Journal of ECT • Volume 30, Number 4, December 2014
Letters to the Editor
block, for example, could cause immediate and significant harm to a patient. It is, without question, a serious error. However, at the other end of the spectrum, slightly mis-setting the stimulus dose is likely to pose no risk to the patient other than the theoretical possibility of a less effective single treatment (or slightly more temporary postictal confusion, if the dose is increased).2 Other errors such as using a different anesthetic than planned (eg, methohexital instead of propofol) are perhaps even less deleterious as far as mistakes in ECT go. However, there is also a troublesome middle ground. A busy practitioner who places electrodes bilaterally rather than unilaterally for a single procedure is unlikely to harm the patient beyond a slight risk of confusion/memory impairment lasting a few hours. Conversely, a single treatment with unilateral, instead of bilateral, electrode placement might theoretically extend the treatment course. Yet these differ from the other errors of minor consequence because, as Rasmussen points out, electrode placement may now be included on consent forms as a check box that patients are expected to select.3 In effect, this takes an otherwise minor error and puts it on par with performing an operation without consent. This is where the matter of dealing with medical errors gets tricky. To be sure, we need robust procedural safeguards in place to prevent errors, even in a noninvasive treatment like ECT. Indeed, before each procedure, we perform a full time out, a systematic checkpoint that was designed to prevent surgical errors like the site/side mistake that served as the basis for the New York Times piece. The development of such system checks is absolutely critical to patient safety. So is holding physicians accountable for negligence or repeated errors; but then, so too is a medical environment in which providers are encouraged to be open and forthright when mistakes are made so that they can be promptly and effectively addressed. To this end, it is important that we thoughtfully develop protocols for dealing with minor and inconsequential errors appropriately—even when all that is required is an apology or an hour or two of monitoring. If we fail to do so (and worse yet, if we instead choose punishment as our way of addressing error), we will continue to go down the path of the ever-expanding consent form, frivolous litigation, and an insular culture of fear of owning up to mistakes. This, in addition to being deeply unpleasant, would be to work against both transparency in medical practice and patient safety. We suggest that the ECT and anesthesiology communities develop such protocols for
e42
www.ectjournal.com
dealing with inconsequential errors now before other third parties, such as administrators and attorneys, with inadequate understanding of clinical consequences do so for us.
3. Rasmussen K. I’ll take a bitemporal with lettuce and cheese…. J ECT. 2011;27:271–2.
Electroconvulsive Therapy in Croatia
Daniel B. Kellner, MS Weill Cornell Medical College New York, NY
Ethan O. Bryson, MD Department of Psychiatry and Anesthesiology Icahn School of Medicine at Mount Sinai New York, NY
Lauren S. Liebman, BA Department of Psychiatry Icahn School of Medicine at Mount Sinai New York, NY
Matthew F. Majeske, MD Department of Psychiatry Icahn School of Medicine at Mount Sinai New York, NY
Amy S. Aloysi, MD Department of Psychiatry Icahn School of Medicine at Mount Sinai New York, NY
Gabriella M. Ahle, BA Department of Psychiatry Icahn School of Medicine at Mount Sinai New York, NY
Charles H. Kellner, MD Department of Psychiatry Icahn School of Medicine at Mount Sinai New York, NY [email protected]
Charles H. Kellner, MD, is supported by a grant from the NIMH and receives honoraria from Cambridge University Press, Psychiatric Times, UpToDate, and the North Shore–Long Island Jewish Health System. The other authors have no conflicts of interest or financial disclosures to report.
REFERENCES 1. Levy, P. Sunday Dialogue: Handling Medical Errors. New York Times. October 18, 2013. Available at: http://www.nytimes.com/ 2013/10/20/opinion/sunday/ sunday-dialogue-handling-medical-errors.html? pagewanted=1&_r=0. Accessed October 20, 2013. 2. Rami L, Goti J, Ferrer J, et al. Cognitive functions after only one ECT session: a controlled study. Psychiatry Res. 2008;158: 389–394.
