A survey of doctors in Sydney, Australia: perspectives and practices regarding epilepsy and those affected by it

Using random selection to exclude socioeconomic bias, a sample of 50 general practitioners (GPs) was interviewed and a piloted questionnaire completed for each respondent. The study defined the doctors' experience and knowledge together with their management practices and attitudes towards the social issues which play such a considerable role in patient care. The findings from this survey were compared with current literature and discrepancies defined and discussed with the aim of indicating how total patient care could be improved.

Rebound exacerbation multiple sclerosis following cessation of oral treatment

BACKGROUND

Multiple sclerosis (MS) management is changing, revolutionized by oral agents. Immune Reconstitution Inflammatory Syndrome (IRIS) describes exaggerated response to both exogenous (infective) and endogenous (non-infective) antigens.

METHODS

This paper reports two cases of MS "rebound" following withdrawal of oral treatments.

RESULTS

Two patients, with suboptimal response to interferons, trialled oral MS treatment (fingolimod and BG12) with excellent response. Upon cessation both experienced MS "rebound" which responded to steroids.

CONCLUSIONS

"Rebound" may occur following withdrawal of oral MS therapies. Patients should be advised accordingly and possibly started on alternative treatment before the immunomodulating effect of therapy has subsided.

An accurate assessment of the prevalence ratio of epilepsy adequately adjusted by influencing factors

The prevalence of epilepsy was estimated by defining an initial prevalence ratio based on a population study and modifying this figure on the basis of various factors which influenced it. The definition required 3 seizures diagnosed by a doctor and the influencing factors included false-negative responses (where the diagnosis was confirmed), false reporting (where the diagnosis had not been established) and falsely low seizure counts (where therapy had reduced the number of seizure below the mandatory 3). As a result of these calculations the figure of approximately 1 in 50 was offered as a reliable and reasonable estimate of the true prevalence ratio of epilepsy within a well-defined Australian population.

Value of therapeutic drug level monitoring and unbound (free) levels

Therapeutic drug monitoring (TDM) has declined with newer anti-epileptic drugs (AEDs) having no therapeutic window. Use of unbound (free) fraction has almost completely disappeared. The case reported highlights its importance and offers sound reason for its retention. A 66-year-old Caucasian man with known epilepsy was admitted with vomiting, ataxia and nystagmus presumably due to AED toxicity. Medications included valproate (VPA) 1g bd; phenytoin (PHT) 200mg tds; carbamazepine (CBZ) 400mg mane, 200mg midi, 400mg nocte; levetiracetam (LEV) 250mg bd. Initial AED-TDM revealed total serum levels of CBZ: 27micromol/L; PHT: 37micromol/L; VPA 499micromol/L, therapeutic or subtherapeutic. Free levels were subsequently measured demonstrating CBZ: 8.2micromol/L; PHT: 5micromol/L; VPA 93micromol/L. Consequently, VPA was initially omitted and dosage reduced with cessation of toxicity. AED regimen was greatly simplified and remained efficacious. This case highlights the value of TDM with polypharmacy and suggested AED toxicity. Total AED levels failed to identify the cause, which the unbound, free fraction identified. While total PHT was borderline subtherapeutic (37micromol/L; range: 40-80) the free level was therapeutic (5micromol/L; range: 4-8) and while VPA was therapeutic (VPA 499micromol/L; range: 300-750) the free level was supratherapeutic (93micromol/L; range: 30-75). Acknowledgement of discordance between total and free levels for highly protein-bound AED is highlighted.

Doctors' perspectives of epilepsy

This study reports the results of a questionnaire designed specifically to define doctors' perspectives of epilepsy. Sixty-two percent of the registered junior medical staff of a major Australian teaching hospital responded to a questionnaire that established information regarding doctor identification, cognition concerning epilepsy and its management, and doctors' attitudes. The results gave evidence of a lack of knowledge regarding epilepsy and its management, as well as a lack of ability to maintain critical evaluation of new material. Many of the negative attitudes about people with epilepsy that have been identified within the general community were also found within the medical profession. This study determined that there is a real need to reappraise the approach to teaching the medical profession about epilepsy.

