Esophageal perforation etiology, outcome, and the role of surgical management - an 18-year experience of surgical cases in a referral center.

INTRODUCTION: Esophageal perforation is a surgical emergency with a high rate of morbidity and mortality. Its poor prognosis is mainly associated with previous patient-specific comorbidities and a lack of timely diagnosis and treatment. The objective of this study was to investigate the etiological factors and different surgical methods of treatment with consideration of mortality rate and comorbidities. METHOD: The present cross-sectional study was conducted on patients who underwent surgical intervention due to esophageal injury from 2002 to 2019 (18 years). Demographic and clinical characteristics along with performed surgical interventions were evaluated accordingly. RESULTS: In this study, 69 patients with a mean age of 38.8 years were evaluated, of which 45 (65.2%) cases were men. In terms of location of the perforation, the thoracic portion of the esophagus followed by the cervical and abdominal esophagus were more frequently injured with a rate of 32 (46.4%), 30 (43.5%), and 19 (27.5%) cases, respectively. Accordingly, foreign body ingestion followed by penetrating injuries were the most common causative agents leading to esophageal perforation. CONCLUSION: Obtaining the desired results from the treatment of this condition depends on factors such as patients' previous comorbidities, cause of the rupture, the location of the esophageal damage, and delay in the start of treatment. Since there is no single gold standard treatment strategy, each patient should be individually evaluated.

The effect of suture techniques on the outcome of tracheal reconstruction: An observational study and review of literature.

BACKGROUND: Tracheal resection and anastomosis surgery is a safe operation and is used to treat various benign and malignant diseases of the trachea. However, tracheal stenosis is among the main anastomotic complications following this procedure. Surgeons use both the continuous and the interrupted suture techniques for tracheal anastomosis, but contradicting results in each technique's complications have been reported in various studies. In this study, we aimed to compare the outcome of these two different suture techniques and a relevant literature review. METHODS: Surgical records during a period of 15 years (2005-2019) were screened for tracheal reconstruction surgery in affiliated hospitals of Shiraz University of Medical Sciences, Shiraz, Iran. A total of 82 patients were evaluated based on surgical and suture features, along with their follow-up bronchoscopy for anastomotic complications. RESULTS: Post-operational subclinical restenosis occurred in 8 (15.3%) out of 52 and 10 (33.3%) of 30 patients who underwent continuous and interrupted suturing techniques, respectively. Also, 6 (20%) patients in the interrupted group developed symptomatic restenosis, while in the continuous group, only one patient was clinically symptomatic. The patients with continuous suture technique had a shorter surgery time than patients whose interrupted technique was used (P < 0.001). CONCLUSIONS: Based on our results, we conclude that restenosis is significantly reduced when the continuous technique is applied for tracheal anastomosis; However, the results are contradicting in relevant literature and due to the retrospective nature of our study, further human studies and clinical trials are warranted.

The role of routine chest radiography after implantable venous access port catheter insertion under the guide of ultrasonography and fluoroscopy.

BACKGROUND: The objective of this study is the evaluation of routine chest radiography following the placement of Implantable venous access port catheter (IVAPC) central lines using combined ultrasound and fluoroscopic guidance by a vascular surgeon in the operating room. MATERIAL AND METHOD: A prospective study of 189 consecutive patients who underwent IVAPC central line insertion in the vascular surgery operating room from 2016 to 2019. Venipuncture was performed with an 18-gauge needle under the guidance of sonography in each case, and the access site was noted. The line position was confirmed by fluoroscopy following the procedure. Multiple tries for puncture and patients under 18 were excluded from our study. Routine radiography of chest was performed for all patients and pneumothorax, hemothorax, and catheter malposition were evaluated in each case. RESULTS: There were 2 cases of asymptomatic pneumothorax, no cases of hemothorax, and all catheter tip positions were optimal or acceptable. The annual cost of chest radiography was 33,000,000IRR, 220 h of hospital and staff time, and 1.1 mSv radiation. CONCLUSION: In conclusion, when imaging guidance is used for IVAPC insertion by an experienced surgeon in a high-volume center, performing post-procedure routine chest radiography shows little benefit.

The incidence and features of Delphian lymph node involvement in patients with papillary thyroid carcinoma.

