Shared care-responsibilities of the doctors

This paper examines 'duty of care' within the context of the sharing of medical management between the family doctor and the specialist consultant. It reviews the referral system which dictates that the consultant has a direct duty of care to the patient while at the same time, needs to meet the obligations of indirect duty of care to maintain proper communications between consultant and fellow-care givers. It concludes that the proximal responsibility dictates that optimal care must be afforded the patient, with full disclosure, informed consent and adequate risk management. Concurrently, there has to be adequate and reliable communication to provide proper supervisory medical care to complement that offered by the specialist.

Examination of the problems confronting those with epilepsy

This paper reports the findings of two studies using similar numbers of patients with epilepsy, but differing referral bases and investigative tools. It demonstrates that people with epilepsy still experience major problems in the areas of emotional adjustment and stability, personal relationships, and employment.

Evaluation of the first 18 months of a specific rehabilitation programme for those with epilepsy

This survey examined the outcome of the first 18 months of the specialized rehabilitation programme at Mt Wilga Rehabilitation Centre, which was designed to cater for the needs of those with epilepsy. Almost 60% of those who underwent the programme were employed at the time of the study, 65% had improved quality of life, approximately 45% acknowledged enhanced self-esteem, and about 45% had an improved control of epilepsy despite the fact that only 30% had their drug therapy altered and of these more than half had either the same or worse control of their seizures. The findings revealed that those patients who were admitted into the residential accommodation, rather than being provided with transport to allow daily attendance while living in their own homes, achieved greater benefit from the rehabilitative programme.

The role of the expert witness in the adversarial legal system

So often we hear the legal profession berate expert witnesses as "hired guns" whose bias is for sale. While this may be relevant to a small minority of "experts", the majority do their job with integrity and in an ethical fashion. An advocate for a proposition will not call a witness to support a claim if it is clear that the witness holds an opposing view. It follows that the bias emanates from the lawyer, not the witness. A witness without a formed view cannot truly claim to be an expert, as the expert should have sufficient knowledge to form an opinion. Once that opinion has been expressed and justified, the lawyer will select the most persuasive and cogently constructed opinion with which to convince the court. The expert witness must commence the assessment without bias or favour; must collect her or his history and examination of the relevant material; evaluate all the facts and evidence provided for scrutiny; seek additional material where there appears to be a deficiency; and draw on all of these data to formulate an opinion in response to questions posed by the instructing lawyer. The expert need not support or refute the stance proposed by the lawyer but the lawyer will only use those opinions favourable to the lawyer's case and hold the remainder as privileged where even that option prevails. It follows that the role of the expert is to provide a well-prepared analysis; it is the lawyer who is paid to be biased.

Demographics of an epileptic population

The demographic data of 100 people with epilepsy were compared with established information concerning the community in which they lived. No real difference was identified.

Neuropsychological assessment in lamotrigine treated epileptic patients

A double-blind, placebo controlled cross over study assessed the efficacy of lamotrigine as adjunct therapy for patients with refractory partial seizures. In addition to the main study, a neuropsychological component evaluated three main areas of cognitive function. These included: i) Concentration and attention; ii) General Cerebral Efficiency, and iii) Mnestic functions--immediate, short term and new learning ability. Ten subjects (4 males, 6 females, age range 22 to 53, mean age 31.3 years) were involved in the study, each assessed 3 times--baseline, end of phase I and end of phase II. Whilst statistical analysis proved impracticable due to differing scores across cells, between the results of lamotrigine and placebo, clinically, there appeared to be a marginal reduction in General Cerebral Efficiency during the lamotrigine phase. In the light of these tests, the conclusion is advanced that lamotrigine does not specifically impair cognitive function, and that it does not impair mnestic function. An alternate hypothesis of interaction effects is posited for the slight reduction in speed of information processing.

A simple and validated tool for the clinician to assess psychosocial status when conducting anticonvulsant drug trials

Using 94 people with epilepsy, categorized as either idiopathic or post-traumatic, and subdivided according to the severity of the disorder, the WPSI was tested and found to be a simple and validated tool for the clinician to assess psychosocial status when conducting anticonvulsant drug trials.

