Although undersampled, this trial shows significantly longer mechanical ventilation with barbiturates and the occurrence of severe treatment-related complications in both arms. We describe practical issues necessary for the success of future studies needed to improve the current unsatisfactory state of evidence.

The STESS reliably identifies SE patients who will survive. Early aggressive treatment could not be routinely warranted in patients with a favorable STESS, who will almost certainly survive their SE episode. A randomized trial using this score would be needed to confirm this hypothesis.

Both levetiracetam (LEV) and phenytoin (PHT) were associated with a low risk of early postoperative seizures and a moderate risk of later epilepsy. LEV was associated with significantly fewer early adverse reactions than PHT and with a higher retention rate in patients who were followed for at least 1 year and developed epilepsy.

Among patients with SE who had MRI changes, those with previous epilepsy or extratemporal structural lesions showed increased diffusion in the hippocampus and may have selective hippocampal vulnerability to seizure-induced hyperexcitability. Patients with hyperintense signal in the cortical gray matter had episodes of possible hypoperfusion or hypoxia.

Children with epilepsy in low-income countries often go undiagnosed and untreated. We examine a portable, low-cost smartphone-based EEG technology in a heterogeneous pediatric epilepsy cohort in the West African Republic of Guinea. Methods: : Children with epilepsy were recruited at the Ignace Deen Hospital in Conakry, 2017. Participants underwent sequential EEG recordings with an app-based EEG, the Smartphone Brain Scanner-2 (SBS2) and a standard Xltek EEG. Raw EEG data were transmitted via Bluetooth ™ connection to an Android ™ tablet and uploaded for remote EEG specialist review and reporting via a new, secure web-based reading platform, crowdEEG. The results were compared to same-visit Xltek 10-20 EEG recordings for identification of epileptiform and nonepileptiform abnormalities. Results: : 97 children meeting the International League Against Epilepsy's definition of epilepsy (49 male; mean age 10.3 years, 29 untreated with an antiepileptic drug; 0 with a prior EEG) were enrolled. Epileptiform discharges were detected on 21 (25.3%) SBS2 and 31 (37.3%) standard EEG recordings. The SBS2 had a sensitivity of 51.6% (95%CI 32.4%, 70.8%) and a specificity of 90.4% (95%CI 81.4%, 94.4%) for all types of epileptiform discharges, with positive and negative predictive values of 76.2% and 75.8% respectively. For generalized discharges, the SBS2 had a sensitivity of 43.5% with a specificity of 96.2%. Conclusions: : The SBS2 has a moderate sensitivity and high specificity for the detection of epileptiform abnormalities in children with epilepsy in this low-income setting. Use of the SBS2+crowdEEG platform permits specialist input for patients with previously poor access to clinical neurophysiology expertise.

These are the duties of a physician: First…to heal his mind and to give help to himself before giving it to anyone else."From the epitaph of an Athenian doctor, 2 AD [1]."As physicians, we hold a unique place in society. We are entrusted with the responsibility of healing people and advancing the health of populations. This role is an honor and a privilege, and yet it is one that comes with the cost of jeopardizing our wellbeing. Physicians may be considered an "at risk" population, with higher rates of depression, anxiety, suicide, divorce, stress, and emotional exhaustion than other segments of the overall population. The role played by physicians requires many sacrifices-long hours, isolation from friends and family, psychological stress and responsibility in caring for very sick patients, tolerance of uncertainty, sleep deprivation, and huge economic burdens following many years of costly education, among others. Threats to the wellbeing of physicians begin early in training. The stresses of medical school, residency, and postgraduate work all involve managing tremendous pressures to acquire information, garner skills, develop and integrate a professional identity with the early-career physician's sense of self, and balance work and life. Roughly half of medical students experience burnout over the first 4 years of medical training. Burnout is defined as emotional exhaustion, depersonalization (i.e., treating patients as objects), and feelings of worthlessness. Burnout results in poor self-care and patient care, diminished empathy, medical error, and poor physical health [2]. Among medical students, more than 20 % will suffer from depression within the first 2 years and up to 9 % will have suicidal ideation before graduation [3]. The number of those who are depressed may increase during the first year of residency [4]. Among practicing physicians, the suicide rate is approximately double the rate in the general population [5]. In the USA, approximately one physician dies by suicide every day-thus each year we lose to suicide about the number of graduates from two medical schools.Many factors contribute to the distress experienced by physicians. Shortages of health care professionals, demanding caseloads, verbal abuse and other belittling or bullying behaviors, tremendous debt following lengthy medical education, increased regulatory pressures, decreased insurance reimbursements for services, and staying current with overwhelming amounts of new knowledge are but a few examples. These challenges are compounded by our profession's hidden curriculum-the reluctance to admit weakness, expose our shame of suffering from the stigma of a psychiatric disorder, or even discuss the pressures we share. It turns out that we are all deeply imperfect and that we will need to overcome much on our paths as physicians.With greater recognition of the risks associated with becoming and being a physician has also come greater understanding that our profession has, to a great extent, failed to

