Objectives To identify risk factors for severe disease and death among patients with diabetes and coronavirus disease 2019 (COVID-19) infection. Methods This retrospective cohort study conducted at three hospitals included 733 consecutive patients with DM admitted with confirmed COVID-19 (March 1 – December 31, 2020). Multivariable logistic regression was performed to identify predictors of severe disease and death. Results The mean age was 67.4 ± 14.3 years, 46.9% were males and 61.5% were African American. Among all patients, 116 (15.8%) died in the hospital. A total of 317 (43.2%) patients developed severe disease, 183 (25%) were admitted to an ICU and 118 (16.1%) required invasive mechanical ventilation. Increasing BMI (OR, 1.13; 95% CI, 1.02–1.25), history of chronic lung disease (OR, 1.49; 95% CI, 1.05–2.10) and increasing time since the last HbA1c test (OR, 1.25; 95% CI, 1.05–1.49) were the preadmission factors associated with increased odds of severe disease. Preadmission use of metformin (OR, 0.67; 95% CI, 0.47–0.95) or GLP-1 agonists (OR, 0.49; 95% CI, 0.27–0.87) was associated with decreased odds of severe disease. Increasing age (OR, 1.21; 95% CI, 1.09–1.34), co-existing chronic kidney disease greater than stage 3 (OR, 3.38; 95% CI, 1.67–6.84), ICU admission (OR, 2.93; 95% CI, 1.28–6.69) and use of invasive mechanical ventilation (OR, 8.67, 95% CI, 3.88–19.39) were independently associated with greater odds of in-hospital death. Conclusion Several clinical characteristics were identified to be predictive of severe disease and in-hospital death among patients with underlying diabetes hospitalized with COVID-19.

Introduction Teriparatide, recombinant human parathyroid hormone (1–34), is a safe and usually well-tolerated medication. We describe two cases of late-onset hypercalcemia associated with teriparatide use and report current evidence of hypercalcemia during the treatment with PTH analogs. Case report Case 1 is a 54-year-old man with a history of osteoporosis, previously treated with 6 months of teriparatide, but had not been consistent in taking the medication. Before restarting teriparatide, his serum calcium, PTH and vitamin D were normal. Six months into the treatment, he developed asymptomatic hypercalcemia of 11.2 mg/dL 24 h after the last dose. Repeat serum calcium was normal and treatment was continued. Case 2 is a 75-year old woman with a history of osteopenia and severe scoliosis. Before starting teriparatide, her calcium, PTH and vitamin D were normal. Six months into the treatment, she developed asymptomatic hypercalcemia of 12.5 mg/dL. Teriparatide was held and subsequently her serum calcium normalized. Discussion Transient hypercalcemia can occur during treatment with teriparatide and usually resolves within 16 h after administration. Late hypercalcemia, occurring more than 24 h after the dose, is rarely seen. It is usually mild, asymptomatic and rarely occurs repeatedly. Hypercalcemia occurs more often in patients with pre-existing hypercalcemia or vitamin D deficiency. It is rarely a cause of treatment disruption (0.18–4%). Conclusion Clinicians should be aware of this side effect, especially in patients who may be at risk of complications of hypercalcemia.

Background : Teriparatide (TPTD) is a recombinant PTH analog used as an anabolic agent in the treatment of osteoporosis that stimulates bone formation and activates bone remodeling. The most common side effects are nausea, vomiting, hypertension and dizziness. Transient hypercalcemia is a known adverse effect which is usually seen a few hours after administration and resolves within 16 hours. However, marked late hypercalcemia is a rare event and may be of concern in clinical practice. Clinical Cases : Case 1 is a 54-year-old man with a history of osteoporosis (lumbar spine T-score of -2.8), previously treated with bisphosphonates and who had been on a course of TPTD for about 6 months in but had not been consistent in taking the medication. Prior to subsequently restarting TPTD, his initial labs were notable for a normal Ca 9.3 mg/dl (8.5 - 10.1 mg/dl), vitamin D 25 OH 49 ng/ml (30.0 - 100.0 ng/ml) and PTH 41.3 pg/ml (8.7 - 77.1 pg/ml). Six months into the treatment, he was noted to have asymptomatic hypercalcemia of 11.2 mg/dl approximately 24 hrs after the last TPTD injection. A repeat calcium of 10.7 mg/dl was obtained while still on therapy with TPTD with normal levels of vitamin D 25 OH of 45 ng/ml. Case 2 is a 75-year-old woman with a history of osteopenia and severe scoliosis, who had been on a course of raloxifene and then preventive doses of alendronate previously. Prior to starting TPTD, her Ca levels were normal at 9.3 mg/dl, PTH was 24 pg/ml and vitamin D 25 OH was 33 ng/ml. However, six months into the treatment she was noted to have elevated Ca of 12.5 mg/dl (24 hrs after the last TPTD dose), with low levels of vitamin D 25 OH of 24.2 ng/ml. Ca levels returned to the baseline of 9.3 mg/dl when TPTD was held. Conclusion : Teriparatide has a long track record of safety and does have the rare side effect of hypercalcemia. 1-3% of patients may have mild hypercalcemia after administration. Intake of calcium and vitamin D should be monitored at the start of therapy given these concerns. Although almost never a cause of discontinuation of treatment in clinical practice, it is important to be aware of this side effect in patients who may be at risk of complications of hypercalcemia.

