Gonadal steroids in critical illness

Critical illness and sex hormones: response and impact of the hypothalamic-pituitary-gonadal axis

Understanding the hypothalamic-pituitary-gonadal (HPG) axis is essential for grasping human responses under extreme physiological and pathological conditions. The HPG axis regulates reproductive and gonadal hormone activities and significantly impacts the body's response to acute and chronic illnesses. This review explores the fundamental functions of the HPG axis, modifications under critical conditions, and impacts on disease progression and treatment outcomes. In addition, it examines interactions between sex hormones and biomolecules like cytokines and gastrointestinal microorganisms, highlighting their roles in immune response regulation. Clinically, this knowledge can enhance patient prognoses. The review aims to provide a comprehensive framework, based on existing research, for understanding and applying the functions of the HPG axis in managing critical diseases, thereby broadening clinical applications and guiding future research.

Endocrine and metabolic alterations in response to systemic inflammation and sepsis: a review article

Severe sepsis is cognate with life threatening multi-organ dysfunction. There is a disturbance in endocrine functions with alterations in several hormonal pathways. It has frequently been linked with dysfunction in the hypothalamic pituitary-adrenal axis (HPA). Increased cortisol or cortisolemia is evident throughout the acute phase, along with changes in the hypothalamic pituitary thyroid (HPT) axis, growth hormone-IGF-1 axis, insulin-glucose axis, leptin, catecholamines, renin angiotensin aldosterone axis, ghrelin, glucagon, hypothalamic pituitary gonadal (HGA) axis, and fibroblast growth factor-21. These changes and metabolic alterations constitute the overall response to infection in sepsis. Further research is essential to look into the hormonal changes that occur during sepsis, not only to understand their potential relevance in therapy but also because they may serve as prognostic indicators.

Lactobacillus Helveticus Improves Controlled Cortical Impact Injury-Generated Neurological Aberrations by Remodeling of Gut-Brain Axis Mediators

Considerable studies augured the potential of gut microbiota-based interventions in brain injury-associated complications. Based on our earlier study results, we envisaged the sex-specific neuroprotective effect of Lactobacillus helveticus by remodeling of gut-brain axis. In this study, we investigated the effect of L. helveticus on neurological complications in a mouse model of controlled cortical impact (CCI). Adult, male and female, C57BL/6 mice underwent CCI surgery and received L. helveticus treatment for six weeks. Sensorimotor function was evaluated via neurological severity score and rotarod test. Long-term effects on anxiety-like behavior and cognition were assessed using the elevated-zero maze (EZM) and novel object recognition test (NORT). Brain perilesional area, blood, colon, and fecal samples were collected post-CCI for molecular biology analysis. CCI-operated mice displayed significant neurological impairments at 1-, 3-, 5-, and 7-days post-injury (dpi) and exhibited altered behavior in EZM and NORT compared to sham-operated mice. However, these behavioral changes were ameliorated in mice receiving L. helveticus. GFAP, Iba-1, TNF-α, and IL-1β expressions and corticotrophin-releasing hormone (CRH) levels were elevated in the perilesional cortex of CCI-operated male/female mice. These elevated biomarkers and decreased BDNF levels in both male/female mice were modified by L. helveticus treatment. Additionally, L. helveticus treatment restored altered short-chain fatty acids (SCFAs) levels in fecal samples and improved intestinal integrity but did not affect decreased plasma levels of progesterone and testosterone in CCI mice. These results indicate that L. helveticus exerts beneficial effects in the CCI mouse model by mitigating inflammation and remodeling of gut microbiota-brain mediators.

A review of the role of testosterone in the care of the critically ill patient

Background

Testosterone is an anabolic and androgenic steroid hormone therapeutically used to produce male sex characteristics. It has also been shown to have a modulating effect on proinflammatory biomarkers. Critical illness is characterised by a proinflammatory and catabolic state and is accompanied by altered testosterone production, which may persist into the recovery phase. Testosterone may, therefore be a potential therapeutic option in critical illness. This paper reviews normal testosterone physiology, and the changes seen during critical illness and systematically reviews testosterone therapy during both the acute and chronic phases of critical illness.

Contribution of the study

This article explains the pathophysiology of testosterone during critical illness and explores the therapeutic value of testosterone in the management of critically ill patients.

