Coma Therapy Research Articles

Protein Requirement Changes According to the Treatment Application in Neurocritical Patients.

Exploring protein requirements for critically ill patients has become prominent. On the other hand, considering the significant impact of coma therapy and targeted temperature management (TTM) on the brain as well as systemic metabolisms, protein requirements may plausibly be changed by treatment application. However, there is currently no research on protein requirements following the application of these treatments. Therefore, the aim of this study is to elucidate changes in patients' protein requirements during the application of TTM and coma therapy. This study is a retrospective analysis of prospectively collected data from March 2019 to May 2022. Among the patients admitted to the intensive care unit, those receiving coma therapy and TTM were included. The patient's treatment period was divided into two phases (phase 1, application and maintenance of coma therapy and TTM; phase 2, tapering and cessation of treatment). In assessing protein requirements, the urine urea nitrogen (UUN) method was employed to estimate the nitrogen balance, offering insight into protein utilization within the body. The patient's protein requirement for each phase was defined as the amount of protein required to achieve a nitrogen balance within ±5, based on the 24-hour collection of UUN. Changes in protein requirements between phases were analyzed. Out of 195 patients, 107 patients with a total of 214 UUN values were included. The mean protein requirement for the entire treatment period was 1.84±0.62 g/kg/day, which is higher than the generally recommended protein supply of 1.2 g/kg/day. As the treatment was tapered, there was a statistically significant increase in the protein requirement from 1.49±0.42 to 2.18±0.60 in phase 2 (p<0.001). Our study revealed a total average protein requirement of 1.84±0.62 g during the treatment period, which falls within the upper range of the preexisting guidelines. Nevertheless, a notable deviation emerged when analyzing the treatment application period separately. Hence, it is recommended to incorporate considerations for the type and timing of treatment, extending beyond the current guideline, which solely accounts for the severity by disease.

A National Survey on Coma Epidemiology, Evaluation, and Therapy in India: Revisiting the Curing Coma Campaign Come Together Survey.

The limited representation from developing countries in the original COME TOGETHER survey gave us an impetus to conduct this survey in the Indian subcontinent. This cross-sectional online survey was conducted from August through September 2022. Participants were health care physicians caring for patients with coma and disorders of consciousness. Fischer's exact test or the Mann-Whitney U-test was used to compare respondents who agreed or disagreed with the preestablished coma definition. Fleiss κ values were calculated to assess agreement among respondents. A p value less than 0.05 was considered statistically significant. The survey was completed by 130 physicians. We found substantial interrater agreement on absence of wakefulness (71.54%; κ = 0.71), Glasgow Coma Score ≤ 8 (78.46%; κ = 0.78), and failure to respond purposefully to visual, verbal, or tactile stimuli (66.15%; κ = 0.66). Reported common etiologies of coma included traumatic brain injury (50.76%), ischemic stroke (30%), and intracerebral hemorrhage (29.23%). The most common clinical assessment tools used for coma included the Glasgow Coma Score (92.3%) and neurological examination (60.8%). Neurological examination was the most commondiagnostic tool used(100%), followed by magnetic resonance imaging (89.2%), basic laboratory studies (88.5%), and head computed tomography/angiography (86.9%). Pharmacological interventions used to stimulate arousal in patients with coma were sedation vacation (91.5%), electrolyte/endocrine correction (65.4%), osmotic therapy with mannitol (60%), hypertonic saline (54.6%), modafinil (46.9%), and antidote for drugs (45.4%). Among the nonpharmacological interventions, sensory stimulation (57.7%) was the most commonly used modality. The most common discharge disposition for comatose patients who survived hospitalization were home with or without services (70.0%). Differences from the global survey were noted regarding the following: traumatic brain injury being the most common etiology of coma in India, more frequent practice of sedation interruption, less frequent use of electroencephalography in India, rare use of pharmacological neurostimulants, and home being the most common discharge disposition in India.