INTRODUCTION: In papillary thyroid cancer patients, the extent of dissection is still a matter of debate. Evaluating Delphian lymph nodes (DLNs) during the surgery has been speculated as a valuable tool to determine the extent of dissection. Herein, we aimed to evaluate the incidence and features of DLNs involvement in patients with papillary thyroid carcinoma. METHOD: We conducted this cross-sectional study among surgical cases of papillary thyroid cancer. Patients were divided based on their DLNs involvement status. Their age, gender, location of the mass, lymphatic involvement, tumor size, tumor characteristics, pathology report, and operation note features were compared between the two groups. Definitive pathology slides of the patients were evaluated regarding DLN features. RESULTS: Of the 61 patients (mean age: 38.2 ± 12.0), 45 (73.8%) were females. In 13 (21.3%) patients, DLNs involvement was reported. A statistically significant relationship was noted between DLNs involvement and other lymph nodes' involvement on the same side of the mass (P < 0.001), the opposite side (P = 0.041), and also central lymph nodes (P < 0.001). Vascular invasion was also significantly higher among patients with DLNs involvement (P = 0.012). CONCLUSION: Since DLNs involvement is significantly associated with extensive nodal involvement, intraoperative evaluation of DLNs is recommended to establish the extent to which dissection should be performed.

Methylprednisolone or dexamethasone, which one is superior corticosteroid in the treatment of hospitalized COVID-19 patients: a triple-blinded randomized controlled trial.

BACKGROUND: Although almost a year has passed since the Coronavirus disease 2019 (COVID-19) outbreak and promising reports of vaccines have been presented, we still have a long way until these measures are available for all. Furthermore, the most appropriate corticosteroid and dose in the treatment of COVID-19 have remained uncertain. We conducted a study to assess the effectiveness of methylprednisolone treatment versus dexamethasone for hospitalized COVID-19 patients. METHODS: In this prospective triple-blinded randomized controlled trial, we enrolled 86 hospitalized COVID-19 patients from August to November 2020, in Shiraz, Iran. The patients were randomly allocated into two groups to receive either methylprednisolone (2 mg/kg/day; intervention group) or dexamethasone (6 mg/day; control group). Data were assessed based on a 9-point WHO ordinal scale extending from uninfected (point 0) to death (point 8). RESULTS: There were no significant differences between the groups on admission. However, the intervention group demonstrated significantly better clinical status compared to the control group at day 5 (4.02 vs. 5.21, p = 0.002) and day 10 (2.90 vs. 4.71, p = 0.001) of admission. There was also a significant difference in the overall mean score between the intervention group and the control group, (3.909 vs. 4.873 respectively, p = 0.004). The mean length of hospital stay was 7.43 ± 3.64 and 10.52 ± 5.47 days in the intervention and control groups, respectively (p = 0.015). The need for a ventilator was significantly lower in the intervention group than in the control group (18.2% vs 38.1% p = 0.040). CONCLUSION: In hospitalized hypoxic COVID-19 patients, methylprednisolone demonstrated better results compared to dexamethasone. TRIAL REGISTRATION: The trial was registered with IRCT.IR (08/04/2020-No. IRCT20200204046369N1 ).

Students' attitude and sleep pattern during school closure following COVID-19 pandemic quarantine: a web-based survey in south of Iran.

BACKGROUND: School closure is one of the main policies of global health care strategies performed worldwide. Despite all benefits, there might be some threats for younger groups spending their time in quarantine. This study aims to determine the impacts of lockdown and school closure on children's major lifestyle aspects, especially their leisure and sleep pattern during the COVID-19 pandemic. METHODS: For the purpose of this study, an online questionnaire was distributed from 14th to 31st of March 2020 among the schools and students from the first grade to the 12th grade (before university) in Fars province, southern Iran. The questionnaire consisted of five sections which included data regarding the students' general information, activity priorities, adherence to quarantine, attitude toward school closure, and sleep patterns. RESULTS: In our study, 20,697 filled questionnaires were received from the participants with an average age of 13.76 years; 29.7% of them were male, 80.6% were from urban areas, and 83.3% were from public schools. The overall first preference of students during school closure was mobile and computer games (30.1%), followed by studying (26.6%) and watching television (13.8%). Our results demonstrated that the majority of students adhered to social distancing and there was also a significant correlation among education levels and desire for schools to be closed till the end of the semester (P = 0.015). Also, regarding sleep patterns, the majority (53.5%) had above 12 h of sleep throughout the day. CONCLUSION: It seems that lockdown following COVID-19 pandemic has changed various aspects of the students' lifestyle remarkably, especially by increasing screen time and even sleep duration and pattern. We believe that certain strategies should be implemented by the Health and Educational Ministry to control not only the visible side effects of the quarantine period, but also the collateral consequences on their psychological and mental health.