Endocrine Aspects of ICU-Hospitalized COVID-19 Patients

The unprecedented scale of the current SARS-CoV-2/COVID-19 pandemic has led to an extensive—yet fragmented—assessment of its endocrine repercussions; in many reports, the endocrine aspects of COVID-19 are lumped together in intensive care unit (ICU) patients and non-ICU patients. In this brief review, we aimed to present endocrine alterations in ICU-hospitalized patients with COVID-19. There are tangible endocrine disturbances that may provide fertile ground for COVID-19, such as preexisting diabetes. Other endocrine disturbances accompany the disease and more particularly its severe forms. Up to the time of writing, no isolated robust endocrine/hormonal biomarkers for the prognosis of COVID-19 have been presented. Among those which may be easily available are admission glycemia, thyroid hormones, and maybe (OH)₂₅-vitamin D3. Their overlap among patients with severe and less severe forms of COVID-19 may be considerable, so their levels may be indicative only. We have shown that insulin-like growth factor 1 may have prognostic value, but this is not a routine measurement. Possibly, as our current knowledge is expanding, the inclusion of selected routine endocrine/hormonal measurements into artificial intelligence/machine learning models may provide further information.

A Screening Tool to Detect Chronic Critically Ill Cardiac Surgery Patients at Risk for Low Levels of Testosterone and Somatomedin C: A Prospective Observational Pilot Study

Objective The neuroendocrine response to critical illness is dichotomous as it is adaptive during the acute phase then transitions to maladaptive as critical illness becomes prolonged in 25-30% of patients. Presently, monitoring all critically ill patients for endocrinopathies is not the standard of care. However, given the negative impact on patient prognosis, a need to identify those at risk for endocrinopathies, may exist. Thus, a screening tool to identify endocrinopathies along the somatotroph and gonadal axes in a cardiothoracic surgery population was developed. Methods A prospective observational pilot study was conducted in two cardiothoracic surgery intensive care units (ICU) within a multi-site healthcare system. Total testosterone and somatomedin C levels were obtained from 20 adult patients who remained in the ICU for greater than seven days after cardiothoracic surgery and were tolerating nutrition, had a risk of malnutrition and a mobility score of moderate to dependent assistance. Results Twenty patients were included for descriptive analysis (seven females). Thirteen patients tested low for total testosterone, with males more likely to have a testosterone-related endocrinopathy as compared to females (100% vs. 0 to 43%, p = 0.0072). A higher proportion of low somatomedin C levels was found in females than males (57% vs. 31%); however, the difference was not statistically significant (p = 0.251). Conclusions The screening tool used in this pilot study accurately predicted low total testosterone in all men and reasonably predicted low somatomedin C in a majority of women. However, the ability of the tool to predict low total testosterone in women and low somatomedin C in men is less certain. A gender-specific screening tool might be necessary to predict hormonal deficiencies.

Sepsis as a Pan-Endocrine Illness-Endocrine Disorders in Septic Patients

Sepsis is defined as "life-threatening organ dysfunction caused by a dysregulated host response to infection". One of the elements of dysregulated host response is an endocrine system disorder. Changes in its functioning in the course of sepsis affect almost all hormonal axes. In sepsis, a function disturbance of the hypothalamic-pituitary-adrenal axis has been described, in the range of which the most important seems to be hypercortisolemia in the acute phase. Imbalance in the hypothalamic-pituitary-thyroid axis is also described. The most typical manifestation is a triiodothyronine concentration decrease and reverse triiodothyronine concentration increase. In the somatotropic axis, a change in the secretion pattern of growth hormone and peripheral resistance to this hormone has been described. In the hypothalamic-pituitary-gonadal axis, the reduction in testosterone concentration in men and the stress-induced "hypothalamic amenorrhea" in women have been described. Catecholamine and β-adrenergic stimulation disorders have also been reported. Disorders in the endocrine system are part of the "dysregulated host response to infection". They may also affect other components of this dysregulated response, such as metabolism. Hormonal changes occurring in the course of sepsis require further research, not only in order to explore their potential significance in therapy, but also due to their promising prognostic value.

Excess Mortality Among Hospitalized Patients With Hypopituitarism-A Population-Based, Matched-Cohort Study

CONTEXT

Patients with hypopituitarism face excess mortality in the long-term outpatient setting. However, associations of pituitary dysfunction with outcomes in acutely hospitalized patients are lacking.

