Functional performance of patients submitted to cardiac surgery with different levels of sleep quality: an observational study.

OBJECTIVE: To describe pulmonary function, muscle strength and functional performance in the different qualities of sleep and the impact of this on the number of physiotherapeutic assistances. METHODS: This is an observational study. In the pre and post operative period, sleep behavior was evaluated using the Pittsburgh questionnaire. Patients were divided into three groups: Good Sleep Quality (GSQ), Poor Sleep Quality (PSQ) and Sleep Disordered (SDB). At this time, other tests were also performed, such as: 6-Minute Walk Test (6MWT), Sit and Stand Test (SST), gait speed test and Timed Up to Go (TUG), Medical Research Council (MRC), maximal inspiratory pressure and maximal expiratory, vital capacity and peak expiratory flow. The functional performance and lung function of each group were compared. RESULTS: A total of 105 people, undergoing cardiac surgery and admitted to hospital were evaluated, 33 with GSQ, 41 with PSQ and 31 with SD. Patients who were in the SDB group had a lower functional performance than the other groups. 6MWT (meters) in the GSQ was 499 ±â€¯87, versus 487 ±â€¯91 in the PSQ and 430 ±â€¯78 in the SD (p = 0.02). In the SST (seconds) it was 10.4 ±â€¯1.1 in the GQS, 11.1 ±â€¯2.3 in the PSQ and 15.4 ±â€¯2.1 in the SD (p = 0.04). Lung function and muscle strength did not differ between groups. Regarding the refusal to perform physical therapy, the SD group was more incident, the main reason being drowsiness. CONCLUSION: Based on the results, we found that sleep quality interferes with functional performance and physical therapy assistance during the hospital stay in patients undergoing cardiac surgery.

Effects of Cycloergometer on Cardiopulmonary Function in Elderly Patients after Coronary Artery Bypass Grafting: Clinical Trial.

Introduction: Despite all the improvements in surgical and anesthetic techniques, this procedure is still associated with pulmonary and cardiovascular complications in the postoperative period, and early rehabilitation, done through the use of cycloergometer, can minimize such complications, besides reducing the length of hospital stay. Objective: Therefore, the aim of the study was to assess the impact of cardiovascular exercise on lung function, respiratory muscle strength, and functional capacity in elderly patients after heart bypass surgery. Methods: To this purpose, a randomized and controlled clinical trial was conducted. Research participants were randomized to the cycle ergometer group (CEG) or to the control group (CG). The CG was managed based on the institution's protocol. The CEG also carried out all the activities of the control group, but there was the inclusion of cycle ergometry through a device built by the researchers. Pulmonary function (vital capacity (VC) and peak expiratory flow (PEF)), ventilatory muscle strength (maximum inspiratory pressure (MIP) and maximal expiratory pressure (MEP)), and functional capacity (six-minute walk test) were evaluated before surgery, at ICU, and hospital discharge. Results: During the research period, 122 patients were evaluated, 61 in each group. The MIP of the cycle ergometry group was higher at discharge from the ICU 95% CI 8 (5.46 to 10.54) and at hospital discharge 95% CI 14 (16.89 to 11.11). MEP was higher in the cycle ergometry group at discharge from the ICU with 95% CI 6 (8.18 to 3.82) and at hospital discharge with 95% CI 9 (11.69 a 6.31). Vital capacity at ICU discharge with 95% CI 6 (7.98 to 4.02) and at hospital discharge with 95% CI 7 (8.98 to 5.02), as well as peak flow at ICU discharge with 95% CI 43 (75.27 to 10.73), showed relevance, being higher in the group that used the cycle ergometer. The CEG showed improvement in functional capacity at the time of hospital discharge with a 95% CI 56 (30.37 to 81.63). Conclusion: We conclude that application of cycloergometry after CABG decreases the loss of pulmonary function, muscle strength, and functional capacity. This trial is registered with RBR-39yrht6.

Development of a malnutrition model in mice: Comparative evaluation of food restriction percentage and different diets.

