Hidden in plain sight: sex and gender in global pandemics

Combined plasma levels of IL-10 and testosterone, but not soluble HLA-G5, predict the risk of death in COVID-19 patients

BACKGROUND

The identification of biomarkers correlated with coronavirus disease 2019 (COVID-19) outcomes is a relevant need for clinical management. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is characterized by elevated interleukin (IL)-6, IL-10, HLA-G, and impaired testosterone production.

OBJECTIVES

We aimed at defining the combined impact of sex hormones, interleukin-10, and HLA-G on COVID-19 pathophysiology and their relationship in male patients.

MATERIALS AND METHODS

We measured by chemiluminescence immunoassay, electrochemiluminescent assays, and enzyme-linked immunosorbent assay circulating total testosterone, 17β-estradiol (E₂ ), IL-10, and -HLAG5 as well as SARS-CoV-2 S1/S2 Immunoglobulin G from 292 healthy controls and 111 COVID-19 patients with different disease severity at hospital admission, and in 53 COVID-19 patients at 7-month follow-up.

RESULTS AND DISCUSSION

We found significantly higher levels of IL-10, HLA-G, and E₂ in COVID-19 patients compared to healthy controls and an inverse correlation between IL-10 and testosterone, with IL-10, progressively increasing and testosterone progressively decreasing with disease severity. This correlation was lost at the 7-month follow-up. The risk of death in COVID-19 patients with low testosterone increased in the presence of high IL-10. A negative correlation between SARS-CoV-2 Immunoglobulin G and HLA-G or IL-10 at hospitalization was observed. At the 7-month follow-up, IL-10 and testosterone normalized, and  HLA-G decreased.

CONCLUSION

Our findings indicate that combined evaluation of IL-10 and testosterone predicts the risk of death in men with COVID-19 and support the hypothesis that IL-10 fails to suppress excessive inflammation by promoting viral spreading.

Sex-specific analysis of clinical features and outcomes in staphylococcal periprosthetic joint infections managed with two-stage exchange arthroplasty

Background: Differences in susceptibility and response to infection between males and females are well established. Despite this, sex-specific analyses are under-reported in the medical literature, and there is a paucity of literature looking at differences between male and female patients with periprosthetic joint infection (PJI). Whether there are sex-specific differences in presentation, treatment tolerability, and outcomes in PJI has not been widely evaluated. Methods: We undertook a retrospective case-matched analysis of patients with staphylococcal PJI managed with two-stage exchange arthroplasty. To control for differences other than sex which may influence outcome or presentation, males and females were matched for age group, causative organism category (coagulase-negative staphylococci vs. Staphylococcus aureus), and joint involved (hip vs. knee). Results: We identified 156 patients in 78 pairs of males and females who were successfully matched. There were no significant baseline differences by sex, except for greater use of chronic immunosuppression among females (16.4 % vs. 4.1 %; p = 0.012 ). We did not detect any statistically significant differences in outcomes between the two groups. Among the 156 matched patients, 16 recurrent infections occurred during a median follow-up time of 2.9 (IQR 1.5-5.3) years. The 3-year cumulative incidence of relapse was 16.1 % for females, compared with 8.8 % for males ( p = 0.434 ). Conclusions: Success rates for PJI treated with two-stage exchange arthroplasty are high, consistent with previously reported literature. This retrospective case-matched study did not detect a significant difference in outcome between males and females with staphylococcal PJI who underwent two-stage exchange arthroplasty.

An Analysis of the Use of the Terms Sex and Gender in Research Reported in Nursing Journals

Accurately measuring and reporting the demographic characteristics of research participants are imperative to provide consumers of research with an understanding of who was included in a study. While researchers often, incorrectly, use the variables sex and gender interchangeably, these 2 variables are different. We conducted a content analysis of 239 randomly selected research articles, with the purpose of describing how researchers have used sex and gender in studies published in nursing journals and identifying opportunities for improved clarity and precision in measuring these 2 variables. We found that significant improvement is needed in the way these variables are used/reported.

