Pathogenic mechanisms and etiologic aspects of Mycobacterium avium subspecies paratuberculosis as an infectious cause of cutaneous melanoma.

Infectious etiologies have previously been proposed as causes of both melanoma and non-melanoma skin cancer. This exploratory overview explains and presents the evidence for the hypothesis that a microorganism excreted in infected ruminant animal feces, Mycobacterium avium subspecies paratuberculosis (MAP), is the cause of some cases of cutaneous melanoma (CM). Occupational, residential, and recreational contact with MAP-contaminated feces, soil, sand, and natural bodies of water may confer a higher rate of CM. Included in our hypothesis are possible reasons for the differing rates and locations of CM in persons with white versus nonwhite skin, why CM develops underneath nails and in vulvar skin, why canine melanoma is an excellent model for human melanoma, and why the Bacille Calmette-Guérin (BCG) vaccine has demonstrated efficacy in the prevention and treatment of CM. The pathogenic mechanisms and etiologic aspects of MAP, as a transmittable agent underlying CM risk, are carefully deliberated in this paper. Imbalances in gut and skin bacteria, genetic risk factors, and vaccine prevention/therapy are also discussed, while acknowledging that the evidence for a causal association between MAP exposure and CM remains circumstantial.

Assessment of seizure duration and utility of using SedLine® EEG tracing in veterans undergoing electroconvulsive therapy: a retrospective analysis.

BACKGROUND: Electroconvulsive therapy (ECT) endures as a definitive treatment for refractory depression and catatonia and is also considered an effective treatment for a number of other severe psychiatric disorders (Lisanby, N Engl J Med 357:1939-1945, 2007)(Weiner and Prudic, Biol Psychiatry 73:105-106, 2013). GA is an essential component of the ECT procedure for various reasons (Lee, Jenkins and Sparkle, Life 11, 2021). Monitoring anesthetic effects on the brain is desirable as anesthetic agents affect seizure duration and recovery (Rasulo, Hopkins, Lobo, et al,  Neurocrit Care 38:296-311, 2023) (Jones , Nittur , Fleming and Applegate,  BMC Anesthesiol 21:105, 2021) (Soehle , Kayser , Ellerkmann and Schlaepfer,  BJA 112:695-702, 2013). Perioperative anesthetic effects on consciousness can be assessed with brain function monitoring using raw electroencephalogram (EEG) traces and processed EEG indices. OBJECTIVE: We examined the usefulness and utility of the SedLine® anesthetic effect monitor during ECT procedures. We hypothesized that the seizure duration as measured by the EEG tracing of the ECT machine is equivalent to the duration assessed by the SedLine® EEG tracing. A secondary objective was to describe the SedLine® patient state indices (PSI) at different phases of treatment. METHODS: Following IRB approval, we analyzed the data of the electronic medical records of 45 ECT treatments of 23 patients in an urban VA medical center between July 01, 2021, and March 30, 2022. We compared the seizure duration in minutes and seconds as measured either by the ECT machine EEG tracing or the SedLine® EEG tracing. We then collected SedLine® processed EEG indices at four different stages during the treatment. Appropriate comparative and observational statistical analyses were applied. RESULTS: There was no significant difference in measured seizure duration between the two methods examined (p < 0.05). We observed a lag of the SedLine PSI value at the time before stimulus delivery and limited PSI utility during the course of ECT. CONCLUSION: The SedLine® EEG tracing can be an alternative to the machine EEG tracing for the determination of seizure duration. The SedLine® processed EEG indices are not consistently useful before and after ECT delivery. Anesthetic effect monitoring during ECT is feasible.

A Quality Improvement Initiative for Detection of Attention-Deficit/Hyperactivity Disorder in an Urban, Academic Safety Net Hospital.

OBJECTIVE: Improve detection of Attention Deficit/Hyperactivity Disorder (ADHD) in a safety net, hospital-based, academic pediatric practice by optimizing screening with the Pediatric Symptom Checklist attention score (PSC-AS) and further evaluation with the Vanderbilt ADHD Diagnostic Rating Scale (VADRS). METHODS: We implemented a multi-component intervention by (1) optimizing electronic medical record (EMR) features; (2) adjusting clinic operational workflow; and (3) creating a decision-making algorithm for pediatric primary care clinicians (PPCCs). We extracted 4 outcomes manually from the EMR (pediatrician acknowledgment of a positive PSC-AS, documentation of a plan for further evaluation, distribution of VADRS, and completion of at least 1 VADRS). Outcomes were measured monthly in run charts compared to the pre-intervention control period, and implementation was optimized with Plan-Do-Study-Act cycles. RESULTS: PPCCs were significantly more likely to acknowledge a positive PSC-AS in the intervention versus control (65.3% vs 41.5%; p < 0.001), although this did not change documentation of a plan (70% vs 67.1%; p -value = 0.565). Significantly more children with a positive PSC-AS were distributed a parent or teacher VADRS in the intervention versus control (30.6% vs 17.7%; p -value = 0.0059), but the percentage of returned VADRS rating scales did not improve (12.9% vs 9.2%; p -value = 0.269). CONCLUSION: Our ADHD detection quality improvement initiative improved use of the PSC-AS to identify attention problems and distribution of VADRS diagnostic rating scales, but additional interventions are needed to improve the completion of ADHD evaluations in primary care to ensure that children are appropriately identified and offered evidence-based care.

Risk Factors for Contralateral ACL Injury: A Single Institution Case-Control Study.

Our purpose was to evaluate if there is any association between requiring contralateral anterior cruciate ligament (ACL) reconstruction and various: (1) demographics, (2) patient characteristics, and (3) surgery-specific factors. A prospectively collected database at a single institution was queried to find all patients who underwent primary ACL reconstruction between 2012 and 2014. We identified 312 primary ACL reconstruction patients with a mean age of 24 years and a mean follow-up of 3 years (range, 2-5 years). This cohort was compared with all those who had primary ACL reconstructions during the same time period without a contralateral procedure. We evaluated: (1) incidence, (2) demographic variables, (3) family history, (4) graft choice, (5) activity causing injury, and (6) mechanism of injury (contact versus noncontact). There were 16 patients (4.8%) with a mean age of 21 years and a mean follow-up of 3 years that required a contralateral reconstruction. More females required contralateral reconstruction when compared with the control cohort (p = 0.049). However, there was no difference in the mean age between the cohorts (p = 0.32). Those who underwent reconstruction using a tibialis anterior allograft were far more likely to require a contralateral reconstruction (p = 0.0002). Bone-tendon-bone patellar autograft (p = 0.16), hamstring autograft (p = 0.76), and hamstring allograft (p = 0.68) had similar incidences of contralateral ACL injury. Lacrosse was associated with higher risk of contralateral procedure (p = 0.03). Mechanism of injury had no association of contralateral reconstruction (p = 0.71). We found that those with the highest risk of contralateral ACL reconstruction following their index procedure were females, those with tibialis anterior allografts, and those who had their ipsilateral injury while playing lacrosse. These data may be used by practitioners when educating patients regarding their potential for requiring a contralateral reconstruction following their index procedure.