Background: Nonconvulsive status epilepticus (NCSE) is a highly heterogeneous clinical condition that is understudied in the pediatric population.
Objective: To analyze the epidemiological, clinical, ...and electroencephalograpic features in pediatric patients with NCSE.
Methods: We identified 19 pediatric patients with NCSE from the epilepsy database of the Comprehensive Epilepsy Center at, Columbia University between June 2000 and December 2003. Continuous electroencephalographic (EEG) monitoring was analyzed and chart review was performed.
Results: The patients ranged from 1 month old to 17 years of age. Five patients developed NCSE following convulsive status epilepticus (CSE), and a further 12 patients developed NCSE after brief convulsions. Two developed NCSE as the first manifestation during a comatose state following hypoxic events. Acute hypoxic‐ischemic injury was the most frequent etiology of NCSE in our population (5 of 19; 26%), followed by exacerbation of underlying neurometabolic disease (4 of 19; 21%), acute infection (3 of 19; 16%), change in antiepileptic drug regimen (3 of 19;16%), refractory epilepsy (2 of 19; 11%) and intracranial hemorrhage (2 of 19; 11%). Six patients had associated periodic lateralized epileptiform discharges (PLEDs), one had generalized periodic epileptiform discharges (GPEDs). Five (5 of 19; 26%) patients died of the underlying acute medical illness. Periodic discharges were associated with worse outcome.
Conclusion: The majority of our patients with NCSE had preceding seizures in the acute setting prior to the diagnosis of NCSE, though most of these seizures were brief, isolated convulsions (12 patients) rather than CSE (five patients). Prolonged EEG monitoring to exclude NCSE may be warranted in pediatric patients even after brief convulsive seizures. Prompt recognition and treatment may be necessary to improve neurological outcome.
The use of continuous electroencephalogram (cEEG) monitoring in the intensive care unit is becoming more widespread, with improvements in data storage capability and networking and the increasing ...awareness of nonconvulsive seizures. Current and potential uses for this technology include seizure detection, ischemia detection, and prognostication. Nonconvulsive seizures are common in the critically ill, particularly those with acute brain injury and those who are comatose. The implications of some of the electrographical patterns observed in critically ill patients are not yet clear. This article discusses findings with cEEG to date, pitfalls in performing and interpreting these studies, and where we should turn our attention with this underutilized brain monitoring technique.
Generalized periodic discharges are increasingly recognized on continuous EEG monitoring, but their relationship to seizures and prognosis remains unclear.
All adults with generalized periodic ...discharges from 1996 to 2006 were matched 1:1 to controls by age, etiology, and level of consciousness. Overall, 200 patients with generalized periodic discharges were matched to 200 controls.
Mean age was 66 years (range 18-96); 56% were comatose. Presenting illnesses included acute brain injury (44%), acute systemic illness (38%), cardiac arrest (15%), and epilepsy (3%). A total of 46% of patients with generalized periodic discharges had a seizure during their hospital stay (almost half were focal), vs 34% of controls (p = 0.014). Convulsive seizures were seen in a third of both groups. A total of 27% of patients with generalized periodic discharges had nonconvulsive seizures, vs 8% of controls (p < 0.001); 22% of patients with generalized periodic discharges had nonconvulsive status epilepticus, vs 7% of controls (p < 0.001). In both groups, approximately half died or were in a vegetative state, one-third had severe disability, and one-fifth had moderate to no disability. Excluding cardiac arrest patients, generalized periodic discharges were associated with increased mortality on univariate analysis (36.8% vs 26.9%; p = 0.049). Multivariate predictors of worse outcome were cardiac arrest, coma, nonconvulsive status epilepticus, and sepsis, but not generalized periodic discharges.
Generalized periodic discharges were strongly associated with nonconvulsive seizures and nonconvulsive status epilepticus. While nonconvulsive status epilepticus was independently associated with worse outcome, generalized periodic discharges were not after matching for age, etiology, and level of consciousness.
The use of continuous electroencephalogram (cEEG) monitoring in the intensive care unit is becoming more widespread, with improvements in data storage capability and networking and the increasing ...awareness of nonconvulsive seizures. Current and potential uses for this technology include seizure detection, ischemia detection, and prognostication. Nonconvulsive seizures are common in the critically ill, particularly those with acute brain injury and those who are comatose. The implications of some of the electrographical patterns observed in critically ill patients are not yet clear. This article discusses findings with cEEG to date, pitfalls in performing and interpreting these studies, and where we should turn our attention with this underutilized brain monitoring technique.
