حمیدرضا سامی مقام

COVID-19 is a viral respiratory disease caused by SARS-COV-2, which affects the lower respiratory tract, and causes pneumonia in patients. The disease rapidly spread around the world after the outbreak in late 2019, and became one of the challenges of health care systems. Older adults and patients with underlying diseases such as cardiovascular diseases, hypertension, and diabetes are at a higher risk for COVID-19, and need more care. Due to its prevalence in older adults and normal population, diabetes is important in terms of putting a burden on intensive care systems during the COVID-19 pandemic. Diabetes is also one of the most common comorbidities in patients with COVID-19, which is considered a risk factor for these patients. In addition, the association between diabetes and respiratory distress syndrome is not yet fully understood. Some studies have suggested that diabetes is not associated with respiratory distress syndrome while some others suggest that pulmonary dysfunction follows diabetes. It is also unclear what factors are associated with disease prognosis and mortality in COVID-19 patients with diabetes. In the current study, we aimed to investigate the status of demographic factors, comorbidities, lifestyle and laboratory results in diabetic patients with COVID-19, and compare them with the non-diabetic population and determine the prognostic factors in diabetic patients with COVID-19.

This study is a cross-sectional study performed on 415 patients with COVID-19 in the COVID-19 ward of Shahid Mohammadi Hospital of Hormozgan University of Medical Sciences from February to September 2020. Based on their diabetes, these patients were divided into diabetic and non-diabetic groups. Then, data on demographic factors, smoking, opioids and alcohol consumption, comorbidities (chronic lung disease, asthma, obesity, chronic kidney disease, type 2 diabetes, dementia, malnutrition, chronic neurological disease, rheumatic disease, hypertension, hyperthyroidism, hypothyroidism, favism, hyperlipidemia, and malignant neoplasms), some personal lifestyle features were determined in diabetic patients and compared with non-diabetic populations. Also, the information on biochemical variables, including hemoglobin, white blood cells, lymphocyte, neutrophils, hematocrit, platelets, prothrombin time, alanine aminotransferase, bilirubin, aspartate transaminase, lactate dehydrogenase, blood urea nitrogen, creatinine, blood glucose, sodium, potassium, C reactive protein were measured patients of the two groups. Also, heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, temperature, and oxygen saturation were determined in diabetic and non-diabetic patients.Quantitative variables were described by number (n) and percentage (٪). Qualitative variables were described using mean and standard deviation (SD), median and interquartile range (IQR). The Shapiro-Wilk test was used to assess the normality of quantitative variables. Independent t-test or Man-Whitney U test, and Chi-square or Fisher's exact tests were used to compare variables. In all statistical analyses, a p-value less than 0.05 was considered statistically significant. Statistical analysis was performed by IBM SPSS version 22 (IBM Corporation, Armonk, NY, USA).

The findings of our study showed that in the diabetic patients’ group 82 patients (41.2%) and in the non-diabetic population 135 patients (55.32 %) were men. In the diabetic group, the mean age of recovered patients was 58.52 years and the mean age of those in the deceased was 57.73 years, which was not statistically significant. In the non-diabetic group, the mean age of patients recovered was 47.98 years and the mean age of those in the deceased was 62.58 years, which was statistically significant (p <0.001). In the diabetic population, 773 patients (42.69 %) and in the non-diabetic population, 132 patients (54.09 %) had positive PCR. In the diabetic population, 18 patients (10.59 %) and in the non-diabetic population, 10 patients (4.09 %) had chronic kidney disease. In the diabetic population, 11 patients (6.43 %) and in the non-diabetic population, 13 patients (5.32 %) smoked. In the population of diabetic patients, the mean level of hemoglobin (P = 0.002) and lymphocyte count (P = 0.043) in the living cases were significantly lower than those in the deceased. The mean levels of neutrophils (P = 0.012), aspartate transaminase (P = 0.020), lactate dehydrogenase (P = 0.041), blood urea nitrogen (P = 0.003), and creatinine (P = 0.011) in the diabetic population were significantly higher in the living cases than those in the deceased, but the comparison of these cases in the non-diabetic population did not show a significant difference.In diabetic patients, there was a significant difference between the number of survival and death in each group of positive and negative PCR (P = 0.011); While the difference in mortality and survival between PCR positive and negative groups in non-diabetic subjects was not significant. In diabetic patients, a significant difference was also reported between the number of survival and death in groups with CKD and without CKD; while in non-diabetic participants there was no significant difference between CKD and non-CKD groups in terms of survival and death. Corticosteroid treatment also significantly led to a difference in the number of survival and death cases among the diabetic population, but a comparison of these cases in the non-diabetic population did not show a significant difference.In the group of diabetic patients, respiration rate (number of breaths per minute) was significantly lower among the living cases compared to those in the deceased (P < 0.05), while our findings in this regard did not show a significant difference in non-diabetic individuals. Also, in diabetic patients, the amount of oxygen saturation was significantly higher among the living cases than those in the deceased (P < 0.05), in which case the same results were observed in non-diabetic patients (P < 0.05).