Management and attitudes of epilepsy by a group of Sydney general practitioners

Previous surveys of general practitioners (GPs) have shown stereotypic attitudes and management of persons with epilepsy (PWE). We mailed a questionnaire to 107 GPs in the Sydney and Illawarra regions of Australia to evaluate changes in knowledge and management of epilepsy and attitudes of GPs toward PWE as compared with results of a similar study made 10 years previously. Most GPs referred patients with epilepsy to a neurologist for initial management in preference to initiating investigation and treatment themselves. GPs were very satisfied with their sharing of care with neurologists, but indicated their high level of dissatisfaction with other health care therapists because of impractical advice and lack of empathy. The GPs' objectives of continuing management were mainly to prevent seizures, monitor of medication and its effects, and reduce the impact of patients' epilepsy on their daily life. Although many GPs believed that PWE were more likely to have emotional and relationship problems, most also believed that such persons contribute equally to society and can have normal quality of life (QOL). Although the GPs prefer to use a neurologist for initial management of PWE, they see themselves as having a role in continuing care and providing psychosocial support. The stereotyped perceptions of GPs indicated in the previous study have improved, although in some respects they remain negative. This study offers an audit of the outcome of a decade of educational promotion regarding epilepsy.

Association between ulcerative colitis and multiple sclerosis

An association between inflammatory bowel disease (IBD) and multiple sclerosis (MS) has been described. The current study was undertaken to explore this association further. Personal records of patients with IBD and MS were reviewed. In addition, a search of medical records at a large tertiary teaching hospital in Sydney was carried out for the years 1996-2006. Four patients (three women and one man) with both ulcerative colitis and MS were identified. MS did not occur in any of our patients with Crohn's disease. The association between ulcerative colitis and MS appears to be real and may help identify common factors involved in the cause of these two diseases. No association was found in this study between MS and Crohn's disease, sparking consideration why such difference should occur. With the increasing use of biological therapies in IBD and their reported propensity to cause demyelination, recognition of an association is all the more important.

The use of CPAP in patients with refractory epilepsy

Four patients, diagnosed with refractory epilepsy, were treated with both continuous positive airway pressure (CPAP) and antiepileptic medication (AEM) and showed > 50% reduction in seizures after 6 months-2 years follow-up. Two patients subsequently had AEM withdrawn and are seizure free and in one such patient, obstructive sleep apnoea (OSA) has remained the only operative diagnosis. This dual approach to care provided a real advantage to the management of patients with the dual diagnoses of OSA and epilepsy, which was refractory to standard AEM therapy.

Low positive predictive value of the ABCD2 score in emergency department transient ischaemic attack diagnoses: the South Western Sydney transient ischaemic attack study

BACKGROUND

The ABCD(2) stroke risk score is recommended in national guidelines for stratifying care in transient ischaemic attack (TIA) patients, based on its prediction of early stroke risk. We had become concerned about the score accuracy and its clinical value in modern TIA cohorts.

METHODS

We identified emergency department-diagnosed TIA at two hospitals over 3 years (2004-2006). Cases were followed for stroke occurrence and ABCD(2) scores were determined from expert record review. Sensitivity, specificity and positive predictive values (PPV) of moderate-high ABCD(2) scores were determined.

RESULTS

There were 827 indexed TIA diagnoses and record review was possible in 95.4%. Admitted patients had lower 30-day stroke risk (n = 0) than discharged patients (n = 7; 3.1%) (P < 0.0001). There was no significant difference in proportion of strokes between those with a low or moderate-high ABCD(2) score at 30 (1.2 vs 0.8%), 90 (2.0 vs 1.9%) and 365 days (2.4 vs 2.4%) respectively. At 30 days the sensitivity, specificity and PPV of a moderate-high score were 57% (95% confidence interval (CI) 25.0-84.2), 32.2% (95% CI 29.1-35.6) and 0.75% (95% CI 0.29-1.91) respectively.

CONCLUSIONS

Early stroke risk was low after an emergency diagnosis of TIA and significantly lower in admitted patients. Moderate-high ABCD(2) scores did not predict early stroke risk. We suggest local validation of ABCD(2) before its clinical use and a review of its place in national guidelines.

Pseudotumour cerebri associated with minocycline therapy for acne

A case of pseudotumour cerebri (PTC) in a 13-year-old girl is reported. This patient experienced menarche seven months before presentation, and subsequently developed acne which necessitated antibiotic therapy. She had been treated with minocycline hydrochloride (100 mg twice a day) for two months before admission to hospital. The role of minocycline therapy associated with menarche in the aetiology of PTC is discussed.

