Letter to the editor: Unexpected high mortality in COVID-19 and diabetic ketoacidosis To the EditorPatients with diabetes mellitus (DM) appear to be at a greater risk for severe symptoms and complications, including death from 2]. DM is a common comorbidity in patients affected with COVID-19 and may cause ketosis, ketoacidosis, and diabetic ketoacidosis (DKA) [3]. In patients with DM, acute hyperglycemic crises such as DKA and hyperosmolar hyperglycemic state can be precipitated by an acute illness such as COVID-19 and it can result in catastrophic outcomes. At Jacobi Medical Center, an epicenter of the COVID-19 pandemic crisis, we noted that a significant proportion of patients with COVID-19 also presented with DKA. We identified 50 such patients admitted with COVID-19 from March 10th to April 30th of 2020 who concomitantly had DKA upon admission or developed DKA during their hospital course. DKA was defined as blood glucose N250 mg/dL, an elevated anion gap, and positive ketones in blood or urine. COVID-19 was confirmed by real-time reverse-transcription polymerase chain reaction (PCR) assay (BioReference Laboratories, Elmwood Park, NJ).Among the evaluated patients, 32 (64%) were male, the median age was 59 years (IQR 42.3-70), 16 (31%) were Hispanic, 15 (30%) were African American, and the median body mass index (BMI) was 27.15 kg/m 2 (see Table 1). Six of the 50 patients (12%) had a previous diagnosis of Type 1 DM with a median hemoglobin A1C (HbA1C) before the admission of 11%. Forty-four (88%) patients had previously diagnosed type 2 DM and their median HbA1c before the admission was 8.05%. Eight patients (16%) had previously undiagnosed DM. Twenty (40%) patients were on oral hypoglycemic agents with only 2 on SGLT2 inhibitors (which are known to increase the risk of ketoacidosis), 24 (48%) were on a home insulin regimen, and 4 (8%) patients were receiving treatment with GLP-1 agonists.The median value of the initial glucose on presentation in our sample population was 506.5 mg/dL (252.0-1485.0 mg/dL). Forty-three (86%) patients were treated with intravenous insulin infusion protocol and 7 (14%) were treated with subcutaneous insulin protocol. The mean insulin and the intravenous fluids requirements in the first 24 h were 115. 5Author contributions NCP, SP, JA, and PK contributed to the design and implementation of the data collection, and to the analysis of the results. All author's discussed the results and contributed to the final manuscript.

Severe obesity increases the risk for negative outcomes in patients with coronavirus disease 2019 (COVID-19). Our objectives were to investigate the effect of BMI on in-hospital outcomes in our New York City Health and Hospitals’ ethnically diverse population, further explore this effect by age, sex, race/ethnicity, and timing of admission, and, given the relationship between COVID-19 and hyperinflammation, assess the concentrations of markers of systemic inflammation in different BMI groups. A retrospective study was conducted in hospitalized patients with COVID-19 in the public health care system of New York City from 1 March 2020 to 31 October 2020. A total of 8833 patients were included in this analysis (women: 3593, median age: 62 years). The median body mass index (BMI) was 27.9 kg/m2. Both overweight and obesity were independently associated with in-hospital death. The association of overweight and obesity with death appeared to be stronger in men, younger patients, and individuals of Hispanic ethnicity. We did not observe higher concentrations of inflammatory markers in patients with obesity as compared to those without obesity. In conclusion, overweight and obesity were independently associated with in-hospital death. Obesity was not associated with higher concentrations of inflammatory markers.

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