Global Neurology: The Good, the Bad, and the Ugly

Global health programs engaging in isolated or short-term medical missions can and do cause harm, reinforce health care disparities, and impede medical care in the regions where it is so desperately needed. Related ethical, medical, and legal concerns are reviewed in this article. The authors recommend abandoning these ill-considered missions and focusing attention and resources on advancing neurology through ethically congruent, multisectoral, collaborative partnerships to establish sustainable, self-sufficient training programs within low- and middle-income countries.

Teaching letter writing to medical undergraduates

Poor quality medical letters epitomise the failing communication skills of Australian doctors. I asked the 11 Australian medical schools to define how these skills are taught to undergraduates, and The Royal Australian College of General Practitioners (RACGP) to comment on the essay section of the college examinations. Six of the 11 universities replied; two of them teach communication. The RACGP supported the need to teach undergraduates communication skills.

Membership survey of the Australasian College of Legal Medicine: Quality assurance

INTRODUCTION

The Council of the Australasian College of Legal Medicine (ACLM) considered it timely to survey its membership to determine how to best accommodate its members' needs.

METHODS

A questionnaire was devised, piloted and circulated amongst the 219 College members (excluding the 13 Honorary Fellows). Yield was maximised with 4 direct mailings, 4 questionnaire insertions in the quarterly College newsletter, 3 targeted emails and follow-up phone calls.

RESULTS

The survey achieved 160 (73%) response rate of whom ∼40% were substantially involved in legal and forensic medicine and ∼40% were occasionally involved. Thirty-five participants (23%) specialised in forensic medicine and 101 (63%) held Fellowship status in other recognised medical specialities. Equal ⅓ of the members had been so for >10 years, 5-10 years or <5 years, demonstrating the dynamic nature of the College. Of them 53% were Fellows, 26% Members and 21% Associates with 50% of the latter groups willing to train towards Fellowship. About half the respondents (48%) regularly attended the Annual Scientific Meeting (ASM) and favoured the Eastern border for such meetings. The collegiate nature of the College was deemed its most positive aspect with a dichotomy of views regarding seeking alternative strand affiliation for specialist recognition, although 80% indicated they would retain College membership even if such affiliation occurred. Those who attended College educative programs found them useful but attendance was between 32 and 49%, depending on the course.

DISCUSSION

There appeared widespread satisfaction with College performance and activities but a low uptake of educative courses, other than Annual Scientific Meetings, thereby identifying marketing of courses as needing extra attention.

Somatosensory evoked potentials, electroencephalography and CT scans in the assessment of the neurological sequelae of decompression sickness

Decompression sickness can lead to neurological complications. Recovery may be studied by somatosensory evoked potentials (SEPs), which are more sensitive than normal methods of neurological examination, and by electroencephalography (EEG). The combination of EEG and SEP may be useful in differentiating among spinal, brainstem and cortical pathology.

Routine use of lamotrigine, a new anti-epileptic medication, and the value of measuring its blood levels

Lamotrigine (LTG) has recently been approved for marketing in Australia as add-on therapy in resistant partial seizure disorders. Early reports cited a therapeutic blood level for LTG of 1-3 mg/L (4-12 mumol/L). Aspects of routine patient care with LTG, devoid of the restrictions of trial protocols, are discussed. Forty-five patients commenced therapy but 15 discontinued LTG. Of the remaining 30 patients, 9 became seizure free, 3 from the de novo trial in focal epilepsy and 6 with generalised epilepsy. Global evaluation of patients showed mild to moderate improvement for those with focal epilepsy and moderate to marked improvement for those with generalised epilepsy. Blood levels of LTG did not provide clinically useful information.

Association of Lesion Topography with Functional Outcomes in Acute Ischemic Stroke Patients Considered for, or Receiving, Reperfusion Therapy: A Meta-Analysis

Background: The impact of lesion topography (LT), characterised by the Alberta Stroke Programme Early CT Score (ASPECTS), on outcomes after reperfusion therapy in acute ischemic stroke (AIS) is poorly elucidated. We investigated the prognostic accuracy of ASPECTS-based LT assessment and its association with clinical outcomes in AIS patients considered for reperfusion therapy or receiving intravenous thrombolysis (IVT), endovascular thrombectomy (EVT), or none or both. Methods: Studies were identified from PubMed with additional studies added from Google Scholar. The prevalence of individual ASPECTS regions will also be determined. The association of individual ASPECTS regions with the functional outcome at 90 days will be assessed using random-effects modelling for various cut-offs, such as 6, 7 and 8. The association of continuous ASPECTS with the functional outcome at 90 days will also be undertaken. Forest plots of odds ratios (ORs) will be generated. Results: A total of 25 studies have been included in the final analysis, encompassing 11,404 patients. Pooled estimates indicate that the highest prevalence rates were in cases involving the insula and lentiform nucleus. Subgroup analysis for ASPECTS < 6 (OR 6.10; 95% CI 2.50−14.90; p < 0.0001), ASPECTS < 7 (OR 4.58; 95% CI 1.18−17.86; p < 0.0001) and ASPECTS < 8 (OR 2.26; 95% CI 1.32−3.89; p < 0.0001) revealed a significant association with poor functional outcome at 90 days. Decreasing ASPECTS significantly increased the odds of poor functional outcomes at 90 days (SMD −1.15; 95% CI −1.77−−0.52; p < 0.0001). Conclusions: Our meta-analysis demonstrates that decreasing ASPECTS is significantly associated with poor functional outcomes. Individual ASPECTS regions associated with the highest odds of poor functional outcomes were identified. Future studies on the association of LT and clinical outcomes specific to EVT are required.