Pentobarbital coma for management of intracranial hypertension following traumatic brain injury: Lack of early response to treatment portends poor outcomes

IntroductionTraumatic brain injury (TBI) results in the death of over 50,000 and the permanent disability of 80,000 individuals annually in the United States. Much of the permanent disability is the result of secondary brain injury from intracranial hypertension (ICH). Pentobarbital coma is often instituted following the failure of osmotic interventions and sedation to control intracranial pressure (ICP). The goal of this study was to evaluate the efficacy of pentobarbital coma with respect to ICP management and long-term functional outcome. MethodsTraumatic brain injury patients who underwent pentobarbital coma at a level 1 trauma center between 2014 and 2021 were identified. Patient demographics, injury characteristics, Glasgow Coma Scale (GCS) scores, intracranial pressures (ICPs), and outcomes were obtained from the trauma registry as well as inpatient and outpatient medical records. The proportion of ICPs below 20 for each hospitalized patient-day was calculated. The primary outcome measured was GCS score at the last follow-up visit. Results25 patients were identified, and the majority were male (n ​= ​23, 92%) with an average age of 30.0 years ​± ​12.9 and median injury severity score of 30 (21.5–33.5). ICPs were monitored for all patients with a median of 464 (326–1034) measurements. The average hospital stay was 16.9 days ​± ​11.5 and intensive care stay was 16.9 ​± ​10.8 days. 9 (36.0%) patients survived to hospital discharge. Mean follow-up time in months was 36.9 ​± ​28.0 (min-max 3–80). 7 of the 9 surviving patients presented as GCS 15 on follow-up and the remaining were both GCS 9. Patients presenting at last follow-up with GCS 15 had a significantly higher proportion of controlled ICPs throughout their hospitalization compared to patients who expired or with follow-up GCS <15 (GCS 15: 88% ​± ​10% vs. GCS <15 or dead: 68% ​± ​22%, P ​= ​0.006). A comparison of the daily proportion of controlled ICPs by group revealed negligible differences prior to pentobarbital initiation. Groups diverged nearly immediately upon pentobarbital coma initiation with a higher proportion of controlled ICPs for patients with follow-up GCS of 15. ConclusionPatients that do not have an immediate response to pentobarbital coma therapy for ICH universally had poor outcomes. Alternative therapy or earlier palliation should be considered for such patients. In contrast, patients whose ICPs responded quickly to pentobarbital had excellent long-term outcomes.

Efficacy of Serum Antithrombin III Test in Patients With Severe Traumatic Brain Injury.

Immune reactions following traumatic brain injury (TBI) cause many complications, including intravascular dissemination. Antithrombin III (AT-III) plays an important role in suppressing abnormal clot formation and ensuring hemostasis. Therefore, we investigated the efficacy of serum AT-III in patients with severe TBI. This retrospective study included 224 patients with severe TBI who visited a single regional trauma center between 2018 and 2020. AT-III levels were measured immediately after the TBI diagnosis. AT-III deficiency was defined as an AT-III serum level <70%. Patient characteristics, injury severity, and procedures were also investigated. Patient outcomes included Glasgow Outcome Scale scores at discharge and mortality. AT-III levels were significantly lower in the AT-III deficient group (n=89; 48.27% ± 1.91%) than in the AT-III sufficient group (n = 135, 78.90% ± 1.52%) (p < 0.001). Mortality occurred in 72 of the 224 patients (33.04%), indicating that there were significantly more patients in the AT-III-deficient group (45/89, 50.6%) than in the AT-III-sufficient group (27/135, 20%). Significant risk factors for mortality included the Glasgow Coma Scale score (P = 0.003), pupil dilatation (P = 0.031), disseminated intravascular coagulopathy (P = 0.012), serum AT-III level (P = 0.033), and procedures including barbiturate coma therapy (P = 0.010). Serum AT-III levels were significantly correlated with Glasgow Outcome Scale scores at discharge (correlation coefficient = 0.455, p < 0.001). Patients with AT-III deficiency after severe TBI may require more intensive care during treatment, because AT-III levels reflect injury severity and correlate with mortality.

