The teaching of legal medicine in Australasia

The interface of medicine and law highlights the difference between doctors and lawyers. It is the doctor's role to determine his or her adversary (diagnosing an illness) and to decide the optimal means for overcoming same, such that the doctor assumes the role which is analogous to not only the lawyer but also the judge and jury when dealing with illness and it is the doctor who prescribes the appropriate remedy. Conversely, the lawyer only represents the objectives of his/her client, thereby only representing a single focus within the complexity of the problem. It is the duty of the system to reach the proper conclusion and prescribe the appropriate remedy. It follows that doctors and lawyers operate under a different set of standard operating procedures and expectations. This paper describes the evolution of the Australian College of Legal Medicine (ACLM) and its contribution to the teaching of legal medicine in Australasia. The ACLM was formed in 1995 and in its first decade of existence has established a range of programs, including the expert witness program, basic law intensive, the advanced law intensive, annual scientific meetings and further educative programs in forensic medicine. The Australian & New Zealand Forensic Medicine Society has been incorporated into the ACLM and the College has formed a partnership with Griffith University to provide the first Master of Legal Medicine course provided from within a School of Medicine, at university level, rather than offering health law from within a legal program. The College has been approached by other medical colleges within Australia to offer training for their Fellows and organised its first offshore training program in 2006.

Analysis of the latest Austroads guidelines for fitness to drive as promulgated in March 2012

After 9 years, Austroads has published new guidelines for fitness to drive. The guidelines have a preamble, which includes a legal disclaimer denying any culpability for those who designed the guidelines. They also warn of the legal responsibility for health professionals to satisfy their obligations, the need to be current with both relevant medical and legal expectations and if in doubt to seek guidance from Medical Defence Organisations. The guidelines are divided into Parts A and B, with A providing broad overview and background information while B deals with specific entities, such as blackouts, epilepsy or sleep disorders. This paper examines the guidelines and offers an appraisal of their content, their relevance to health practitioners and an assessment of their role in assisting to improve road safety.

Generic Substitution and Advice to Patients -Potential Legal Medicine Consequences - From A (Australia) to U (United Kingdom or United States of America)

INTRODUCTION

This paper reviews the potential legal ramifications of prescribing or dispensing generics for people with epilepsy (PWE) and the international perspective.

SPECIAL CONSIDERATIONS

Anti-seizure medications (ASM) control ~70% of seizures. Generic alternatives must respect -20% to +25% of the bioequivalence of the 'parent' medication but are not tested, one against another. The first generic may reflect -20% and the next +25%, almost halving or doubling the bioequivalence. While doctors in some countries, prescribing ASM, have the option to deny generic substitution, this may not always be respected by the 'learned intermediary'. Use of trade name, be it of a specific generic or the parent compound, obviates the potential for substitution, especially if prohibiting substitution.

LEGAL CONSEQUENCES ATTACHED TO BRAND SUBSTITUTION

Patients given a generic substitute, without warning of potential risks who experience serious consequences, may litigate for medical negligence. This responsibility rests with the provision and failure to warn, be it doctor, pharmacist or institution. Where a pharmacist ignores a doctor's instruction, there is also the potential of professional misconduct.

INTERNATIONAL PERSPECTIVE

In the USA, litigation against manufacturers failed but litigating against prescribers or dispensers remains possible. While generic substitution is preferred, US doctors retain the right to reject brand substitution. Other jurisdictions likewise advocate generics, some mandating the same, but most offer the option to refuse brand substitution.

CONCLUSIONS

Generic substitution, particularly for PWE, has the potential for serious harm. There is a duty of care to warn of such risks. It is the responsibility of the provider to so warn, thereby achieving informed consent.

Can head trauma trigger adult-onset Rasmussen's encephalitis?

