CONTEXT: The optimal pharmacologic treatment for early convulsive status epilepticus is unclear. OBJECTIVE: To analyze efficacy, tolerability and safety data for anticonvulsant treatment of children and adults with convulsive status epilepticus and use this analysis to develop an evidence-based treatment algorithm. DATA SOURCES: Structured literature review using MEDLINE, Embase, Current Contents, and Cochrane library supplemented with article reference lists. STUDY SELECTION: Randomized controlled trials of anticonvulsant treatment for seizures lasting longer than 5 minutes. DATA EXTRACTION: Individual studies were rated using predefined criteria and these results were used to form recommendations, conclusions, and an evidence-based treatment algorithm. RESULTS: A total of 38 randomized controlled trials were identified, rated and contributed to the assessment. Only four trials were considered to have class I evidence of efficacy. Two studies were rated as class II and the remaining 32 were judged to have class III evidence. In adults with convulsive status epilepticus, intramuscular midazolam, intravenous lorazepam, intravenous diazepam and intravenous phenobarbital are established as efficacious as initial therapy (Level A). Intramuscular midazolam has superior effectiveness compared to intravenous lorazepam in adults with convulsive status epilepticus without established intravenous access (Level A). In children, intravenous lorazepam and intravenous diazepam are established as efficacious at stopping seizures lasting at least 5 minutes (Level A) while rectal diazepam, intramuscular midazolam, intranasal midazolam, and buccal midazolam are probably effective (Level B). No significant difference in effectiveness has been demonstrated between intravenous lorazepam and intravenous diazepam in adults or children with convulsive status epilepticus (Level A). Respiratory and cardiac symptoms are the most commonly encountered treatment-emergent adverse events associated with intravenous anticonvulsant drug administration in adults with convulsive status epilepticus (Level A). The rate of respiratory depression in patients with convulsive status epilepticus treated with benzodiazepines is lower than in patients with convul-

Trauma survivors are individuals who have been involved in an experience that includes the likelihood of loss of life or grievous harm to oneself or others (Allen, 1995;Matsakis, 1998; Rosenbloom, Williams, & Watkins, 1999). Trauma survivors may have experienced an accident, natural disaster, abuse, crime victimization, or violence including sexual assault, incest, or physical abuse (Rosenbloom et al., 1999). Shengold (1979) referred to trauma events as indignities imposed by one human being upon another and labeled their outcome as "soul murder"@. 533). An individual's capacity to cope with the traumatic experience is determined by their cognitive, emotional, behavioral, intellectual, and psychological capacities, as well as their support system. Shengold (1979) noted that the outcome of trauma experiences is often the developmental arrest of the individual's soul, psychological structure, and functioning. It is possible that these trauma experiences may have had a negative impact on the psychological, physical, and emotional development of these individuals (Allen, 1995; .... Bowen, 1982; Erickson & Egeland, 1987;Parker & Parker, 1991). Consequently, many trauma survivors often experience difficulties with trust, guilt (Rosenbloom et al., 1999), self-esteem, decision making, assertiveness, fear of success, and anxiety (Allen, 1995; Gianakos, 1999, Ibrahim & Herr, 1987 Peterson & Priour, 2000). Diane H. Coursol is a professor of counselor education, and JacquelineOne aspect of an individual's functioning that may be affected by trauma is their ability to engage in activities that are related to career and work. An important element of this area of development is career maturity (Super, 1990). Career maturity refers to an individual's capacity to handle the developmental tasks appropriate to their life stage (Super, 1990). This construct encompasses the individual's biological, psychological, and social development. However, few studies have addressed the impact of the trauma experience on the process of career development (Bowen, 1982; Erickson & Egeland, 1987;Ibrahim & Herr, 1987;Parker & Parker, 1991). Given the consequences of trauma, it is possible that the career maturity of trauma survivors may be arrested and can prevent them from achieving their full potential within the world of work. Consequently, the issue of career maturity warrants attention during the career counseling process.When trauma survivors seek career counseling, it is important for counselors to understand the expectations that these clients have for the counseling process. Understanding expectations is important because client expectations for counseling have been shown to affect the process (Corbishley & Yost, 1989). Galassi, Crace, Martin, James, and Wallace (1992) investigated preferences of clients for duration, outcomes, client and counselor roles, and career assessment. The study found that clients knew what they wanted to accomplish from career counseling but were uncertain about what the process involved. Clients preferred...