In this study, the mortality rate in diabetic patients was significantly associated with lymphopenia, elevated aspartate transaminase, lactate dehydrogenase, blood urea nitrogen, and creatinine compared to non-diabetic patients.  Our findings suggest that individuals with type 2 diabetes are more prone to complications of COVID-19 and its related mortality; therefore these patients need more medical attention in the COVID-19 pandemic. Also, considering that so far limited studies have focused on the possible differences in the complications of Covid-19 disease and its mortality in diabetic individuals compared to non-diabetic individuals, it is recommended that more studies with higher sample sizes in other populations be performed to confirm the results of the present study.

Tendinopathy is defined as an overuse injury that is histologically associated with tenocyte proliferation, collagen fiber degradation, and increased non-collagen matrix, fluid accumulation between fibers, capillary proliferation, and calcification. Early diagnosis of tendinopathy is important in order to prevent severe tendon damage or even rupture. Tendinopathies, especially of the shoulder tendons, are common in hemodialysis patients due to loss of tendon elasticity and weakening of the structures, uremic toxins, accumulation of β2-microglubolin and malnutrition.  Tendon rupture is a complication of several disorders including chronic kidney disease and hemodialysis, systemic lupus erythematosus, gout, rheumatoid arthritis, diabetes mellitus, obesity and trauma. Bone changes and soft tissue calcification, spontaneous tendon rupture are some of the factors that can increase tendon thickness in chronic kidney disease patients. The tendons most affected are the quadriceps tendon, the patella tendon, and the Achilles tendon. There has also been a rare case of abdominal muscle tendon in a hemodialysis patient. Secondary hyperparathyroidism is an important factor in tendon rupture. In all patients with elevated Parathyroid hormone (PTH) levels, the risk of spontaneous tendon rupture increases, and there is also an increase in this risk in patients treated with quinolones and steroids. Although magnetic resonance imaging (MRI) and computerized tomography (CT) scan are the main diagnostic methods for assessing joint and surrounding joint pathology worldwide, diagnostic ultrasound has become increasingly used to assess musculoskeletal structure. Ultrasonography (US) is used to evaluate the superficial tendons and ligaments that attach to the joint. The device can detect the presence and features of joint fibrosis, bursae or joint cysts, and can also detect abnormal structures in the joints. Ultrasonography is an effective, inexpensive imaging modality in the evaluation of tendons and is an affordable way to diagnose tendon lesions, especially in dialysis patients. Ultrasonography has been shown to be a successful imaging modality for diagnosis of tendinopathies of shoulder. Early diagnosis of tendinopathies and conservative treatment are essential to prevent severe tendon damage or even rupture. Changes in tissue elasticity can be detected by USE before being detected on B-mode ultrasonography. Elastography methods use changes in soft tissue elasticity as a result of specific pathological or physiological processes. For example, many solid tumors are mechanically different from the surrounding healthy tissue. Also, fibrosis associated with chronic liver disease makes liver tissue harder than normal tissue. In this way, elasticity methods can be used to distinguish involved tissues from natural tissue for diagnostic applications. In recent years, this method has been used to evaluate liver fibrosis or to characterize breast lesions. Ultrasound elasticity test can provide more complete information about tissue hardness along with other measured parameters In some studies, tendon ultrasound showed the presence of calcified tissue and increased tendon thickness, which was positively correlated with parathyroid hormone level and duration of dialysis. This correlation was more significant with the increase of parathyroid hormone. Studies show a significant increase in the thickness of the supraspinatus tendon, biceps tendon, triceps tendon and sub scapular tendon in hemodialysis patients. Therefore, the aim of this study was to evaluate the ultrasound findings of biceps and supraspinatus tendons in chronic hemodialysis patients compared to non-dialysis patients.

