Managing the menopause during the pandemic

The structure of the presentation will be 1) Pandemic-Epidemiology 2) General Pandemic-Management 3) HRT and COVID 4) Different spectrum of menopausal symptoms (Europe/Asia) 5) Different risks lead to different HRT. 1) Pandemic-Epidemiology: SARS-COVID-19 has got to be a new disease, China was the first to suffer from the pandemic starting in December 2019 with spread all over the world. Diagnosis, treatment and protective measures have started in Europe in March 2020;up from autumn 2022 in Europe the pandemic changed to endemic, but protective measures still should be continued in risk patients like in hospitals and nursing homes. Rehabilitation will for long-time be an issue like treatment of "Post-" and "Long-COVID". China pursued a zero-COVID-policy until Dec 2022. The sudden stop of almost all measures led to a sharp increase in infections, which shows that the disease will remain a global risk. 2) General Pandemic-Management: Protective measures like vaccination, surgical masks, screening/testing, isolation management, travel/residence history in high-risk regions, education of patients and families had to be the first priority, ahead of other issues such as the management of menopause. 3) HRT and COVID: Already the first prelimary data assessed in Wuhan/China have shown that women with low estradiol-levels had more severe infections with COVID. An analysis of health records of 68,466 COVID-positive patients from 17 countries showed that the fatality risk for women > 50 years receiving HRT was reduced by more than 50% compared to those women not taking HRT (Seeland, 2020). Likewise from a case-control study analyzing the self-reported data of 1.6 million UK menopausal women through the COVID-Symptoms Study Smartphone application (control populations adjusted for age, body mass index, and smoking status) was concluded, that HRT not only can be used, but even can protect from COVID-infections and/or their sequelae (Costeira, 2021). 4) The different spectrum of menopausal symptoms (independent of COVID-infections) comparing data in Europe (showing more vasomotor symptoms) and China (more somatic symptoms) will be presented, including own data. 5) Different risks during HRT consequently lead to different use of HRT, especially more transdermal estrogen combined with progesterone in Europe due to much higher VTE-risk, but more management of the high bleeding-problems in China using individualized (mostly oral) estrogen/progestogen combinations. Copyright © 2023

Upfront Oncotype DX in early breast cancer management

Introduction: Oncotype DX, a 21 gene assay has prognostic and chemotherapy predictive value. During COVID pandemic, guidance issued extended use of genomic testing to avoid chemotherapy to node positive patients. We aimed to identify impact of Oncotype DX testing in pre-operative setting of early breast cancer. Method(s): We retrospectively reviewed those patients where MDT recommended upfront Oncotype DX testing from 1st March 2020 till Sept 2022. Result(s): 59 patients were identified. The mean age was 55.7 +/- 11.4 years. Two-thirds were postmenopausal. Four-fifth had symptomatic presentation. the mean tumour size was 28.8 +/- 8.7 mm. Invasive ductal carcinoma was seen in 81% (N=48). Progesterone receptor positivity was seen in 93% (n=55). Node positivity was seen in 44% (n=26) while nodes were negative in 56% (n=33). Overall, low, intermediate and high score was seen in 47% (n=28), 8% (n=5) and 45% (n=26) respectively. In node negative patients, low, intermediate, and high score was seen in 45% (n=15), 10% (n=3) and 45% (n=15) respectively. Chemotherapy was avoided in 55% patients. In node positive patients, low, intermediate, and high score was seen in 50% (n=15), 8% (n=2) and 42% (n=11) respectively. Overall, chemotherapy was avoided in 23% patients with node positive disease. Conclusion(s): Upfront Oncotype DX testing can be used in node negative breast cancer patients. However, it should be used very cautiously in node positive women.Copyright © 2023

Hysterectomies for endometrial hyperplasia decreased during the first year of the COVID-19 pandemic: where have all the patients gone?