Malnutrition is a complicated illness that affects people worldwide and is linked to higher death rates, a heightened vulnerability to infections, and delayed cognitive development. Experimental models have been constructed to comprehend the mechanisms associated with hunger. In this regard, the current study used two different types of food aiming to validate a murine model of malnutrition based on dietary restriction. The study was conducted with fifty-six Swiss male mice (eight-week-old) divided into eight groups (n=7 each) and fed the following experimental diets (10 weeks): Standard Diet (ST) ad libitum; ST 20% dietary restriction; ST 40% dietary restriction; ST 60% dietary restriction; AIN93-M diet ad libitum; AIN93-M 20% dietary restriction; AIN93-M 40% dietary restriction; AIN93-M 60% dietary restriction. Body, biochemical, and histological parameters were measured, and the restriction effects on genes related to oxidative stress (GPX1 and GPX4) in epididymal adipose tissue were evaluated. The results obtained showed that 20%, 40%, and 60% of dietary restrictions were able to reduce body weight when compared to controls, highlighting the accentuated weight loss in animals with 60% restrictions, especially those fed with AIN-93 M, which showed physical changes such as whitish skin and dull coat, voracious eating, and hunched posture. The present animal model also showed biochemical changes with hypoalbuminemia, as well as histological epididymal adipose tissue modulation. The presence of increased oxidative stress was observed when evaluating the GPX4 gene. Given the results, 60% food restriction using the AIN93-M diet was the best protocol for inducing malnutrition.

Supraperiosteal technique protocol for forehead filling with a mixture of calcium hydroxyapatite and hyaluronic acid: Double-blind, randomized controlled clinical trial.

OBJECTIVE: The current study aims to investigate the safety and efficacy of using calcium hydroxyapatite (CaHA) versus CaHA associated with hyaluronic acid (HA) for forehead volume replacement and contour restoration without forehead irregularities. METHODS: This interventional study involved 132 participants in a two-arm, parallel, double-blind trial for forehead treatment using the supraperiosteal technique. Group A received CaHA, and Group B received a combination of CaHA and HA as filler materials. Follow-up assessments occurred at 30 and 180 days, incorporating the 5-point Global Aesthetic Improvement Scale (GAIS) and photographic analysis for forehead volume replacement, contour restoration, and without forehead irregularities. Safety assessments included monitoring adverse events, particularly nodules. RESULTS: The study included all 132 enrolled patients who completed the trial. Applying CaHA in combination with HA resulted in a statistically significant improvement in both GAIS scale scores and the reduction of forehead irregularities. The total incidence of nodules was 3.7%. Group A had four times more occurrences of nodules than Group B. Furthermore, Group B exhibited lower rates of forehead irregularities following the treatment compared to Group A. CONCLUSION: The supraperiosteal application of CaHA and HA for forehead treatment demonstrates superior efficacy in addressing signs of aging compared to the isolated use of CaHA.

Cytoprotective Effect of Gallic Acid against Injuries Promoted by Therapeutic Ionizing Radiation in Preosteoblast Cells.

Gallic acid (GA) is a powerful antioxidant extracted from plants of the Brazilian Cerrado. Oxidative stress plays an important role in the occurrence of radiation-induced osteonecrosis in patients treated for head and neck cancer. There is a need to develop research aimed at developing complementary therapies to prevent or reverse bone damage. The aim of the present study was to investigate the effect of GA in preosteoblasts exposed to therapeutic ionizing radiation. MC3T3-E1 preosteoblast cells were treated with 10 µM GA and exposed to 6 Gy ionizing radiation. We performed in vitro assays of cell proliferation, oxidative stress analysis by detection of reactive oxygen species, and alkaline phosphatase assay. GA at lower concentrations was able to significantly increase proliferation and inhibit radiation-induced generation of reactive oxygen species in osteoblast precursor cells, despite ionizing radiation-induced injury. Furthermore, GA significantly increased alkaline phosphatase at a dose of 6 Gy. The findings suggested that GA could attenuate ionizing radiation-induced injuries in osteoblast precursor cells. Moreover, in vivo studies are needed to better investigate the role of GA in osteonecrosis, especially in cancer patients undergoing radiotherapy or taking antiresorptive drugs.