Contribution of Sex Differences to HIV Immunology, Pathogenesis, and Cure Approaches

Approximately 38 million people were living with human immunodeficiency virus (HIV) in 2020 and 53% of those infected were female. A variety of virological and immunological sex-associated differences (sexual dimorphism) in HIV infection have been recognized in males versus females. Social, behavioral, and societal influences play an important role in how the HIV pandemic has affected men and women differently. However, biological factors including anatomical, physiologic, hormonal, and genetic differences in sex chromosomes can each contribute to the distinct characteristics of HIV infection observed in males versus females. One striking example of this is the tendency for women to have lower HIV plasma viral loads than their male counterparts early in infection, though both progress to AIDS at similar rates. Sex differences in acquisition of HIV, innate and adaptive anti-HIV immune responses, efficacy/suitability of specific antiretroviral drugs, and viral pathogenesis have all been identified. Sex differences also have the potential to affect viral persistence, latency, and cure approaches. In this brief review, we summarize the major biological male/female sex differences in HIV infection and their importance to viral acquisition, pathogenesis, treatment, and cure efforts.

Disparities by Sex in COVID-19 Risk and Related Harms Among People with Opioid Use Disorder

Objectives: (1) Report sex-specific prevalence of coronavirus disease 2019 (COVID-19) test positivity among an opioid use disorder (OUD) cohort (2) Assess sex-specific rates of opioid overdose and mortality. Methods: A retrospective cohort study was performed on all adult patients with OUD who received a COVID-19 test in calendar year 2020 at a large academic medical center in Richmond, Virginia. Our study outcomes were positive COVID-19 test, opioid overdose, and all-cause in-hospital mortality. Sex-stratified multivariable logistic regression assessed sociodemographic factors associated with COVID-19 test positivity. Results: A total of 2,600 patients (males = 1,294, females = 1,306) with OUD received a COVID-19 test. Approximately 5% across both sexes tested positive for COVID-19 (p = 0.420), whereas 7% presented with an opioid overdose (males 10%; females 4%; p < 0.0001). However, mortality rates were similar across sex. Among males, individuals in the other racial group had increased odds of COVID-19 test positivity (adjusted odds ratio or AOR: 5.03, 95% confidence interval [CI]: 1.70-14.88), whereas black females had higher odds of COVID-19 test positivity (AOR: 1.92, 95% CI: 1.01-3.62) compared to their white counterparts. Conclusions: Opioid overdose, more often than COVID-19, impacted the health of patients with OUD presenting to a public safety net health system. Despite a female advantage documented in the general population for COVID-19 susceptibility, COVID-19 test positivity rates were similar across sex in an OUD cohort; yet, racial disparities emerged with notable sex-related variation. Sex and gender are important variables that modify health outcomes, including OUD and COVID-19, and should be further investigated using an intersectionality framework.

COVID-19 and varicocele: the possible overlap factors and the common therapeutic approaches

Varicocele is recognized as one of the main attributable causes of male infertility which can affect spermatogenesis by various pathophysiological mechanisms. Recent studies have identified oxidative stress and reduction in antioxidant, hyperthermia, hypoxia, hormonal dysfunction, and inflammatory conditions as major factors in the pathophysiology of varicocele, all of which have known direct associations with the coronavirus disease 2019 (COVID-19) and can significantly increase the risk of detrimental COVID-19-related outcomes. Emerging data have shown an association between COVID-19 and inflammation, overproduction of cytokine, and other pathophysiological processes. The present review, summarizes the current understanding of the pathophysiology of varicocele and investigates the potential correlation between the severity of COVID-19 and the varicocele disease. In addition, various possible treatments which can be effective in both diseases were examined. Despite numerous challenges associated with the prevalence of COVID-19 in healthcare systems in infected countries, special attention should be given to maintaining a high level of care for complex patients with a pre-existing disease such as varicocele and providing appropriate practical advice for optimal control of the COVID-19 disease. This article is protected by copyright. All rights reserved.