Objectives: To determine change in number of hysterectomies (hyst) and levonorgestrel intrauterine device (IUD) placements as treatment for endometrial hyperplasia (EH), and in the number of diagnostic procedures for abnormal uterine bleeding (AUB) and postmenopausal bleeding (PMB) performed during the first year of the COVID-19 pandemic compared to pre-pandemic levels. Method(s): Hospitals submitting data to the Vizient database for the period 2/1/19 through 2/1/21 provided the study population. We queried Vizient to identify patients undergoing (1) hyst, (2) IUD placement for EH, and (3) endometrial biopsy (EMB) or dilation and curettage (D&C) for AUB or PMB by month (mo.). We defined the pre-pandemic period as 2/1/19 through 1/31/20;2/1/20 began the pandemic period. Mean number/mo of EH hyst, EH IUD placement, and EMB or D&C for AUB or PMB for the pre-pandemic period established a baseline for comparison to mos during the first pandemic year. Result(s): 314 hospitals reported data on 2,374 EH hysts, 2,006 EH IUD placements, and 99,782 diagnostic procedures for AUB and PMB. The mean number of EH hysts was 118/mo pre-pandemic and 79.9/mo during the pandemic;the mean difference was 38.2/mo (95%CI 23.2- 53.1, p=0.00015). Mean EH IUD placements pre-pandemic were 87.6/ mo, and 79.6/mo during the pandemic;mean difference was 8/mo (95%CI -11-27, p=0.37). The mean number of combined EMBs and D&Cs pre-pandemic was 4,547/mo and 3,768/mo during the pandemic;mean difference was 778/mo (95%CI 80-1477, p=0.032).[Formula presented] Conclusion(s): During the first year of the COVID-19 pandemic, the number of EH hysts performed per mo decreased. We found no increase in EH IUD placement. Although Vizient does not report the number of patients prescribed oral progesterone as an alternative treatment, we found that the total number of patients undergoing diagnostic procedures for AUB and PMB decreased significantly during the pandemic period, suggesting that the deficit in hysts performed for EH is due, in part, to fewer patients presenting for workup of abnormal bleeding. Together with our earlier report that 20% fewer hysts for EC were done during the first pandemic year, our findings suggest a meaningful delay in care. More research is needed to determine if this delay will impact stage, treatment and outcome. Data for the 2nd pandemic year will be analyzed in time for the meeting.Copyright © 2022 Elsevier Inc.

CLINICAL AND GENETIC DETERMINANTS OF SEVERE COURSE OF COVID-19 IN PREGNANT WOMEN.

Objectives: to determine the clinical and genetic determinants of the severe course of COVID-19 in pregnant women in order to identify a risk group and search for therapeutic targets. Materials and methods. 21 patients (group 1) with a severe course of COVID-19 who required intensive care in the Anesthesiology and Intensive Care Unit (AICU) and 126 pregnant women with moderate severity treated in the Infectious-Obstetrics Unit (IOCU) were examined (group 2). Genomic DNA for molecular genetic analysis of gene variants ACE (I/D, rs 4340), PGR (Alu insertion), ESR1 (A351G, rs 9340799), PON1 (C108T, rs 705379) was isolated from the peripheral blood of patients using a commercial Quick-DNA Miniprep Plus Kit (Zymo Research, USA). Variants of ACE and PGR genes were determined using allele-specific polymerase chain reaction;polymerase chain reaction followed by restriction analysis was used to determine ESR1 and PON1 gene variants. Results. Severe course of COVID-19 is observed in 18.2% of pregnant women, critical condition in 7.5%. A third of AICU patients are over 35 years old. Somatic anamnesis was complicated in 23.8% of patients;thyroid gland pathology (14.3%) and varicose disease (19.0%) prevailed. A significant factor in the severe course of COVID-19 is obesity of the III-IV degree in 28.5% cases. The severe course of the disease was associated with complications of pregnancy (oligohydramnios - 52.4%, ahydramnios - 14.3%, fetal growth retardation syndrome - 33.3%, circulatory disorders - 57.1%, fetal distress - 47.6%, preeclampsia - 14.3%), labor (caesarean section - 57.1%, premature birth - 28.6%), disorders of newborns state (asphyxia - 35.6%). These patients are characterized by anemia (58.7%), thrombocytopenia (23.8%), leukocytosis (33.3%), lymphopenia (90.5%), a shift of the leukocyte formula to the left (an increase of rod-nuclear leukocytes by 85.7%). There were significantly increased levels of transaminases: alanine aminotransferase in 47.6%, aspartate aminotransferase in 76.2%. Prothrombotic changes are indicated by a decrease in prothrombin time and activated partial thromboplastin time in 66.7%, which is confirmed by an increase in D-dimer in 85.7% of patients up to the maximum 15,000 ng/ml in 9.5% of women. An increase in inflammation markers (C-reactive protein and interleukin-6 in all AICU patients, procalcitonin in 66.7%) is a reflection of the destructive effect of inflammatory processes. The genetic determinants of the severe course of COVID-19 in pregnant women can be the ID genotype of the ACE I/D rs4340 polymorphism (81.0%), the T2/T2 PROGINS genotype (19.0%), the ESR1 A351G rs9340799 GG genotype (28.5%). Conclusions. The use of separate clinical, laboratory and genetic indicators in pregnant women with COVID-19 will contribute to the selection of the risk group of a coronavirus severe course and the determination of targets of therapeutic impact.Copyright © 2022 Trylyst. All rights reserved.