Microbiological characterization of neuropathic diabetic foot infection: a retrospective study at a Portuguese tertiary hospital.

Diabetic foot infection imposes a significant burden and is the major cause of nontraumatic limb amputation. Adequate patient management with effective antibiotic therapy is crucial.This retrospective cohort study aimed to characterize the microbiology and resistance patterns of moderate to severe neuropathic diabetic foot infection in patients hospitalized at a tertiary referral hospital between January 2020 and June 2023. Deep tissue specimens from ulcers were collected for culture.Sixty inpatients were included (62% male, mean age 59.1 ± 11.5 years). Osteomyelitis was present in 90% of the patients. Among 102 microorganisms (average of 1.91 ± 1.25 pathogens per patient), 60.8% were gram-positive bacteria, 31.4% were gram-negative, 3.92% were anaerobic bacteria, and 3.92% were fungi. Staphylococcus aureus (19%) and Enterococcus faecium (17%) were the most common. Pseudomonas aeruginosa (8%) and bacteria of the Enterobacterales family (24%) accounted for all the isolated gram-negative bacteria. Sixteen percent of Staphylococcus aureus and 67% of coagulase-negative Staphylococci were resistant to methicillin. Resistance to ampicillin was found in 11% of Enterococci. All Pseudomonas aeruginosa isolates were sensitive to piperacillin-tazobactam, ceftazidime, or cefepime. Among the Enterobacterales, resistance rates were 35% for piperacillin-tazobactam, 38% for ceftazidime, 21% for cefepime, and 13% for carbapenems.Although the prevalence of methicillin-resistant staphylococci was lower than that in other studies, carbapenem resistance among gram-negative bacteria warrants attention. This study highlights the importance of understanding local epidemiology for effective diabetic foot infection management and resistance mitigation.

Metformin Radiosensitizing Effect on Hypoxic Oral Squamous Cell Carcinoma Cells by GAPDH and TAGLN2.

OBJECTIVE: Tumor hypoxia is associated with a poorer prognosis in cancer patients and can diminish the efficacy of radiation therapy (RT). This study investigates the potential of metformin to enhance radiosensitivity in hypoxic cancer cells. METHODS: Preliminary experiments were conducted to validate the impact of hypoxia on radiation response. Reactive oxygen species (ROS) levels, cell migration, and cell death were assessed in hypoxic, radiated cells treated with metformin. Proteomic and ontological analyses were employed to identify molecular targets associated with the radiosensitizing effect of metformin. Proteomic and ontological findings were validated through patient samples and in vitro studies. RESULTS: Metformin amplified cell death, induced DNA fragmentation, decreased cell migration, and elevated ROS levels in hypoxic, radiated cells. Proteomic analyses revealed that GAPDH and TAGLN2 were identified as pivotal targets linked to the radiosensitizing effect of metformin. Oral cancer patients exhibited elevated levels of TAGLN2 and reduced levels of GAPDH. Metformin downregulated TAGLN2 and upregulated GAPDH in hypoxic, radiated cells. Additionally, metformin reduced levels of mutated p53. CONCLUSIONS: This study suggests that metformin can enhance radiosensitivity in hypoxic cells, operating through modulation of GAPDH and TAGLN2. Furthermore, metformin effectively reduces mutated p53 levels in radiated cells under hypoxic conditions.

Juvenile Nasopharyngeal Angiofibroma: A Series of 96 Surgical Cases.