OBJECTIVE

The objective of this work is to assess clinical outcomes of hospitalized patients with hypopituitarism with or without diabetes insipidus (DI).

DESIGN, SETTING, AND PATIENTS

In this population-based, matched-cohort study from 2012 to 2017, hospitalized adult patients with a history of hypopituitarism were 1:1 propensity score-matched with a general medical inpatient cohort.

MAIN OUTCOME MEASURES

The primary outcome was in-hospital mortality. Secondary outcomes included all-cause readmission rates within 30 days and 1 year, intensive care unit (ICU) admission rates, and length of hospital stay.

RESULTS

After matching, 6764 cases were included in the study. In total, 3382 patients had hypopituitarism and of those 807 (24%) suffered from DI. All-cause in-hospital mortality occurred in 198 (5.9%) of patients with hypopituitarism and in 164 (4.9%) of matched controls (odds ratio [OR] 1.32, [95% CI, 1.06-1.65], P = .013). Increased mortality was primarily observed in patients with DI (OR 3.69 [95% CI, 2.44-5.58], P < .001). Patients with hypopituitarism had higher ICU admissions (OR 1.50 [95% CI, 1.30-1.74], P < .001), and faced a 2.4-day prolonged length of hospitalization (95% CI, 1.94-2.95, P < .001) compared to matched controls. Risk of 30-day (OR 1.31 [95% CI, 1.13-1.51], P < .001) and 1-year readmission (OR 1.29 [95% CI, 1.17-1.42], P < .001) was higher among patients with hypopituitarism as compared with medical controls.

CONCLUSIONS

Patients with hypopituitarism are highly vulnerable once hospitalized for acute medical conditions with increased risk of mortality and adverse clinical outcomes. This was most pronounced among those with DI.

Chronic critical illness: are we saving patients or creating victims?

The technological advancements that allow support for organ dysfunction have led to an increase in survival rates for the most critically ill patients. Some of these patients survive the initial acute critical condition but continue to suffer from organ dysfunction and remain in an inflammatory state for long periods of time. This group of critically ill patients has been described since the 1980s and has had different diagnostic criteria over the years. These patients are known to have lengthy hospital stays, undergo significant alterations in muscle and bone metabolism, show immunodeficiency, consume substantial health resources, have reduced functional and cognitive capacity after discharge, create a sizable workload for caregivers, and present high long-term mortality rates. The aim of this review is to report on the most current evidence in terms of the definition, pathophysiology, clinical manifestations, treatment, and prognosis of persistent critical illness.

Endocrine and Metabolic Alterations in Sepsis and Implications for Treatment

Sepsis induces profound neuroendocrine and metabolic alterations. During the acute phase, the neuroendocrine changes are directed toward restoration of homeostasis, and also limit unnecessary energy consumption in the setting of restricted nutrient availability. Such changes are probably adaptive. In patients not recovering quickly, a prolonged critically ill phase may ensue, with different neuroendocrine changes, which may represent a maladaptive response. Whether stress hyperglycemia should be aggressively treated or tolerated remains a matter of debate. Until new evidence from randomized controlled trials becomes available, preventing severe hyperglycemia is recommended. Evidence supports withholding parenteral nutrition in the acute phase of sepsis.

Adjunctive Steroid Therapy for Treatment of Pediatric Septic Shock

Septic shock remains the major cause of childhood morbidity and mortality worldwide. Although early sepsis recognition, fluid resuscitation, timely administration of antimicrobials, and vasoactive-inotropic drug infusions are all key to achieving good sepsis outcomes, therapy using various steroid drug classes remains an attractive adjunctive intervention to minimize the duration of septic shock and transition to multiple organ dysfunction syndrome. All steroid drug classes possess biological plausibility to affect a beneficial clinical effect among children with septic shock, but none has undergone rigorous, prospective assessment in a large, high-quality pediatric interventional trial.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of sex steroids on neuroinflammatory processes and experimental multiple sclerosis