Predicting outcome in patients with poor-grade subarachnoid hemorrhage (SAH) may help guide therapy and assist in family discussions. The objective of this study was to determine if continuous ...electroencephalogram (cEEG) monitoring results are predictive of 3-month outcome in critically ill patients with SAH.
We prospectively studied 756 patients with SAH over a 7-year period. Functional outcome was assessed at 3 months with the modified Rankin Scale (mRS). Patients that underwent cEEG monitoring were retrospectively identified and EEG findings were collected. Multivariate logistic regression analysis was performed to identify EEG findings associated with poor outcome, defined as mRS 4 to 6 (dead or moderately to severely disabled).
In 116 patients with SAH, cEEG monitoring and 3-month mRS were available. Of these patients, 88% had a Hunt & Hess grade of 3 or worse on admission. After controlling for age, Hunt & Hess grade, and presence of intraventricular hemorrhage on admission CT scan, poor outcome was associated with the absence of sleep architecture (80 versus 47%; odds ratio OR 4.3, 95%-confidence interval CI 1.1-17.2) and the presence of periodic lateralized epileptiform discharges (PLEDS) (91 versus 66% OR 18.8, 95%-CI 1.6-214.6). In addition, outcome was poor in all patients with absent EEG reactivity (n = 8), generalized periodic epileptiform discharges (n = 12), or bilateral independent PLEDs (n = 5), and in 92% (11 of 12) of patients with nonconvulsive status epilepticus.
cEEG monitoring provides independent prognostic information in patients with poor-grade SAH, even after controlling for clinical and radiological findings. Unfavorable findings include periodic epileptiform discharges, electrographic status epilepticus, and the absence of sleep architecture.
Summary
Purpose: We have previously demonstrated that it is common for alerting stimuli to induce electrographic seizures and other periodic or rhythmic patterns in the critically ill; however, only ...1 of the first 33 patients we reported with this phenomenon had a detectable clinical correlate.
Methods: Review of charts and video EEG findings in critically ill patients in a neurological ICU at a tertiary care medical center in Manhattan.
Results: We identified nine patients who had focal motor seizures repeatedly induced by alerting stimuli. All patients were comatose, and 8/9 had nonconvulsive status epilepticus at some point during their acute illness. Imaging abnormalities involved bilateral thalami in three patients, upper brainstem in one, and the perirolandic region in five.
Discussion: We hypothesize that in encephalopathic patients, alerting stimuli activate the arousal circuitry, and, when combined with hyperexcitable cortex, result in epileptiform activity or seizures. This activity can be focal or generalized, and is usually nonconvulsive, as is true of seizures in general in the critically ill. However, when the cortex is hyperexcitable in a specific region only, focal EEG findings arise. If the electrographic seizure activity is adequately synchronized and involves motor pathways, this can present as focal motor seizures, as seen in these nine patients.
Alerting can induce seizures in encephalopathic/comatose patients. The observation of clear focal clinical seizures removes the last remaining doubt that these stimulus‐induced patterns are indeed seizures by any definition, not simply abnormal arousal patterns.
In Yuz Aleshkovsky's prose, the writer creates the literary image of the Soviet Union's 'new man' and his reflection on Soviet history. Representing the third wave of Russian Literature in ...immigration, Aleshkovsky published his samizdat works in the West. This thesis includes an in-depth coverage of three Aleshkovsky novels: The Hand and Kangaroo written in the Soviet Union and circulated in the underground, and A Ring in a Case, a work compiled and published in the United States which covers the intra-collapse era of the Soviet Regime. The goal of this argument is to explore through the prism of Bakhtin's carnival, Aleshkovsky's literary image of the 'new-man' versus the ordinary man as an alternative to the literary images of socialist realism; and discuss the depictions of history and historical figures as Aleshkovsky's post-modern response to the state-mandated socialist-realist aesthetic. In Aeshkovky's works the main protagonists suffer from the complication of sexual impotence. This artistic method provides Aleshkovsky the necessary framework to present his treatment of the theme of masculinity and how it was affected by the Soviet experiment, contrasting the 'new-man' with who is referred to as either a 'regular' or ordinary man. To depict the Soviet reality in which the 'new-man' lives, Aleshkovsky portrays Soviet history using mennipean satire. This thesis explicates Aleshkovsky's image of Soviet history by applying Mikhail Bakhtin's characteristics of the mennipea. This methodology illuminates how Aleshkovsky renders history as carnival, creating the inverted paradigm in which the grotesque and absurd allow the reader a truer depiction of the Soviet reality than any official history. Aleshkovsky's use of demonic imagery works to contradict the socialism and radicalism of the revolutionaries in his works. Those who created the Soviet state did so in service of the Ideal, Truth, and Purpose. They believed that their ends would justify their means. Portraying those who worked for the good of the people as demonic is the complete reversal of the official Party line, adding to Aleshkovsky's alternative yet parallel world omnipresent in his works. The absurdist depiction of the revolutionaries underscores Aleshkovsky's aversion to fanatical ideology, notably socialism. The man of the new type, being so possessed by the idea of historical necessity is concerned not with his own fate but the fate of the collective, and if the new-man is not concerned with his own fate how could he be with that of another? The men lack any sense of reason; unable to think for themselves, they believe to sit in prison is their duty in the building of socialism. To accomplish his rejection of the effects of communism on society and history within the Soviet Union and then the emerging Russian state, Aleshkovsky employs the literary devices of skaz and constructs a poetic, carnivalesque world in which the absurd and grotesque are more realistic depictions than any official history.
