We conclude that chemoradiotherapy is superior to radiotherapy alone for patients with advanced nasopharyngeal cancers with respect to PFS and overall survival.

The Southwest Oncology Group (SWOG) has conducted a phase II study to explore the efficacy and toxicity of initial, concurrent use of radiation therapy with cisplatin, etoposide (VP-16), and vincristine in limited-stage small-cell carcinoma of the lung. Two courses of cisplatin, VP-16, and vincristine chemotherapy were given with concurrent radiotherapy (XRT) to the primary tumor to a total dose of 4,500 cGy. Elective brain XRT was given to all patients concurrent with a third course of cisplatin/VP-16 therapy. Consolidation chemotherapy consisting of vincristine, methotrexate, and VP-16 alternating with Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH) and cyclophosphamide, was given for 12 weeks following the initial induction chemotherapy/XRT program. Patients with a complete response had all therapy discontinued. Among 154 eligible patients treated, the complete response rate was 56%, with a partial response rate of 27%. The median survival is 17.5 months with an estimated 30% survival rate at 4 years from initiation of treatment. Combined modality toxicities were acceptable with the predominant toxicity being moderate to severe leukopenia and mild radiation esophagitis. The results of this treatment program appear superior to any previously reported by our group and compare favorably to those in the literature at large.

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The SARS-CoV2 virus is well known for causing atypical pneumonia in addition to other symptoms. Various neurological symptoms have been reported including anosmia, headaches, and stroke like symptoms. Here we report a case of a critically ill patient who developed encephalopathy with evidence of multiple bilateral acute strokes.

SARS-CoV2 is known for causing atypical pneumonia with rapidly progressive respiratory failure requiring intubation. Usage of steroids have been shown to be of benefit in similar disease processes caused by other coronaviruses specifically SARS/MERS. Currently in the literature there is lack of consensus regarding steroids use in severely ill patients with COVID-19 pneumonia. We conducted a retrospective analysis to evaluate the efficacy of systemic corticosteroids and outcomes in COVID-19 patients with severe respiratory symptoms requiring ICU admission in a community hospital in Michigan. METHODS: This retrospective cohort study was conducted with 181 patients of COVID-19 with severe respiratory symptoms requiring ICU admission in a community hospital in Michigan March 18 to April 15, 2020. Patients were then divided into 2 groups, with or without steroid treatment. Treatment group received oral prednisone, doses range from 10 to 60mg twice daily for an average of 5 days, most of which received a loading dose of intravenous methylprednisolone. The primary outcome for the study was mortality rate, secondary outcome was extubation rate. RESULTS: 177 patients met inclusion criteria and among those, 93 patients received systemic steroids. Of the total 93 patients in the treatment group, 42 patients were admitted to ICU, 38 of which were intubated. Of the total 84 patients in the control group, 14 patients were admitted to ICU and 10 were intubated. The mortality rate was 53% in the treatment group compared to 57% in the control group (p>0.05); the extubation rate was 71% in the treatment group compared to 50% in the control group (p>0.05). Our results showed a clinically important difference between the two groups.

Hyperosmolar Hyperglycemic State (HHS) and Diabetic Ketoacidosis (DKA) are associated with decompensated Diabetes mellitus. On many instances' patients may present with a mixed picture of both conditions. This acute decompensation may result from infarction, medication noncompliance, or infections. With DKA and HHS, hemoconcentration is common due to dehydration. Many nonspecific enzyme values maybe elevated with these conditions, which may cause other underlying pathologies to go unnoticed. Here we report a case of post-COVID HHS/DKA with elevated lipase and features of pancreatitis.CASE PRESENTATION: 52-year-old African-American female with obesity and Type two diabetes presented with nausea, abdominal pain and dizziness of 1 day. She was in the recovery stages of COVID, past 10 days since her diagnosis at the time of admission. She stated that due to altered taste sensation, likely COVID symptom, she was not eating properly, drinking more caffeinated beverages, and less water. Her glucose was >1000 mg/dl, creatinine 1.7, anion gap > 31, elevated betahydroxybutyrate, minimal urine ketones and a bicarb of 13 on admission. Her lipase was >2000 and Amylase >1000. Lab values along with abdominal pain was enough to consider underlying pancreatitis. At that time both DKA/HHS and acute pancreatitis required aggressive fluid hydration, but the patient continued to deteriorate. Fear of fluid overload with tachypnea, along with continued abdominal pain requiring pain medications produced a 'catch 21' with her respiratory status. Ultrasound of the abdomen was unremarkable. CT abdomen did prove acute pancreatitis. Triglycerides were not elevated enough to be the culprit of pancreatitis. She denied use of alcohol or other infections. She was however recovering from SARS-CoV2 infection (>10 days since diagnosis), which may have been the inciting factor for pancreatic inflammation. Her BISAPS score was 4; very severe form of acute pancreatitis with a high mortality risk.DISCUSSION: This case shows how DKA/HHS states can mask pancreatitis. This case also presents an interesting cause of her pancreatitis. Viral etiologies like mumps or coxsackie viruses are known instigators of acute pancreatitis. Given the lack of other etiologies, COVID-19 is likely the trigger to her symptoms. COVID has been known to be a precipitator of DKA in this last year, but little is known in its' involvement in acute pancreatitis. One theory to link pancreatitis to decompensated diabetic states with COVID is cytokine mediated damage to the pancreatic beta cells, causing inflammation of the pancreas and worsening glycemic control precipitating DKA or HHS.CONCLUSIONS: An association of AP with DKA or HHS increases the risk of mortality. It's a rare phenomenon for SARS-Cov2 infection as the provoking factor. More studies should be done on the link of decompensated DM with AP, and how these conditions are affected by COVID-19.

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