Attitudes of healthcare workers towards COVID-19 and affecting factors

The COVID-19 outbreak, which was first reported in December 2019, has affected the whole world. The first case in Turkey was confirmed on March11, 2020. Healthcare workers fight at the frontline against this virus with intense infectivity and are the occupational group under the highest risk. 7.428 health workers were infected in Turkey in late April 2020. Anxiety levels of healthcare workers have increased due to this high risk exposure. The aim of this study is to examine the attitudes of healthcare workers towards COVID-19 and the affecting factors. The study is cross-sectional. The study population consists of the healthcare workers working in the province of Samsun (N = 11926). The sample size of the study was determined as 370 people within the 5% margin of error and 95% confidence interval. The study data were collected between April 1, 2020 and April 30, 2020. Questionnaires were used as a data collection tool in the study. The questionnaire consists of two parts. The first part includes descriptive questions to determine individual characteristics. The second part is the covid attitude survey created by reviewing the literature. Descriptive statistics, Student's t test and One-Way Anova were used to evaluate the data. The age distribution of the participants is 34.81 +/- 8.54. In the study, it was determined that gender, marital status, title, working year, having children or not, chronic disease status, and health and life satisfaction were the factors affecting the attitude towards Covid-19 (p <0.05). It was ascertained that the COVID-19 attitudes of women, those who were still married, midwives, those who had been working for 11-20 years, those with children, those with chronic diseases, and those with a poor health perception and life quality were more negative compared to others. COVID-19 causes especially healthcare workers to become concerned both for themselves and their relatives since it is an unrecognized infection and easily transmitted. It might be important to follow different strategies particularly for healthcare workers who are married, have children and have health problems.Copyright © 2020 Necati Ozpinar. All rights reserved.

Is The Co-administration of Metformin and Clomiphene Superior to Induce Ovulation in Infertile Patients with Poly Cystic Ovary Syndrome and Confirmed Insulin-resistance: A Double Blind Randomized Clinical Trial

Objective: This study aimed to compare the effects of clomiphene citrate (CC) combined with metformin or placebo on infertile patients with poly cystic ovary syndrome (PCOS) and insulin resistance (IR). Material(s) and Method(s): We included 151 infertile women with PCOS and IR in a university hospital from November 2015 to April 2022 in this prospective, double-blind, randomized, placebo-controlled trial. Patients were randomized into two groups;group A: received CC plus metformin (n = 76) and group B: received CC plus placebo (n = 75). The ovulation rate was the main outcome measure. Clinical pregnancy, ongoing pregnancy, live birth and abortion rates were secondary outcome measures. Result(s): There was no remarkable difference in ovulation rate in two groups. Moreover, no significant changes were observed in clinical pregnancy, ongoing pregnancy, live birth and abortion rates between two groups. A larger proportion of women in group A suffered from side effects of metformin (9.3% versus 1.4%;p=0.064), although this was not significant. Conclusion(s): In IR infertile women with PCOS, metformin pre-treatment did not increase the ovulation, clinical pregnancy and live birth rates in patients on clomiphene citrate.Copyright © 2023 Tehran University of Medical Sciences.

Simultaneous Primary Sinonasal Adenocarcinoma and Breast Adenocarcinoma: A Case Report

