Refractory and super-refractory status epilepticus in adults: a 9-year cohort study.

While status epilepticus (SE) persisting after two antiseizure agents is called refractory (RSE), super-refractory status epilepticus (SRSE) defines SE continuing after general anaesthesia. Its prevalence and related clinical profiles have received limited attention, and most studies were restricted to intensive care facilities. We therefore aimed at describing RSE and SRSE frequencies and identifying associated clinical variables. Between 2006 and 2015, consecutive adult SE episodes were prospectively recorded in a registry. Occurrence of RSE and SRSE and their relationship to clinical variables of interest, including outcome, were analysed. Of 804 SE episodes, 268 (33.3%) were RSE and 33 (4%) SRSE. Coma induction for SE treatment occurred in 79 (9.8%) episodes. Severe consciousness impairment (OR 1.67; 95% CI 1.24-2.46; P = 0.001), increasing age (OR 1.01, 95% CI 1.01-1.02), and lack of remote symptomatic SE aetiology (OR 0.48; 95% CI 0.32-0.72) were independently associated with RSE, while severe consciousness impairment (OR 4.26; 95% CI 1.44-12.60) and younger age (OR 0.96; 95% CI 0.95-0.99) correlated with SRSE; however, most SRSE episodes were not predicted by these variables. Mortality was 15.5% overall, higher in RSE (24.5%) and SRSE (37.9%) than in non-refractory SE (9.8%) (P < 0.001). Super-refractory status epilepticus appears clearly less prevalent in this cohort than previously reported, probably as it is not restricted to intensive care unit. SRSE emerges in younger patients with marked consciousness impairment, pointing to the underlying severe clinical background, but these variables do not predict most SRSE developments. There is currently a knowledge gap for prediction of SRSE occurrence that needs to be filled

Design of Thermo Mechanicaln Processing and Transformation Behaviour of Bulk Si-Mn Trip Steel

In the last decade, a lot of effort has been paid to optimising the thermomechanical processing of TRIP steels that stands for transformation induced plasticity. The precise characterization of the resulting multiphase microstructure of low alloyed TRIP steels is of great importance for the interpretation and optimisation of their mechanical properties. The results obtained in situ neutron diffraction laboratory experiment concerning the austenite to ferrite transformation in Si-Mn bulk TRIP steel specimens, displaying the transformation induced plasticity (TRIP), are presented. The advancement of ferrite formation during transformation in conditioned austenite is investigated at different transformation temperatures and has been monitored using neutron diffraction method. The relevant information on transformation proceeding is extracted from neutron diffraction spectra. The integrated intensities of austenite and ferrite neutron diffraction profiles developed during the transformation are then assumed as a measure of the phase volume fractions of both phases in dependence on transformation temperature and austenite conditioning. According to the yielding information on ferrite volume fractions from isothermal transformation kinetics data the thermo mechanical processing of bulk specimen was designed in order to support austenite stabilization through bainitic transformation. The volume fractions of retained austenite resulting at alternating transformation conditions were measured by neutron and X-ray diffraction respectively. The stability of retained austenite in bulk specimens during room temperature mechanical testing was characterized by in situ neutron diffraction experiments as well

Tinjauan Kasus : Klien Menarik Diri

Menarik diri adalah suatu pola tingkah laku menghindari kontak dengan orang, situasi atau lingkungan yang penuh dengan stress yang dapat menyebabkan kecemasan fisik dan psikologis. Individu yang menarik diri cenderung untuk menghindari hubungan interpersonal dan dalam menghadapi realitas. Dampak dari perilaku menarik diri adalah gangguan perawatan diri, gangguan penampilan dii dan potensial terjadinya halusinasi bahkan keinginan untuk bunuh diri. Mengingat dampak tersebut maka diperlukan asuhan keperawatan yang komprehensif dan intensif khususnya untuk menarik diri. Withdrawal is a pattern of behavior to avoid contact with others, stressful situation and environment which can cause the physical and psychological distress. The individual who withdrawal tends to avoid interpersonal relationship, and face the reality. The withdrawal behavior can lead to problems related to self care and personal appearance and potential hallucination even attempted suicide. Considering the impact of withdrawal behaviors on individual, comprehensive and intensive nursing care specifically planned for client with withdrawal are acquired

Therapeutic drug monitoring of newer generation antiseizure medications at the point of treatment failure.

The benefit of therapeutic drug monitoring (TDM) of newer generation antiseizure medications (ASM) has been little studied. A recent randomized study suggested that TDM at each medical visit did not bring a significant benefit, but the study did not investigate TDM in cases of treatment failure. Accordingly, we realized a post hoc analysis of this trial. We analyzed 282 TDMs in 136 patients. We compared TDM performed at visits after treatment failure versus without treatment failure, reporting the proportion of drug levels out of range and the prescriber's adherence to dosage recommendations according to measured drug levels. There was no statistical difference in terms of proportion of out of range plasma drug levels (47% vs 50%, p = 0.7) or adherence of prescribers to the clinical pharmacologists' dosage recommendations (21% vs 30%, p = 0.6) between visits after treatment failure and visits without treatment failure, respectively. Knowledge of prior drug levels did not modify the results. Systematic TDM at appointments following treatment failure showed similar results to TDM at visits without treatment failure. The prescribers' adherence with dosage recommendations was low in both cases. It is not clear whether better prescriber adherence would improve patient outcome. Furthermore, the ability to detect poor patient compliance is limited in a planned outpatient appointment. The study setting does not reflect on the general usefulness of TDM

Levetiracetam circulating concentrations and response in status epilepticus.

Intravenous levetiracetam (LEV) is broadly used in the treatment of status epilepticus (SE). A loading dose is usually infused, aiming to reach quickly the range of plasma concentrations considered as therapeutic (12-46 mg/l). The aim of the study was to evaluate the response to LEV in SE, correlated exposure assessed by plasma concentration monitoring, as well as calculated exposure parameters. We retrospectively analyzed a SE registry, including patients since 2015 with at least one available LEV plasma level measured less than 36 h after loading. A Bayesian maximum likelihood approach based on a population pharmacokinetic model was used to estimate LEV exposure parameters. We compared plasma levels and pharmacokinetics parameter estimates between responders and nonresponders. Therapeutic response was defined as SE cessation within 24 h following LEV introduction without a need for additional antiepileptic drug (AED). We included 29 patients (45 plasma levels). Variability was salient in LEV loading doses (ranging between 17 and 38 mg/kg) and monitoring practice. There was no difference in median plasma concentrations (19.5 versus 21.5 mg/l; p = 0.71), median estimated LEV exposure (25.8 versus 37.0 mg/l; p = 0.61), peak (30.4 versus 41.5 mg/l; p = 0.36), or residual levels after loading dose (14.4 versus 20.5 mg/l; p = 0.07) between responders and nonresponders. Levetiracetam exposure does not seem to differ significantly between responders and nonresponders; greater exposure was not associated with better outcome. Loading doses of 30 mg/kg seem, however, appropriate to quickly reach the target exposure level. The short LEV half-life makes standardized sampling measurement necessary to obtain directly interpretable LEV levels