IntroductionOccipital lobe seizures are a recognized manifestation of diabetic nonketotic hyperglycemia, though not as common as focal motor seizures. Occipital lobe white matter T2 hypointensity may suggest this diagnosis.MethodsWe present a case of a 66-year-old man with hyperglycemia-related occipital lobe seizures who presented with confusion, intermittent visual hallucinations, and homonymous hemianopia.ResultsMagnetic resonance imaging showed subcortical T2 hypointensity within the left occipital lobe with adjacent leptomeningeal enhancement. These findings were transient with disappearance in a follow-up MRI. The EEG captured frequent seizures originating in the left occipital region. HbA1c level was 13.4% on presentation, and finger stick blood glucose level was 400 mg/dl.ConclusionHyperglycemia should be considered in the etiology of differential diagnosis of patients with visual abnormalities suspicious for seizures, especially when the MRI shows focal subcortical T2 hypointensity with or without leptomeningeal enhancement.

Summary: Migraine and epilepsy are common neurological conditions that may share a pathophysiologic and genetic basis.The following case is presented to illustrate key aspects of their relationship. Key Words: Migraine-Epilepsy.The coexistence of migraine and epilepsy has been a subject of intense interest for more than a century, and intrigued both Jackson and Gowers. Jackson discussed the spectrum of these disorders and analyzed their relationship (1), whereas Gowers concluded that any relationship was rare, indirect, and frequently constituted "a source of error" (2). Over a hundred years later, there is still not consistent agreement on the pathophysiologic and genetic relationship between these disorders. The three main possibilities are well reviewed by Andermann (3): (i) both migraine and epilepsy are relatively common and will cooccur by chance; (ii) there is a shared pathophysiological or genetic basis; and (iii) they are causally related, with one leading to the other. The third possibility encompasses the condition termed "migralepsy" by Lennox, wherein a classic migraine attack evolves into an epileptic seizure (4). CASE REPORTA 22-year-old right-handed college student with migraine headaches and epilepsy was transferred to our institution for treatment of status epilepticus. Birth and development had been normal. At 12 years of age, she began having 2-3 min episodes of fluorescent-colored flashing lights, black spots, and squiggly lines. At age 13, the visual symptoms began to be followed by bifrontal headaches and nausea lasting half an hour, with a catamenial component. At age 15, she had her first convulsion. It occurred in the context of worsened headaches after she had been struck in the head by a car door several weeks previously. The day of the convulsion, she had had her typical migraine, with left visual field scintillations. Though she Address correspondence and reprint requests to Dr. Edward B. Bromfield at Department of Neurology, Brigham and Women's Hospital, Boston, MA 02115, U.S.A. E-mail: ebromfield@partners.org would typically have rested to minimize the headache, on this occasion, she did not want to miss her softball game. While playing, she lost vision and then had a convulsion; she was admitted to the local hospital. Examination showed left facial weakness and saccadic pursuit movements to the left. EEG and MRI were normal. She began taking valproic acid. Over the next 4 years, she had 1-2 secondarily generalized seizures a year, on and off valproic acid, all preceded by the identical visual aura. Compliance with valproate treatment was variable in part because of associated weight gain. At 19 years of age, her regimen was changed to topiramate and perimenstrual acetazolamide.Past medical history included sinus surgery and counseling for depression and anxiety. Socially, she was a senior in college with good grades and many friends, and was active in religious organizations. Family history included many maternal relatives who had migraine with visual aura (mother, grandmother, a...