Use of Interval Therapy with Benzodiazepines to Prevent Seizure Recurrence in Stressful Situations

INTRODUCTION

Antiseizure medications (ASMs) control 70-75% of seizures. Accepting stress as a trigger for seizures, intervention, at the time of predictable stress, should offer a therapeutic option. Mode of intervention: Intervention requires the maintenance of an accurate seizure diary to identify a recurring pattern. With a questioning approach to that diary, the clinician may intervene when stressful provocateurs occur. Benzodiazepines, such as clobazam, initiated prior to the predictable stress, and continued until after it has passed, should be short lived, making serious adverse effects unlikely. Benzodiazepines have a dual benefit, being both anxietolytic and raising the seizure threshold in patients with epilepsy.

DISCUSSION

Many patients claim stress provokes their seizures and may not be aware the stress was the provocateur, until after a seizure occurred, leading to a retrospective claim of the relationship. To confirm the relationship, permitting preventative measures, before exposure to provocative factors, often unable to be avoided, requires maintenance and review of a detailed diary. Interval temporary use of benzodiazepines, such as clobazam, or alternatively clonazepam, diazepam or nitrazepam, offers a reasonable response to obviate subsequent seizures, and should be continued, for a brief period, after the risk has abated. Subsequent review of the diary, over a period of repeated exposures to the identified stress, will confirm or refute the therapeutic effect.

CONCLUSION

Judicious use of interval therapy, with one of the benzodiazepines, covering the period of stressful provocation, offers adjunctive treatment of possible refractory epilepsy, based upon the review of the strictly maintained epilepsy/seizure diary.

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.

Automatism: comparison of common law and civil law approaches--a search for the optimal

This article reviews common and civil law approaches to automatism with discussion of legal definitions and the conditions in which automatism occurs. The common law approach to sane (exogenous) and insane (endogenous) automatism is examined. Despite a change in the law, which obviates mandatory incarceration for all persons found not guilty on the basis of insane automatism, the stigma of insanity remains. A number of Continental jurisdictions, though, have adopted an approach divorced from judgmental labels, whereby acts, which result from automatism, are classified under the rubric of unconsciousness. The article draws upon this approach, analyses alternatives to insane automatism and proposes instead an analysis by reference to "cognitive dysfunction", thereby removing all reference to the concept of insanity.

Conflict of interests--criticising the critics

Examining the relationship between the pharmaceutical industry and medical profession the BMJ raised concern including: describing doctors as 'lapdogs to drug firms'; unethical recruiting in third world countries; manipulating codes of conduct; and medicine corrupted by industry largess. This paper offers an alternative perspective, questioning if largess is automatically contrary to societal needs. Serving on advisory boards allows critical input. Critics who denigrate those who accept support often have undisclosed conflicts of interest. These critics usually do not come from private practice and hence responsible for their own expenses and do not acknowledge costs faced by private practitioners when attending meetings. Private practice does not provide salary when not consulting, has no trust fund support and cannot amortise sponsorship as is often done in the public sector. Failure to disclose this represents concealed conflict of interest, amplified by the 'publish or perish' philosophy, which may well underwrite some publications.

Ethical dilemmas of potential adverse events

Doctors should advise patients of recognised adverse events of proposed therapy. It remains unclear what responsibility attaches to suspected potential for adverse events if these have not been reported. Vigabatrin (VGB) is a gabaergic anti-epileptic medication (AEM) reported to produce tunnel vision with constricted fields. Tiagabine (TGB), also a gabaergic AEM recently approved for sale, has not been reported to cause field defects but raising GABA also raises concern. Doctors must decide what needs to be discussed with patients; should patients on TGB have field testing similar to those on VGB; what should be done if constricted fields are confirmed in asymptomatic patients; and what reporting procedures should be adopted.

Neurologists' use and interpretation of antiepileptic drug monitoring in the treatment of epilepsy

Of the 150 local Ordinary Members of the Australian Association of Neurologists (AAN), 118 responded to a questionnaire on the use of AED level measurement in the management of epilepsy. AED level measurement is widely employed, but only phenytoin levels were accepted as being reliable by more than 90% of AAN members. Respondents questioned absolute reliance being placed on any of the other AED levels.