Comparison Between Complications of Pentothal Coma Therapy and Targeted Temperature Management in Traumatic Brain Injury Patients

BackgroundPentothal coma therapy (PCT) and targeted temperature management (TTM) are considered the most aggressive medical care for patients with severe traumatic brain injury (TBI). However, there is very little comparison between these two options. We compared the survival rates and complications between the two treatments.MethodsNineteen patients who received treatment for PCT or TTM after severe TBI between March 2018 and April 2022 were retrospectively enrolled. Medical records were reviewed, including general information, neurologic status, treatment courses, survival rate, and complications. Patients were divided into two groups according to the treatment modalities (PCT vs. TTM), and comparison analyses were conducted.ResultsThe survival rate in the TTM group was 33.3% (3/9), which was higher than that in the PCT group (1/10, 10%). However, this difference was not significant (p = 0.213). In terms of complications, there were no statistically significant differences in hemodynamic instability, cardiovascular disability, hepatic dysfunction, renal dysfunction, pneumonia, urinary tract infection, hyperkalemia, hypokalemia, coagulopathy, or hyperglycemia. Commonly observed complications included hypokalemia in the TTM group (100% in the TTM group vs 70% in the PCT group; p = 0.073) and hyperkalemia in the PCT group (50% in the PCT group vs 11.1% in the TTM group; p = 0.069).ConclusionSevere TBI patients treated with TTM has non-significantly lower mortality than them with PCT (66.7% vs. 90%); however, complications of hypokalemia can be frequently observed (100%). Further study was necessary to evaluate the efficacy and safety of TTM.

Prognostic effects of treatment protocols for febrile convulsive status epilepticus in children

BackgroundFebrile status epilepticus is the most common form of status epilepticus in children. No previous reports compare the effectiveness of treatment strategies using fosphenytoin (fPHT) or phenobarbital (PB) and those using anesthetics as second-line anti-seizure medication for benzodiazepine-resistant convulsive status epilepticus (CSE). We aimed to examine the outcomes of various treatment strategies for febrile convulsive status epilepticus (FCSE) in a real-world setting while comparing the effects of different treatment protocols and their presence or absence.MethodsThis was a single-center historical cohort study that was divided into three periods. Patients who presented with febrile convulsive status epilepticus for ≥60 min even after the administration of at least one anticonvulsant were included. During period I (October 2002–December 2006), treatment was performed at the discretion of the attending physician, without a protocol. During period II (January 2007–February 2013), barbiturate coma therapy (BCT) was indicated for FCSE resistant to benzodiazepines. During period III (March 2013–April 2016), BCT was indicated for FCSE resistant to fPHT or PB.ResultsThe rate of electroencephalogram monitoring was lower in period I than period II+III (11.5% vs. 85.7%, p<0.01). Midazolam was administered by continuous infusion more often in period I than period II+III (84.6% vs. 25.0%, p<0.01), whereas fPHT was administered less often in period I than period II+III (0% vs. 27.4%, p<0.01). The rate of poor outcome, which was determined using the Pediatric Cerebral Performance Category scale, was higher in period I than period II+III (23.1% vs. 7.1%, p=0.03). The rate of poor outcome did not differ between periods II and III (4.2% vs. 11.1%, p=0.40).ConclusionsWhile the presence of a treatment protocol for FCSE in children may improve outcomes, a treatment protocol using fPHT or PB may not be associated with better outcomes.

New-onset refractory status epilepticus (NORSE) and febrile infection-related epilepsy syndrome (FIRES) of unknown aetiology: A comparison of the incomparable?

PurposeThe discussion is ongoing whether new-onset refractory status epilepticus (NORSE) in adults and febrile infection-related epilepsy syndrome (FIRES) in children are one syndrome if the aetiology is unknown. In this study we will compare an adult cohort with NORSE and a paediatric cohort with FIRES in order to determine if they are similar or different. MethodsWe retrospectively compared 18 adults with NORSE versus 48 children with FIRES, both cohorts without identifiable cause despite extensive investigations. We analyzed demographic and clinical data using Mann-Whitney-U and χ2- tests. ResultsNORSE affected more women (78% vs. 42%; P = 0.009) than in FIRES. Median acute hospital stay was longer in FIRES (35 days [interquartile range, IQR=36] vs. 20 days [IQR=19]; P<0.001). FIRES was treated more frequently with coma therapy (82% vs. 28%; P<0.001) and with a higher median number of antiseizure medicines (7 [IQR=5] vs. 4 [IQR=2]; P<0.001). Children with FIRES showed a higher cerebrospinal fluid (CSF) cell count (10 cells/μl; P = 0.002) but a lower CSF protein level than adults with NORSE (48 mg/dl; P = 0.028). Immunotherapy was administered more frequently in FIRES (73% vs. 22%; P<0.001) than in NORSE. Group differences in number of antiseizure medicines after hospital stay (P = 0.229) and in overall mortality (P = 0.327) were not significant. ConclusionIn our explorative comparison, differences prevailed. NORSE and FIRES should be compared prospectively in age-matched cohorts.

