Sternal wound infection caused by Mycobacterium chelonae.

INTRODUCTION: Sternal wound infection caused by Mycobacterium chelonae, a member of the rapidly growing nontuberculous mycobacteria (NTM), is rare and may present without signs and symptoms of systemic infection. METHODS: We present a patient who had a M. chelonae infection of the sternum following excision of a left atrial myxoma and conducted a review of the literature from 1976 to 2013. RESULTS: Seventy cases of NTM sternal wound infection after cardiac surgery were identified, including six outbreaks and ten sporadic cases including the present case. Thirty-four cases were isolated coronary artery bypass grafting (CABG) surgery, 16 cases were isolated valve replacement, and two cases were valve replacement with CABG. The age range of the patients was between 6 and 78 years. The average time from the surgery was 49 ± 58 days which was longer than the usual bacterial mediastinitis. The overall mortality rate was 29%. CONCLUSION: NTM sternal wound infection is rare but may be fatal if not properly treated. The toxic signs are often subtle and it will take longer to isolate compared to typical bacterial mediastinitis. Early recognition, the use of appropriate antibiotics based on susceptibility tests, and aggressive surgical debridement are required for full recovery

Fate of the lower extremity in patients with VA-ECMO via femoral cannulation

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a salvage therapy in patients with severe cardiopulmonary failure. Femoral cannulation is associated with limb complications including ischemia, limb loss, arterial infections and wound infections. This study aims to evaluate these complications and management related to successful outcomes. Methods: A retrospective review was conducted in 17 patients requiring VA- ECMO support via femoral cannulation from 1/ 2010 till 4/2012. After cannulation, all patients had near infared spectroscopy (NIRS) monitoring after cannula placement and most had placement of distal arterial perfusion catheters (DPC). At decannulation, all patients had femoral cutdown with closure of arteriotomies by primary repair or patch angioplasty with bovine pericardium. Primary study endpoints included ischemia, limb loss, arterial infection; secondary endpoints were wound infection and post-discharge symptoms. Results: Seventeen patients were supported with VA-ECMO during the study period with arterial cannula size of 16-20 French. All patients had NIRS monitoring after cannula placement and 13/17 patients had DPC placement, with no subsequent ischemia. Two of 4 patients without DPC developed ischemia; one was decannulated and the other resolved spontaneously. At decannulation, open arterial repair was performed as described. In this study population, simple wound infection occurred in 3/17with Vacuum Assisted Closure (VAC) devices were placed at the timed if appropriate. There were no arterial infections and no instances of limb ischemia requiring amputation. There were no complaints of rest pain during outpatient follow-up. Conclusions: Limb complications related to femoral cannulation for VA-ECMO can lead to prolonged morbidity and limb loss. NIRS and placement of DPC, primary repair of arteriotomy or patch angioplasty, along with aggressive wound care, can dramatically decrease rates of limb ischemia, limb loss and infection

Assessment of nutritional adequacy in patients on extracorporeal membrane oxygenation.

Introduction: Nutrition is a key element of recovery from the state of critical illness. Little is known about nutritional adequacy in patients supported on extracorporeal membrane oxygenation (ECMO) for severe cardio-respiratory dysfunction. A study was performed whether or not early nutrition support improve outcomes of the patients on ECMO. Methods: A retrospective IRB approved review was conducted of all patients supported on ECMO from 7/10 to 6/12. The patients were divided into 2 groups, survivors and non-survivors. Age, sex, preoperative comorbidities, type and duration of ECMO, day to initiation and goal feeding, caloric intake, weekly biomarkers (pre-albumin, albumin, C-reactive protein), and end organ recovery (metabolic, hepatic, renal, pulmonary) scores were compared between 2 groups. Results: There were 45 consecutive patients that underwent ECMO during the study period; 16 patients survived and 29 did not survive. Age, sex, preoperative co-morbidity, type and duration of ECMO were similar between 2 groups. Survivors had better preoperative SOFA scores (average of 11 in survivors vs 13 in non-survivors. p=0.01), preoperative SAPS scores (52 vs 62, p=0.01), and preoperative creatinine values (1.2 mg/dl vs 1.8 mg/dl, p=0.03). All patients that survived were started on tube feeds within 2 days of ECMO initiation in contrast to 59% of non-survivors (P= 0.004). 88% of survivors versus 59% of non-survivors met adequate caloric feeding goals by day 3 (P= 0.04). TPN was more frequently utilized in survivors in addition to tube feeds (50% vs 14%, p=0.009). Conclusion: We found that the patients who were started on feeds earlier and the patients who met calorie goals in the earlier stages after initiation of ECMO had lower mortality, although other factors may contribute to survival as well

Modelling human choices: MADeM and decision‑making

Research supported by FAPESP 2015/50122-0 and DFG-GRTK 1740/2. RP and AR are also part of the Research, Innovation and Dissemination Center for Neuromathematics FAPESP grant (2013/07699-0). RP is supported by a FAPESP scholarship (2013/25667-8). ACR is partially supported by a CNPq fellowship (grant 306251/2014-0)

A Bcl-xL–Drp1 complex regulates synaptic vesicle membrane dynamics during endocytosis

Following exocytosis, the rate of recovery of neurotransmitter release is determined by vesicle retrieval from the plasma membrane and by recruitment of vesicles from reserve pools within the synapse, the latter of which is dependent on mitochondrial ATP. The Bcl-2 family protein Bcl-x(L), in addition to its role in cell death, regulates neurotransmitter release and recovery in part by increasing ATP availability from mitochondria. We now find, however, that, Bcl-x(L) directly regulates endocytotic vesicle retrieval in hippocampal neurons through protein/protein interaction with components of the clathrin complex. Our evidence suggests that, during synaptic stimulation, Bcl-x(L) translocates to clathrin-coated pits in a calmodulin-dependent manner and forms a complex of proteins with the GTPase Drp1, Mff and clathrin. Depletion of Drp1 produces misformed endocytotic vesicles. Mutagenesis studies suggest that formation of the Bcl-x(L)-Drp1 complex is necessary for the enhanced rate of vesicle endocytosis produced by Bcl-x(L), thus providing a mechanism for presynaptic plasticity