  The present study was performed as a case-control study in hemodialysis patients referred to Rasoul Akram Hospital, Tehran. Inclusion criteria included advanced renal failure and regular hemodialysis for at least 6 months three times a week for 4 hours per session. The control group was selected from healthy volunteers.This study was approved with the ethics ID IR.IUMS.FMD.REC.1399.355. First, written consent was obtained from the individuals to enter the study. After obtaining written patient consent, complete patient history and laboratory data (CBC performed on Cell Dyn 1700; serum BUN and creatinine, serum calcium, serum phosphate (PO4), performed with BioLis24I autoanalyzer and stable PTH level Or iPTH was measured on ELISA kits developed by GenWay Biotech.The sonographic evaluation was performed by an experienced rheumatologist using a supersonic device with a linear probe at a frequency of 5.5-7 MHz. The use of ultrasonography due to the high accuracy in the diagnosis of various tendon disorders is either incomplete or complete. The presence of focal or diffuse heterogeneity in tissues with the presence of hypoechogenicity foci, swelling, and calcification in the tendon sheath or soft tissues around the tendon, irregular tendon margins, and fluid accumulation were among the sonographic findings. The data were collected in a checklist designed by the researcher based on the variables and evaluations performed.Data were analyzed using SPSS version 22. First, the variables were tested using the Kolmogorov-Smirnov criterion. Quantitative data were expressed as mean ± standard deviation and qualitative data were expressed as frequency and percentage. Significance level was determined at P <0.05.

During the study period, 60 people (30 dialysis patients as a patient group and 30 healthy individuals as a control group) who met the inclusion criteria were included in the study. There was no statistically significant difference between the studied groups in terms of age, weight and body mass index. The cross-sectional area of the supraspinatus tendon on the right side was significantly higher in patients than in healthy individuals. The mean elastography of the left biceps tendon in patients was significantly higher than healthy individuals. This parameter was not different in the supraspinatus tendon. There was no statistically significant difference between different levels of PTH and tendon thickness and cross sectional area.  In the present study, the elastographic indices of right and left biceps and supraspinatus tendons were not statistically significant in almost all parts of the tendons of patient group in comparison with healthy group. This finding confirms the effect of the other factors on the elasticity of the tendon along with its thickness and cross sectional area. In the study of correlation between elastography of biceps and supraspinatus tendons with age, PTH and tendon thickness, it was found that there is no statistically significant relationship between the mentioned variables and elastography.

In the present study, ultrasound indices of different parts of biceps and supraspinatus tendons of the right and left shoulders of patients and control group were compared with each other. Although it was not statistically significant in most cases, these indicators were generally higher in patients than healthy individuals. Findings of the present study showed that in the patient group, the thickness and cross-sectional area of the right supraspinatus was higher than the control group. Evaluation of ultrasonographic indices did not show a significant change in tendon elasticity in dialysis patients compared to healthy individuals.

Compared with the general population, hemodialysis patients are at increased risk of vascular calcification, which in turn is associated with an increased risk of mortality. Regarding the role of vitamin D in bone formation, regulation of calcium, phosphate and iPTH level and correlation of these variables in survival, this study was performed to evaluate the vitamin D serum level and its correlation with vascular calcification in hemodialysis patients.
In this analytical, cross-sectional study one hundred hemodialysis patients who referred for dialysis to Shahid Mohammadi hospital in Bandar Abbas were evaluated in 2011. Patients older than 15 years on regular hemodialysis (at least dialyzed for 3 months) were selected as study population and patients who had undergone parathyroidectomy were excluded. Variables such as age, sex, BMI, hemodialysis duration, vitamin D, ferritin, PTH, calcium, phosphate, hemoglobin and CRP were specified. Vascular calcification in lateral x-ray of abdomen determined based on scoring system to abdominal aortic calcification in front of lumbar spines (L1-L4). Data analysis was performed by SPSS software and t-test and Chi-Square test.
In this study 25% of hemodialysis patients had vitamin D deficiency that in male and female were similar. The prevalence of vascular calcification based on plain lateral abdominal x-ray was 52. 2%, that was included 55% women and 45% men. No relationship was found between vascular calcification and Vitamin D serum level, but there was positive correlation between vascular calcification and patient's age, also higher level of serum Ferritin was detected in patients with higher Vitamin D level (P=0.001).
In summary our study results showed the low prevalence (25%) of Vitamin D deficiency in hemodialysis patients as compared to similar studies in other countries that may be related to geographical situation of the region. No relationship was found between Vitamin D serum level and vascular calcification. In this study the vascular calcification has been evaluated with plain x-ray that is not a high sensitive test. For measuring vascular calcification our recommendation is to perform more sensitive tests

One of the main complications associated with arteriovenous fistula in hemodialysis patients is the median nerve ischemic neuropathy in the wrist. This study was conducted to examine the effect of arteriovenous fistula on the development of carpal tunnel syndrome. This cross-sectional study was conducted on 37 hemodialysis patients at Shahid Mohammadi Hospital of Bandar Abbas in 2007-2008. All of the patients had either a distal or a proximal arteriovenous fistula in one hand. Nerve conduction velocity and median nerve distal sensory and motor latency were applied to the diagnosis of carpal tunnel syndrome. The limb with fistula (the case) was compared to the one without it. Data were analyzed through independent t-test and Pearson product correlation. Overall, 17 patients had proximal and the rest had distal fistulas. Fistulas aging more than one year were seen in 15 patients and 22 patients had fistulas less than one year old. Carpal tunnel syndrome had developed in 25 wrists with fistula (17 motor and 8 sensory cases) and 27 wrists without fistula. A significant difference was observed in the median nerve distal sensory latency between the wrists with fistula and those without it. There was not a significant difference between the variables. In addition, there was a significant difference between the age of the fistulas and the incidence of carpal tunnel syndrome. The rate of the development of carpal tunnel syndrome in wrists with or without fistula is the same. Also, the site of the fistula does not have any effects on the incidence of the median nerve ischemic neuropathy.