Rozwój wczesnych biologicznych metod leczenia schizofrenii po II wojnie światowej

Development of early biological methods of treatment of schizophrenia after the II World War The article tells about the history of development the fi rst biological methods of treatment of schizophrenia, introduced after the II World War. At fi rst, there was insulin shock therapy, introduced for the fi rst time in 1933, then electroconvulsive therapy, applied in 1938 and lobotomy, which became popular method of treatment in 40s and 50s. Introducing every of this methods was an important step in schizophrenia research, altough all of them were mainly ineffective. Moreover all of this methods contain many side effects, even dangerous to life. It seems that development of each of this methods was crucial step important to introduce much more effective and safety ways of treatment of this disease.

'A landmark in psychiatric progress'? The role of evidence in the rise and fall of insulin coma therapy.

This paper examines the evidence behind the use and decline of insulin coma therapy as a treatment for schizophrenia and how this was viewed by the psychiatric profession. The paper demonstrates that, from the time of its introduction, there was considerable debate regarding the evidence for insulin treatment, and scepticism about its purported benefits. The randomized trials conducted in the 1950s were the result, rather than the origins, of this debate. Although insulin treatment was subsequently abandoned, it was still regarded as a historic moment in the modernization of psychiatry. Then, as now, evidence does not speak for itself, and insulin continued to be incorporated into the story of psychiatric progress even after it was shown to be ineffective.

Pentobarbital coma therapy for super-refractory status epilepticus and in-hospital mortality: an observational study.

Treatment of super-refractory status epilepticus (SRSE) is associated with various complications of anaesthetic coma therapy. This study aimed to describe the factors affecting the prognosis, especially in-hospital mortality, of patients receiving pentobarbital coma therapy for the treatment of SRSE. This was a retrospective cohort study conducted in a single tertiary referral centre with patients who received pentobarbital coma therapy for the treatment of SRSE from 2006 to 2018. Exploratory analyses were performed for clinical, laboratory, electrographic, and radiological factors for the entire cohort and were compared between the mortality and survivor groups. In total, 19 patients were enrolled, and five (26.3%) patients died in the hospital. The maximal pentobarbital infusion dose was higher in the mortality group than in the survivor group (4.4±1.0mg/kg/h vs. 2.9±1.4mg/kg/h, respectively; p=0.025). The high-dose pentobarbital infusion group (>3.75mg/kg/h) underwent longer mechanical ventilation (24 [20-36.75] vs. 41 [28-70], p=0.025) and blood culture results were more frequently positive, suggestive of septicaemia (8.3% vs. 57.1%, p=0.038). The group of SRSE patients treated with pentobarbital coma therapy who died in the hospital received a higher pentobarbital infusion dose compared to survivors; a complication of high-dose pentobarbital infusion was septicaemia. Considering the high rate of septicaemia observed, systematic treatment strategies focusing on infectious complications should be established and implemented. The association between maximal pentobarbital infusion dose and in-hospital mortality needs to be further validated.

Flumazenil therapy for a gabapentin-induced coma: a case report

BackgroundSpasticity and neuropathic pain are common in patients after spinal cord injury and negatively affect patients’ quality of life. Gabapentin and baclofen are frequently used to treat these conditions. We present a flumazenil-reversed gabapentin-induced coma case, which, to our knowledge, is the second one described in scientific literature.Case presentationA 70-year-old Caucasian man was admitted to our neurorehabilitation ward following a fall with cervical trauma that resulted in immediate tetraplegia. During his stay, he suffered from lower limb pain, both neuropathic and due to severe spasticity. Gradual baclofen and gabapentin administration was prescribed, with reduction in both pain and spasticity. One morning, the patient was found unresponsive, with a Glasgow Coma Score of 3. Head computerized tomography, electrocardiogram, electroencephalogram, vital signs, blood tests, breathing, and blood oxygenation were normal. Renal and liver failure were ruled out. Intravenous 0.25 mg of flumazenil (Anexate) was administered, resulting in complete neurocognitive recovery with a Glasgow Coma Score of 15.Discussion and conclusionsThis case report highlights the importance of the individual response to certain pharmacological agents and suggests that further studies need to be conducted both on flumazenil and gabapentin pharmacodynamics to better understand their molecular–receptor activity, and on possible multiple flumazenil mechanisms of action, beyond its classical strict benzodiazepine antagonist action.