Introduction Juvenile nasopharyngeal angiofibroma (JNA) is a benign vascularized tumor that affects almost exclusively male adolescents. Surgery is the treatment of choice for JNA. Objectives The present study is a 42-year retrospective review of a series of JNA cases treated surgically without previous embolization. Methods The present is a retrospective, descriptive study based on medical records of 96 patients with JNA who underwent microscopic or endoscopic excision without previous embolization from 1978 to 2020 in a single institution. The patients were categorized according to the Andrews et al. stage, and data were collected on age, gender, tumor staging, surgical approach, affected side, and outcome. Results All patients were male, with an average age of 17 years. The predominant tumor stage consisted of type II, with 52.1%. A total of 33.3% of the patients were submitted to the microscopic technique and 66.7%, to the endonasal technique. The rate of intraoperative blood transfusion was of 17.7%. Conclusion The present study reinforces that resection of JNA in various stages is viable without previous artery embolization.

Dietary supplementation with black cricket (Gryllus assimilis) reverses protein-energy malnutrition and modulates renin-angiotensin system expression in adipose tissue.

Edible insects are recognized as promising food sources due to their nutritional composition. Some species, such as Gryllus assimilis, contain proteins, lipids, and carbohydrates of high biological value, which regulate several metabolic functions, including the Renin-Angiotensin System (RAS). In this context, the present study aimed to assess the effects of dietary supplementation with whole Gryllus assimilis powder on the metabolism of malnourished mice. Thirty-two male Swiss mice were used and divided into four treatment groups. The groups were identified as (AIN93-M); AIN93-M + Gryllus assimilis diet (AIN93-M + GA); AIN93-M + Renutrition diet (AIN93-M + REN) and AIN93-M + Renutrition diet + Gryllus assimilis (AIN93-M + REN + GA). The results showed that whole Gryllus assimilis powder inclusion promotes recovery from protein-energy malnutrition, reduces adiposity, and improves glucose tolerance and insulin sensitivity. It also reduces total cholesterol, triglycerides, VLDL, and adipocyte area. We also observed a significant increase in the expression of RAS-related genes, such as ACE2 and MasR, followed by a reduction in Angiotensinogen and ACE. The main findings of the present study suggest the use of black cricket as a viable strategy for the prevention and treatment of protein-energy malnutrition, as well as the reduction of adiposity, and improvement of lipid and glycemic parameters, with antihypertensive potential.

Lymph node tuberculosis-associated paradoxical immune reconstitution inflammatory syndrome in a non-HIV patient: Case report and review of literature.

Tuberculosis (TB) is a global health threat, especially in HIV patients who may experience immune reconstitution inflammatory syndrome (IRIS) upon Mycobacterium tuberculosis infection. Diagnosing and defining IRIS in non-HIV patients remains challenging. A 63-year-old male with acute leukaemia underwent induction therapy with a regimen containing fludarabine. Febrile neutropenia led to further investigations, revealing non-cavitary pulmonary TB, prompting anti-tuberculosis therapy (ATT) alongside resumed leukaemia treatment with sorafenib. Persistent extra-pulmonary TB, specifically lymph node involvement, were observed and IRIS was suspected, evidenced by enlarged lymphadenopathies, scrofula, and skin lesions that developed during the 13-month course of ATT, with no recurrence after its cessation. This article explores a case of lymph node TB-associated paradoxical IRIS in a non-HIV leukaemia patient, revealing the intricate interplay between tuberculosis and haematological malignancies and emphasizing the lack of standardized diagnostic criteria and treatment consensus. Challenges in lymph node TB diagnosis and management highlight the need for tailored therapeutic approaches. The report explores the potential immunomodulatory effects of fludarabine and sorafenib, questioning their roles in TB-IRIS. This case illuminates TB-IRIS dynamics in non-HIV patients, urging further research and collaborative efforts to enhance understanding and outcomes. As medical complexities persist, personalized therapeutic approaches and advancements in TB-IRIS research are crucial.

Safety and feasibility of early mobilization in patients submitted to cardiac surgery using subxiphoid drain.