Sinonasal cancer accounts for roughly only 3% of upper respiratory tract malignancies and generally presents as a primary malignancy. Although extremely rare, the sinonasal cavity is also a known location for metastasis, with 8% of these cases originating from primary breast cancer. When attempting to differentiate primary disease from metastasis, immunohistochemical analyses play a crucial role in reaching the correct diagnosis. To date, there are a handful of reports describing metastasis involving the paranasal sinuses but even fewer reporting primary sinonasal cancer with coexisting primary malignancy. Here we present a case of primary sinonasal adenocarcinoma in the setting of a long-standing history of breast cancer. The patient, a 73-year-old female, was diagnosed with T1cN1aM0, progesterone receptor positive and estrogen receptor negative ductal carcinoma in situ of the left breast in November 2019. She subsequently underwent bilateral mastectomy and treated with 3 cycles of chemotherapy and anastrozole, which were both discontinued due to intolerance. Of note, in March 2019, MRI of the head incidentally found a 3 x 2 cm mass in right nasal cavity extending into ethmoid sinus. One year later, she presented with mild right sided nasal obstruction and drainage, and biopsy revealed squamous and respiratory mucosa with chronic inflammation. The patient elected to cancel initial surgical resection of the mass due to the COVID-19 pandemic. The patient returned in March 2022 with complaints of eye pressure, double vision, headaches, and worsening nasal obstruction. PET/CT scan was negative for distant metastasis but demonstrated increased uptake in sinus cavity. MRI showed a larger 5 x 3.7 cm mass impressing on medial inferior margins of orbit. Imaging also suggested evidence of dehiscence of lamina and irregular neo-osteogenesis of the skull base. She underwent approach and resection of the mass with histology demonstrating a well differentiated, low grade non-intestinal mucinous adenocarcinoma. Immunohistochemistry was positive for pankeratin and CK7, favoring a primary sinonasal origin. It was estrogen receptor negative and negative for GATA3, a sensitive and fairly specific stain in mammary carcinoma. Adjuvant radiation was recommended postoperatively, however the patient declined this therapy. This case highlights the role of immunohistochemistry to discriminate a new primary cancer from metastasis in patients with a history of breast cancer. Clinically, patients with sinonasal metastasis can present with symptoms ranging from unilateral nasal obstruction, facial pain, diplopia, and decreased vision. On imaging, suspicion of malignancy is raised when there is evidence of destruction of bony boundaries and invasion of surrounding tissues such as the orbit and anterior skull base, as found in our patient. Notably, metastasis to the paranasal sinuses can mimic a primary cancer of the nasal cavity, with both tumors showing epithelial differentiation. However, primary tumors often show neoplastic changes in the overlying respiratory epithelium and do not express estrogen receptor, progesterone receptor, or HER2 positivity, which are known to be correlated with breast cancer. In this setting, GATA3 and estrogen receptor negativity allowed us to diagnose primary nasal cancer more confidently. Therefore, clinicians should be aware of metastatic disease and expand immunohistochemistry panels when appropriate.

The relationship between sex steroids (E2, progesterone, and AMH) levels and severity and fatality of COVID-19: A systematic review.

Sex steroids are powerful modulators of the immune system and they may affect the immune response and inflammatory consequences of COVID-19. This systematic review aims to explore the impact of sex steroids on COVID-19 mortality and complications. We looked up the keywords of the study in Scopus, PubMed, and Web of Science. All related original articles published in English, as of October 16, 2021, were reviewed to be included in our research. Concerns regarding the effect of sex hormones on COVID-19, eight full texts have been identified for the conclusion. In these studies, the relationship between estradiol and COVID-19 mortality has been mentioned. The most significant findings were the higher COVID-19 mortality rate in men, compared to women; also, in menopausal women compared to younger women and who received estradiol. In two studies, oral contraceptive pills had a protective effect on the morbidity of SARS-CoV-2 infection. In a randomized controlled trial, subcutaneous injection of progesterone in hospitalized men significantly reduced their symptoms and need for oxygen therapy. Hormone replacement therapy was positively associated with reducing COVID-19 symptoms. Although the results were insufficient for a conclusion, this study represents estrogen as an appropriate pharmacological method for preventing and diminishing the inflammation related to COVID-19 disease. However, future prospective studies and clinical trials are needed to clarify and approve this protective effect.

Carbon Dots Conjugated Antibody as an Effective FRET-Based Biosensor for Progesterone Hormone Screening.

In this work, carbon dots (CDs) were synthesized by a one-step hydrothermal method using citric acid and ethylene diamine, and covalently functionalized with antibodies for the sensing of progesterone hormone. The structural and morphological analysis reveals that the synthesized CDs are of average size (diameter 8-10 nm) and the surface functionalities are confirmed by XPS, XRD and FT-IR. Further graphene oxide (GO) is used as a quencher due to the fluorescence resonance energy transfer (FRET) mechanism, whereas the presence of the analyte progesterone turns on the fluorescence because of displacement of GO from the surface of CDs effectively inhibiting FRET efficiency due to the increased distance between donor and acceptor moieties. The linear curve is obtained with different progesterone concentrations with 13.8 nM detection limits (R2 = 0.974). The proposed optical method demonstrated high selectivity performance in the presence of structurally resembling interfering compounds. The PL intensity increased linearly with the increased progesterone concentration range (10-900 nM) under the optimal experimental parameters. The developed level-free immunosensor has emerged as a potential platform for simplified progesterone analysis due to the high selectivity performance and good recovery in different samples of spiked water.