A double-blind, placebo-controlled crossover study of vigabatrin 2 g/day and 3 g/day in uncontrolled partial seizures

The efficacy and tolerability of vigabatrin as add-on therapy was assessed in patients with uncontrolled partial seizures. Ninety-seven patients entered this seven-centre, double-blind, placebo-crossover study. Vigabatrin (2 g or 3 g) or placebo was administered daily. Vigabatrin was well-tolerated and did not cause clinically significant adverse drug effects when added to established anticonvulsant therapy. No significant differences were observed between dose groups for the overall incidence of adverse events, although drowsiness and visual disturbances (diplopia, ataxia, visual abnormalities) showed a dose-related increase with vigabatrin treatment. The results of this study indicate that vigabatrin, given in a daily dose of either 2 g or 3 g is significantly more effective than placebo in reducing seizure frequency among patients with partial seizures.

Therapeutic recreation programmes for children with epilepsy

Amongst children with epilepsy, research has shown that most have a negative self-concept and consequently a low level of self-esteem. This elusive concept of the self is constantly being assessed and reassessed by each child throughout the process of social development. Early literature has suggested that children with disabilities, especially chronic medical or biological disabilities, typified by epilepsy and diabetes, are more susceptible to the development of psychopathology and negative self-concepts. This paper reports that intervention in the form of therapeutic recreation programmes can help rectify this problem of negative self-concept and low self-esteem in children with epilepsy. The Piers-Harris Self Concept Scale, a Self Report Inventory on six dimensions of self-concept, was assessed both pre- and post-therapeutic recreational intervention to show significant improvement in the child's self-concept and acceptance of their epilepsy. Educational components within the programme have demonstrated significant learning and increased treatment compliance--particularly with long-term medications. The Adolescent Psychosocial Seizure Inventory, an adolescent version of the Washington Psycho-Social Seizure Inventory (WPSI), both of which have been validated as a reliable clinical assessment for use in Australia, has provided further evidence to suggest that improvements occur in children's self-concept as a consequence of therapeutic recreation, however use of this protocol appears limited to adolescents over the age of 13 years.

Role of diabetes in stroke: Recent advances in pathophysiology and clinical management

The increasing prevalence of diabetes and stroke is a major global public health concern. Specifically, acute stroke patients, with pre-existing diabetes, pose a clinical challenge. It is established that diabetes is associated with a worse prognosis after acute stroke and the various biological factors that mediate poor recovery profiles in diabetic patients is unknown. The level of association and impact of diabetes, in the setting of reperfusion therapy, is yet to be determined. This article presents a comprehensive overview of the current knowledge of the role of diabetes in stroke, therapeutic strategies for primary and secondary prevention of cardiovascular disease and/or stroke in diabetes, and various therapeutic considerations that may apply during pre-stroke, acute, sub-acute and post-stroke stages. The early diagnosis of diabetes as a comorbidity for stroke, as well as tailored post-stroke management of diabetes, is pivotal to our efforts to limit the burden. Increasing awareness and involvement of neurologists in the management of diabetes and other cardiovascular risk factors is desirable towards improving stroke prevention and efficacy of reperfusion therapy in acute stroke patients with diabetes.

Rotigotine transdermal system as add-on to oral dopamine agonist in advanced Parkinson's disease: an open-label study

BACKGROUND

Achieving optimal symptom control with minimal side effects is a major goal in clinical practice. Dual-agent dopamine receptor agonist (DA) therapy in Parkinson's disease (PD) may represent a promising approach to treatment, as the combination of different pharmacokinetic/pharmacological profiles may result in a lesser need for high dosages and, accordingly, may be well tolerated. The objective of the current study was to investigate safety and efficacy of rotigotine transdermal system as add-on to oral DA in patients with advanced PD inadequately controlled with levodopa and low-dose oral DA.

METHODS

PD0015 was an open-label, multinational study in patients with advanced-PD and sleep disturbance or early-morning motor impairment. Patients were titrated to optimal dose rotigotine (≤8 mg/24 h) over 1-4 weeks and maintained for 4-7 weeks (8-week treatment). Dosage of levodopa and oral DA (pramipexole ≤1.5 mg/day, ropinirole ≤6.0 mg/day) was stable. Primary variable was Clinical Global Impressions (CGI) item 4: side effects, assessing safety. Other variables included adverse events (AEs), Patient Global Impressions of Change (PGIC), Unified Parkinson's Disease Rating Scale (UPDRS) II and III, Parkinson's Disease Sleep Scale (PDSS-2), Pittsburgh Sleep Quality Index (PSQI), and "off" time.