INTRODUCTION: Patients submitted to heart surgery are restricted to the bed of the Intensive Care Units (ICUs), due to this period of immobility the individual is likely to present clinical and functional alterations. These complications can be avoided by early mobilization; however, in some hospitals, this is not feasible due to the use of subxiphoid drain in the immediate postoperative period. OBJECTIVE: To verify the safety and feasibility of mobilizing patients after cardiac surgery using subxiphoid drain. METHODS: This was a prospective cohort study. On the first day the patient was positioned in sedestration in bed, then transferred from sitting to orthostasis, gait training and sedestration in an armchair. On the second postoperative day the same activities were performed, but with walking through the ICU with a progressive increase in distance. At all these moments, the patient was using the subxiphoid and intercostal drain. The patients were seen three times a day, but physical rehabilitation was performed twice. The adverse events considered were drain obstruction, accidental removal or displacement, total atrioventricular block, postoperative low output syndrome, cardiorespiratory arrest, pneumomediastinum, infection, and pericardial or myocardial damage. RESULTS: 176 patients were evaluated. Only 2 (0.4 %) of the patients had complications during or after mobilization, 1 (0.2 %) due to drain obstruction and 1 (0.2 %) due to accidental removal or displacement. CONCLUSION: Based on the data observed in the results, we found that the application of early mobilization in patients using subxiphoid drain after cardiac surgery is a safe and feasible conduct.

Effects of gallic acid and physical training on liver damage, force, and anxiety in obese mice: Hepatic modulation of Sestrin 2 (SESN2) and PGC-α expression.

Obesity and overweight are multifactorial diseases affecting more than one-third of the world's population. Physical inactivity contributes to a positive energy balance and the onset of obesity. Exercise combined with a balanced diet is an effective non-pharmacological strategy to improve obesity-related disorders. Gallic acid (GA), is a natural endogenous polyphenol found in a variety of fruits, vegetables, and wines, with beneficial effects on energetic homeostasis. The present study aims to investigate the effects of exercise training on obese mice supplemented with GA. Animal experimentation was performed with male Swiss mice divided into five groups: ST (standard control), HFD (obese control), HFD + GA (GA supplement), HFD + Trained (training), and HFD + GA + Trained (GA and training). The groups are treated for eight weeks with 200 mg/kg/body weight of the feed compound and, if applicable, physical training. The main findings of the present study show that GA supplementation improves liver fat, body weight, adiposity, and plasma insulin levels. In addition, animals treated with the GA and a physical training program demonstrate reduced levels of anxiety. Gene expression analyses show that Sesn2 is activated via PGC-1α independent of the GATOR2 protein, which is activated by GA in the context of physical activity. These data are corroborated by molecular docking analysis, demonstrating the interaction of GA with GATOR2. The present study contributes to understanding the metabolic effects of GA and physical training and demonstrates a new hepatic mechanism of action via Sestrin 2 and PGC-1α.

Clinical and functional outcomes associated with pulmonary complications after coronary artery bypass grafting.

INTRODUCTION: Coronary artery bypass grafting(CABG) is a surgical treatment for coronary artery disease aiming at improving symptoms and life expectancy. Despite this, there are pulmonary and functional complications that may arise during the postoperative period due to invasive mechanical ventilation(IMV), cardiopulmonary bypass and immobility, leading to longer hospital stays. OBJECTIVE: To evaluate the clinical and functional outcomes related to pulmonary complications in the postoperative period of CABG. METHODS: Prospective cohort. During the ICU stay the patients were divided into: Non Complicated Group(NCG) who did not present complications and Complicated Group(CG) who presented complication. Functional variables were applied as the six-minute walk test(6MWT), gait speed, sit up and stand up test, Timed Up and Go, peripheral muscle strength, ventilatory, pulmonary function and Functional Independence Measure. These tests were applied preoperatively, at ICU discharge, hospital discharge and six months after surgery. RESULTS: The study evaluated 90 patients, 59 in the NCG and 31 CG. In the 6MWT there was a 2%(p = 0.43) decrease in the NCG, while the decrease was 13%(p < 0.01) in the CG. In the MRC the drop was 2%(p = < 0.01) in the CNG, while in the CG the drop was 14%(p = < 0.01). In MIP the NCG had a 6%(p = 0.67) decrease, while the CG had a 16%(p = < 0.01) decrease. CONCLUSION: Patients with postoperative complications of CABG may have reduced functional performance, muscle strength, and pulmonary function at hospital discharge and after six months.