Common carotid artery intima-media thickness (CCA-IMT) correlates with cardiovascular mortality in patients under hemodialysis. In this investigation, we evaluated relationship between CCA-IMT with dependent and independent cardiovascular risk factors in chronic hemodialysis patients. In this cross-sectional study, 51 chronic hemodialysis patients, (31 males and 20 females) were enrolled. left and right CCA-IMT were measured using high resolution B-mode ultra sonography and maximum measure was considered. Based on ultra sonographic findings, patients were divided into two groups, one with carotid intima thickness of ≥0.8mm and another group with carotid intima thickness of <0.8mm. Data was analyzed, using Minitab software. Mean age of these with carotid intima thickness ≥0.8mm was significantly higher than these with carotid intima thickness <0.80mm (P<0.05), (60.7±8.4 vs 41.3±18.7). Although, there were differences in hemodialysis duration, systolic and diastolic blood pressure, blood cholesterol and triglyceride LDL, diabetes and smoking history of these two groups, but the differences were not significant. This study indicates that there is no significant correlation between CCA-IMT and cardiovascular risk factors in chronic hemodialysis patients

Left ventricular hypertrophy (LVH) is reported to be common in chronic hemodialysis patients and also increases risk for mortality and morbidity in such patients. Effects of PTH on LVH are approved by clinical and experimental studies. Therefore, PTH control is important in LVH prevention. In some centers PTH can be measured, so we conducted a descriptive study about the relationship between Ca, P, alkaline phosphatase and LVH in chronic hemodialysis patients.

56 chronic hemodialysis patients were included in this descriptive-analytical study and followed for one year. The patients were divided into LVH group and non- LVH group by echocardiographic findings. The mean Ca, P, Alkaline Phosphatase (Alk),Ca×P product, Hb, HCT, serum Albumin were checked monthly moreover HTN frequency, hemodialysis duration, cardiac calcification and ACE in, EPO use were compared in the two groups. Relationship between these factors and LVH was evaluated using Chi-Square T.test and fisher-Exact test.

Results showed that 32 patients (57.1%) had LVH, among them 19 patients (59.4%) were male and 13 patients were (40.6%) female (P<0.05). Mean age of patients with LVH was 53.5+13.3 which had not statistically significant difference with patients without LVH (P>0.05). The mean serum levels of Ca, P, Alk P, Hb were not significantly different in both groups but mean of Ca×P product was significantly higher in the LVH group(P<0.05) (58.7±16.6 versus 47.6±18.2).

HTN control, ACE inhibitor and EPO use are important in prevention of LVH in chronic hemodialysis patients but maintenance of Ca×P product in acceptable level is another important factor for this prevention.

Arteriovenous fistulas (AVF) make chronic hemodialysis easy, but the complications are unpredictable. Ischemic neuropathy due to arterial insufficiency is one of the most important complications of AVF. This study was designed to evaluate ischemic neuropathy using electro diagnostic method in the extremity carrying fistula.

In this cross-sectional study, 37 hemodialysis patients at the hemodialysis center of Shahid-Mohammadi hospital (Bandar-Abbas) were enrolled. All of the patients had only one AVF in one extremity. NCV of median and ulnar nerves of both upper extremities were evaluated and the intact extremity of all patients served as the control group.

In patients with distal AVF, ulnar motor conduction velocities were significantly increased (p: 0.034). Distal and proximal amplitudes of ulnar nerve were decreased only in non-diabetic and hypertensive patients (p<0.05). Median sensory nerve action potential was increased, distal amplitude decreased (p: 0.04) and sensory latency was increased (p: 0.02). In patients with proximal AVF, ulnar proximal amplitude and median motor conduction velocities were decreased (p: 0.05). There was a negative correlation between the age of AVF and development of neuropathy. In most patients with neuropathy, AVF age was less than one year.

Ulnar nerve is more sensitive to ischemia than median nerve and sensory fibers are more sensitive than motor fibers. The site of fistula had no affect on the rate of development of ischemic neuropathy. We recommend using electrodiagnostic study for screening of ischemic neuropathy every 6 months in hemodialysis patients.