Citations

Purpose To determine baseline individual and school-related factors associated with increased risk of developing depression symptoms by year four (Y4) of medical school, and to develop a prognostic index that stratifies risk of developing depression symptoms (Depression-PI) among medical students. Method The authors analyzed data from 3,743 students (79% of 4,732) attending 49 U.S. medical schools who completed baseline (2010) and Y4 (2014) surveys. Surveys included validated scales measuring depression, stress, coping, and social support. The authors collected demographics and school characteristics and conducted multivariate analysis to identify baseline factors independently associated with Y4 depression symptoms. They used these factors to create a prognostic index for developing depression. They randomly divided the data into discovery (n = 2,455) and replication (n = 1,288) datasets and calculated c statistics ( c ). Results The authors identified eight independent prognostic factors for experiencing depression symptoms during training within the discovery dataset: age; race; ethnicity; tuition; and baseline depression symptoms, stress, coping behaviors, and social support. The Depression-PI stratified four risk groups. Compared with the low risk group, those in the intermediate, high, and very high risk groups had an odds ratio of developing depression of, respectively, 1.75, 3.98, and 9.19 ( c = 0.71). The replication dataset confirmed the risk groups. Conclusions Demographics; tuition; and baseline depression symptoms, stress, coping behaviors, and social support are independently associated with risk of developing depression during training among U.S. medical students. By stratifying students into four risk groups, the Depression-PI may allow for a tiered primary prevention approach.

SummaryWorsening pharmacoresistance to antiseizure drugs is common with ongoing excitotoxic neuronal and systemic injury. Early initiation of anesthetic drugs in refractory status epilepticus (RSE) may halt these processes while allowing time for treatment targeting the cause of the seizures. Current guidelines support the use of anesthetic drugs as the third line pharmacologic therapy in generalized convulsive status epilepticus but do not clearly define the indications for these drugs in other types of status epilepticus. There is wide practice variation in choice of third line therapy for RSE, but there is overall consensus that anesthetics should be initiated earlier in generalized convulsive status epilepticus than in nonconvulsive forms. More recently, doubt has been cast on the appropriateness of anesthetic treatment of RSE following a series of studies associating their use with higher mortality and morbidity. This suggests that efforts should focus on determination of who benefits most, optimal use, and prevention of refractoriness. The risk‐benefit ratio of anesthetic use is discussed, with specific indications proposed. In addition, anesthetic dosing, supportive neurocritical care, electroencephalogram suppression target, and weaning of anesthesia are reviewed.

SummaryDespite phenobarbital (PB) being a key component in status epilepticus (SE) treatment algorithms for decades, it has fallen out of favor compared to newer nonsedating medications due to potential for respiratory suppression and prolonged sedation. We retrospectively analyzed all nonintubated patients with refractory SE treated with parenteral PB. Forty patients were identified as having received PB in the neurologic intensive care unit at Mayo Clinic over a 7‐year period through our pharmacy dispensing database. Patients who received PB for maintenance therapy, those replenishing subtherapeutic levels, those who were already intubated, and those receiving PB for a non‐SE indication were excluded. Clinical data, prior treatments, therapeutic response, and outcome were reviewed. Eight patients were identified. Ages ranged from 24 to 77 years (median = 64 years); all had focal SE, and none was comatose. Seizure activity improved acutely following PB administration in seven and stopped in six. Dosages ranged from 5 to 19.8 mg/kg (median = 10.1 mg/kg); none required intubation, and one received supplemental oxygen. Patients received a median of four antiepileptic drugs prior to PB. Median interval between first drug and PB was 23.5 hours. Glasgow Coma Scale score did not change following PB administration. One patient required intervention for hypotension. Moderate‐dose parenteral PB was effective in attaining seizure control in a significant proportion of noncomatose refractory SE patients. None required ventilatory support. PB dosages below those in recent guidelines may be sufficient to stop SE without clinically significant cardiopulmonary complications.

Summary To describe the demographics, etiologies, types of status epilepticus ( SE ), and outcomes in people with refractory and super‐refractory SE from around the world, we prospectively collected cases of refractory SE ( RSE ) treated with continuous intravenous anesthetic drugs in an intensive care unit setting through online questionnaires using “active surveillance.” We collected information about 776 cases of RSE in 50 countries over 4 years. Control of SE was achieved in 74% of the cases. Neurologic outcomes were poor in 41% of patients, and 24% died. Good outcome was associated with younger age and a history of epilepsy. Etiology strongly influenced the outcome. Patients from Asia were younger, more frequently presented with convulsive SE , and were more frequently affected by infectious etiologies when compared with patients from Europe and the Americas. Despite these differences, outcomes were similar in all countries. Demographics of patients with RSE in a global audit are similar to those in prior single center series, providing evidence of generalizability of those studies. Important differences exist among patients with RSE from different regions of the world, but these do not seem to significantly influence patient outcomes.