RESULTS

Of 90 patients who received rotigotine, 79 (88%) completed the study; 5 (6%) withdrew due to AEs. Most (83/89; 93%) had a CGI-4 score <3 indicating that rotigotine add-on therapy did not interfere with functioning; 6 (7%) experienced drug-related AEs that interfered with functioning (score ≥3). AEs occurring in ≥5% were application site pruritus (13%), dizziness (10%), orthostatic hypotension (10%), nausea (8%), dyskinesia (8%), and nasopharyngitis (6%). Numerical improvements in motor function (UPDRS III), activities of daily living (UPDRS II), sleep disturbances (PDSS-2, PSQI), and reduction in "off" time were observed. The majority (71/88; 81%) improved on PGIC.

CONCLUSIONS

Addition of rotigotine transdermal system to low-dose oral DA in patients with advanced-PD was feasible and may be associated with clinical benefit.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT01723904 . Trial registration date: November 6, 2012.

Analysis and overview of the guidelines for assessing fitness to drive for commercial and private vehicle drivers

Guidelines on fitness to drive were released by AUSTROADS and the National Road Transport Commission in September 2003. No recognised legal medical authority was cited. There are three parts in the document: (i) background information, (ii) specific medical conditions and (iii) appendices of relevant documents and contacts. This paper analyses the relevance of the guidelines for physicians and notes that the disclaimer exonerates its authors from potential repercussions. Guidelines for both private and commercial drivers are combined in the document and the basis for such delineation is defined. A lack of universal Australian standards with no State indicating the driver's responsibility to report changes in health standards on the issued licences is confirmed by the guidelines. Not all States indemnify physicians for reporting contrary to patients' wishes, while South Australia and the Northern Territory mandate reporting those at risk. Much of the language is patronizing, expecting '... conciliatory and supportive ...' behaviour even with recalcitrant patients. No allowance is made for patients who may not fulfil the guidelines but whom the doctor may consider fit to drive. Ambiguity regarding responsibility to report, as identified in the background section, may leave the doctor vulnerable for not reporting a patient who subsequently may cause injury. Attempt is made to differentiate the role of the specialist from the family general practitioner (GP), advocating specialists for commercial drivers, although this is largely left to the discretion of the GP. There is an implied onus on doctors to report all patients with the conditions under review. Some diagnoses, such as syncope, are discussed in different sections with application of conflicting limitations. Inappropriate language, such as reference to a seizure being '... an isolated non-epileptiform event ...', or withdrawal of medications failing to be restricted to anti-epileptic medications confounds interpretation. Some sections, such as that on sleep and epilepsy, are effectively analysed, while illnesses such as dementia are considered superficially. The guidelines are an attempt to assess fitness to drive, but contain serious flaws and provide limited information upon which to base decisions. Ambiguous language complicates application of the guidelines and places the health care professional at risk, despite a disclaimer protecting its authors.

A pilot study of compassionate use of Levetiracetam in patients with generalised epilepsy

Levetiracetam (LEV) has proven effective for partial seizures, suggesting the need to trial it in generalised epilepsy. Ten patients with generalised epilepsy were given compassionate use of LEV as a pilot study, attending 7 visits with seizure count (using diary) and compliance checked (pill count) with option for long term use. Seizure frequency was compared to baseline mean of the last 2 months and mean of follow-up. Patients were commenced on 500 mg I b.d, and titrated to a maximum of 3 g/day. There were 10 patients (7 females), aged 28-48, of whom 6 had primary generalised epilepsy (PGE) and 4 Lennox-Gastaut syndrome (LGS). At 7 month evaluation: 1 was seizure-free, 1 was 70% reduced, 3 were > or = 50% reduced, 2 were 30-35% reduced; 1 had no change; 1 was 10% increased and 1 was excluded because confounding pseudo seizures. Follow-up was 8-17 months (mean 13.8). The seizure-free patient became pregnant and had 2 seizures, but has been seizure-free for 2 months, at time of submission. A 16 months are three months seizure-free. One was 50% reduced at months 6 and 7, was 2 months seizure-free but then reverted to 50% per baseline. With respect to LGS, 1 withdrew due to aggression, 2 had 40% and 35% reduction at 13 and 15 months respectively and 1 had 25% increase (10% at 7 months). All patients were compliant. These data suggest that LEV may be effective for generalised epilepsy with a need for a larger clinical trial.