Epidemiological and clinical features of 2019 novel coronavirus diseases (COVID-19) in the South of Iran.

BACKGROUND: In March 2020, the WHO declared the novel coronavirus (COVID-19) outbreak a global pandemic. Although the number of infected cases is increasing, information about its clinical characteristics in the Middle East, especially in Iran, a country which is considered to be one of the most important focal points of the disease in the world, is lacking. To date, there is no available literature on the clinical data on COVID-19 patients in Iran. METHODS: In this multicenter retrospective study, 113 hospitalized confirmed cases of COVID-19 admitted to university affiliated hospitals in Shiraz, Iran from February 20 to March 20 were entered in the study. RESULTS: The mean age was 53.75 years and 71 (62.8%) were males. The most common symptoms at onset were fatigue (75: 66.4%), cough (73: 64.6%), and fever (67: 59.3%). Laboratory data revealed significant correlation between lymphocyte count (P value = 0.003), partial thromboplastin time (P value = 0.000), international normalized ratio (P value = 0.000) with the severity of the disease. The most common abnormality in chest CT scans was ground-glass opacity (77: 93.9%), followed by consolidation (48: 58.5%). Our results revealed an overall 8% (9 out of 113 cases) mortality rate among patients, in which the majority was among patients admitted to the ICU (5: 55.6%). CONCLUSION: Evaluating the clinical data of COVID-19 patients and finding the source of infection and studying the behavior of the disease is crucial for understanding the pandemic.

Evaluation of epilepsy and burn patterns in a tertiary hospital in southwestern Iran.

PURPOSE: Based on the high rates of burn injuries in patients with epilepsy, it is crucial to evaluate the epidemiological factors, etiology, types of burns, and outcome of these certain individuals and to enhance knowledge about the possible risks of epilepsy-related burns by preventive actions and programs. METHOD: Our retrospective study was carried out from September 2013 to February 2017 in Amir-al Momenin Hospital, a tertiary referral burns and plastic surgery healthcare center. Because of the fact that a number of patients with burns had experienced their trauma at the time of convulsion or in postconvulsion phase, it is necessary to evaluate the outcome, burn patterns, etiology of injury, and related epidemiological factors in order to develop a greater understanding of possible risks of epilepsy-related burns by preventive actions and programs. RESULT: In our study, 2715 patients who referred to burn centers and hospitalized with a mean age of 26.838 (standard deviation (SD) = 21.186) were enrolled, in which 29 patients were involved in burn accidents due to epilepsy and seizure, resulting in a 1.1% epilepsy incidence in these individuals. In patients with seizure disorder, there was a mean rate of 5.8 (SD = 1.923) cases per year. Eighteen (62.1%) were male, and 11 (37.9%) were female. There were no cases of seizure-induced burn injury in pediatrics (<15 years) in our study. Among the patients with seizure-induced burns, 11 (out of 1101; 37.9%) were from rural areas, while 18 (out of 1570; 62.1%) were from urban locations. The occurrence of accidents due to seizure was also categorized based on the season, with the highest occurrence during winter (12 out of 683; 41.4%) and lowest during spring (3 out of 659; 10.3%). The mechanism of burn in patients with seizures was also documented, in which 12 (41.4%) were due to liquid, 12 (41.4%) due to fire, 1 (3.4%) due to explosion, and 1 (3.4%) due to other objects. Out of patients with seizure-induced burns, 21 (72.4%) were discharged, 2 released with their own will, 1 was transferred, and 5 (17.2%) died in the course of hospitalization. CONCLUSION: This study demonstrates that burn injuries by epilepsy are a public health concern in low- and middle-income countries. Therefore, we suggest the execution of a strong national epilepsy preventive actions and programs, as well as proper education for both medical practitioners and patients of the possible dangers as part of an injury control program.

Suicide by self-immolation in southern Iran: an epidemiological study.

