARS-CoV-2 and osteoarthritis on endothelial and adipose tissue, as well as neuronal function, showed similar perturbations. At a molecular level, this could be attributed to the angiotensin-converting enzyme 2 expression, renin-angiotensin system dysfunction, and inflammation. Finally, the influence of the nicotinic cholinergic system is being evaluated as a new treatment strategy. This is combined with the current knowledge of musculoskeletal aging to pave the road towards the treatment of long-term COVID-19.

COVID-19 in Elderly Patients Surgically Treated for Lower Limbs Fracture

Background: The coronavirus disease 2019 (COVID-19) pandemic outbreak has posed new problems in the context of patients suffering from other diseases. In particular, musculoskeletal sequelae related to the state of debilitation associated with COVID-19 are important to consider in elderly patients undergoing surgery after lower limbs fracture, especially in the post-operative period. The objective of this study was to evaluate whether COVID-19 influenced biochemical parameter, recovery and mortality of surgically treated patients suffering from lower extremity fractures. Methods: Laboratory and clinical data of 30 patients were extrapolated and analyzed in the pre-operative and post-operative periods. Among these patients, 13 had COVID-19 infection (COVID-19 +), whereas 17 had no signs of COVID-19 infections (COVID-19 −). Long-term clinical and functional outcomes were also analyzed. Results: Lower calcium, slightly higher values of CRP and much higher values of CPK and AST were observed pre-operatively in COVID-19 + patients, who also showed higher prevalence of long-term sequelae than COVID-19 − patients. Conclusions: COVID-19 affects long-term outcome of elderly patients with lower limb fractures in a multifactorial way. First, the virus directly damages the muscle tissue. Secondly, the lung function impairment worsens the overall performance, making rehabilitation more challenging.

Epidemiological Characteristics of Hospitalized Patients with Moderate versus Severe COVID-19 Infection: A Retrospective Cohort Single Centre Study

COVID-19 has a devastating impact worldwide. Recognizing factors that cause its progression is important for the utilization of appropriate resources and improving clinical outcomes. In this study, we aimed to identify the epidemiological and clinical characteristics of patients who were hospitalized with moderate versus severe COVID-19 illness. A single-center, retrospective cohort study was conducted between 3 March and 9 September 2020. Following the CDC guidelines, a two-category variable for COVID-19 severity (moderate versus severe) based on length of stay, need for intensive care or mechanical ventilation and mortality was developed. Data including demographic, clinical characteristics, laboratory parameters, therapeutic interventions and clinical outcomes were assessed using descriptive and inferential analysis. A total of 1002 patients were included, the majority were male (n = 646, 64.5%), Omani citizen (n = 770, 76.8%) and with an average age of 54.2 years. At the bivariate level, patients classified as severe were older (Mean = 55.2, SD = 16) than the moderate patients (Mean = 51.5, SD = 15.8). Diabetes mellitus was the only significant comorbidity potential factor that was more prevalent in severe patients than moderate (n = 321, 46.6%; versus n = 178, 42.4%; p < 0.001). Under the laboratory factors; total white cell count (WBC), C-reactive protein (CRP), Lactate dehydrogenase (LDH), D-dimer and corrected calcium were significant. All selected clinical characteristics and therapeutics were significant. At the multivariate level, under demographic factors, only nationality was significant and no significant comorbidity was identified. Three clinical factors were identified, including; sepsis, Acute respiratory disease syndrome (ARDS) and requirement of non-invasive ventilation (NIV). CRP and steroids were also identified under laboratory and therapeutic factors, respectively. Overall, our study identified only five factors from a total of eighteen proposed due to their significant values (p < 0.05) from the bivariate analysis. There are noticeable differences in levels of COVID-19 severity among nationalities. All the selected clinical and therapeutic factors were significant, implying that they should be a key priority when assessing severity in hospitalized COVID-19 patients. An elevated level of CRP may be a valuable early marker in predicting the progression in non-severe patients with COVID-19. Early recognition and intervention of these factors could ease the management of hospitalized COVID-19 patients and reduce case fatalities as well medical expenditure.

Rays of immunity: Role of sunshine vitamin in management of COVID-19 infection and associated comorbidities

The catastrophic pandemic engendered due to the Novel coronavirus (COVID-19) outbreak which causes severe clinical afflictions on the respiratory system has severely high morbidity and mortality rates. The requirement of novel compounds is at utmost importance due to lack of targeted drug molecule to treat the afflictions and restrict the viral infection and for the usage of prophylactic treatment to avoid the spread of the infection is of utmost importance. Vitamin D is one such naturally available multifunctional molecule, which plays an eminent role in the immune system and instigation of numerous cellular pathways further promoting health benefits and enhancing the human quality of life. This article reviews the current standpoint scenario and future prevalence of vitamin D supplementation in the management of covid-19 patients. Novel findings of Vitamin D suggest that along with regulation of cell growth, neuroprotective and mood-stabilizing effects, it regulates the immune response also modulate cytokine Interleukin-6 (IL-6) by inducing progesterone-induced blocking factor (PIBF), given the IL-6 levels are considerably high in COVID-19 patients which increases the further complications. Vitamin D also have its effect on angiotensin converting enzyme (ACEII) inhibitor through which the COVID-19 virus makes cell entry. Numerous research data elucidate the play of Vitamin D, in complications of COVID-19 including the most common comorbid conditions, neurological manifestations and immunological aspects makes it an ideal molecule for adjuvant therapy. Including Vitamin D as add-on therapy in the management of COVID-19 might aid the arrest of infection and helps fight this arduous epidemic.

Vitamin D: Dosing, levels, form, and route of administration: Does one approach fit all?

The 4th International Conference on Controversies in Vitamin D was held as a virtual meeting in September, 2020, gathering together leading international scientific and medical experts in vitamin D. Since vitamin D has a crucial role in skeletal and extra-skeletal systems, the aim of the Conference was to discuss improved management of vitamin D dosing, therapeutic levels and form or route of administration in the general population and in different clinical conditions. A tailored approach, based on the specific mechanisms underlying vitamin D deficiency in different diseases that were discussed, was recommended. Specifically, in comparison to healthy populations, higher levels of vitamin D and greater amounts of vitamin D were deemed necessary in osteoporosis, diabetes mellitus, obesity (particularly after bariatric surgery), and in those treated with glucocorticoids. Emerging and still open issues were related to target vitamin D levels and the role of vitamin D supplementation in COVID-19 since low vitamin D may predispose to SARS-CoV-2 infection and to worse COVID-19 outcomes. Finally, whereas oral daily cholecalciferol appears to be the preferred choice for vitamin D supplementation in the general population, and in most clinical conditions, active vitamin D analogs may be indicated in patients with hypoparathyroidism and severe kidney and liver insufficiency. Parenteral vitamin D administration could be helpful in malabsorption syndromes or in states of vitamin D resistance.Specific guidelines for desired levels of vitamin D should be tailored to the different conditions affecting vitamin D metabolism with the goal to define disease-specific normative values.

Successful Management of Subacute Thyroiditis Following SARS-CoV-2 Infection

Subacute thyroiditis (SAT) is a disorder of the thyroid gland and difficult to diagnose. It is probably triggered by a viral infection. Recently, several articles have reported SAT after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, reports describing SAT after SARS-CoV-2 in Japan are lacking. We herein report the first case of SAT after SARS-CoV-2 infection in Japan. After SARS-CoV-2 infection, some patients can develop not only pneumonia but also SAT. Thus, a careful follow-up is recommended for patients after SARS-CoV-2 infection. Furthermore, the effect of SARS-CoV-2 infection on thyroid dysfunction should not be ignored.