Rasmussen's encephalitis (RE) is a rare unilateral inflammatory brain disorder that causes progressive neurocognitive deterioration and refractory epilepsy including epilepsia partialis continua (EPC). We describe a patient with a unique presentation, where right upper limb EPC due to RE began within 2weeks of a concussive left frontal head injury, in a 36-year-old female without other identifiable etiology, no prior neurological deficit nor suggestion of intracranial pathology or infection, and no preceding seizures. The diagnosis of RE followed extensive investigation, excluding confounding diagnoses, with supportive histopathology, and her EPC has proven refractory to treatment. In the absence of a satisfactory alternative etiology and exclusion of differential diagnoses, the most likely cause or precipitant of this patient's RE was head trauma.

T2-hyperintense, non-gadolinium-enhancing, diffusion-restricted symmetrical curvilinear lesion of the anterior pons: a rare radiological pattern of leptomeningeal metastatic disease secondary to likely lung adenocarcinoma

Leptomeningeal carcinomatosis is a devastating sequelae of metastatic cancer. It has protean manifestations on imaging. An elderly woman presented to our tertiary centre with symptoms suggestive of a cerebrovascular accident. Investigations revealed no evidence of this. There was clinical, contextual and radiological evidence of an underlying neoplasm.Magnetic resonance imaging (MRI) demonstrated evidence of a rare morphology (anterolateral pontine leptomeningeal enhancement) in the presence of a probable concomitant lung adenocarcinoma. Other reports have previously described this same neuroradiology, seemingly always in association with lung adenocarcinoma.The purpose of this report is to highlight an unusual case and discuss its peculiarity and pathophysiology. Our patient is the latest documented of a small cohort with this constellation of clinical and neuroradiological features.This study demonstrates the importance of differential diagnosis in stroke medicine, specifically the need to consider neoplastic phenomena in patients admitted following putative cerebrovascular events.

Confidentiality and the management of patients with epilepsy who fail to comply with doctor's advice not to drive: a survey of medical/legal opinions in Australia

This study sought the opinions of a select group of professionals, trained in medicine and law concerning: professional privilege; management of patients who posed risks to society; and the legal charge to impose upon a patient with uncontrolled epilepsy who caused a fatality by driving contrary to medical advice. The second Academic Seminar of the Australian College of Legal Medicine was surveyed to define demographics and opinions. Of 23 respondents, 14 were trained in law and medicine, of whom eight had post graduate medical qualifications and seven had more than basic legal training; 20/23 supported professional privilege in medicine but 18/23 denied its absoluteness; 22/23 felt the doctor had a right to divulge information in the public interest. Only 14/23 (although still a majority opinion) felt this right was a duty and 6/23 refuted the same. When concerned regarding compliance not to drive, 7/23 would discuss it with family/friends in contravention of patient consent, 12/23 would report to the driving authorities where concern became fact, 13/23 would advise the patient that a report would be sent, 4/23 would report without the patient's knowledge and four would threaten but not send the report. In the case of a fatality consequent to non-compliance, 10/23 considered murder and 22/23 considered manslaughter charges to be appropriate. The majority supported professional privilege in the doctor/patient relationship but also supported the right or even a duty to report risks to society. Where a concern arose that a patient with epilepsy may drive contrary to advice, one-third of doctors would discuss with family/friends, without consent, one-half would report the patient to the driving authorities, while almost three-quarters would report the patient if concern was realised. Murder and manslaughter, serious charges, were deemed appropriate for patients who caused death by driving against medical advice.

Justification for conducting neurological clinical trials as part of patient care within private practice

The aim of this review was to assess the benefits and drawbacks of conducting neurological clinical trials and research in private practice for the patients, clinician, Practice Manager, sponsors/Clinical Research Organisations (CROs) and Clinical Trial Coordinator (CTC) to determine if this is justified for all involved. A combination of literature reviews, original research articles and books were selected from 2005 to 2015. Provided that the practice has sufficient number of active trials to prevent financial loss, support staff, adequate facilities and equipment and time, the benefits outweigh the drawbacks. Clinical trials provide patients with more thorough monitoring, re-imbursement of trial-related expenses and the opportunity to try an innovative treatment at no charge when other options have failed. For the clinician, clinical trials provide more information to ensure better care for their patients and improved treatment methods, technical experience and global recognition. Trials collect detailed and up-to-date information on the benefits and risks of drugs, improving society's confidence in clinical research and pharmaceuticals, allow trial sponsors to explore new scientific questions and accelerate innovation. For the CTC, industry-sponsored clinical trials allow potential entry for a career in clinical research giving CTCs the opportunity to become Clinical Research Associates (CRAs), Study Start-Up Managers or Drug Safety Associates.

