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Background: Patients with moderate to severe hypothyroidism and mainly patients with myxedema may exhibit reduced sodium levels (<135 mmol/L). Summary: The aim of this short review is the presentation of the mechanisms of hyponatremia and of the available data regarding its implications and treatment in patients with hypothyroidism. Hypothyroidism is one of the causes of hyponatremia, thus thyroid-stimulating hormone determination is mandatory during the evaluation of patients with reduced serum sodium levels. The main mechanism for the development of hyponatremia in patients with chronic hypothyroidism is the decreased capacity of free water excretion due to elevated antidiuretic hormone levels, which are mainly attributed to the hypothyroidism-induced decrease in cardiac output. However, recent data suggest that the hypothyroidism-induced hyponatremia is rather rare and probably occurs only in severe hypothyroidism and myxedema. Other possible causes and superimposed factors of hyponatremia (e.g. drugs, infections, adrenal insufficiency) should be considered in patients with mild/moderate hypothyroidism. Treatment of hypothyroidism and fluid restriction are usually adequate for the management of mild hyponatremia in patients with hypothyroidism. Patients with possible hyponatremic encephalopathy should be urgently treated according to current guidelines. Conclusions: Severe hypothyroidism may be the cause of hyponatremia. All hypothyroid patients with low serum sodium levels should be evaluated for other causes and superimposed factors of hyponatremia and treated accordingly.

INTRODUCTION Telehealth for COVID-19 patients is still limited. We aimed to assess the clinical effects of a home-based tele-rehabilitation exercise program following hospital discharge during the first lockdown in Greece, April to July 2020. METHODS A pre-and post-intervention design was applied in two stages. Firstly, patients were instructed to use a specially designed for COVID-19, e-book during four tele-health sessions. Afterwards, a 2-month home-based program consisted of self-practice exercise and one-hour supervised telerehabilitation exercise sessions every 10 days, was delivered. At baseline and at the end of the program, participants were interviewed about their physical, psychological status and quality of life (QoL) during the posthospitalization period. The IPAQ-Gr, the HADS and the SF-36 questionnaires were used, respectively, and the participants were functionally assessed via teleconferences, using the 60 sec Sit to Stand Test (60secSTS), the Short Physical Performance Battery (SPPB) and the 3 min Step Test (3MST). RESULTS Seventy-four patients, median age 52.5 (IQR: 43-61) years were included at the first stage. From those, only 22 patients, mean ± SD age 50.1 ± 13.2 years completed the 2-month exercise program. The training program was well tolerated by all 22 patients. The mean number of unsupervised exercise sessions was 18.4 ± 3.5. No adverse effects were observed either during initial and follow-up assessment via tele-communication or during home-exercise sessions. Training improved significantly (p<0.001) lower limb muscle performance ], anxiety [median (IQR) HADS: 9 (6-13) to 4.3 (3.2-9.6)], depression [median (IQR) HADS: 5 (3-8) to 1.8 (0.9-3.7)], QoL [mean ± SD SF-36pcs: 37.5 ± 10.3 to 52.1 ± 6, and mean ± SD SF-36mcs: 42.9 ± 11.6 to 45.5 ± 12.3]. CONCLUSIONS Tele-rehabilitation may be feasible and may improve physical and psychological status of COVID-19 patients after hospital discharge.

Background Acute respiratory distress syndrome and cytokine release syndrome are the major complications of coronavirus disease 2019 (COVID-19) associated with increased mortality risk. Objectives We performed a meta-analysis to assess the efficacy and safety of anakinra in adult hospitalized non-intubated patients with COVID-19. Search methods Relevant trials were identified by searching literature until 24 April 2021 using the following terms: anakinra, interleukin 1, coronavirus, COVID-19, SARS-CoV-2. Selection criteria Trials evaluating the effect of anakinra on the need for invasive mechanical ventilation and mortality in hospitalized non-intubated patients with COVID-19. Results Nine studies (n = 1,119) were eligible for inclusion in the present meta-analysis. Their bias risk with reference to the assessed parameters was high. In pooled analyses, anakinra reduced the need for invasive mechanical ventilation (odds ratio, OR: 0·38, 95% confidence interval, CI: 0·17–0·85, p= 0.02, I2=67%; 6 studies, n = 587) and mortality risk (OR: 0·32, 95% CI: 0·23–0·45, p&lt; 0·00001, I2=0%; 9 studies, n = 1,119) compared with standard of care therapy. There were no differences regarding the risk of adverse events, including liver dysfunction (OR: 0·75, 95% CI: 0·48–1·16, p&gt; 0·05, I2=28%; 5 studies, n = 591) and bacteremia (OR: 1·07, 95% CI: 0·42–2·73, p&gt; 0·05, I2=71%; 6 studies, n = 727). Conclusions Available evidence shows that treatment with anakinra reduces both the need for invasive mechanical ventilation and mortality risk of hospitalized non-intubated patients with COVID-19 without increasing the risk of adverse events. Confirmation of efficacy and safety requires randomized placebo-controlled trials.

Hyponatremia (Na(+) <135 mmol/l) is the most common electrolyte disorder. Cirrhosis represents a rather frequent cause of hyponatremia mainly due to systemic and splanchnic vasodilation resulting in decreased effective arterial blood volume, which leads to excessive non-osmotic secretion of antidiuretic hormone. However, hyponatremia of multifactorial origin may be seen in patients with liver diseases. The review focuses on the factors and pathogenetic mechanisms of decreased sodium levels other than the hemodynamic compromise of cirrhosis in patients with liver diseases. The mechanisms and causal or contributing role of pseudohyponatremia, hyperglycemia, infections, drugs and toxins as well as of endocrine disorders, renal failure and cardiac disease in patients with liver disease are meticulously discussed. Hyponatremia of multifactorial origin is frequently observed in patients with liver diseases, and special efforts should be made to delineate the underlying causative and precipitating factors as well as the risk factors of the osmotic demyelination syndrome in order to properly manage this serious electrolyte disorder and avoid treatment pitfalls.