Context: Refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE) are neurological emergencies with considerable mortality and morbidity. In this paper, we provide an overview of causes, evaluation, treatment, and consequences of RSE and SRSE, reflecting the lack of high-quality evidence to inform therapeutic approach. Sources: This is a narrative review based on personal practice and experience. Nevertheless, we searched MEDLINE (using PubMed and OvidSP vendors) and Cochrane central register of controlled trials, using appropriate keywords to incorporate recent evidence. Results: Refractory status epilepticus is commonly defined as an acute convulsive seizure that fails to respond to two or more anti-seizure medications including at least one nonbenzodiazepine drug. Super-refractory status epilepticus is a status epilepticus that continues for ≥24 hours despite anesthetic treatment, or recurs on an attempted wean of the anesthetic regimen. Both can occur in patients known to have epilepsy or de novo, with increasing recognition of autoimmune and genetic causes. Electroencephalography monitoring is essential to monitor treatment response in refractory/super-refractory status epilepticus, and to diagnose non-convulsive status epilepticus. The mainstay of treatment for these disorders includes anesthetic infusions, primarily midazolam, ketamine, and pentobarbital. Dietary, immunological, and surgical treatments are viable in selected patients. Management is challenging due to multiple acute complications and long-term adverse consequences. Conclusions: We have provided a synopsis of best practices for diagnosis and management of refractory/superrefractory status epilepticus and highlighted the lack of sufficient high-quality evidence to drive decision making, ending with a brief foray into avenues for future research.

The use of levetiracetam for the treatment of epilepsy in women of childbearing age has increased as more evidence of teratogenicity of other broad-spectrum antiepileptic medications becomes available. Levetiracetam appears to be associated with a low incidence of major congenital malformations based on data from pregnancy registries. Major pregnancy-related changes in the pharmacokinetics of levetiracetam have been described in several case series, demonstrating a role for careful therapeutic drug monitoring of levetiracetam in pregnant patients. Extended-release levetiracetam provides a way to improve medication adherence in adults with epilepsy by allowing once/day dosing and may be considered for use in pregnancy to minimize the fluctuation of levetiracetam levels throughout the day, thus potentially minimizing dose-related adverse effects. In this case report, we describe a 16-year-old, compliant, pregnant patient who experienced subtherapeutic levetiracetam blood concentrations that occurred with use of extended-release levetiracetam. She experienced a breakthrough seizure with once/day dosing during her third trimester with low subsequent trough levels despite multiple dose increases. After changing to twice/day dosing of extended-release levetiracetam at delivery, the patient experienced no seizures and delivered a healthy infant without complications. This is the first case report, to our knowledge, to describe seizure breakthrough during pregnancy with an extended-release formulation of an antiepileptic medication. Pharmacokinetic changes associated with pregnancy may increase apparent clearance of extended-release formulations of levetiracetam, leading to periods of subtherapeutic blood or central nervous system concentrations. These changes support the important role of therapeutic monitoring of levetiracetam plasma concentrations to help maintain seizure control in women with epilepsy during pregnancy.

Introduction Busulfan is a chemotherapy agent used in hematopoietic stem cell transplant (HSCT) conditioning regimens. Busulfan is associated with tonic‐clonic seizures in ~10% of patients if administered without seizure prophylaxis. Historically, phenytoin was the most commonly utilized seizure prophylaxis agent; however, phenytoin is associated with CYP450 drug interactions and potentially increases the clearance of busulfan. Levetiracetam is being used more recently for busulfan seizure prophylaxis and is not associated with drug‐drug interactions; however, data supporting use in pediatric patients are limited. The primary objective is to determine whether there is any difference in seizure rates or safety profile between phenytoin and levetiracetam when used for seizure prophylaxis. Methods We conducted a retrospective chart review including patients who received busulfan between 2010 and 2019 were identified. The data were evaluated to compare the incidence of busulfan‐induced seizures in HSCT patients receiving either phenytoin or levetiracetam and to determine the impact of drug‐drug interactions on treatment outcomes/adverse events. Results A total of 342 patients were included with a median age of six years. Overall, five patients within the phenytoin group (n = 126) (4%) and zero patients in the levetiracetam group (n = 216) experienced a seizure (P = .007). There were no differences in liver enzyme elevations, recurrence rates of primary disease, and veno‐occlusive disease. Conclusion Levetiracetam is effective at preventing seizures associated with busulfan administration with no clinically significant adverse effects when compared to phenytoin.