To the Editor: e have performed the first survey on the use of electroconvulsive therapy (ECT) in Croatia. Electroconvulsive therapy in Croatia has a 7-decade-long history; it was introduced in the Croatian psychiatric facilities in the early 1940s. As usual for that period, ECT was performed in psychiatric wards by psychiatrists, without premedication or anesthesia. In the 1950s and early 1960s, ECTwas frequently administered in combination with insulin coma. Muscle relaxation and anesthesia were used for the first time in the late 1960s. From the 1990s, it was offered almost exclusively in the Zagreb University Hospital Centre (ZUHC) and very rarely in the Osijek University Hospital Centre (OUHC) and Split University Hospital Centre (SUHC). We surveyed the ECT practice using a 20-item questionnaire in ZUHC, OUHC, and SUHC, the only 3 facilities that have provided ECT, between July 2012 and July 2013. The survey instrument was used in a similar survey in Hungary and was translated with the author's permission. The questionnaire covered the clinical and technical aspects, personnel, and training of ECT. Three psychiatrists who are actively involved in ECT in the 3 institutions were requested to complete the questionnaire. Only adult patients are admitted to all 3 centers. In the ZUHC, 51 patients (28 men [55%]), 4.7% of the 1082 admissions during the given period, were treated with ECT. There was no upper age limit for ECT, although none of the patients who received it in the survey period were older than 65 years of age. Three patients were residents of neighboring countries (Slovenia, Bosnia, and Herzegovina). Most patients were treated for schizophrenia (n = 32 [63%]). Six of the 7 patients with schizoaffective disorder (n = 7 [14%]) were in depressive phase and one was in mixed phase. All patients with bipolar disorder were treated in depressive phase (n = 5 [10%]). Further indications included acute psychosis (n = 4 [8%]), depression (n = 1 [2%]), postpartum psychosis (n = 1 [2%]), and delusional disorder (n = 1 [2%]). The number of sessions ranged between 3 and 13, given 3 times a week. Two patients received continuation therapy while in the hospital, but no maintenance ECT was offered. In the OUHC,
W
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Journal of ECT • Volume 30, Number 4, December 2014
ECT was administered to only 3 patients (2 men), just 0.18% of the 1600 admissions in the same period. In the SUHC, ECT was administered to only one male patient (0.1% of the 991 hospital admissions in the same period). The condition of all patients was diagnosed as schizophrenia, and they received 6 and 10 to 12 sessions of ECT in the SUHC and OUHC, respectively. Patients in all 3 centers underwent the same pretreatment evaluation: physical examination, electroencephalogram, electrocardiogram, standard laboratory tests and CT scan, and approval by a physician and an anesthesiologist. Written informed consent for ECT given by the patient or his/her legal guardian was mandatory. Printed information leaflets for patients about ECT were available. The only contraindication to treatment was a severe medical condition such as fever, acute infection, and uncontrolled high blood pressure. No significant adverse effect was reported during the survey period. The ECT team comprised a psychiatrist, an anesthesiologist, and psychiatric and anesthesiology nurses. Before the ECT, atropine (0.01 mg/kg) was given as premedication 5 minutes before ECT to avoid parasympathetic reaction. After oxygenation with 100% O2, general anesthesia was induced with propofol (1mg/kg); in one case, sugammadex was used. Intravenous succinylcholine (0.5 mg/kg) was administered for muscle relaxation, and ventilation was assisted with a face mask and 100% oxygen. Electroconvulsive therapy was administered using Thymatron Model DGx device (Somatics Inc, 1995). Electrodes were placed bifrontally. Seizure threshold titration was not practiced; only age-based method was used in all cases. Seizure activity was monitored with visual observation and electroencephalogram. During ECT, pulse rate, blood pressure, electrocardiogram, peripheral oxygen saturation (SpO2) and endexpiratory CO2 partial pressure (end-tidal CO2) were regularly monitored. Patients were moved from the recovery room when they are fully conscious/alert. There was no fixed number of sessions of ECT, which would continue until adequate treatment response was achieved as judged by the treating psychiatrist. In contrast to most other centraleastern European countries,1 only 3 institutions offered ECT in Croatia. A similarly low number of ECT centers were reported from Bulgaria2 and Ukraine,3 indicating rather limited accessibility to ECT in these countries. As for the indications of ECT, the Croatian practice closely resembles that of some other central-eastern European countries,1 whereas with regard © 2014 Lippincott Williams & Wilkins