Adolescent Drivers - Are We Doing Enough?

The minimum eligible driving age in Australia is 15 years 9 months, in the Australian Capital Territory, and 16 years elsewhere in the country. Approval to drive mandates: appropriate age; completing computer-generated testing; and monitored Graduated Licensing Schemes. The National Road Safety Strategy 2011-2020, released by the Australian Transport Council, either has been or is being implemented, including sponsorship of the Australasian College of Road Safety and establishing Cabinet representation for road safety. Factors include: driving ability; developmental factors; personality; demographics; general environment; and driving environment. The Graduated Licensing process has counted driver inexperience, but immaturity and peer pressure remain additional considerations. Complementing Graduated Licensing, parental and respected directives and guidance are essential to minimise negative peer pressure. Specific counselling and other targeted interventions may also assist. Attention Deficit Hyperactivity Disorder or adolescent epilepsy demand appropriate management to facilitate driving in accordance with the AUSTROADS Guidelines. A composite targeted approach is required to deal with adolescent road fatalities and injuries.

Ethics in clinical drug trial research in private practice

INTRODUCTION

Private clinics and clinicians have been involved in clinical drug trials for approximately two decades. This paper reviews the ethical consideration inherent in this process.

METHODS

Involvement of a single community based, private, Australian neurological clinic in the conduct of trials was audited. Changes in ethical considerations were analysed.

RESULTS

The clinic previously audited its clinical trial involvement, starting with pharmaceutical company orchestrated trials. These were vetted by hospital based ethics committees (ECs) which then refused to review private research. A private EC accommodating NH & MRC standards was formed to assess private research. Indemnity concerns forced return to institutional ECs with government guaranteed indemnification. Trials evolved to investigator initiated, company sponsored studies thence a company asking the clinic to devise, sponsor and manage a trial. The latter relegated trial co-ordination to the clinic which would control publication thereby creating new ethical standards.

DISCUSSION

Private practice trial involvement evolved from reluctant inclusion to a pivotal role in privately sponsored studies. Access to ECs is government endorsed and publication is independent for investigator-sponsored trials. There has been modification of standard operating procedures and enhanced ethical standards.

The impact of chronic kidney disease on prognosis in acute stroke: unraveling the pathophysiology and clinical complexity for optimal management

BACKGROUND

Chronic kidney disease (CKD) significantly increases stroke risk and severity, posing challenges in both acute management and long-term outcomes. CKD contributes to cerebrovascular pathology through systemic inflammation, oxidative stress, endothelial dysfunction, vascular calcification, impaired cerebral autoregulation, and a prothrombotic state, all of which exacerbate stroke risk and outcomes.

METHODS

This review synthesizes evidence from peer-reviewed literature to elucidate the pathophysiological mechanisms linking CKD and stroke. It evaluates the efficacy and safety of acute reperfusion therapies-intravenous thrombolysis and endovascular thrombectomy-in CKD patients with acute ischemic stroke. Considerations, such as renal function, drug dosage adjustments, and the risk of contrast-induced nephropathy, are critically analyzed. Evidence-based recommendations and research priorities are drawn from an analysis of current practices and existing knowledge gaps.

RESULTS

CKD influences stroke outcomes through systemic and local pathophysiological changes, necessitating tailored therapeutic approaches. Reperfusion therapies are effective in CKD patients but require careful monitoring of renal function to mitigate risks, such as contrast-induced nephropathy and thrombolytic complications. The bidirectional relationship between stroke and CKD highlights the need for integrated management strategies to address both conditions. Early detection and optimized management of CKD significantly reduce stroke-related morbidity and mortality.

CONCLUSION

Optimizing stroke care in CKD patients requires a comprehensive understanding of their pathophysiology and clinical management challenges. This article provides evidence-based recommendations, emphasizing individualized treatment decisions and coordinated care. It underscores the importance of integrating renal considerations into stroke treatment protocols and highlights the need for future research to refine therapeutic strategies, address knowledge gaps, and consider tailored interventions to improve outcomes and quality of life for this high-risk population.

Creutzfeldt-Jakob Disease in South West Sydney 2014-2020: An Unusually High Incidence of a Rare Disease

INTRODUCTION

Creutzfeldt-Jakob disease (CJD), a spongiform encephalopathy, caused by a transmissible misfolded cellular prion protein, is a rapidly progressive, debilitating neurodegenerative disorder with no effective treatment. The estimated global incidence is at 1/million inhabitants. This retrospective study examined the incidence of CJD in South Western Sydney Local Health District (SWSLHD) from 2014 to 2020.