P0008 / #640: EPIDEMIOLOGY AND INITIAL CLINICAL MANAGEMENT OF PEDIATRIC HEAD TRAUMA IN A BRAZILIAN TRAUMA CENTER – RESULTS OF A 2-YEAR RETROSPECTIVE COHORT

Aims & Objectives: Traumatic Brain Injury (TBI) poses a significant healthcare concern given the developmental consequences of early brain damage. Studies show that TBI contributes to 20-50% of pediatric injuries in different populations. This study aims to describe the epidemiologic characteristics and initial management of a 2-year cohort of TBI cases in Brazil. Methods: This observational study was conducted in a tertiary trauma center in Sao Paulo using clinical data registry of children (age 1month – 18 years) admitted from July 2017 to December 2019 after a diagnosis of TBI, with an initial Glasgow Coma Scale (GCS) of 3-12. All the records were reviewed. The main outcome measure was PICU mortality. Results: We included 66 patients (73% males), with a mean age of 7.5 years, in the study period. According to the initial GCS, 61% had severe and 26% moderate TBI. 19 patients did not have a reported GCS at admission and were included on basis of clinical evolution. The most used sedatives were Fentanyl (94%) and Propofol (88%), with an average 5.9 days of continuous sedation. Despite neuroprotective measures, 32% of patients needed osmotic agents for intracranial pressure control, 23% needed barbiturate coma therapy and 5% decompressive craniotomy. Mean PICU LOS was 8 days and mean MV duration was 5 days, but still 16 patients required tracheostomy. 4 patients (6%) died during PICU stay, 2 of these deaths declared by neurological criteria. Conclusions: TBI represent a relevant cause of death and disability in children and can be prevented by proper vigilance and safe driving practices.

Experimental Treatments: Women, Gender, and ‘Maternal Insanity’ in Victorian Psychiatric Institutions, 1920–36

This article investigates new and experimental medical treatments used to cure ‘maternal insanity’ in women committed to Victorian psychiatric institutions between 1920 and 1936. Close examination of the women's clinical files reveals the use of numerous treatments, vaccines, and tests that produced a wide range of patient outcomes. Patients received the ‘medically safe’ typhoid vaccine and Wassermann test, while the more controversial insulin coma therapy, ultraviolet ‘rays’, sterilisation, and abortion posed serious health risks. Gender influenced doctors 'therapeutic rationale in most cases, while in other instances treatments strengthened the patient—doctor relationship by offering patients hope for recovery. The treatments prescribed to insane mothers remind us of the stark realities of experimental physical treatments in Australia's past.

Severe hypokalemia and rebound hyperkalemia during barbiturate coma in patients with severe traumatic brain injury

ObjectivesTo evaluate the incidence of severe potassium disturbances during barbiturate coma therapy in patients with severe traumatic brain injury (TBI), and the characteristics of these patients. MethodsThe study comprised 37 patients with severe TBI who were treated for barbiturate coma between 2015 and 2017 in level 3 intensive care units of two hospitals. ResultsNo potassium disturbance occurred in 14 patients. Seventeen patients developed mild-moderate hypokalemia (2.6–3.5mEq/L), and 6 patients developed severe hypokalemia (<2.5mEq/L) following the induction of barbiturate therapy. The incidence of mild-to-severe barbiturate-induced hypokalemia was 62.2% and the rate of severe hypokalemia was 16.2%. The mean potassium supply per day during thiopentone therapy was statistically significantly different between patients with mild-to-moderate hypokalemic and those with severe hypokalemic (p<0.001). Four of 6 patients with severe hypokalemia developed rebound hyperkalemia exceeding 6mEq/L following the cessation of barbiturate infusion. The nadir potassium concentration was 1.5mEq/L and the highest value was 6.8mEq/L. The mean time to reach nadir potassium concentrations was 2.8 days. The mortality rate of the 6 patients was 66.7%. Of the 2 survivors of severe hypokalemia, the Glasgow Outcome Scale (GOS) on discharge and the extended GOS one year after the trauma were 5 and 8 respectively. ConclusionsSevere hypokalemia refractory to medical treatment and rebound hyperkalemia is a serious adverse effect of thiopentone coma therapy in patients with severe TBI. Excessive and aggressive potassium replacement during the barbiturate-induced hypokalemia period must be avoided. Weaning barbiturate treatment over time may be advantageous in the management of severe serum potassium disturbances.