Synthetic and natural estrogens as well as progestins modulate neuronal development and activity. Neurons and glia are endowed with high-affinity steroid receptors. Besides regulating brain physiology, both steroids conciliate neuroprotection against toxicity and neurodegeneration. The majority of data derive from in vitro studies, although more recently, animal models have proven the efficaciousness of steroids as neuroprotective factors. Indications for a safeguarding role also emerge from first clinical trials. Gender-specific prevalence of degenerative disorders might be associated with the loss of hormonal activity or steroid malfunctions. Our studies and evidence from the literature support the view that steroids attenuate neuroinflammation by reducing the pro-inflammatory property of astrocytes. This effect appears variable depending on the brain region and toxic condition. Both hormones can individually mediate protection, but they are more effective in cooperation. A second research line, using an animal model for multiple sclerosis, provides evidence that steroids achieve remyelination after demyelination. The underlying cellular mechanisms involve interactions with astroglia, insulin-like growth factor-1 responses, and the recruitment of oligodendrocytes.

Influence of gender on the outcome of severe sepsis: a reappraisal

BACKGROUND

The influence of gender on survival of patients with severe sepsis is unclear. Earlier studies suggested better survival in women, possibly related to the sex-steroid profile.

METHODS

To investigate whether mortality from severe sepsis was higher in men than in women and whether the difference varied with menopausal status, we studied 1,692 patients with severe sepsis included in the OutcomeRea database over an 8-year period. We conducted a nested case-control study, accurately matching men and women on three criteria: a death propensity score, age, and center. Subgroup analyses were performed on individuals <or= 50 years old (men vs premenopausal women) and > 50 years old (men vs postmenopausal women).

RESULTS

We matched 1,000 men to 608 women with severe sepsis before and after adjustment for confounding factors (ie, chronic respiratory failure; metastatic cancer; immunocompromised status; emergency surgery, acute respiratory failure, and shock at admission; urinary tract infection; and type of microorganism). Overall hospital mortality was significantly lower in women (adjusted odds ratio [OR], 0.75; 95% confidence interval [CI], 0.57 to 0.97; p = 0.02). In the group > 50 years old (481 women, 778 men), hospital mortality was significantly lower in women (OR, 0.69; 95% CI, 0.52 to 0.93; p = 0.014). Hospital mortality was not significantly different between men and women in the younger group (127 women, 222 men) [OR, 1.01; 95% CI, 0.52 to 1.97; p = 0.98]. Level of care, as assessed using the nine equivalents of nursing manpower use score, was identical in men and women.

CONCLUSIONS

Among individuals > 50 years old with severe sepsis, women have a lower risk of hospital mortality than men.

Nutrition support and the chronic critical illness syndrome

Critical illness can be viewed as consisting of 4 distinct stages: (1) acute critical illness (ACI), (2) prolonged acute critical illness, (3) chronic critical illness, and (4) recovery. ACI represents the evolutionarily programmed response to a stressor. In ACI, substrate is shunted away from anabolism and toward vital organ support and inflammatory proteins. Nutrition support in this stage is unproven and may ultimately prove detrimental. As critical illness progresses, there is no evolutionary precedent, and man owes his life to modern critical care medicine. It is at this point that nutrition and metabolic support become integral to the care of the patient. This paper (1) delineates and develops the 4 stages of critical illness using current evidence, clinical experience, and new hypotheses; (2) defines the chronic critical illness syndrome (CCIS); and (3) details an approach to the metabolic and nutrition support of the chronically critically ill patient using the metabolic model of critical illness as a guide. It is our hope that this clinical model can generate testable hypotheses that can improve the outcome of this unique population of patients.

Influence of Gender on Outcome of Severe Sepsis

Whether gender influences the outcome of severe sepsis remains a matter of debate. Because many confounding variables may affect observed associations between gender and mortality, high-quality statistical analyses are essential to carefully adjust the two groups of patients. About 55% to 65% of patients with sepsis have chronic co-morbidities associated with immune dysfunction (e.g., chronic renal failure, diabetes mellitus, human immunodeficiency virus [HIV] infection, and alcohol abuse), which increase the susceptibility to sepsis [1]. Genetic polymorphisms that affect the susceptibility to infection and/or the severity of the systemic response to infection [2] may lead to variability among individuals and between males and females [3]. Access to healthcare, another determinant of the incidence and outcome of sepsis, varies according to age, ethnic group, and gender, although a recent study conducted in the USA found only relatively small quality-of-care differences between males and females or across income groups compared to the gap for each subgroup between observed and desirable quality of health care [4]. Here, we review the data on the existence of, and reasons for, associations between gender and outcome of severe sepsis (Fig. 1).