BACKGROUND: Self-immolation, as a method of suicide, is one of the most violent and extreme ways which is usually attempted by the ignition of inflammable materials, with more than 70% fatality rate. In the literature, Iran has been reported to have a high rate of self-immolation; therefore, this study aimed to evaluate the prevalence and epidemiological features of self-immolated patients. METHODS: In this retrospective cross-sectional multicenter study, data from burn patients from 2007 till 2017 due to self-immolation and suicide were enrolled in our study. RESULTS: Based on our data, 657 out of 3530 burn patients (18.6%) with a mean age of 31.15 (SD = 0.452) were documented as suicidal attempts; the majority were female (63.2%) and married (66.3%). Most of the patients were from rural areas (58.3%) with an education level of under diploma (63.2%). Of the patients in our study, 22 (8.7%) had comorbid systemic diseases and 115 (50.5%) had psychiatric disorders. CONCLUSION: Due to the high prevalence of suicide by self-immolation among the Iranian population, further studies to evaluate the risk factors and clarify the high-risk group for more targeted approaches are recommended.

Intrapulmonary mature cystic teratoma of the lung: case report of a rare entity.

BACKGROUND: Intrapulmonary teratoma (IPT) is a rare type of extra gonadal teratoma which often presents with non-specific symptoms and can be misdiagnosed as other diseases. Here we report a patient with IPT which was initially misdiagnosed as lung hydatid cyst versus abscess. CASE PRESENTATION: We report an intrapulmonary teratoma in a 27-year-old female presenting with persistent chest pain and dyspnea since a few years prior to her admission with associated symptoms of cough and fever. Chest x-ray only showed left side massive pleural effusion and computed tomography scan of the lungs was suggestive of hydatid cyst or a lung abscess. She underwent lobectomy and postoperative histopathological study revealed IPT as the final diagnosis. CONCLUSION: Due to the non-specific symptoms and rarity, IPT can be easily misdiagnosed at first. It is essential that physicians take into account the possibility of IPT when approaching a new case of lung mass.

Evaluation of the predictors and frequency of silent hypoxemia in COVID-19 patients and the gap between pulse oximeter and arterial blood gas levels: A cross-sectional study.

Background: Silent hypoxemia is when patients do not experience breathing difficulty in the presence of alarmingly low O2 saturation. It could cause rapid deterioration and higher mortality rates among patients, so prompt detection and identifying predictive factors could result in significantly better outcomes. This study aims to document the evidence of silent hypoxemia in patients with COVID-19 and its clinical features. Methods: A total of 78 hospitalized, nonintubated patients with confirmed COVID-19 infection were included in this study. Their O2 saturation was measured with a pulse oximeter (PO), and arterial blood gas (ABG) was taken. Demographic and clinical features were recorded. The Borg scale was used to evaluate dyspnea status, and patients with a score of less than two accompanied by O2 saturation of less than 94% were labeled as silent hypoxic. Univariate analysis was utilized to evaluate the correlation between variables and their odds ratio (OR) and 95% confidence interval (CI). Results: Silent hypoxemia was observed in 20 (25.6%) of the participants. The average difference between the PO and ABG methods was 4.36 ± 3.43. Based on regression analysis, dyspnea and respiratory rate demonstrated a statistically significant correlation with the O2 saturation difference between PO and ABG (OR: 2.05; p = 0.026; 95% CI: 0.248-3.847 and OR: 0.144; p = 0.048, 95% CI: 0.001-0.286). Furthermore, the Borg scale (OR: 0.29; p = 0.009; 95% CI: 0.116-0.740) had a significant reverse correlation with silent hypoxia. Conclusions: Silent hypoxemia can be a possible complication that affects some COVID-19 patients. Further care should be bestowed upon the younger population and those with underlying neurological or mental illnesses. Furthermore, the respiratory rate, pulse oximeter, and arterial blood gas O2 levels should be considered alongside each other.

The trend of mortality rates following hospitals downgrading and closures due to outbreak of COVID-19 in Fars province: A comparative cohort study.

Background and Aims: Hospitals are one of the most important healthcare centers for providing the patients with different medical needs. Several different factors might cause hospitals to downgrade their services or departments or close down overall. One of the most multifaceted reasons for hospital downgrading or closure is infectious disease outbreaks. In this regard, we aimed to evaluate the effects of hospital closure and downgrading due to the COVID-19 pandemic on the mortality rate of the people residing in Fars province, Iran. Methods: We gathered mortality information, including the cause of death, age, sex, place, and time of death of all deceased cases occurring during a period of 3 years, from February 20, 2018 to March 2021 from the forensic medicine and also the Department of Biostatistics in Shiraz University of Medical Sciences. Results: A total of 71,331 deaths have been reported since 2018 through the first quarter of 2021, with 57.9% of total mortality cases attributed to male gender. The total mortality counts ranged from 4229 to 9809 deaths per quarter, from which the minimum rate was reported in the first quarter of 2018 and the maximum in the fourth quarter of 2020. Based on the causes of death, diseases of the circulatory system were shown to be the all-time most frequent cause of death, accounting for a total of 42.8% of recorded deaths, followed by neoplasms (9.77%) and diseases of the respiratory system (9.45%). Conclusion: Although the large number of deaths at the time of the pandemic are immediately due to COVID-19 infection, deaths due to a notable number of other causes have had a significant increase which, along with the specific trend of place and causes of death, shows that the downgrading and closure of hospitals have had a significant impact on overall population mortality.