Testosterone in males with COVID-19: A 7-month cohort study

Background

Circulating testosterone levels have been found to be reduced in men with severe acute respiratory syndrome coronavirus 2 infection, COVID‐19, with lower levels being associated with more severe clinical outcomes.

Objectives

We aimed to assess total testosterone levels and the prevalence of total testosterone still suggesting for hypogonadism at 7‐month follow‐up in a cohort of 121 men who recovered from laboratory‐confirmed COVID‐19.

Materials and methods

Demographic, clinical, and hormonal values were collected for all patients. Hypogonadism was defined as total testosterone ≤9.2 nmol/L. The Charlson Comorbidity Index was used to score health‐significant comorbidities. Descriptive statistics and multivariable linear and logistic regression models tested the association between clinical and laboratory variables and total testosterone levels at follow‐up assessment.

Results

Circulating total testosterone levels increased at 7‐month follow‐up compared to hospital admittance (p < 0.0001), while luteinizing hormone and 17β‐estradiol levels significantly decreased (all p ≤ 0.02). Overall, total testosterone levels increased in 106 (87.6%) patients, but further decreased in 12 (9.9%) patients at follow‐up, where a total testosterone level suggestive for hypogonadism was still observed in 66 (55%) patients. Baseline Charlson Comorbidity Index score (OR 0.36; p = 0.03 [0.14, 0.89]) was independently associated with total testosterone levels at 7‐month follow‐up, after adjusting for age, BMI, and IL‐6 at hospital admittance.

Conclusions

Although total testosterone levels increased over time after COVID‐19, more than 50% of men who recovered from the disease still had circulating testosterone levels suggestive for a condition of hypogonadism at 7‐month follow‐up. In as many as 10% of cases, testosterone levels even further decreased. Of clinical relevance, the higher the burden of comorbid conditions at presentation, the lower the probability of testosterone levels recovery over time.

Severely low testosterone in males with COVID-19: A case-control study

Background

Circulating androgens could have a relevant pathobiological role in clinical outcomes in men with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection (COVID‐19).

Objectives

We aimed to assess: (a) circulating sex steroids levels in a cohort of 286 symptomatic men with laboratory‐confirmed COVID‐19 at hospital admission compared to a cohort of 281 healthy men; and (b) the association between serum testosterone levels (tT), COVID‐19, and clinical outcomes.

Materials and Methods

Demographic, clinical, and hormonal values were collected for all patients. Hypogonadism was defined as tT ≤9.2 nmol/l. The Charlson Comorbidity Index (CCI) was used to score health‐significant comorbidities. Severe clinical outcomes were defined as patients either transferred to intensive care unit (ICU) or death. Descriptive statistics and multivariable linear and logistic regression models tested the association between clinical and laboratory variables and tT levels. Univariable and multivariable logistic regression models tested the association between tT and severe clinical outcomes.

Results

Overall, a significantly lower levels of LH and tT were found in patients with COVID‐19 compared to healthy controls (all p < 0.0001); conversely, healthy controls depicted lower values of circulating E₂ (p < 0.001). Testosterone levels suggestive for hypogonadism were observed in 257 (89.8%) patients at hospital admission. In as many as 243 (85%) cases, hypogonadism was secondary. SARS‐CoV‐2 infection status was independently associated with lower tT levels (p < 0.0001) and greater risk of hypogonadism (p < 0.0001), after accounting for age, BMI, CCI, and IL‐6 values. Lower tT levels were associated with higher risk of ICU admission and death outcomes (all p ≤ 0.05), after accounting for clinical and laboratory parameters.

Conclusions

We unveil an independent association between SARS‐CoV‐2 infection status and secondary hypogonadism already at hospital admission, with lower testosterone levels predicting the most severe clinical outcomes.