Older adults, appendicular anthropometric measurements, and poor functional performance are predictors of sarcopenia in individuals with head and neck squamous cell carcinoma.

OBJECTIVE: To identify predictors of sarcopenia (demographical, anthropometric measurements, tumor-related clinical characteristics, performance status, and serum C-reactive protein (CRP) and albumin levels in individuals with head and neck squamous cell carcinoma (HNSCC). MATERIAL AND METHODS: This cross-sectional study selected diagnosed with HNSCC (n = 125). Sarcopenia was defined as low muscle strength and low physical performance. Association between sarcopenia and anthropometric assessments (weight, height, body mass index, triceps skinfold, mid-upper arm circumference [MUAC], mid-upper arm muscle circumference, mid-upper arm fat area [UFA], mid-upper arm bone free muscle area, calf circumference, and appendicular skeletal muscle mass and index), tumor clinical characteristics (anatomical site, tumor size, and cervical metastasis), performance status scale (Eastern Cooperative Oncology Group Performance Status [ECOG-PS]), and CRP and albumin levels was analyzed using binary logistic regression models. RESULTS: The diagnosis of sarcopenia was identified in 28 (22.4%) individuals with HNSCC. Being an older adult increases the odds of association with sarcopenia in individuals with HNSCC (odds ratio [OR] = 1.05). Increments in MUAC measurement reduce the odds of association with sarcopenia (OR = 0.69), while the increase in the UFA measurement increases the odds of association with sarcopenia (OR = 1.33). Poor ECOG-PS scores increase the odds of association with sarcopenia in individuals with HNSCC (OR = 5.54). CONCLUSION: Early identification of easy-to-perform, cost-effective predictors of sarcopenia tends to favor the implementation of personalized therapeutic and supportive interventions in individuals with HNSCC.

Feasibility of the Two-Minute Walk Test in Elderly Patients After Acute Myocardial Infarction: A Cross-Sectional Study

Abstract Background Pathologies involving the heart are still the main causes of death, and acute myocardial infarction (AMI) is consistently present in this index. The two-minute walk test (2MWT) is ideal for assessing the functional capacity of this patient. Objective To describe the feasibility of the 2MWT in older people after AMI. Methods This is a cross-sectional study. At hospital discharge, patients were invited to perform the 2MWT. Before starting the test, systolic blood pressure (SBP), diastolic blood pressure (DBP), peripheral oxygen saturation (SpO2), heart rate (HR) and the Double Product (DP) were checked. After checking the vital signs, the patients were accompanied by an examiner, who was positioned laterally to ensure safety and verbally encouraged during the test; after the completion of the test, all vital signs were reassessed in two moments, at the immediate end and after 20 minutes of rest. ANOVA was used for the comparison of pre and post-test and pre and recovery. A p<0.05 was considered significant. Results We evaluated 51 patients, 4 (80%) males with a mean age of 67±8 years. The distance walked on the 2MWT had a mean of 157 ± 22 meters. The SBPmmHg Pre-Test 112±21 vs 131±15 Post-Test (p=0.24) and 119±22 at Recovery (p = 0.34) and HR (bpm) Pre-Test 75±15 vs 89±19 Post-Test (p=0.15) and 79±15 at Recovery (p = 0.59). After a rest, all variables analyzed followed the same pattern, returning to values close to the pre-test moment. Conclusion The performance of the 2MWT in the hospital environment presents good feasibility in the evaluation of submaximal capacity in elderly patients after AMI.

Analysis of Different Tidal Volumes on Ventilatory Mechanics and Arterial Blood Gas Variables in Patients Undergoing Cardiac Surgery.