Hypertonic saline solution 5% as an effective cost-beneficial alternative to normal saline for wound healing in patients with diabetic lower-extremity ulcers: a randomized controlled trial.

Background: Diabetic foot ulcer is among the most common complications and causes of mortality and morbidity in patients with diabetes. Herein, we propose using 5% Hypertonic Solution as an alternative to Normal Saline in treating patients with diabetic foot ulcers as an effective cost-benefit therapeutic approach. Methods: In this clinical trial, 100 patients with diabetic foot ulcers were divided into two groups. Foot ulcer was washed and treated three times a day with the 5% hypertonic saline solution in the first group, while the second group was treated with normal saline 0.9% and normal washing. Patients were examined for the size and depth of the wound weekly, and the results were recorded after six weeks. Results: The mean length and width of the wound in the experimental group significantly decreased six weeks after the start of treatment with hypertonic saline (p < 0.05). The wound healing rate was lower after treatment in both groups of patients who had a longer disease duration and higher HbA1c. Conclusion: Treating diabetic foot ulcers with hypertonic saline solution may help improve wound healing. Therefore, rinsing with hypertonic saline is a cheap, safe, simple, and non-invasive treatment protocol for these patients.

Prevalence of Suicide by Self-immolation Among Children in Southern Iran.

Self-immolation is considered among the most rigorous acts of suicide. Lately, this act has increased in children. We evaluated the frequency of self-immolation among children in the largest burn referral center in southern Iran. This cross-sectional study was conducted from January 2014 to the end of 2018 at a tertiary referral burn and plastic surgery healthcare center in southern Iran. Subjects were pediatric self-immolation burn patients registered as outpatients or inpatients. The patients' parents were contacted regarding any incomplete information. Among 913 children admitted due to burn injuries, 14 (1.55%) were admitted with an impression of suicidal self-immolation. Among self-immolation patients, the ages ranged from 11 to 15 years (mean: 13.64 ± 1.33), and the average burnt percentage of total body surface area was 67.07 ± 31.19%. The male-to-female ratio was 1:1, and the majority were from urban areas (57.1%). The most frequent cause of burn injury was fire (92.9%). There was no history of family mental illness or suicide among the patients, and only one of the patients had an underlying disease of intellectual disability. The mortality percentage was 64.3%. The percentage of childhood suicidal attempts by burn injuries was alarmingly high among children aged from 11 to 15. While contrary to many reports, we reported this phenomenon to be relatively similar between genders, and also between urban and rural patients. Compared with accidental burn injuries, the self-immolation group had significantly higher age and burn percentage, and were more frequently caused by fire, occurred outdoors, and resulted in mortality.

Demographic, clinical, and paraclinical features of patients operated with the diagnosis of acute descending necrotizing mediastinitis: a retrospective study in Southern Iran.

INTRODUCTION: Descending necrotizing mediastinitis (DNM) is a type of acute mediastinitis that is rarely reported but is regarded as a fatal disease despite improvements in technological methods and antibiotic therapies. We aimed to determine the demographic, clinical, and paraclinical features of patients diagnosed with acute DNM. METHODS: In this retrospective study, patients' hospital records with a diagnosis of DNM admitted to the Namazi hospital in southern Iran during 18 years (2002-2019) were reviewed. Demographic and clinical features were recorded and subsequently analyzed via SPSS 22. RESULTS: Out of 67 mediastinitis patients, 25 (37.3%) were diagnosed as DNM with an average age of 37.2 ± 16.7 years, and 68% were male. Regarding etiology, 52.0% were due to neck infection. Based on the technique of surgery, 52% of the patients underwent the combined method, which was mostly among type I and IIA DNM, while thoracotomy was mostly performed on type IIB DNM (P = 0.08). Based on the incision, type IIA and IIB had the highest frequency of thoracotomy and cervicothoracic incisions (P = 0.02 and 0.002). Puss discharge was significantly lower in type I DNM (P = 0.01). Based on the presenting symptoms of our patients, the majority (72.0%) had a chief complaint of neck pain, followed by chills and fever (48%). There were no reports of mortality during our short-term follow-up. CONCLUSION: We report one of the largest retrospective studies of DNM patients in our referral center, with a high prevalence of the disease among younger populations, especially under 40 years. The method of treatment should be chosen based on the extent of infection and can be limited to neck exploration in upper mediastinal infections, though thoracic or combined approach in more broad infections.

