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INTRODUCTION: Throughout the coronavirus disease 2019 (COVID-19) pandemic, studies have repeatedly shown that COVID-19 outcomes are more severe in the elderly and those with comorbidities, with diabetes being a significant risk factor associated with more severe infection. Here, we present the clinical characteristics of 25 patients with pre-existing type 2 diabetes mellitus who presented with diabetic ketoacidosis (DKA) and COVID-19 in a community hospital in Brooklyn, New York, and identify possible predictors of mortality. METHODS: This retrospective case series recruited patients from March 1st to April 9th, 2020, with lab-confirmed COVID-19 and met DKA criteria on admission (based on American Diabetes Association diagnostic criteria for DKA). RESULTS: Of the 25 patients who met the inclusion criteria, 22 were African American and three were Hispanic. Common comorbidities in addition to diabetes were hypertension, obesity, coronary artery disease, and dyslipidemia. Fever, cough, myalgias, and shortness of breath were common presenting symptoms. Most patients had elevated inflammatory markers erythrocyte sedimentation rate, C-reactive protein, D-dimer, and ferritin, but higher values increased the odds of mortality. The overall survival was 64%, with those recovering having more extended hospital stays but requiring less time in the intensive care unit. At the same time, those who died were more likely to require mechanical ventilation, have an acute cardiac injury, and/or be obese. Despite numerous studies on COVID and diabetes, only a few studies described DKA. CONCLUSION: This observational retrospective study illustrated that patients with diabetes are at risk of developing DKA with COVID-19 and identified some predictors of mortality. However, further studies with larger sample sizes and a control group are necessary to understand better the effects of COVID-19 on DKA and their clinical outcomes.
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BACKGROUND: Guidelines recommend colectomy for appendiceal carcinoid tumors larger than 2 cm, but physicians debate whether colectomy would be beneficial in treating smaller tumors. We sought to determine when colectomy confers a survival advantage over appendectomy. METHODS: Appendiceal carcinoid patients in the US Surveillance, Epidemiology, and End Results (SEER) database (1988-2011) were stratified by age group, gender, TNM stage, tumor grade, and race. Kaplan-Meier and logistic regression analyses relating grade, stage, and receipt of colectomy to overall and cancer-specific survival were performed. RESULTS: Of 817 patients who underwent surgical extirpation of an appendiceal carcinoid, 338 (41%) had appendectomy alone and 479 (59%) had additional colectomy. Surprisingly, patients who underwent colectomy had worse cancer-specific survival (HR 1.98, 95% CI 1.32-2.98, p = 0.001) than those who underwent appendectomy, and colectomy did not confer a survival advantage over appendectomy in any subset analysis including low-grade or high-grade tumors, smaller or larger than 2 cm, or node-positive, non-metastatic tumors. Even when accounting for stage and grade, colectomy was not associated with significantly better survival rates. Furthermore, as colectomy frequency has increased over the last decade, the 5-year survival rate has trended down. The main predictors of cancer-specific mortality in carcinoid patients were high-grade (grades 3-4) and high-stage (node positive or metastatic) tumors. CONCLUSIONS: Survival in patients with carcinoid tumor of the appendix is primarily determined by tumor grade and stage. Our study found no survival advantage to colectomy over appendectomy in a large cohort of patients with the disease. Further investigation is necessary prior to recommending change of practice for patients with appendiceal carcinoid tumors.