This dissertation deals primarily with the tension between the institutionalization of writing studies and what I conceive of as the promise of literacy. I discuss institutionalization on a global ...scale, the institutionalization of composition as a discipline, and how writing teachers might transgress this institutionalization. I argue that at least since the early 1970s composition has been closely aligned with theories of transgression—conceiving itself as political and finding ways to allow others to become political through writing. Many compositionists feel writing is one mechanism that allows human beings to become entities in the world, to exist, to become recognized as individuals, and to have a social impact in creating democratic dialogue. However, I argue that when put into practice, many of the techniques that define resistance or transgression theories have often resulted in little more than a repackaging of what writing teachers have always done—privilege. In order for writing studies to have genuine political effects, those working in composition and resistance should ask how institutional logics often delimit the kinds of action we can take in the public field and how the discipline of composition might itself be implicated in the difficulties and complexity of that transgression. In the first two chapters I combine both ontological and materialist critiques and argue that while transgression theories are usually tied to one or the other, they are rarely used in combination, which is how they need to be utilized to be effective. Chapters three and four focus specifically on the development of the discipline of composition and demonstrate the discrepancy between the theories and practices of resistance. I conclude with the suggestion that to undermine the social logic of totalitarianism, teachers of writing can use literacy as a way to construct new social worlds—to construct the personal (that is, a post-humanist ethics) after modernism. To do this, however, teachers of writing must realize the system of totalitarianism under which they operate and find ways to locally transgress it. This type of resistance is one that must remain communal, contingent, and fluctuating.
Recent environmental policy in the United States requires unprecedented insight into the subsurface environment. Many new laws have been passed to clean up existing contamination and protect water ...resources that require information about the physical and chemical properties of subsurface materials. The general principle behind each of these laws is that it is not possible to protect the environment from damage if we do not understand the physics, chemistry, and toxicology of the processes we are attempting to regulate. Most federal and state water pollution control legislation is based on our ability to determine impacts by estimating the effects of an environmental release. Increasingly, models are used to identify the range of probable impacts. Consequently, models of subsurface processes have become tools of public policy. While policy objectives may always be quite clear (e.g., protect groundwater from pollution) it is less obvious how to assure the desired outcome. Groundwater flow and contaminant transport modeling can be used to gain insight into the environmental factors controlling the range of options available. However, there are several problems with using this particular class of models to guide public policy: 1) Areas of interest often overlap. (2) Models are valid at a particular scale. (3) Transport models can be used to inform our understanding of contamination risk. Each of these problems stimulated a separate line of research. Modeling was used to assess the potential impacts of global climate change in a regional bedrock aquifer and new techniques were developed to build and interpret very large scale, supra-regional models. New model-building tools and practical techniques for calibration are presented. A set of basin-scale, regional models demonstrate how hydrogeologic properties of a basin can affect hydrologic response to drought. New techniques were developed to nest a local groundwater flow model in a regional domain and to evaluate how the conceptual model of flow through a separating clay layer can change our interpretation of aquifer vulnerability. Numerical experiments were conducted using a saturated-unsaturated flow and transport model to create a drinking water contamination index based on the toxicity, mobility, and persistence of releases.
This thesis attempts to take a critical look at how the discipline of composition has grown since the turn of the century and what problems developed as a result. It makes few overt disciplinary ...claims, but does suggest that because of composition's history, and because of its relationship with literature, composition has not been able to discover itself. Composition's practitioners are only beginning to discover the cultural implications, the social dynamics, and the craft of the discipline. To those of us who love teaching writing, for those of us who want to engage our students in the acts of discovery, representation, and creativity, we must examine the discipline and make genuine attempts to be more inclusive in our pedagogy. I offer one avenue of discovery, the inclusion of academic and student history in the formation of classroom curriculum.
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