Introduction: Cardiovascular diseases have been increasing gradually each year, and their incidence has reached 80%. Mechanical ventilation (MV) is essential in the postoperative period of cardiac surgery (CS) due to anesthetic induction. The tidal volume (TV) is a parameter that depends on the conditions of the respiratory system mechanics, aiming at the reduction of dynamic hyperinflation. Objective: Analyze the effect of different TVs on blood gas analysis variables and respiratory mechanics in patients submitted to CS. Materials and methods: This was an uncontrolled randomized clinical trial. Patients were randomized by lottery into the following two groups: One group was ventilated with a TV of 6 mL/kg; while the other received a TV of 8 mL/kg. After 30 minutes of admission with the VT, blood gas analysis data were evaluated, such as pH, oxygen arterial pressure (PaO2), arterial pressure of carbon dioxide (PaCO2), and peripheral oxygen saturation (SpO2). The evaluation of respiratory mechanics was composed of static and dynamic compliance, airway resistance, and driving pressure. Results: A total of 78 patients were included, 58% of whom were males with a mean age of 55 ± 13 years. It was observed that there were no significant differences regarding respiratory mechanics, only the driving pressure presented statistical significance, the group 6 mL/kg was 8.3 ± 2.5 in the group 8 mL/kg 10.4 ± 2.1 presenting a value of (p < 0.001). Conclusion: Based on the findings of the present study, we conclude that different TVs do not significantly alter the blood gas variables and do not influence the respiratory mechanics of patients undergoing CS. How to cite this article: Cordeiro A, Souza A, de Brito Lima CR, Araújo J, Mascarenhas H, Guimarães A. Analysis of Different Tidal Volumes on Ventilatory Mechanics and Arterial Blood Gas Variables in Patients Undergoing Cardiac Surgery. Indian J Crit Care Med 2023;27(12):930-933.

Disseminated Mycobacterium bovis Infection: A Rare Complication of Bacillus Calmette-Guérin Immunotherapy.

Intravesical instillation of bacillus Calmette-Guérin (BCG) is a crucial adjunctive therapy in the treatment of bladder carcinoma. Its systemic complications are rare but include disseminated Mycobacterium bovis (M. bovis) infections, the diagnosis of which is a challenging task that requires keen clinical awareness. We report the case of an adult male treated with BCG who presented with fever, nonspecific constitutional symptoms, hepatic cytolysis, and cholestasis. After a detailed workup, the diagnosis was made of disseminated M. bovis infection with hepatic, pulmonary, renal, and ureteral involvement. Prompt anti-tuberculosis treatment resulted in clinical and analytical improvement. This case highlights the importance of early recognition of this serious complication in patients with BCG exposure, as well as the difficulty in confirming the diagnosis for proper treatment.

Forearm floating with a terrible triad in the elbow after fall, case report.

Perilunate fracture dislocation with an elbow dislocation, it is referred to as a floating forearm. Very few cases have been described worldwide. We report a case of a 37-year-old man diagnosed with a floating forearm (trans-scaphoid perilunate fracture dislocation combined with a terrible triad injury), after a fall of the top of an olive tree. Urgent closed reduction of the elbow and wrist was obtained. A double approach to the wrist was used: dorsal approach to fix the scaphoid and to reduce the carpus and a volar approach to release the median nerve and repair the volar capsule. A lateral approach to the elbow was performed to fix the radial head and to repair the lateral collateral ligament. At 3 months postoperative, the patient had no pain in the elbow and in the wrist. He returned to Work with some restriction at 4-month post operatively.

Simultaneous Bilateral Anterior Shoulder Dislocation After Low-Energy Trauma: A Case Report.

Unilateral shoulder dislocation is known to be one of the most common joint dislocations. However, simultaneous bilateral shoulder dislocations are rare, especially anterior dislocations. We report a case of an 84-year-old woman who presented to the urgency room with symmetrical bilateral anterior shoulder dislocation 12 hours after falling on a treadmill. She presented with bilateral pain, functional impairment, prominent acromion, flattened shoulder, and, in the right upper limb, paresthesias on the dorsum of the hand and extension deficit of the fingers. Closed reduction of both shoulders was performed under sedation, and she was immobilized bilaterally with an arm sling in internal rotation. A full recovery was achieved six months after the injury.