Primary malignant epithelioid hemangioendothelioma of the pleura: A review and report of a novel case.

Epithelioid hemangioendothelioma is considered an uncommon tumor originating from vascular tissues. Although this disease is an extremely rare malignant cancer, its pleural subtype is even less common. We discuss a 68-year-old man with isolated pleural epithelioid hemangioendothelioma, along with a literature review of all similar cases.

Socioeconomic Features of Burn Injuries in Southern Iran: A Cross-sectional Study.

Burn injuries are among the most traumatic incidences which could be associated with substantial morbidity and mortality. The incidence of these injuries differs based on population socioeconomic characteristics. In this study, we aim to evaluate the distribution of burn injuries based on socioeconomic and causative factors. Relative features from the targeted population were obtained and evaluated. Data were extracted in August 2019 and statistical analysis of the data was conducted from February 2020 to April 2020. This cross-sectional record-based study was conducted from 2008 to 2016 in a main referral center for burn injuries in the southern Iran. Participants included burn survivors and burn patients who were registered as outpatients or inpatients. A total of 4919 burn cases with a mean age of 31.91 ± 17.33, including 2926 (59.5%) males and 1993 (40.5%) females was reported. The majority of our cases had an educational level of under diploma (40.72%). A significant correlation between age, gender, and percentage of burn with the level of education was recorded (P < .001). The most frequent cause of burn injuries was flame with 2537 (51.9%) cases. The most susceptible population to burn injuries were reported to be poorly educated individuals, which emphasizes the preventive role of education.

Experiences with intestinal failure from an intestinal rehabilitation unit in a country without home parenteral nutrition.

OBJECTIVE: For the first time, we reported experiences with an intestinal rehabilitation unit (IRU) from a country without home parenteral nutrition (HPN). METHODS: We included patients with a diagnosis of intestinal failure (IF) since the establishment of our IRU from February 2018 to February 2020. We further report on our protocols for management of enterocutaneous fistulas (ECFs), short-bowel syndrome (SBS), chronic intestinal pseudo-obstruction and motility disorders. RESULTS: Among a total of 349 patients who have been admitted, 100 patients had IF and were included . Mean (SD) age of patients was 46.3 ± 16.1 years. Most common cause of IF was ECFs (32%), SBS (24%), and SBS + fistula (22%). Most common causes of SBS were mesenteric ischemia (63.3%) and repeated surgery (22.4%). Median (interquartile range [IQR]) duration of parenteral nutrition (PN) for patients was 32 (18-60) days. The most common reconstructive surgery performed was resection and anastomosis (75.4%), followed by serial transverse enteroplasty procedure (10.5%) and closure of ostoma (7%). Patients were hospitalized for a median (IQR) of 33 (17.5-61) days. Most common complications were sepsis (45%), catheter infections (43%), and catheter thrombosis (20%), respectively. At the final follow-up, 61% stopped receiving PN, 23% became candidates for transplantation, and 16% died. CONCLUSION: Considering that most countries lack facilities for HPN, by establishing IRUs using specific treatment protocols and autologous gastrointestinal reconstruction techniques will provide a means to manage patients with IF, thus decreasing death rates and number of patients who require intestinal transplantations due to IF.

ROHHAD Syndrome an Inconspicuous Cause of Hypernatremia, A Case Report.

Rapid-onset obesity with hypoventilation, hypothalamic dysfunction, and autonomic dysregulation (ROHHAD) syndrome is a rare, life threatening disease with unknown etiology. Dysnatremia is a common finding in these patients. Here we present a 12-year-old boy with multiple admissions due to hypernatremia and was repeatedly misdiagnosed. An eventual diagnosis of ROHHAD syndrome was made by integration of the previous ignored findings of sleep apnea and obesity. The diagnosis of this rare but potentially fatal syndrome should be considered in patients with dysnatremia associated with obesity and sleep apnea disorders.