Pilot study of prevalence of Parkinson's disease in Australia

Parkinson's disease is a common neurological disease and its prevalence increases with age. Because of an ageing population and changing environment compared to the last epidemiological study done in Australia over 30 years ago, we have conducted a door-to-door pilot survey which looked at the latest prevalence as well as putative risk factors in a random population. We used a two-phase investigation method (screening followed by detailed examination) in a random community sample of 2,820 households (with 527 individuals aged 55 and over) along with 203 residents in aged care facilities (single-phase examination for residents aged 55 and above) in the Randwick area of Sydney, New South Wales. We had a 75% participation rate in the community and a 94% in the aged care facilities. The results of the survey in this sample of 730 subjects indicated that the crude prevalence of Parkinson's disease was between 3.6 and 4.9% (higher in the aged care facilities). The putative risk factors positively identified using chi-square method were 'family history' (p < 0.01) and 'exposure to chemicals at work or in surrounding environment' (p < 0.05). The age-adjusted prevalence rate of Parkinson's disease revealed at least a 42.5% increase in the disease compared to 1966. We conclude that there may be an increase in the disease in Australia due to ageing and other risk factors.

The role of computed tomography in the assessment of neurologic sequelae of decompression sickness

Computed tomographic (CT) scans were performed on 47 patients who had received recompression treatment for decompression sickness. A retrospective review of the case notes disclosed that 24 of the 47 patients had symptoms that suggested cerebral involvement. None of the reported CT abnormalities could be correlated with the clinical manifestations at presentation. It was concluded that the CT scan is not a cost-effective investigative tool for the posttreatment evaluation of decompression sickness.

SUDEP revisited - a decade on: have circumstances changed?

PURPOSE

A paper, published a decade ago, endorsed doctors' right to avoid discussing Sudden Unexpected Death in Epilepsy (SUDEP). It did not negate discussion, advocating same where appropriate. This paper investigates the current situation to identify any changes.

METHODS

The tort of negligence includes a duty to discuss "material risks" and adhere to accepted practice. Within the last decade, "material risks" for SUDEP have not altered significantly and international practice discusses SUDEP with those patients who seek advice or in whom such discussion is designed to improve patient compliance.

RESULTS

Doctors are unlikely to be found negligent for not discussing SUDEP, acknowledging a push encouraging same, despite it being contrary to routine practice in the US, Italy, UK and elsewhere. Doctors should continue to practice the "art of medicine", discuss SUDEP when warranted and with patients seeking such advice. They must warn about risks, such as bathing alone, avoiding accident and injuries and possibly SUDEP in non-compliant patients and also consider the impact of such discussion. With no 'material' changes in the last decade, doctors must recognise when to discuss SUDEP, with which patients and in what context, accepting it may have a negative psychosocial impact on family dynamics unless discussed in a culturally competent fashion, to avoid causing additional stress for families where accepting the diagnosis of epilepsy may already prove difficult.

CONCLUSION

Having formed a therapeutic relationship with the patient, discussion of SUDEP should be considered within that context, acknowledging the "art of medicine" and the implications of such discussion, similar to the situation a decade ago.

The Effect of Biofeedback as a Psychological Intervention in Multiple Sclerosis: A Randomized Controlled Study

BACKGROUND

Relaxation, mindfulness, social support, and education (RMSSE) have been shown to improve emotional symptoms, coping, and fatigue in multiple sclerosis (MS). Biofeedback was trialed as a psychological intervention, designed to improve self-control, in two groups of patients with MS. Both groups received RMSSE, and one group additionally received biofeedback.

METHODS

Forty people with relapsing-remitting MS were recruited from three sites in Sydney, Australia. The mean disability score (Expanded Disability Status Scale; EDSS) was 2.41 ± 1.46 (95% confidence interval [CI], 1.46-3.36); the mean age in years was 45.9 ± 12.42 (95% CI, 41.92-49.87). Participants were randomly assigned to two active treatment groups (n = 20 per group). All participants received one 1-hour session per week for 3 weeks of RMSSE, while biofeedback equipment measured breathing rate and muscle tension. Members of one group used biofeedback screens to regulate physiological response.

RESULTS

Whole-group pre- and post-treatment scores demonstrated a reduction of 38% for anxiety and 39% for depression scores (P = .007 and P = .009, respectively). A post-treatment comparison failed to demonstrate any significant difference between the two active treatment groups in anxiety and depression scores. The biofeedback group showed significant pre- to post-treatment improvement or trends toward improvement in anxiety, fatigue, and stress (P = .05, .02, and .03, respectively). Comparison of pre-post treatment results between groups showed improvements for the biofeedback group in breathing rate and muscle tension (P = .06 and .09).

CONCLUSIONS

For relapsing-remitting MS patients receiving biofeedback in addition to RMSSE, there was a demonstrable reduction in anxiety, fatigue, and stress. There was also a trend toward significant reduction of breathing rate and muscle tension in favor of biofeedback.