Effect of COVID-19 infection on sex hormone levels in hospitalized patients: A prospective longitudinal study in Iran.

Introduction: This study aimed to evaluate the levels of sex hormones in patients with COVID-19 in Ahvaz, Iran. Methods: A prospective longitudinal study was conducted at Razi hospital, Ahvaz, Iran, from July 2020 to Febuary 2021. The levels of sex hormones including estradiol, progesterone, luteinizing hormone (LH), follicle stimulating hormone (FSH), and total and free testosterone were measured in 162 patients with COVID-19 infection during hospitalization and 1 month after discharge. A demographic questionnaire and a checklist were used to collect the data. Mann-Whitney U test, χ 2 test, Fisher's exact test, Wilcoxon test, and logistic regression were used to analyze the data. Results: Sex hormones were assessed in 162 patients at baseline; however, a month after discharge, only 69 patients provided consent for assessment, and 9 had passed away. The estradiol level was 407.70 ± 623.37 and 213.78 ± 407.17 pg/ml in female patients with severe and moderate diseases at baseline, respectively which reduced to 195.33 ± 380.04 and 58.20 ± 39.45 pg/ml after discharge (p = 0.011 and p = 0.001). The alteration in the levels of progesterone, LH, and FSH were not significant.The level of LH in both groups of male patients with severe (6.64 ± 2.91 IU) and moderate disease (6.42 ± 4.44 IU) was high, which reduced after discharge (4.16 ± 2.44 and 3.93 ± 3.15 IU, respectively), but this decrease was significant only in the patients with severe disease (p < 0.0001). The alteration of FSH and free testosterone were not significant. The level of testosterone was 1.19 ± 0.73 and 1.46 ± 1.22 ng/ml at baseline in patients with severe and moderate diseases which increased to 2.64 ± 1.25 ng/ml, p < 0.0001, and 2.54 ± 0.93 ng/ml, p = 0.001, respectively after discharge. Conclusion: Our findings showed that the level of estradiol in female patients increased significantly while the level of testosterone in male patients decreased during the active phase of infection. Due to the attrition of patients in the follow-up period, more studies are needed to confirm these results.

Association between diet quality and BMI with side effects of Pfizer-BioNTech COVID-19 vaccine and SARS-CoV-2 immunoglobulin G titers

PurposeThe nutritional and anthropometric status can be essential in determining their immune response to vaccines. The purpose of this paper was to investigate the association between diet quality and anthropometric indices with the side effects of the Pfizer-BioNTech COVID-19 vaccine and the SARS-CoV-2 immunoglobulin G titer among Kurdish adults. Design/methodology/approachThis cross-sectional survey-based study was conducted between December 2021 and February 2022. This paper included data on 115 adults, 20-89 years old, from the Kurdistan region. Dietary information was collected using a short food frequency questionnaire, and diet quality was assessed using a plant-based healthy diet score. A blood test was performed to measure the SARS-CoV-2 immunoglobin G (IgG) titer after the vaccination's first and second doses. FindingsOverweight and obese subjects reported more local pain, myalgia, headache, local bruising and local reactions after receiving the first dose of the vaccine (p = 0.04). People on a less healthy diet reported more local pain, myalgia and headache (p = 0.04) and more local bruising and reactions (p = 0.01) after receiving the second dose of the vaccine. On the other hand, the authors observed that those with healthy dietary habits had more IgG titer after the first and second doses of vaccination than those with less healthy dietary habits (p = 0.001). Originality/valueThe results showed that participants with a healthy diet and normal weight status had fewer side effects of the Pfizer-BioNTech COVID-19 vaccine than obese people and those with a less healthy diet.

