Evaluation of Characteristics and Outcomes for Patients with Diabetic Ketoacidosis (DKA) With and Without COVID-19 in Elmhurst Queens During Similar Three-Month Periods in 2019 and 2020

Aim

There are reports of COVID-19 patients presenting with new onset diabetes, diabetic ketoacidosis (DKA), and hyperosmolar hyperglycemic syndrome (HHS). We compared the characteristics of patients with DKA with and without COVID-19 and their effect on mortality.

Research design and methods

A retrospective study at Elmhurst Hospital Center in Queens, New York was performed using ICD-10 codes to identify patients with DKA from March 1 to May 31 in 2019 and 2020.

Results

While comparing COVID-19 patients with DKA to the DKA patients without COVID-19 in both 2019 and 2020, hispanic patients, males, and type 2 diabetes predominated. COVID-19 patients were older (p=0.010), had more hypertension (p=0.002), and severe lactic acidosis (p=0.006). Mortality for DKA patients with COVID-19 was 57%, for DKA patients without COVID-19 it was 2.1% (p=0.0001), and for diabetic patients (no DKA) with COVID-19 it was 39% (p=0.035). Within the COVID-19 group, older age (mean age 65), (p=0.014), elevated CRP (p=0.012), low O₂ saturation (p=0.001), and beta blocker use (P=0.01) were associated with increased mortality.

Conclusions

COVID-19 patients are older, have a history of hypertension, more severe DKA and lactic acidosis than patients without COVID-19. There was no increase in DKA with HHS. DKA, but not diabetic parameters, hypertension, and older age predicted a poor outcome.

Case Series: Hypercalcemia From Granulomatous Silicosis Developing After COVID-19 Infection

Hypercalcemia is one of the most commonly encountered laboratory abnormalities in clinical medicine. Various causes have been well established. However, it is likely that the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), may be a newly found cause of this frequent finding, especially amongst those with a history of cosmetic surgery, specifically by means of silicone injection. In this case series, we describe 2 patients presenting with symptomatic hypercalcemia likely from their prior silicone injections. Interestingly, each patient only developed symptoms of hypercalcemia following infection with SARS-CoV-2.

A Case of Refractory Myxedema Coma

We present a case of myxedema coma refractory to traditional treatments. Morbidity and mortality from myxedema coma are frequently due to a missed or delayed diagnosis. It tends to respond very well to intravenous levothyroxine replenishment as long as this treatment is initiated early. We report a case of a 71-year-old man who presented with altered mental status and severe bradycardia who was promptly diagnosed with myxedema coma on laboratory studies sent in the emergency department (thyroid-stimulating hormone 94.74, free T4 0.17, and free T3 0.69). However, while the diagnosis was recognized immediately, and he was treated aggressively with intravenous thyroxine replacement, he strangely remained refractory to treatment for a prolonged period of time. While he did respond to intravenous thyroxine initially, he dramatically decompensated each time he was transitioned to oral therapy. This case brings to question why rarely certain patients fail the transition to oral therapy, and how to treat these patients.

Using a brief 10-item generic measure of quality of life in English and Spanish speaking diabetic patients

OBJECTIVES

Validation of the Multicultural Quality of Life Index (MQLI), a 10-item self-rated generic multilingual quality of life (QOL) measure in ethnically-diverse diabetic patients.

METHODS

Diabetic adult patients (n = 180) in New York City completed the MQLI, English or Spanish version. Its internal consistency, factorial structure, and construct validity were analyzed. Depression screening (PHQ-9) scores were used to divide subjects into two sub-samples with presumed different QOL levels.

RESULTS

A Cronbach's alpha of 0.92 demonstrated its internal consistency (English-version = 0.90, Spanish-version = 0.94). A one-single factor structure was documented (all items loadings > or = 0.64), accounting for 59% of the items variance in the total sample; similar results were found for each language version. Correlation of the MQLI and PHQ-9 scores yielded an r = -0.58. Mild negative correlations with self-disclosed diagnosis of depression or other mental disorders, diabetes duration, and abnormal sensation on foot exam were found, but were non-significant with other diabetes aspects (e.g., HbA1c, retinopathy). A significant difference (p < 0.001) between the scores of two subsamples with presumed different levels of QOL (means = 8.02 vs. 5.84) was found.

CONCLUSIONS

The MQLI demonstrated coherence around the QOL concept. It correlated significantly with mental health (particularly depression), duration of diabetes, and possible neuropathy, but not with some diabetes-related factors. Its use in diabetic care settings is recommended, possibly supplemented by QOL diabetic-specific instruments.

