AUStralian study of titration to effect profile of safety (AUS-STEPS): high-dose gabapentin (neurontin) in partial seizures

PURPOSE

To evaluate the safety, tolerability, efficacy, and impact on quality of life of gabapentin (Neurontin; GBP) as adjunctive therapy in patients with refractory partial seizures.

METHODS

AUS-STEPS was an open-label, multicenter, prospective study in patients experiencing partial seizures who were inadequately controlled with one to three concurrent antiepileptic drugs (AEDs). GBP treatment was titrated to a maximum of 4,800 mg/day, over a treatment period of 24 weeks, to achieve an efficacious and tolerable dosage. Efficacy was assessed by seizure-frequency data. Quality of life was evaluated by using the QOLIE-10 questionnaire, and safety was assessed by adverse-event reports and clinical laboratory findings.

RESULTS

A total of 176 patients received treatment with GBP, with 174 evaluable for intention-to-treat (ITT) efficacy analysis. A reduction of >50% in overall seizure frequency was observed in 93 patients (53%). There was a small (4.6%) overall improvement in QOLIE-10 score. The most frequent adverse events were dizziness (31%), fatigue (29%), somnolence (27%), headache (21%), and ataxia (20%), with no major increase seen in adverse events necessitating discontinuation as the dose of GBP was titrated upward.

CONCLUSIONS

This study indicates that patients with partial epilepsy may be effectively treated with GBP at dosages of < or =4,800 mg/day, without altering the safety profile of the drug.

Health law in the 21st century

INTRODUCTION

Law and health operate within different models affecting health law.

AGEING POPULATION

Ageing and changed dynamics focuses health law on chronic illness, resource allocation, mobility and driving.

SHRINKING PLANET

Swine Flu mandates health law to manage epidemiology, international travel and disease virulence.

ACCESS TO HEALTHCARE

Population changes, doctors' numbers and remuneration, health insurance and demographics restrict healthcare access, impacting on health law.

GENETICS

Genetic interpretation allows discrimination against undiagnosed people with genetic propensity to diseases, necessitating legal protection.

COMPUTERS AND ELECTRONIC MEDICINE

E-medicine, telemedicine, record privacy and professional standards are relevant to health law.

CONCLUSION

Issues concerning health law in the 21st century were reviewed.

Paraesthesia and peripheral neuropathy

BACKGROUND

Paraesthesia reflects an abnormality affecting the sensory pathways anywhere between the peripheral sensory nervous system and the sensory cortex. As with all neurology, the fundamental diagnostic tool is a concise history, devoid of potentially ambiguous jargon, which properly reflects the true nature of what the patient is experiencing, provocateurs, precipitating and relieving factors, concomitant illnesses, such as diabetes, and any treatments that could evoke neuropathies.

OBJECTIVE

Some localised neuropathies, such as carpal tunnel syndrome (CTS) or ulnar neuropathy, produce classical features, such as weakness of the 'LOAF' (lateral two lumbricals, opponens pollicis, abductor pollicis brevis and flexor pollicis brevis) median innervated muscles, thereby obviating need for further neurophysiology. Nerve conduction studies may be necessary to diagnose peripheral neuropathy, but they may also be normal with small fibre neuropathy. Even with a diagnosis of peripheral neuropathy, definition of the underlying cause may remain elusive in a significant proportion of cases, despite involvement of consultants.

DISCUSSION

Treatment is based on the relevant diagnosis and mechanism to address the cause. This includes better glycaemic control for diabetes, night splint for CTS or elbow padding for ulnar neuropathy, modifying lifestyle with reduced alcohol consumption or replacing dietary deficiencies or changing medications where appropriate and practical. Should such intervention fail to relieve symptoms, consideration of intervention to relieve symptoms of neuropathic pain may be required.

The neurological aspects of atrial myxoma

2 cases of left atrial myxoma are presented, with a review of the recent literature on the topic, in order to bring this rare condition to the attention of clinicians. Both cases presented to the Neurological Unit of the Queen Elizabeth Hospital during 1978. The cases helped to emphasise the role of echocardiography in the routine appraisal of the stroke patient, especially if there are multiple lesions or if the patient concerned is young. The second case raised interseting questions regarding electrocardiographic changes associated with altered states of consiousness. Until recently cardiac myxomas were usually a postmortem diagnosis, but now with the effective combination of echocardiography and cine-angiography, cases are being effectively diagnosed and treated. It is hoped that with an increased awareness of the condition, diagnosis will be made sooner and thus prevent more severe sequelae occuring.