BACKGROUND

SWSLHD had an estimated population of 1,038,534 in 2020, with CJD data being limited.

METHODS

The New South Wales (NSW) Health Information Exchange (HIE) database, for all admissions with CJD diagnoses in SWSLHD, between 2014 and 2020, was reviewed according to the WHO diagnostic criteria, consistent with the Australian national CJD registry. Only probable CJD cases were included. Incidence was calculated based on the projected SWSLHD population.

RESULTS

Thirty-five patients, diagnosed with CJD, were identified. Each was evaluated by 2 independent investigators, including clinical presentation, MRI, EEGs, 14-3-3, and RT-QuIC results, before assigning CJD-probable status. Four failed the CJD criteria and were excluded. Of the 31 CJD-probable cases, most (59%) were male and older (37%, range 61-70 years). The incidence rate peaked at 9/million in 2017 and was above 2/million, throughout the 7 years, with an average of 4.859/million/year.

CONCLUSIONS

The incidence of CJD, in SWSLHD, exceeds the national average of 1/million. Cost-effective, adequate diagnostic and screening tools, implementable over a large population, will become increasingly essential.

Futile treatment - when is enough, enough?

Objective This paper examines two aspects of treatment decision making: withdrawal of treatment decisions made by a patient; and decisions to not proceed with treatment by a health professional. The paper aims to provide an overview of the law relating to the provision of treatment, then highlight the uncertainty as to the meaning of and costs associated with futile treatment. Methods The paper reviews the current legal and medical literature on futile treatment. Results Continuing treatment which is futile is not in the patient's best interests. Futility may be understood in both quantitative and qualitative terms. Recent legal cases have expanded the definition of futility to focus not on the nature of the treatment itself, but also on the health of the patient to whom treatment is provided. Conclusions As Australia's population ages, there is likely to be an increased focus on the allocation of scarce health resources. This will, inevitably, place constraints on the number and variety of treatments offered to patients. The level of constraint will be felt acutely where a proposed treatment offers little clinical efficacy. It is time to try to understand and agree on a workable definition of futility.

Doctors and pharmaceutical industry

The pharmaceutical industry is seen as seducing doctors by providing expensive gifts, subsidising travel and underwriting practice expenses in return for those doctors prescribing products that otherwise they would not use. This paints doctors in a very negative light; suggests doctors are available to the highest bidder; implies doctors do not adequately act as independent agents; and that doctors are driven more by self-interest than by patient needs. Similar practices, in other industries, are accepted as normal business behaviour but it is automatically assumed to be improper if the pharmaceutical industry supports doctors. Should the pharmaceutical industry withdraw educational grants then there would be: fewer scientific meetings; reduced attendance at conferences; limited post graduate education; and a depreciated level of maintenance of professional standards. To suggest that doctors prescribe inappropriately in return for largesse maligns their integrity but where there is no scientific reason to choose between different treatments then there can be little argument against selecting the product manufactured by a company that has invested in the doctor and the question arises as to whether this represents bad medicine? This paper will examine what constitutes non-professional conduct in response to inducements by the pharmaceutical industry. It will review: conflict of interest; relationships between doctors and pharma and the consequences for patients; and the need for critical appraisal before automatically decrying this relationship while accepting that there remain those who do not practice ethical medicine.

Travelling with medications - some lessons learned

Travelling with medication overseas can require additional care and thought in case the medication is lost or stolen. There are basic steps to follow to ensure medications can be easily replaced while overseas. This article outlines some valuable lessons learned from one patient's experience.

Adverse events in medical management--vigabatrin as a paradigm of forensic responsibility with novel therapy

The ethics of medical management are not always straightforward. There are many contributing factors: the condition treated; its effects on the patient; the required treatment; the effects of that treatment; and a cost/benefit ratio. Treatment of epilepsy with vigabatrin (VGB) exemplifies these problems. VGB has recently been reported to cause constricted visual fields. Formal testing of visual fields of patients attending an outpatient epilepsy service showed constriction with tunnel vision, even in patients who are asymptomatic. The ethical questions include: Should all reports of adverse events be subjected to tests of validity and subsequent quality assurance? Should treatment with VGB be stopped, risking recurrence of seizures? What are the legal consequences of continuing VGB? Does informed consent protect the doctor? After stopping VGB can the patient drive?

Informed consent--should Bolam be rejected?

Informed consent requires the person to correctly understand the nature of what is offered and to be free to choose without coercion. Where there are impediments to such decision-making, then appropriate guardians or mental health laws have been provided to enhance protection. Where consent was not fully informed, an injured patient may resort to the tort of battery or negligence for remedy unless the intrusion was as a consequence of emergency treatment to an unconscious patient in the absence of next of kin. This paper reviews the UK Bolam Principle where professional standards were set by peer standards of professional conduct and the US prudent person test in which needs of a prudent patient assume priority. It concludes that there is a need to balance both the rights of patients and obligation of doctors to ensure that justice prevails. It recognises that the final standard of duty of care remains under scrutiny, and that there was a ground swell against absolute adherence to the Bolam Principle, and a need to review the circumstances of each case.