Chronic high-dosage androgen administration to ovulatory women does not alter adrenocortical steroidogenesis

OBJECTIVE

To evaluate the role of chronic long-term exogenous androgen administration to normal ovulatory women on adrenal steroidogenesis.

DESIGN

Prospective study of four consecutive female-to-male transsexuals before and during chronic testosterone (T) therapy.

SETTING

Clinical Research Center of the Mount Sinai Medical Center.

PATIENTS

Four female-to-male transsexuals were studied before and during 6 to 12 months of chronic T enanthate therapy for desired virilization. All four subjects were ovulatory before treatment. Adrenocorticotropic hormone (ACTH) testing was performed before, and 6 and 12 months of androgen therapy and various adrenal androgens as well as precursor:product pairs were evaluated as an index of specific adrenocortical biosynthetic defects.

RESULTS

Baseline and 1 hour after 0.25 mg ACTH intravenously, adrenal androgen levels as well as adrenal precursor/product pairs demonstrated no difference before and during chronic T treatment. Studies included determinations of plasma 17-hydroxypregnenolone, 17-hydroxyprogesterone, dehydroepiandrosterone, androstenedione, 11-deoxycortisol, and cortisol.

CONCLUSION

It is concluded that chronic hypertestosteronemia does not alter adrenal steroidogenesis.

Effect of castration on prostaglandin-mediated changes in membrane potential and prostaglandin synthesis in guinea-pig seminal vesicle tissue

Arachidonic acid stimulated an increase in transmural electrical potential difference (p.d.) in guinea-pig seminal vesicle tissue in vitro. Pretreatment with indomethacin abolished this response. Indomethacin pretreatment did not prevent the p.d. from increasing in response to theophylline. Changes in p.d. in response to arachidonic acid were greatly attenuated, and the response to theophylline was abolished in seminal vesicle tissue taken from castrated guinea-pigs. Seminal vesicles, aorta and ileum taken from castrated guinea-pigs synthesized and released more prostaglandins than did those from control animals. It is concluded that the effects of arachidonic acid on p.d. are mediated by its metabolism to prostaglandins; the inability of seminal vesicles from castrated animals to respond to arachidonic acid is not a result of a decrease in prostaglandin production, but is more likely a result of other degenerative changes attendant upon castration; and androgens appear to have some regulatory function on prostaglandin synthesis in a variety of tissues.

Enhanced arachidonic acid lipoxygenation by K562 cells stimulated with 12-O-tetradecanoylphorbol-13-acetate

The arachidonic acid lipoxygenase products released into culture supernatants by the human myeloid cell line K562 were quantitated by high-performance liquid chromatography. During 2 hr of incubation, K562 cells spontaneously released a mean of 9 ng of 15-monohydroxyeicosatetraenoic acid, 35 ng of 5-monohydroxyeicosatetraenoic acid, and 87 ng of a partially resolved mixture of 11- and 12-monohydroxyeicosatetraenoic acid per 10(7) cells. The addition of 50 micrograms of arachidonic acid per ml to the cell cultures increased the quantities of monohydroxyeicosatetraenoic acids generated after 2 hr of incubation by 10- to 100-fold; changes in the ratios of these lipoxygenase products occurred over 24 hr of incubation. The tumor promoter 12-O-tetradecanoylphorbol-13-acetate, at concentrations of 5 to 25 ng/ml increased arachidonic acid lipoxygenation 1- to 2-fold in cultures containing 50 micrograms of arachidonic acid per ml, and up to 20-fold in cultures not supplemented with arachidonic acid. The lipoxygenation of arachidonic acid was enhanced 2- to 9-fold for up to 24 hr after a 2-hr exposure of K562 cells to 12-O-tetradecanoylphorbol-13-acetate. Nordihydroguaiaretic acid, a lipoxygenase inhibitor, blocked the effects of 12-O-tetradecanoylphorbol-13-acetate, suggesting that the monohydroxyeicosatetraenoic acids are the products of specific lipoxygenases rather than of nonenzymatic oxidative reactions. The capacities of phorbol esters to promote tumors in the mouse skin model corresponded to their respective capacities to enhance the lipoxygenation of arachidonic acid to 15- and 5-monohydroxyeico-satetraenoic acid but not to 11- and 12-monohydroxyeico-satetraenoic acid.