Polymorphs and isostructural cocrystals of dexamethasone: towards the improvement of aqueous solubility

Dexamethasone (DEX) is a corticosteroid drug used to treat arthritis and asthma and considered a promising drug for the treatment of COVID-19. The major drawback of DEX is its poor aqueous solubility (89 mg L-1). In order to enhance its solubility, polymorph and cocrystal screening was performed, which resulted in the crystallization of the metastable polymorph (commercial Form A) along with two novel cocrystals with catechol (CAT) and resorcinol (RES). These solid forms were characterized by powder-XRD, DSC, and finally single-crystal XRD. The commercial Form A (P2(1)2(1)2(1), Z ' = 1, new) and reported Form B (P2(1)2(1)2(1), Z ' = 2) were harvested concomitantly during crystallization from CH3CN. While Form A constitutes a trimer ring motif, Form B maintains a dimer synthon between two symmetry independent DEX molecules and they are designated as synthon as well as packing polymorphs. The presence of CAT/RES breaks dimer/trimer synthons in the cocrystal lattice of the drug molecule and forms a hydrogen-bonded sandwich between two anti-parallel DEX chains. In addition, both DEX-CAT and DEX-RES are proved to be isostructural cocrystals based on their identical lattice parameters and molecular packing arrangement. Aqueous solubility (24 h) experiments indicated that commercial Form A was 1.5-fold more soluble than Form B and inversely correlated with their melting points. DEX-CAT and DEX-RES cocrystals improved the aqueous solubility by 2-5-fold than commercial Form A, although both the cocrystals transformed to the mixture of polymorphs during solubility experiments. The improved solubility of the DEX-CAT cocrystal may offer more bioavailability of DEX.

NIGHT SWEATS IN AN ELDERLY FEMALE

CASE: 74 year old woman with history of anxiety, depression, and nonsecretory adrenal adenoma presented with two months of progressive night sweats. Initially, she described waking up damp all over, but without needing to change her sheets. Her weight had been stable, and she denied recent travel. Her recent health changes included starting sertraline and receiving the Moderna COVID vaccines. Her other medications included atorvastatin and lisinopril. Her vital signs were all within normal range and her physical exam was unremarkable. Night sweats described were mild, so work up began with checking a CBC with differential and a TSH level. Initial labs were normal. However, the patient called a week later with night sweats that were worsening. She also recalled being treated for tuberculosis at age fifteen. This prompted additional bloodwork including Quantiferon, ACTH, androstenedione, estradiol, testosterone, progesterone, and DHEAS levels, as well as urine catecholamines and metanephrines. Additionally, it was noted sertraline could be a potential cause of night sweats. The dose was halved with the goal to taper off and discontinue the medication. All lab results came back within normal limits, so CT scans of the chest/ abdomen/ pelvis were ordered, and blood cultures collected. Imaging showed an unchanged adrenal adenoma and blood cultures had no growth. Ultimately, after five months of symptoms, her night sweats completely resolved five weeks after stopping sertraline. IMPACT/DISCUSSION: When working up night sweats, first, the severity of symptoms should be determined and medications reviewed. Mild night sweats with no associated red flag symptoms (weight loss, lymphadenopathy, and fever) do not need immediate or extensive work up. Further work up is essential in the setting of any red flag symptoms. Without a clear etiology, the work up includes the following items: chest radiography along with bloodwork including Quantiferon test, CBC, TSH, HIV serology, and CRP. If these results are normal then a CT of the chest, abdomen, and pelvis could be obtained as well as a bone marrow biopsy. Little evidence exists to guide an exact order of workup for night sweats, so it remains the clinician's responsibility to determine which tests to prioritize. Classes of medications that tend to cause night sweats are cholinergics and anti-depressants. Anti-depressants most associated with night sweats include TCAs and SNRIs. Sertraline has been implicated as a cause of night sweats, but little data exists as to how often this occurs and how often severe presentations like the one described occur. Given that selective serotonin reuptake inhibitors are a first line treatment in depression, recognizing this adverse effect is important in primary care and could prevent unnecessary extensive work ups for night sweats. CONCLUSION: -An initial step in evaluating persistent night sweats should be medication review -Many antidepressants including sertraline can have night sweats as an adverse effect.