Letters to the Editor
to ECT delivery—brief pulse stimulation and bifrontal electrode placement—it is close to the Western European and international standards. Electroconvulsive therapy is taught as a part of the regular medical curricula in the Zagreb School of Medicine, the Osijek School of Medicine, and the Split School of Medicine, which are linked with the ZUHC, OUHC, and SUHC, respectively. Electroconvulsive therapy is part of the standard psychiatric training course run at the ZUHC. However, there are no certified courses on ECT or any formal training for mental health professionals on the theory and practice of ECT. Similar to other European countries,4 training is informally provided by senior psychiatrists experienced in ECT as mentors. There are no national guidelines on ECT in Croatia, although the overall standard of ECT practice conforms to international recommendations.5 Martina Rojnic Kuzman, MD, PhD University Hospital Centre Zagreb Zagreb, Croatia and Zagreb School of Medicine Zagreb, Croatia [email protected]
Tamara Pranjkovic Zagreb School of Medicine Zagreb, Croatia
Dunja Degmecic, MD, PhD University Hospital Centre Osijek Osijek, Croatia and Osijek School of Medicine Zagreb, Croatia
Davor Lasić, MD University Hospital Centre Split Split, Croatia
Ana Medic Zagreb School of Medicine Zagreb, Croatia
Gábor Gazdag, MD, PhD Centre for Psychiatry and Addiction Medicine Szent István and Szent Laszló Hospitals Budapest, Hungary and Department of Psychiatry and Psychotherapy Semmelweis University Faculty of Medicine Budapest, Hungary
The authors have no conflicts of interest or financial disclosures to report. REFERENCES 1. Leiknes KA, Jarosh-von Schweder L, Høie B. Contemporary use and practice of electroconvulsive therapy worldwide. Brain Behav. 2012;2:283–344. 2. Hranov LG, Hranov G, Ungvari GS, et al. Electroconvulsive therapy in Bulgaria: a snapshot of past and present. J ECT. 2012;28:108–110.
3. Oleksev A, Ungvari GS, Gazdag G. ECT practice in Ukraine. J ECT. 2014. [Epub ahead of print]. 4. Dragasek J. Electroconvulsive therapy in Slovakia. J ECT. 2012;28:7–8. 5. Rush G, Kimmich O, Lucy JV. Electroconvulsive therapy: international guidelines, clinical governance and patient selection. Ir J Psychol Med. 2007;24:103–107.
Transient Babinski Sign After Electroconvulsive Therapy (ECT) Dear Editor: he Babinski sign, or extensor plantar response, was first described by Joseph Francois Felix Babinski, a French neurologist of Polish descent, in his monograph of 1898.1 This reflex is characterized by extension of the big toe, occasionally accompanied by fanning of the rest of the toes, in response to the stimulus of stroking the lateral aspect of the sole of the foot.2 Initially of use in distinguishing hysteria from organic disease, the Babinski sign reflects dysfunction of the pyramidal tract anywhere along its course from the cortex, subcortical white matter, or brainstem to the spinal cord.2,3 A reliable sign of upper motor neuron dysfunction, the upgoing toe, reflects release of descending inhibition on spinal motor neurons, as well as inhibition of the local segmental cutaneous reflex, which normally triggers plantar flexion.4 Neonates will also exhibit an extensor response owing to incomplete development of the pyramidal tract; however, with maturation of upper motor neuron pathways, the Babinski sign disappears, and stimulation of the sole elicits the flexor response at approximately 12 to 24 months of age.3 We report a middle-aged woman with depression and a medical history of hypothyroidism and prior thyroid resection who developed a transient Babinski response after her initial right unilateral electroconvulsive therapy (ECT) dose-titration session. Her medications included diphenhydramine, 50 mg, oral, every night at bedtime; lorazepam, 1 mg, oral, 2 times a day; aripiprazole, 5 mg, oral, daily; mirtazapine, 7.5 mg, oral, every night at bedtime; paroxetine, 40 mg, oral, daily; and levothyroxine, 100 μg oral, daily. Anesthesia was induced with 50 mg of methohexital followed by 50 mg of succinylcholine. She received a single stimulus at 5% “energy” (25 mC; pulse width, 0.25 millisecond), resulting in a motor seizure of 38 seconds and an electroencephalographic seizure of 77 seconds. The Babinski phenomenon was bilateral, was elicited immediately after cessation of the seizure, and resolved within 15 minutes.
