Background: Delayed hyponatremia is a common phenomenon following transsphenoidal surgery. Recent evidence suggests that the risk of developing intensive care unit-acquired hyponatremia is high following cardiac surgery. Herein, we report management of persistent hyponatremia after offpump coronary artery bypass in a patient with diabetes and hypothyroidism who was on diuretics. Case description: An 81-year-old man with diabetes and hypothyroidism was admitted to Valiasr hospital in Birjand (Iran) with history of typical chest pain and dyspnea since a month ago. Coronary angiography revealed a critical triple vessel disease, and therefore, the patient was considered a candidate for coronary artery bypass grafting. His pre-operative sodium level was normal but decreased to 128mEq/L on sixth postoperative day. Conclusion: When hyponatremia is detected in a patient with hypothyroidism, even if severe, in the absence of myxedema coma, it may not be directly associated with the lack of thyroid hormones. Thus, other possible etiologies should be considered.

Background: Opium has been used for thousands of years for medical and analgesic purposes, and its misuse has also increased in recent years. Methadone, a synthetic opioid, has been used as an analgesic and to help patients quit opium addiction. However, some evidence suggests that long-term use of opioids can affect the hypothalamic-pituitary-adrenal axis. Objectives: We aimed to evaluate the serum cortisol level and response to the cosyntropin stimulation test in opium addicts on methadone treatment. Methods: The study was conducted in November 2019 at Imam Reza Hospital Rehab Center, Birjand, Iran. Thirty-eight methadone-treated opium addicts participated in the study. A blood sample was initially obtained, then 250 µg intramuscular cosyntropin was injected. After 30 and 60 minutes, two other blood samples were obtained. The data were analyzed using SPSS. Results: There was a significant difference between serum cortisol levels and the normal value in methadone users (9.46 ± 5.42 vs. 14 µg/dL) (P < 0.001). The mean response to the cosyntropin stimulation test in methadone users was 9.34 ± 8.11 µg/dL. Also, 55% of the participants had adrenal insufficiency. Conclusions: Serum cortisol levels significantly differed from normal values in methadone-treated patients. Therefore, we recommend measuring serum cortisol levels in methadone-treated patients before major medical procedures to consider the stress doses of corticosteroids.

Background: Burn donor site care is one of the most important concerns in burn surgery. Traditional dressings for donor sites have some disadvantages, which interfere with epithelial growth and final results. Objectives: This study evaluated the role of a novel complex dressing in the management of donor burn site. Patients and Methods: After harvesting skin graft from the donor site, two different methods of dressing were selected. In control group (53 patients), traditional dressing was put on the donor site, but in investigation group (54 patients), a combination dressing consist of an absorbent dressing (Melolin) and a protective transparent film (Flexigrid) was used. Results: Epithelialization time was approximately 2.5 times shorter in the investigational group (P < 0.05). The infection rates were 4% and 21% (P < 0.05) in the investigation and control groups, respectively. Hospitalization time was decreased significantly, thus decreasing the final cost of about 25%. Cosmetic results were better in the investigation group and more acceptable than the control group. Conclusions: This new technique of dressing in burn donor sites not only can decrease the epithelialization time, but also can lead to better cosmetic results, lower infection rates and decreased final costs; thus, recommendable for all skin donor sites in burn.

Introduction: Complex regional pain syndrome (CRPS) is characterized by extreme pain in a limb disproportional to the clinical history or physical findings accompanied by the signs of autonomic dysfunction. The pathophysiology of CRPS is obscure, making it challenging to treat. Treatment options include medications, physical therapy, and psychological support. In some cases, surgery or other minimally-invasive procedures such as nerve blocks may be recommended, while several novel treatments, such as ozone therapy, lack sufficient clinical evidence. Case Presentation: A 40-year-old man with CRPS was referred to our clinic with pain in his right arm and left lower leg. The patient had a history of trauma to the ulnar nerve and had undergone a sural to ulnar nerve autograft surgery. After the surgery, the patient’s symptoms began, primarily in the right arm. Despite receiving conventional drugs, multiple nerve blocks, and lidocaine patches, the patient’s symptoms persisted. In addition, we tried medical ozone for 14 sessions along with ketamine infusion, but these treatments were also ineffective. Conclusions: We emphasize the importance of studying and developing more effective treatments for CRPS and suggest that further randomized clinical trials are needed to determine whether ozone therapy is effective for patients with severe, intractable CRPS symptoms.