Decreasing presentations of seizures to emergency departments in a large Australian population

This study was designed (1) to compare the prevalence of emergency department (ED) presentations in Western Zone Sydney South West Area Health Service (WZS) between 1998-2002 and 2003-2007 for epilepsy (including status epilepticus (SE) and convulsions), hospital admission rates, and proportion of first seizure presentations; and (2) to compare these data with those for New South Wales (NSW) and Australia-wide figures. Using health department data sets, we found 19,834 presentations to WZS EDs between 1998 and 2007 (24.85/10,000 population/year). When the periods 2003-2007 and 1998-2002 in WZS are compared, ED presentations fell by 3% (P=0.03) and hospital admissions fell by 6% (P=0.001). The prevalence of ED presentations for seizures in NSW did not change (P=0.92), but hospital admissions fell by 3% (P<0.0001). When 1999/2000-2002/2003 was compared with 2003/2004-2006/2007, the prevalence of hospital admissions in Australia fell by 1% (P=0.0002). Rates of presentation for epilepsy in WZS have fallen over the last decade. Most presentations were first seizures rather than recurrences. The reason for this is speculative, but may reflect improved levels of education and health care delivery.

Chromosome fragility in the Lennox-Gastaut epilepsy syndrome

Chromosome fragility was sought in a well-defined cohort of patients with Lennox-Gastaut epilepsy syndrome. Twenty-five patients plus 25 age- and sex-matched normal controls had cytogenetic studies performed. All patients were taking sodium valproate, and four were also on hydantoin. Blood cultures from both patients and controls were set up simultaneously in an appropriate medium designed to elicit fragile-sites. Harvesting took place after 96 h by standard techniques. In addition to routine banded analysis, at least 50 cells were scored for chromosome breaks and gaps from each patient and control. Results showed no difference between the patients and the control group in the overall occurrence of fragility or the type of aberration detected. No fragile-X syndrome was detected. This study found no effect due to sodium valproate on the occurrence of chromosome aberrations.

Clinical implications for substandard, nonproprietary medicines in multiple sclerosis: focus on fingolimod

Both proprietary and nonproprietary medicines are expected to undergo rigorous preapproval testing and both should meet stringent health authority regulatory requirements related to quality to obtain approval. Nonproprietary (also known as copy, or generic) medicines, which base their authorization and use on the proprietary documentation and label, are often viewed as a means to help lower the cost and, thus, increase patient access. If these medicines fail to meet quality standards, such as good manufacturing practice and bioequivalence (in humans), they are then defined as substandard copies and can pose serious risks to patients in terms of safety and efficacy. Potentially noncontrolled or different manufacturing process and excipients in nonproprietary medicines may result in poor batch-to-batch reproducibility (accurate and consistent quantity of each ingredient in each capsule/tablet) and lower quality. Substandard, nonproprietary copies of medicines that are immunomodulatory or immunosuppressive are of concern to patients due to their possible untoward safety and lack of efficacy events. This article reviews the potential risks associated with nonproprietary medicines that do not meet the regulatory requirements of the United States Food and Drug Administration, the European Medicines Agency, or the World Health Organization. The clinical implications for patients are described. This article focuses on nonproprietary medicines for multiple sclerosis, particularly fingolimod, that are not identical to proprietary versions and could thus fail to meet efficacy expectations or have different impact on the safety of patients with multiple sclerosis.