Elevated risk of venous thromboembolism among post-traumatic brain injury patients requiring pharmaceutical immobilization

Traumatic brain injury (TBI) patients are known to have a high rate of venous thromboembolism (VTE), and additional neuromuscular blockade or barbiturate coma therapy has the theoretical risk of exacerbating baseline hemostasis and elevating the incidence of thromboembolic events. We conducted a single-institution retrospective review of patients surviving severe TBI, as determined by need for intracranial pressure (ICP) monitoring, who further required paralytics or barbiturate therapy to maintain ICP control. Patients were administered VTE prophylaxis as clinically appropriate. Predictors for VTE were subsequently determined with univariate and logistic multivariate regression analyses. The main cohort includes 144 patients, 34 of whom received pharmaceutical immobilization for ICP control. Mean ISS and GCS at intake were 31.9 and 5.2, respectively. Among those receiving vs not-receiving paralytics and/or barbiturate therapy, there was a statistical difference of 12/34 (35.3%) vs 18/110 (16.4%, p = 0.0280) in VTE events, at a mean time greater than two weeks from the time of trauma. Multivariate logistics regression indicated 3.2 times increased odds of developing a VTE (log odds = 1.17, p = 0.023). No pediatric patients were positive for an event (0/12 vs 7/22, p = 0.0356), and infections were only documented among those with VTE (0/22 vs 4/12, p = 0.0107). Overall, paralytics and barbiturate therapy were correlated with a higher incidence of VTE among TBI patients. Although the need for ICP control will outweigh an increase in thromboembolic risk, there is value for increased surveillance and screening during the prolonged inpatient stay of these patients.

Severe hypokalemia and rebound hyperkalemia during barbiturate coma in patients with severe traumatic brain injury.

To evaluate the incidence of severe potassium disturbances during barbiturate coma therapy in patients with severe traumatic brain injury (TBI), and the characteristics of these patients. The study comprised 37 patients with severe TBI who were treated for barbiturate coma between 2015 and 2017 in level 3 intensive care units of two hospitals. No potassium disturbance occurred in 14 patients. Seventeen patients developed mild-moderate hypokalemia (2.6-3.5mEq/L), and 6 patients developed severe hypokalemia (<2.5mEq/L) following the induction of barbiturate therapy. The incidence of mild-to-severe barbiturate-induced hypokalemia was 62.2% and the rate of severe hypokalemia was 16.2%. The mean potassium supply per day during thiopentone therapy was statistically significantly different between patients with mild-to-moderate hypokalemic and those with severe hypokalemic (p<0.001). Four of 6 patients with severe hypokalemia developed rebound hyperkalemia exceeding 6mEq/L following the cessation of barbiturate infusion. The nadir potassium concentration was 1.5mEq/L and the highest value was 6.8mEq/L. The mean time to reach nadir potassium concentrations was 2.8 days. The mortality rate of the 6 patients was 66.7%. Of the 2 survivors of severe hypokalemia, the Glasgow Outcome Scale (GOS) on discharge and the extended GOS one year after the trauma were 5 and 8 respectively. Severe hypokalemia refractory to medical treatment and rebound hyperkalemia is a serious adverse effect of thiopentone coma therapy in patients with severe TBI. Excessive and aggressive potassium replacement during the barbiturate-induced hypokalemia period must be avoided. Weaning barbiturate treatment over time may be advantageous in the management of severe serum potassium disturbances.