The correlation between the concentration of ovarian steroid and the severity of COVID-19 in females

Background: Coronaviruses are positive single-stranded RNA viruses that have a spherical shape and some spike-shaped proteins (spike proteins) that project from their surface, from which they derive their name because they resemble a solar corona. The RNA sequence of SARS-CoV-2 is approximately thirty thousand nucleotides in length and encodes both structural and non-structural proteins. Objective: To assess the relation between the concentration of ovarian steroid and the severity of covid-19 in females. Patients and method: A cross sectional study carried at Consulting clinic for chest and respiratory diseases in Babylon Governorate at the period from 1st of January 2021 to the 1st of June 2021. Patients were female infected with COVID-19 with in age between 25-65 years old. Results: mean age in the studied group was (44.75±13.87) years and the main age group between 40-49 years (29.6%), the majority of the patients (96.3%) were married women, and (71.6%) were obese. fever was found in 68 (84.0%) of patients, diarrhea in 40 (49.4%), loss of smell in 48 (59.3%) of patients and loss of taste were found in 59 (72.8%) of them, and 46 (56.8%) of patients with COVID-19 presented with cough, the level of progesterone and estrogen were decreased with increase of lobe involvement. Conclusion: Ovarian steroid play an important role to decrease the severity of COVID-19. © 2022 International Journal of Health Sciences.All rights reserved.

SEVERE IRON DEFICIENCY ANAEMIA SECONDARY TO UTERINE FIBROIDS CAUSING CEREBRAL VENOUS SINUS THROMBOSIS

Background and aims: Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke, contributing to less than 1%. We report an unusual case of severe iron deficiency anaemia (IDA) causing CVST in a young woman with menorrhagia. Methods: Case report: A 40-year-old female with underlying anaemia presented with headache, right leg numbness and expressive dysphasia. She experienced massive menstrual bleeding prior to the symptoms onset on background of uterine fibroids. There was no history of contraceptive pills consumption, massive blood transfusion, COVID-19 infection or vaccination. Systemic review was unremarkable. Results: Blood investigations revealed haemoglobin of 4.5g/dl, MCV 52.3fL, platelet 657x1////////09/L and low ferritin level. Coagulation profile, connective tissue disease, thrombophilia screening, serum homocysteine and HIV test were normal. Computed tomography (CT) of the head showed left temporoparietal lobe infarct and left dural venous sinus thrombosis. CT venography revealed CVST within the distal left transverse sinus and the vein of Labbe. Pelvic ultrasound showed multiple uterine fibroids. She was warfarinised and had iron and red cell transfusion. She agreed to take progesterone-only pill and interval hysterectomy after gynaecological review. Discussion: CVST in association with IDA is rare in adults and is more prevalent in men. In IDA, hypercoagulability and venous stasis play a vital role in thrombus formation. One study found that IDA in women caused arachidonic acid-induced platelet dysfunction causing menorrhagia which is reversible with iron repletion. Conclusion: IDA is a rare cause of CVST but should be considered in the context of relevant history and blood tests.

Baby Blues: A Rare Case of Transient Pulmonary Arteriovenous Malformation During Pregnancy

Unexplained hypoxia in a pregnant patient is an alarming finding for patient and provider. The differential for hypoxia is broad, and many imaging techniques and procedures are contraindicated in pregnancy. Transient pulmonary arteriovenous malformations (AVMs) are a rare and relatively poorly studied cause of hypoxia in pregnancy. Our patient is a 27-year-old G1P0 female with a remote history of asthma who presented to clinic with slowly progressive exertional dyspnea, exertional tachycardia, and paroxysmal nocturnal dyspnea. She reported use of a home oximeter which read in the high 80s% during exertion. Prior to presentation, the patient was evaluated in the Emergency Department and noted to have an oxygen saturation of 86% on room air. A transthoracic echocardiogram, computed tomography angiography of chest, and basic laboratories including B-type natriuretic peptide, troponin, COVID-19, and hemoglobin were unremarkable. Her clinical timeline is presented in Figure 1. Further testing was obtained, including pulmonary function testing, bubble echocardiogram, nocturnal oximetry, and shunt study. Work-up revealed a 15-20% shunt, depending on calculation, and insignificant desaturations during nocturnal oximetry. Her symptoms progressed, and repeat nocturnal oximetry showed marked overnight desaturations requiring supplemental oxygen for the remainder of her pregnancy. She delivered a healthy baby girl via cesarean section without serious complication. Repeat testing in the post-partum period showed resolution of nocturnal desaturations and decreased shunt, and her exertional dyspnea and desaturations resolved spontaneously. This case illustrates the challenging diagnosis of transient pulmonary AVM in pregnancy. Case reports of this phenomenon have been published, but as in our case, no definitive diagnosis was made secondary to testing limitations in pregnancy and quick resolution of symptoms in the post-partum period. Some reports describe pre-existing pulmonary AVM becoming worse during pregnancy causing hemothorax, fetal demise and even death. While the mechanism is not known, theories include the vasodilatory effects of progesterone on vascular smooth muscle as well as other physiologic changes in pregnancy such as increased plasma volume. These AVM are thought to be like those seen in hepatopulmonary syndrome. Similar to our case, increasing positional hypoxia has been reported as the pregnancy progresses. Further research dedicated to early and accurate detection of pulmonary AVMs in pregnancy is necessary. (Figure Presented).