A Diagnostic Dilemma of White Matter Lesions and Cerebral Oedema without Identifiable Cause-A Neurological Conundrum

INTRODUCTION

This paper describes a case of bi-frontal vasogenic oedema associated with bilateral frontal lobe and left parietal lobe white matter lesions where extensive investigations, including brain biopsy, failed to establish a diagnosis.

CASE REPORT

A 67-year-old female presented with three weeks' history of memory loss, fatigue, insomnia, nausea, and occasional dysphasia. Physical examination was unremarkable, yet cerebral CT and MRI showed bilateral frontal lobe vasogenic oedema. Extensive investigations, including: biochemical; radiological; immunological; microbiological; haematological; histopathological; and cytological, failed to establish a confirmed diagnosis. A multidisciplinary team could not achieve a consensus for this atypical presentation. Brain biopsy was unusual, showing destructive inflammatory and subtly granulomatous disease, but an exhaustive list of auxiliary tests could not confirm a cause, and consensus favoured glial fibrillary acidic protein (GFAP) autoimmune encephalopathy.

DISCUSSION

A definitive diagnosis could not be established for this patient despite a gamut of investigations. Although some of the presenting features were consistent with GFAP astrocytopathy, initial staining of the patient's CSF for neuronal antibodies was negative. Her symptoms and radiological changes of brain imaging improved without any corticosteroid therapy.

CONCLUSIONS

Through this case report, the aim is to add to the repository of neurological sciences in the hope that future similar presentations could potentially lead to discovery of a new aetiology or contribute towards better understanding of an existing disease process.

The legal status of the fetus in New South Wales

The issue of how to define the legal status of the fetus is complex. Three clinical cases with fetal losses following motor vehicle accidents raise important issues regarding the legal status of the unborn child. Legislation was submitted to the New South Wales Parliament in the form of the Crimes Amendment (Grievous Bodily Harm) Bill 2005 (NSW) but was subsequently repealed. Medical technological advances make the viability of a fetus a shifting standard and encourage the comparison between newborns and late-term fetuses, offer increased fetal health status information and provide greater capacity to maintain the life of babies born prematurely. In view of the sophisticated state of medical care available in New South Wales, the three cases reviewed highlight the discrepancy between the medical recognition of the fetus as a patient and its lack of legal recognition.

The law(s) of the rings: boxing and the law

To threaten harm is to assault and to realise that threat is to batter. To do so intentionally for the purpose of producing injury amounts to causing harm with intent and one cannot consent to be the victim of such violence. Despite these clearly enunciated legal principles, such conduct is routinely practised in the name of sport. Boxing is widely accepted as a highly paid professional sporting activity in which the ultimate goal is to inflict a concussive head injury upon an opponent or at least cause sufficient damage to render an opponent incapable of further self-defence. Spectators pay to watch the anticipated systematic abuse of one human being by another in much the same way they delighted in gladiators who were forced to fight for the pleasure of others. This article reviews these concepts and challenges the legal ethics of authorised violence associated with these activities undertaken in the name of sport.

Legal medicine--how to prepare a report

Legal medicine often requires the provision of a report by the general practitioner. This may be either as the treating doctor or as the expert witness providing peer evaluation of a colleague, or to assess professional standards and/or delivery of health services. This article reviews the process and obligations attached to the provision of such a report.

Use of total and free anticonvulsant serum levels in clinical practice

Total and free (unbound) anticonvulsant drug levels in serum (361 analyses) were measured in a series of 117 patients who attended for routine management of epilepsy. Comparison of predetermined therapeutic ranges for the two types of level demonstrated disagreement in as many as 30% of assessments. The clinical significance of this finding is discussed and wider acceptance of the use of free drug levels in the management of epilepsy is advocated.

Obstructive sleep apnoea presenting as a stroke mimic

Obstructive sleep apnoea (OSA) is never considered the aetiology of focal neurological symptoms or in the differential of stroke-like symptoms. Although it is a risk factor for stroke and can produce global neurological symptoms, such as confusion and decreased consciousness, it has never been reported to produce focal neurology. This case describes a patient with OSA, diagnosed through polysomnography, who had multiple presentations of focal stroke-like symptoms and signs, despite initial optimal post-stroke management. Symptomatic cessation was only achieved after the patient received continuous positive airway pressure therapy.