Prognostic significance of subsequent extra-temporal involvement in cryptogenic new onset refractory status epilepticus (NORSE) initially diagnosed with limbic encephalitis

IntroductionNew-onset refractory status epilepticus (NORSE) is defined as refractory SE in patients without active epilepsy or relevant neurological disorder with no clear active causes. Diverse types and etiologies of NORSE are reported in various groups. Limbic encephalitis (LE) is reported as one of etiologies of NORSE. In this study, we investigated whether there were any intersections between NORSE and limbic encephalitis, as well as the presence of prognostic factors in intersection patients. MethodsWe retrospectively analyzed patients who met both the definition of NORSE and diagnostic criteria of LE at the initial presentation from our database. Clinical characteristics and blood test, cerebrospinal fluid, electroencephalography, and magnetic resonance imaging results were reviewed. Prognosis was recorded as ICU admission stay, total length of hospitalization, and modified Rankin Scale at discharge. In particular, we determined which factors were associated with patients’ prognosis. ResultsThirteen patients were selected. Nine of the 13 patients had myalgia and 8 patients had fever in the prodromal period. Twelve of the 13 patients had acute memory impairment or confusion before SE development. In addition, 46.2% of the patients showed leukopenia or thrombocytopenia. Median body temperature at hospital arrival was 37.6 °C. Nine patients showed generalized tonic-clonic SE. All patients were treated with immunotherapy and 11 of the 13 patients achieved burst suppression through induced coma therapy. Ten patients showed lesion extension on follow-up imaging. The most common extension site was the claustrum. Patients with more lesion extension showed poorer outcomes than those without lesion extension. ConclusionSubsequent extratemporal lesion extension was closely associated with poor prognosis in NORSE-LE patients. This study explores a new subtype of NORSE and suggests a possible common underlying pathomechanism between NORSE and LE.

Prognostic factors in pediatric pneumococcal meningitis patients in mainland China: a retrospective multicenter study.

Background: Prognosis of pneumococcal meningitis (PM) remains very poor, especially in less developed countries. Currently, few multi-centric studies on pediatric PM have been reported in mainland China.Objectives: This study aimed to explore the correlation of clinical and laboratory findings with complications and prognosis in pediatric PM.Methods: The pediatric PM patients were retrospectively recruited from ten pediatric tertiary hospitals across China between January 2013 and June 2018. Clinical, biochemical, and microbiological data and follow-up information were collected. Predictive factors for complications and prognostic factors for overall survival (OS) and sequelae-free survival (SFS) were analyzed.Results: A total of 132 pediatric PM patients were included. Seventy-one patients had complications, 25 patients died, and 39 patients had neurological sequelae. Multivariate logistic regression suggested that age less than 28 months (adjusted OR=2.654, 95%CI=1.067–6.600, P=0.036) and lower white blood cells in blood (aOR=3.169, 95%CI=1.395–7.202, P=0.006) were associated with high risk of complications. Multivariate Cox’s proportional hazard regression suggested that age less than 28 months (aHR=6.479, 95%CI=1.153–36.404, P=0.034), coma (aHR=9.808, 95%CI=2.802–34.323, P=0.000), and non-adjuvant steroid therapy (aHR=4.768 95%CI=1.946–11.678, P=0.001) were independent prognostic factors for poor OS; coma (aHR=5.841, 95%CI=2.652–12.864, P=0.000), septic shock on admission (aHR=2.949, 95%CI=1.049–8.290, P=0.040), and lower glucose level in cerebrospinal fluid (CSF) (aHR=2.523, 95%CI=1.336–4.765, P=0.004) were independent prognostic factors for poor SFS.Conclusion: Age, coma, and adjuvant steroid therapy were independent factors for OS, while coma, septic shock on admission, and lower glucose level in CSF were independent factors for SFS in pediatric PM patients. These factors might be used to identify PM patients with poor prognosis and guide individual treatment.