T
www.ectjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
e43
Letters to the Editor
block, for example, could cause immediate and significant harm to a patient. It is, without question, a serious error. However, at the other end of the spectrum, slightly mis-setting the stimulus dose is likely to pose no risk to the patient other than the theoretical possibility of a less effective single treatment (or slightly more temporary postictal confusion, if the dose is increased).2 Other errors such as using a different anesthetic than planned (eg, methohexital instead of propofol) are perhaps even less deleterious as far as mistakes in ECT go. However, there is also a troublesome middle ground. A busy practitioner who places electrodes bilaterally rather than unilaterally for a single procedure is unlikely to harm the patient beyond a slight risk of confusion/memory impairment lasting a few hours. Conversely, a single treatment with unilateral, instead of bilateral, electrode placement might theoretically extend the treatment course. Yet these differ from the other errors of minor consequence because, as Rasmussen points out, electrode placement may now be included on consent forms as a check box that patients are expected to select.3 In effect, this takes an otherwise minor error and puts it on par with performing an operation without consent. This is where the matter of dealing with medical errors gets tricky. To be sure, we need robust procedural safeguards in place to prevent errors, even in a noninvasive treatment like ECT. Indeed, before each procedure, we perform a full time out, a systematic checkpoint that was designed to prevent surgical errors like the site/side mistake that served as the basis for the New York Times piece. The development of such system checks is absolutely critical to patient safety. So is holding physicians accountable for negligence or repeated errors; but then, so too is a medical environment in which providers are encouraged to be open and forthright when mistakes are made so that they can be promptly and effectively addressed. To this end, it is important that we thoughtfully develop protocols for dealing with minor and inconsequential errors appropriately—even when all that is required is an apology or an hour or two of monitoring. If we fail to do so (and worse yet, if we instead choose punishment as our way of addressing error), we will continue to go down the path of the ever-expanding consent form, frivolous litigation, and an insular culture of fear of owning up to mistakes. This, in addition to being deeply unpleasant, would be to work against both transparency in medical practice and patient safety. We suggest that the ECT and anesthesiology communities develop such protocols for
e42
www.ectjournal.com
dealing with inconsequential errors now before other third parties, such as administrators and attorneys, with inadequate understanding of clinical consequences do so for us.
3. Rasmussen K. I’ll take a bitemporal with lettuce and cheese…. J ECT. 2011;27:271–2.
Electroconvulsive Therapy in Croatia
Daniel B. Kellner, MS Weill Cornell Medical College New York, NY
Ethan O. Bryson, MD Department of Psychiatry and Anesthesiology Icahn School of Medicine at Mount Sinai New York, NY
Lauren S. Liebman, BA Department of Psychiatry Icahn School of Medicine at Mount Sinai New York, NY
Matthew F. Majeske, MD Department of Psychiatry Icahn School of Medicine at Mount Sinai New York, NY
Amy S. Aloysi, MD Department of Psychiatry Icahn School of Medicine at Mount Sinai New York, NY
Gabriella M. Ahle, BA Department of Psychiatry Icahn School of Medicine at Mount Sinai New York, NY
Charles H. Kellner, MD Department of Psychiatry Icahn School of Medicine at Mount Sinai New York, NY [email protected]
Charles H. Kellner, MD, is supported by a grant from the NIMH and receives honoraria from Cambridge University Press, Psychiatric Times, UpToDate, and the North Shore–Long Island Jewish Health System. The other authors have no conflicts of interest or financial disclosures to report.
REFERENCES 1. Levy, P. Sunday Dialogue: Handling Medical Errors. New York Times. October 18, 2013. Available at: http://www.nytimes.com/ 2013/10/20/opinion/sunday/ sunday-dialogue-handling-medical-errors.html? pagewanted=1&_r=0. Accessed October 20, 2013. 2. Rami L, Goti J, Ferrer J, et al. Cognitive functions after only one ECT session: a controlled study. Psychiatry Res. 2008;158: 389–394.
