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We aim to describe use of electroconvulsive therapy (ECT) to treat super refractory status epilepticus (SRSE) in pregnancy and review the literature regarding utility and safety of ECT in refractory status epilepticus.Status epilepticus (SE) is a commonly encountered emergency in neuro-critical care world. Pharmacotherapy of status epilepticus in pregnancy is very challenging given the effect of the majority of antiepileptic drugs (AEDs) on fetal development. Although there has been growing evidence for use of ECT in status epilepticus, data about its utility in pregnancy is lacking.A twenty-one year old Caucasian female with history of epilepsy presented at 8 weeks of gestation as status epilepticus (SE) after abrupt discontinuation of her AEDs. Treatment was initiated with standard regimen of benzodiazepine and levetiracetam, which was progressively expanded to include approximately 10 anti-epileptic drugs over the course of 30 days. The status epilepticus was super refractory to sedation. She underwent ECT on day 31 with remarkable improvement in electroencephalogram (EEG) pattern and resolution of status epilepticus following a single ECT session. We reviewed PubMed and collated case reports involving the use of ECT in status epilepticus with emphasis on differences in various confounding factors esp. etiology of status and age group.Our case is the first reported case of ECT for successful treatment of SRSE in pregnancy. While majority AEDs pose a significant maternal and fetal risk during pregnancy, ECT could be a potential frontline therapy for SE in pregnancy.

Transcranial magnetic stimulation is typically administered daily for 6 to 9 weeks with gradual resolution of major depressive disorder. However, there is little evidence to guide clinicians when clinical improvement is not forthcoming as the course proceeds. We describe a patient whose depression score remained unchanged after 10 single daily intermittent thetaburst transcranial magnetic stimulation sessions targeting F3 in the dorsolateral prefrontal cortex and our efforts to modify the technique and monitor progress with heart rate variability (HRV) measures. The motor threshold position and intensity were verified to be unchanged from the baseline visit. Stimulation of F3 and treatment target 6 cm anterior to the mapped motor cortex site seemed to slow heart rate and increase HRV equally. We increased the number of daily intermittent thetaburst pulse trains for the remainder of the treatment course, targeting the 6-cm target. Our patient subsequently improved, and we observed concurrent changes in HRV suggestive of enhanced parasympathetic activity. These improvements were found to be durable at 10-week follow-up.

Background Uncomplicated urinary tract infection (uUTI) is often treated empirically without antibiotic (AB) susceptibility testing; however, antimicrobial-resistant bacteria could lead to suboptimal treatment and progression to complicated UTI (cUTI). We examined the likelihood of uUTI progression to cUTI in patients with susceptible and non-susceptible uropathogens. Methods We performed a retrospective cohort study using data from a large Mid-Atlantic US integrated delivery network’s electronic health records from July 1, 2016 to March 31, 2020. Patients included were female, aged ≥ 12 years with incident uUTI (diagnosis code or urine culture), and given an oral AB ± 5 days of diagnosis and ≥ 1 antibiotic susceptibility test. The primary outcome was progression to cUTI, defined as: new fever, nausea, or vomiting, in addition to uUTI symptoms; or receipt of intravenous antibiotic 3–28 days after index uUTI. Probability of progression to cUTI was assessed comparing patients with non-susceptible and susceptible isolates, with 1:1 propensity score matching. Patients retained for analysis had a nonzero predicted probability of being in the case and control group and were retained for analysis only if there were patients in the mirror group with similar propensity scores. Data were analyzed with logistic regression. Sensitivity analyses were performed to test the robustness of the primary analysis (Table). Results A total of 2565 patients were included: 1030 (40.2%) had non-susceptible isolates and 1535 (59.8%) had susceptible isolates. Mean age was 43.5 years and 59.5% of the cohort was White. After propensity score matching, patients with non-susceptible isolates were more than twice as likely to progress to cUTI versus patients with sensitive isolates (10.7% versus 4.9%; odds ratio, 2.35; p < 0.001; Figure). In sensitivity analyses, patients with non-susceptible isolates remained significantly more likely to progress to cUTI (p ≤ 0.009), excluding those receiving fluoroquinolones only (Table). Figure. Probability of progression to cUTI Table. Sensitivity analyses of the probability of uUTI progressing to cUTI in patients with non-susceptible versus susceptible isolates (matched population) Conclusion Patients with uUTI and AB-resistant isolates were significantly more likely to progress to cUTI than those with susceptible isolates. This finding highlights the need for greater understanding of antimicrobial resistance and has implications for the clinical management of uUTI. Disclosures Jason Shafrin, PhD, Precision Medicine Group (Employee, Former employee of Precision Medicine Group, which received funding from GlaxoSmithKline plc. to conduct this study) Alen Marijam, MSc, GlaxoSmithKline plc. (Employee, Shareholder) Ashish V. Joshi, PhD, GlaxoSmithKline plc. (Employee, Shareholder) Fanny S. Mitrani-Gold, MPH, GlaxoSmithKline plc. (Employee, Shareholder) Katie Everson, MSc, Precision Medicine Group (Employee, Employee of Precision Medicine Group, which received funding from GlaxoSmithKline plc. to conduct this study) Rifat Tuly, MPH, Precision Medicine Group (Employee, Employee of Precision Medicine Group, which received funding from GlaxoSmithKline plc. to conduct this study) Peter Rosenquist, MSc, Precision Medicine Group (Employee, Employee of Precision Medicine Group, which received funding from GlaxoSmithKline plc. to conduct this study) Michael Gillam, MD, MedStar Health (Employee, Employee of MedStar Health and received funding from GlaxoSmithKline plc. through Precision Medicine Group to conduct this study) Maria Elena Ruiz, MD, Nothing to disclose

INTRODUCTION Controversy surrounding ECT creates skepticism about the ethics of conducting ECT research. This paper discusses the ethical conduct of clinical research and then focus on the ethics as applied to ECT. METHODS PubMed was searched for articles related to the ethical conduct of research and that of ECT research published in English. RESULTS ECT research is ethically justified and should always continue to be conducted with the highest ethical standards. ECT research entails few ethical peculiarities such as involving multiple sessions were capacity to consent can change. It would be unethical not to conduct ECT research. CONCLUSION ECT research must be based on sound hypotheses in the presence of a clinical equipoise in well-designed studies. ECT studies must select a fair and non-biased sample of participants. It is important that participants represent the broad population of the people that would be receiving ECT for that specific indication. ECT research is ethical; and more research in this field could help decrease stigma and barriers to treatment, and/or reduce side effects and improve efficacy of a potentially life-saving intervention.

Electroconvulsive therapy (ECT) is a highly effective treatment for certain psychiatric disorders with relatively few serious adverse effects or complications. Tardive seizures are one of these rare but potentially fatal complications. Recognizing and treating tardive seizures is essential to prevent prolonged postictal confusion, progression to status epilepticus and associated soft tissue injury, anoxia, aspiration, and death. Currently, there is an unknown prevalence of their occurrence and an overall lack of clinical description of their phenomenology. We describe a case in which a patient develops a tardive seizure followed by a receptive and expressive aphasia, thought to be a variant of Todd's postictal paralysis. This case is further unique in that there was a lateralization of a motor seizure presumably to the hemisphere contralateral to the right unilateral electrode placement.