Objective: Glycemic variability (GV) is a well-established and important metric when assessing glycemic control in clinical practice. The objective of this study was to identify factors associated with high GV in patients with diabetes mellitus (DM) hospitalized with COVID-19. Methods: This retrospective, observational study done at three different sites included 685 consecutive patients with DM hospitalized with COVID-19 from March 2020 to December 2020. Demographic characteristics, DM history, comorbidities, laboratory and COVID-19 treatment data were collected. All blood glucose levels, by laboratory serum measurement or by point-of-care testing were collected for the entire hospital stay. GV was expressed as the percentage coefficient of variation for glucose (%CV), derived from the following formula: ([SD of glucose] / [mean glucose]) x 100. High GV was defined as %CV 36%. We used elastic-net regression model (R version 4.1.0, package "glmnet") to select the most important covariates affecting GV of the cohort. Out of the potential 34 variables, 13 had nonzero coefficients and were included in a logistic regression model with high GV as a dependent variable. Results: A total of 685 hospitalized patients were included in the analysis, with a mean age of 67.4±14.1, mean BMI of 32.2±8.3, median (IQR) hemoglobin A1c of 7.4 (6.6-9.0), 323 (47.2%) were male and 425 (62%) were African-American race. The total number of glucose values for the study population was 41,335. A total of 239 (34.9%) patients had %CV of glucose greater than 36%. In the multivariable analysis, the use of systemic steroids [adjusted OR 3.33 (95% CI, 2.21-5.08)], outpatient treatment with insulin [adjusted OR 2.10 (95% CI, 1.42-3.14)], African American race [adjusted OR 1.94 (95% CI, 1.31-2.89)], ICU admission [adjusted OR 1.85 (95% CI,] and CKD greater than stage 3 [adjusted OR 1.81 (95% CI, 1.12-2.94)] were independent factors associated with higher GV. On the other hand, every 5-point increase in BMI was inversely associated with higher GV [adjusted OR 0.80 (95% CI, 0.70-0.90)]. Discussion/Conclusion: Our results show that in hospitalized patients with DM and COVID-19, use of steroids, outpatient treatment with insulin, African-American race, ICU admission and CKD greater than stage 3 were independently associated with higher GV. Otherwise, BMI was inversely associated with higher GV.

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Pituitary apoplexy (PA) is a known, often under-recognized medical emergency and is characterized by ischemic or hemorrhagic necrosis of the pituitary gland. It is a rare clinical syndrome that occurs in 2-12% of pituitary tumors. Hyponatremia can occur secondary to hypocortisolism (12-40%) or, rarely, to the syndrome inappropriate antidiuretic hormone (ADH) secretion. We present the case of a 69-year-old man who presented with altered mental status on post-operative day 3 from total knee replacement surgery. Initial testing revealed hyponatremia of 124 mmol/L, low serum osmolality of 266 mOsm/kg, and high urine osmolality of 664 mOsm/kg with urine sodium of 179 mmol/L. Head computerized tomography revealed a sellar mass of 1.8 x 2.4 cm. Initial testing revealed low prolactin (0.7 ng/mL), normal TSH (0.458 mcIU/mL) with borderline low free T4 of 0.72 ng/dL. Morning cortisol was 12.7 mcg/dL with ACTH of 8.5 pg/mL. Cosyntropin stimulation test was done revealing baseline cortisol of 5.8 mcg/dL (at midnight), increasing to 25.8 mcg/dL after 30 minutes and to 30.9 mcg/dL 60 minutes after cosyntropin administration. His sodium and mental status initially improved with fluid restriction and salt tablets, for the assumed syndrome of inappropriate ADH secretion. The patient remained hemodynamically stable. On the fourth day, however, his mental status deteriorated. Magnetic resonance imaging revealed expansion of sella with hyperintense mass 2.2 x 2.0 x 2.8 cm with compression of the optic chiasm. He was given stress dose hydrocortisone and levothyroxine and underwent emergency transsphenoidal resection. Biopsy revealed acute hemorrhage within infarcted adenoma. Postoperatively, both the patient’s sodium and mental status improved significantly and he was discharged to home on hydrocortisone and levothyroxine. The main clinical concern in the management of PA remains under-diagnosis at presentation. Prognosis is dependent on management during the acute phase. PA can present as hyponatremia even in the absence of overt hypocortisolism, presumably due to inappropriate ADH secretion. Therefore, PA should be considered as one of the differential diagnoses in hemodynamically stable patients with altered mental status and hyponatremia.