Relation between Sex Hormones and COVID 19

Coronavirus is one of the major viruses that mainly attack human respiratory system . there are similarities in symptoms between COVID – 19 and earlier Coronavirus infections such as fever, dry cough, however, COVID – 19 showed unique clinical feature, that involve the targeting of the lower airways as evident by upper respiratory tract symptoms such as rhinorrhea, sneezing and sore throat . The severity of COVID- 19 as indicated by hospitalization, admission to intensive care unit, has been greater in men than women . Many hypotheses have been found to explain this difference in susceptibility and severity of the disease . The difference in immune response between sex is consider the main factor in outcomes of viral infection . Estrogen has immunoenhancing effect on the immune system, while testosterone has immunosuppressive role, also progesterone inhibits inflammatory innate immune response . In this review, its concluded that sex hormones have relation with COVID-19 severity .It was concluded that estrogen and progesterone reduce disease severity in contrast, testosterone increase the severity and susceptibility for COVID-19 .

New coronavirus and hypothalamic-pituitary-ovarian axis in women: A narrative review

Introduction: The COVID-19 epidemic has severely affected the life of people around the world. Periods of stress and psychological distress caused by this pandemic can affect a woman's menstrual cycle. The COVID-19 pandemic has had a significant impact on women's reproductive health. This narrative review was performed with aim to evaluate the effect of coronavirus on different aspects of each part of this axis and its relationship with women's health considering hypothalamic-pituitary-ovarian axis. Methods: In this narrative review study, the databases of Pubmed, Scopus, and Embase were searched using the keywords of "Female Reproductive System", "Hypothalamus", "Pituitary" and "Ovary" with the keywords of "COVID-19" and "SARS-COV-2" with a time limit from 2020 onwards. Then, the studies were summarized conceptually and the findings were categorized and interpreted in terms of the effect of coronavirus on the hypothalamus, pituitary gland, and ovary. Results: The potential neuronal invasion by the coronavirus could had led to its direct effect from the beginning to the end of this axis. Although more studies have examined the effect of COVID-19 on the regulation of sex hormones in women with COVID-19, most studies on the hypothalamic and pituitary axis have been based on genetic simulations. Conclusion: Coronavirus can have a wide impact on all organs involved in the female reproductive system. Over time, our understanding of the possible effects of this disease on female fertility will increase.

The Effects of Sex Hormones and some Respiratory Diseases on the Severity of Corona Virus Infection

Sex hormones and chronic respiratory diseases play a role in the pathogenesis and the management of Covid-19 infection. Present research tries to shed light on the role of sex hormones, bronchial asthma and lung cancer on the severity of Covid-19 infection and the resulting mortality rate. This study included a follow-up of the health status of 85 patients infected with Covid-19, and all the patients previously diagnosed had hereditary respiratory diseases (bronchial asthma (64) and lung cancer (21)). The serum level of progesterone and testosterone and the stages of lung cancer development were measured in the laboratories of Diwaniyah Teaching Hospital. After conducting medical examinations, computed tomography and x-rays, the severity of Covid-19 infection was classified according to the WHO to moderate, severe and critical infection. The current results showed that most of the hospitalized cases were males (65%) with a death rate (18%), so bronchial asthma was associated with the death rate in males (70% of dead males), followed by postmenopausal (POM) women (66.7% of the dead woman), while pre-menopausal (PRM) women had the highest cure rate (100%). The results of the study showed that the rise in the mean of progesterone in PRM (13.55 ng/ml) was associated with moderate symptoms of Covid-19, while the increased testosterone in males and POM (1018 ng/dL and 67.3 ng/dL, respectively) was associated with an increase in the severity of the infection. In conclusion, asthma and high testosterone directly affected the increase in the severity of Covid-19 and the high mortality rate among the Corona sufferers. While advanced lung cancer had a clear role in that, at the same time, progesterone appeared as a protective factor in young women. © 2022 by the authors.