ABSTRACT
ObjectivesTo audit implementation of a local protocol for the treatment of vitamin D deficiency (VDD) among patients hospitalized for Coronavirus Disease 2019 (COVID-19), including an assessment of the prevalence of VDD in these patients, and of potential associations with disease severity and fatality. DesignThis was not a study or clinical trial, but rather a retrospective interim audit (Newcastle-upon-Tyne Hospitals Registration No. 10075) of a local clinical care pathway for hospitalized patients with COVID-19-related illness. The Information (Caldicott) Guardian permitted these data to be shared beyond the confines of our institution. SettingA large tertiary academic NHS Foundation Trust in the North East of England, UK, providing care to COVID-19 patients. ParticipantsOne hundred thirty-four hospitalized patients with documented COVID-19 infection. Main outcome measuresAdherence to local investigation and treatment protocol; prevalence of VDD, and relationship of baseline serum 25(OH)D with markers of COVID-19 severity and inpatient fatality versus recovery. Results55.8% of eligible patients received Colecalciferol replacement, albeit not always loaded as rapidly as our protocol suggested, and no cases of new hypercalcaemia occurred following treatment. Patients admitted to ITU were younger than those managed on medical wards (61.1 years {+/-} 11.8 vs. 76.4 years {+/-} 14.9, p<0.001), with greater prevalence of hypertension, and higher baseline respiratory rate, National Early Warning Score-2 and C-reactive protein level. While mean serum 25(OH)D levels were comparable [i.e. ITU: 33.5 nmol/L {+/-} 16.8 vs. Non-ITU: 48.1 nmol/L {+/-} 38.2, mean difference for Ln-transformed-25(OH)D: 0.14, 95% Confidence Interval (CI) (-0.15, 0.41), p=0.3], only 19% of ITU patients had 25(OH)D levels greater than 50 nmol/L vs. 39.1% of non-ITU patients (p=0.02). However, we found no association with fatality, potentially due to small sample size, limitations of no-trial data and, potentially, the prompt diagnosis and treatment of VDD. ConclusionsSubject to the inherent limitations of observational (non-trial) audit data, analysed retrospectively, we found that patients requiring ITU admission were more frequently vitamin D deficient than those managed on medical wards, despite being significantly younger. Larger prospective studies and/or clinical trials are needed to elucidate the role of vitamin D as a preventive and/or therapeutic strategy for mitigating the effects of COVID-19 infection in patients with VDD. What is already known on this topicO_LIVitamin D deficiency (VDD) is associated with increased risk for acute respiratory tract infections C_LIO_LIA link between VDD and severity of COVID-19 pathophysiology has been proposed C_LIO_LITwo recent (non-peer-reviewed) studies have reported crude associations between VDD in defined geographic populations and COVID-19 severity and mortality C_LI What this study addsO_LIThese data do not arise from a clinical study; rather from an audit of a local replacement protocol for VDD in COVID-19 inpatients in a large UK centre, which found a significantly higher prevalence of VDD among ITU patients compared to non-ITU patients, despite the ITU patients being significantly younger. C_LIO_LIPrompt treatment of VDD following a local protocol did not result in any adverse events, such as hypercalcaemia. C_LIO_LIWhilst by no means conclusive, these data suggest an important association between VDD and COVID-19 severity; hence our report of interim findings in advance of achieving completed outcomes (fatality vs. recovery) for all patients. C_LIO_LIThere is an urgent need for larger studies exploring vitamin D as a potential preventative measure and/or treatment of Covid-19-related illness among individuals with VDD. C_LI
ABSTRACT
BackgroundThe Covid-19 pandemic brings major new challenges to health services resulting from the lack of a vaccine and from the enormous resources it can consume over a prolonged period. The available control measures are currently limited to quarantining, contact tracking and tracing and social distancing. Disease transmission to health care workers is common and deaths among clinical and nursing staff have been reported in the UK (where serious concerns about the availability of personal protective equipment - PPE - have been raised) and elsewhere; particularly in Lombardy, where General Practitioners (Medici di Base) have died in disproportionate numbers. MethodsData from Italy and Spain was obtained from publicly available sources which are more comprehensive than that available to date (April 2020) in the UK and the advanced timing of the crisis in these locations allows their sources to propose a strategy of allocating staff roles with due respect to the age and sex of staff in order to reduce the pressure on the limited resource of critical care beds and diminish the quantity of hospital acquired infections encountered in treating the known large proportions of patients who were infected as healthcare workers. Such strategy would dramatically reduce unnecessary death and illness in the caring professions and assist employers in reasonable health and safety compliance for their workforce. In addition to those staff employed in patient care roles prior to the pandemic, doctors and nurses who have recently retired from the NHS have been invited via their respective regulatory bodies such as the United Kingdom General Medical Council (GMC) and Nursing & Midwifery Council (NMC) to return to the front-line. Those who are qualified for clinical and nursing roles, but who are now working in research, education and management roles have also been welcomed by the NHS and placed in clinical roles undertaking face-to face delivery of care. The first COVID-19-related deaths reported in NHS doctors were all male clinicians from BAME background over 50 years of age. ResultsHerein, we construct a measure of fatality as a function of population Covid-19 status to examine the data from Spain and Italy, where the pandemic struck much sooner. This shows a doubling in relative risk for men compared to women and a 20-fold increase for those 60-19 compared to women 40-49. ConclusionThe analyses suggest a stratified approach to allocating staff, through making these results available to those who volunteer for front line roles. This should result in preserving as many of the valuable older doctors and nurses as possible with their expertise, experience, managerial skills and to maintain the coherence and leadership of their teams and research groups.
ABSTRACT
Male hypogonadism—rebadged by some as testosterone deficiency syndrome—is a clinical and biochemical diagnosis of increasing worldwide interest. Organic male hypogonadism—usually permanent—is well-established, but aging men may also exhibit lower serum testosterone levels; principally due to burden of extra-gonadal comorbidities such as obesity, diabetes and metabolic syndrome, but with an underlying intact hypothalamo-pituitary-testicular (HPT) axis capable of springing back into operation once comorbidities are addressed. Despite encouraging observational data and plausible theoretical underpinning, evidence for efficacy and safety of testosterone in this “aging” group of men is lacking; addressing comorbid illnesses remains the key priority instead. Nevertheless, in recent years, accumulation of misleading information online has triggered a global tsunami of testosterone prescriptions. Despite this, many men with organic hypogonadism remain undiagnosed or untreated; many more face a diagnostic odyssey before achieving care by the appropriate specialist. As testosterone therapy is not without risk several clinical practice guidelines have been published specialist societies to guide physicians on best practice. However, these are heterogeneous in key areas, reflecting divergent approaches to the same evidence basis. Herein, we navigate the major clinical practice guidelines on male hypogonadism and test their respective recommendations against current best evidence.