To the Editor: e have performed the first survey on the use of electroconvulsive therapy (ECT) in Croatia. Electroconvulsive therapy in Croatia has a 7-decade-long history; it was introduced in the Croatian psychiatric facilities in the early 1940s. As usual for that period, ECT was performed in psychiatric wards by psychiatrists, without premedication or anesthesia. In the 1950s and early 1960s, ECTwas frequently administered in combination with insulin coma. Muscle relaxation and anesthesia were used for the first time in the late 1960s. From the 1990s, it was offered almost exclusively in the Zagreb University Hospital Centre (ZUHC) and very rarely in the Osijek University Hospital Centre (OUHC) and Split University Hospital Centre (SUHC). We surveyed the ECT practice using a 20-item questionnaire in ZUHC, OUHC, and SUHC, the only 3 facilities that have provided ECT, between July 2012 and July 2013. The survey instrument was used in a similar survey in Hungary and was translated with the author's permission. The questionnaire covered the clinical and technical aspects, personnel, and training of ECT. Three psychiatrists who are actively involved in ECT in the 3 institutions were requested to complete the questionnaire. Only adult patients are admitted to all 3 centers. In the ZUHC, 51 patients (28 men [55%]), 4.7% of the 1082 admissions during the given period, were treated with ECT. There was no upper age limit for ECT, although none of the patients who received it in the survey period were older than 65 years of age. Three patients were residents of neighboring countries (Slovenia, Bosnia, and Herzegovina). Most patients were treated for schizophrenia (n = 32 [63%]). Six of the 7 patients with schizoaffective disorder (n = 7 [14%]) were in depressive phase and one was in mixed phase. All patients with bipolar disorder were treated in depressive phase (n = 5 [10%]). Further indications included acute psychosis (n = 4 [8%]), depression (n = 1 [2%]), postpartum psychosis (n = 1 [2%]), and delusional disorder (n = 1 [2%]). The number of sessions ranged between 3 and 13, given 3 times a week. Two patients received continuation therapy while in the hospital, but no maintenance ECT was offered. In the OUHC,
W
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Journal of ECT • Volume 30, Number 4, December 2014
ECT was administered to only 3 patients (2 men), just 0.18% of the 1600 admissions in the same period. In the SUHC, ECT was administered to only one male patient (0.1% of the 991 hospital admissions in the same period). The condition of all patients was diagnosed as schizophrenia, and they received 6 and 10 to 12 sessions of ECT in the SUHC and OUHC, respectively. Patients in all 3 centers underwent the same pretreatment evaluation: physical examination, electroencephalogram, electrocardiogram, standard laboratory tests and CT scan, and approval by a physician and an anesthesiologist. Written informed consent for ECT given by the patient or his/her legal guardian was mandatory. Printed information leaflets for patients about ECT were available. The only contraindication to treatment was a severe medical condition such as fever, acute infection, and uncontrolled high blood pressure. No significant adverse effect was reported during the survey period. The ECT team comprised a psychiatrist, an anesthesiologist, and psychiatric and anesthesiology nurses. Before the ECT, atropine (0.01 mg/kg) was given as premedication 5 minutes before ECT to avoid parasympathetic reaction. After oxygenation with 100% O2, general anesthesia was induced with propofol (1mg/kg); in one case, sugammadex was used. Intravenous succinylcholine (0.5 mg/kg) was administered for muscle relaxation, and ventilation was assisted with a face mask and 100% oxygen. Electroconvulsive therapy was administered using Thymatron Model DGx device (Somatics Inc, 1995). Electrodes were placed bifrontally. Seizure threshold titration was not practiced; only age-based method was used in all cases. Seizure activity was monitored with visual observation and electroencephalogram. During ECT, pulse rate, blood pressure, electrocardiogram, peripheral oxygen saturation (SpO2) and endexpiratory CO2 partial pressure (end-tidal CO2) were regularly monitored. Patients were moved from the recovery room when they are fully conscious/alert. There was no fixed number of sessions of ECT, which would continue until adequate treatment response was achieved as judged by the treating psychiatrist. In contrast to most other centraleastern European countries,1 only 3 institutions offered ECT in Croatia. A similarly low number of ECT centers were reported from Bulgaria2 and Ukraine,3 indicating rather limited accessibility to ECT in these countries. As for the indications of ECT, the Croatian practice closely resembles that of some other central-eastern European countries,1 whereas with regard © 2014 Lippincott Williams & Wilkins