“To suit the occasion, I wore my schizophrenic fancy dress”1 – the life of Janet Frame

Janet Frame (1924-2004) was one of New Zealand's most celebrated authors. Much of her work stems from her experiences as a psychiatric patient. She was hospitalised for about eight years with a diagnosis of schizophrenia. Treatments included insulin coma therapy and unmodified electroconvulsive therapy. Her doctors then planned for her to have a leucotomy, which was cancelled upon discovery that one of her works had won a prestigious literary award. She subsequently moved to England and was assessed at the Maudsley Hospital by Sir Aubrey Lewis. She was found to never have suffered from schizophrenia; her condition was instead attributed to the effects of overtreatment and prolonged hospitalisation. She reflected profoundly on these experiences in her writing, and those who are interested in psychiatry are truly fortunate to have access to her autobiographies, fiction and poetry. Janet Frame has written both autobiographical and fictional accounts of her many years of psychiatric treatment, describing individuals, interpersonal relationships, and everyday life in these institutions. Her own life story demonstrates extraordinary recovery and achievement.

Donatien Raffegeau (1855–1931), fondateur de la clinique « La Villa des Pages » au Vésinet ; ses collaborateurs et successeurs : B.-A. Casalis, H. Leulier, P.-M. Leulier, R. Leulier et H. Mignon

Donatien Raffegeau (1855–1931) was born in Vendée. He studied medicine in Nantes and Angers. He was successively the intern of Aurèle Petrucci (1880–1906), medical director at Saint-Gemmes-sur-Loire asylum, Ambroise-Eusebe Mordret (1822–1904), head doctor at the mental asylum of Le Mans and Jules Christian (1847–1907) during 15 months at the National House of Charenton. In 1884, he qualified as a medical doctor. Raffegeau worked for a short period of time in a private asylum located at 130 rue Glacière in Paris and then he found a house of health in 1890. Its name was “Hydrotherapeutic Institute of Vésinet” and called later “La Villa des Pages”. It was a winter and summer sanatorium for cases of convalescents and all nervous disorders. The insane were not admitted. Raffegeau promoted a treatment approach by the hydrotherapy, the thermotherapy and the massotherapy. He used the electrotherapy, the light therapy and the suggestion according to Liebeault’ method. The gymnastic or the fencing were used as therapeutic adjuvants. Raffegeau prescribed for specific patients a therapeutic stay at the “Villa des Charmilles” (Castle of Port-Cé) near Saint-Nazaire (Loire Atlantique). In 1908, he acquired this peacefull place located on the waterfront. Member of various societies: medico-psychological society, anthropology society, hypnotism society, astronomy society and vice-president of the psychotherapy society, he was elected Mayor of his native city from 1908 to 1931 and Vésinet municipal counsellor. In the flow of mental hygienist school, he insisted on the important role of the school doctor on the mental and physic health. After the Great War, Raffegeau was the first to prescribe the Gardénal epilepsy treatment (Luminal of the Germans), which became a classic treatment. The quality of social and professional life of the patients has been improved. This treatment was developed at the Villa des Pages clinic (Le Vésinet). Over the years, the Villa des Pages has opened its doors to the psychiatric patients. The physiotherapy had to give way partially to the new therapeutic approaches developed in public hospitals: malaria therapy, insulin shock therapy, electroshock, caradiazol therapy. No psychiatric doctor could not ignore them in their practice. They have been introduced by the doctors Henri Mignon (1870–1854), Pierre-Maximin Leulier (1884–1952), Bernard-Alfred Casalis (1902–1975) as proved their articles published in “Annales Médico-Psychologiques”. From 1947 to 1981, their successors Roger Leulier (1913–1998) and Hélène Leulier (1913–) trained by pioneers of modern psychiatry (J. Delay, P. Guiraud, G. Heuyer, J. Rondepierre) have assumed the medical direction. The latter was a member of the Psychiatric Evolution (1946) and an adherent member of the Psychoanalytic Society of Paris (1953). She introduced the psychoanalysis in the Villa des Pages. After having been directed by two psychiatrists (A. Campagne and A. Sonnier), this old “Hydrotherapy Institute of Vésinet” is an establishment whose destiny is in the hands of the ORPEA group since 2002. We acknowledge that the renewal of the clinic's doctors since being set up in 1890 who took account of therapeutic advances in the field of psychiatric by integrating them into their practice had allowed that this Health Home survived throughout the centuries and to maintain in the world of French psychiatric.