Letters to the Editor
to ECT delivery—brief pulse stimulation and bifrontal electrode placement—it is close to the Western European and international standards. Electroconvulsive therapy is taught as a part of the regular medical curricula in the Zagreb School of Medicine, the Osijek School of Medicine, and the Split School of Medicine, which are linked with the ZUHC, OUHC, and SUHC, respectively. Electroconvulsive therapy is part of the standard psychiatric training course run at the ZUHC. However, there are no certified courses on ECT or any formal training for mental health professionals on the theory and practice of ECT. Similar to other European countries,4 training is informally provided by senior psychiatrists experienced in ECT as mentors. There are no national guidelines on ECT in Croatia, although the overall standard of ECT practice conforms to international recommendations.5 Martina Rojnic Kuzman, MD, PhD University Hospital Centre Zagreb Zagreb, Croatia and Zagreb School of Medicine Zagreb, Croatia [email protected]
Tamara Pranjkovic Zagreb School of Medicine Zagreb, Croatia
Dunja Degmecic, MD, PhD University Hospital Centre Osijek Osijek, Croatia and Osijek School of Medicine Zagreb, Croatia
Davor Lasić, MD University Hospital Centre Split Split, Croatia
Ana Medic Zagreb School of Medicine Zagreb, Croatia
Gábor Gazdag, MD, PhD Centre for Psychiatry and Addiction Medicine Szent István and Szent Laszló Hospitals Budapest, Hungary and Department of Psychiatry and Psychotherapy Semmelweis University Faculty of Medicine Budapest, Hungary
The authors have no conflicts of interest or financial disclosures to report. REFERENCES 1. Leiknes KA, Jarosh-von Schweder L, Høie B. Contemporary use and practice of electroconvulsive therapy worldwide. Brain Behav. 2012;2:283–344. 2. Hranov LG, Hranov G, Ungvari GS, et al. Electroconvulsive therapy in Bulgaria: a snapshot of past and present. J ECT. 2012;28:108–110.
3. Oleksev A, Ungvari GS, Gazdag G. ECT practice in Ukraine. J ECT. 2014. [Epub ahead of print]. 4. Dragasek J. Electroconvulsive therapy in Slovakia. J ECT. 2012;28:7–8. 5. Rush G, Kimmich O, Lucy JV. Electroconvulsive therapy: international guidelines, clinical governance and patient selection. Ir J Psychol Med. 2007;24:103–107.
Transient Babinski Sign After Electroconvulsive Therapy (ECT) Dear Editor: he Babinski sign, or extensor plantar response, was first described by Joseph Francois Felix Babinski, a French neurologist of Polish descent, in his monograph of 1898.1 This reflex is characterized by extension of the big toe, occasionally accompanied by fanning of the rest of the toes, in response to the stimulus of stroking the lateral aspect of the sole of the foot.2 Initially of use in distinguishing hysteria from organic disease, the Babinski sign reflects dysfunction of the pyramidal tract anywhere along its course from the cortex, subcortical white matter, or brainstem to the spinal cord.2,3 A reliable sign of upper motor neuron dysfunction, the upgoing toe, reflects release of descending inhibition on spinal motor neurons, as well as inhibition of the local segmental cutaneous reflex, which normally triggers plantar flexion.4 Neonates will also exhibit an extensor response owing to incomplete development of the pyramidal tract; however, with maturation of upper motor neuron pathways, the Babinski sign disappears, and stimulation of the sole elicits the flexor response at approximately 12 to 24 months of age.3 We report a middle-aged woman with depression and a medical history of hypothyroidism and prior thyroid resection who developed a transient Babinski response after her initial right unilateral electroconvulsive therapy (ECT) dose-titration session. Her medications included diphenhydramine, 50 mg, oral, every night at bedtime; lorazepam, 1 mg, oral, 2 times a day; aripiprazole, 5 mg, oral, daily; mirtazapine, 7.5 mg, oral, every night at bedtime; paroxetine, 40 mg, oral, daily; and levothyroxine, 100 μg oral, daily. Anesthesia was induced with 50 mg of methohexital followed by 50 mg of succinylcholine. She received a single stimulus at 5% “energy” (25 mC; pulse width, 0.25 millisecond), resulting in a motor seizure of 38 seconds and an electroencephalographic seizure of 77 seconds. The Babinski phenomenon was bilateral, was elicited immediately after cessation of the seizure, and resolved within 15 minutes.
T
www.ectjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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