Treatment satisfaction in patients with relapsing-remitting multiple sclerosis initiated on teriflunomide in routine clinical practice: Australian observational data

BACKGROUND

Adherence and persistence are critical to optimising therapeutic benefit from disease-modifying therapies (DMTs) in relapsing-remitting multiple sclerosis (RRMS). This prospective, open-label, multicentre, observational study (AubPRO), conducted in 13 hospital-based neurology clinics around Australia, describes treatment satisfaction in patients newly initiated on teriflunomide (Aubagio) and evaluates the use of an electronic patient-reported outcome (PRO) tool.

METHODS

Patients (≥18 years) newly initiated on teriflunomide (14 mg/day) were followed up at 24 and 48 weeks. Patients completed questionnaires and pill counts electronically using MObile Data in Multiple Sclerosis. The primary endpoint was treatment satisfaction, measured by the Treatment Satisfaction Questionnaire for Medication (TSQM, V.1.4), at week 48. Secondary endpoints included treatment satisfaction at week 24, other PRO scales, clinical outcomes, medication adherence and safety.

RESULTS

Patients (n=103; 54 (52.4%) treatment naive) were mostly female (n=82 (79.6%)), aged 49.5 (11.8) years, with MS duration since symptom onset of 9.1 (11.8) years and a median Expanded Disability Status Scale score of 1.0. Mean treatment satisfaction scores were high (≥60%) across all domains of the TSQM V.1.4 at week 24 and at week 48. Compared with week 24, week 48 treatment satisfaction increased for patients who were treatment naïve and for those previously on another oral or injectable DMT. Over 48 weeks, PROs remained stable across a range of measures including disability, physical health, emotional health and mobility, and there were improvements in work capacity and daily life activity. Adherence was high throughout the study with mean compliance (pill counts) of 93.2%±6.26%, and 98 of 103 (95.1%) patients remained relapse-free.

CONCLUSION

This cohort of Australian patients with RRMS, newly initiated on teriflunomide, and treated in a real-world clinical practice setting, reported high treatment satisfaction and adherence at 24 and 48 weeks. Patient-reported measures of disability remained stably low, work capacity and daily life activity improved, and most patients remained relapse-free.

Application of amendments to the Privacy Act (Cth) 1988 as they affect private clinical practice

INTRODUCTION

The amendments to the Privacy Act (Cth) 1988 came into force on 21st December 2001. These changes expand the impact of the Act to include the private sector and will have considerable consequences upon healthcare delivery in Australia. This paper reports the findings of a survey, which examined the implications of the Act for doctors in private practice.

METHOD

Both Government and private agencies were canvassed to seek clarification of various aspects of the Act. Responses were analysed to determine what needed to be done to ensure compliance with the Act and were reviewed in the light of published material provided by commentators.

RESULTS

Of twenty-one contacts, only ten responded of which five were Government agencies. Government agencies chose to deflect commentary and did not respond to specific questions. The Medical Defence Organisations (MDOs) provided the most useful commentary, highlighting various 'grey areas' of concern.

DISCUSSION

Government agencies tasked with the enforcement of the Act were unhelpful in providing useful guidelines to specific questions. MDOs offered by guidelines to risk management obviate litigation. This survey emphasised the concept that legislation developed for general purposes required redefinition to be applicable to the medical profession and had the capacity to negatively impact upon patient well-being.

The ethics of clinical research and the conduct of clinical drug trials: international comparisons and codes of conduct

Human research must respect most rigorous ethical standards to protect both the investigators and subjects. Codes of ethical practice relevant to such research are subjected to reviews around the world including The European Union (EU), the Canadian Tri-Council Policy Statement (including the Medical Research Council, the Natural Sciences and Engineering Research Council and the Social Sciences and Humanities Research Council), the Finnish Parliament Research Act (April 1999) and the National Statement on Ethical Conduct in Research Involving Humans in accordance with the NHMRC Act 1992 (Cth) from the National Health and Medical Research Council of Australia. The Australian Statement was endorsed by the Australian Vice-Chancellors' Committee, the Australian Research Council, the Australian Academy of the Humanities, the Australian Academy of Science and the Academy of Social Sciences in Australia and supported by the Academy of Technological Sciences and Engineering. This reflects the extensive ramifications of human experimentation and the range of stack holders. Private organisations have also produced interpretations of minimum standards of good clinical practice. The paper that follows analyses approaches to human experimentation and the minimal ethical expectations in the conduct of such research.

Disparities in Access to Reperfusion Therapy for Acute Ischemic Stroke (DARTS): A Comprehensive Meta-Analysis of Ethnicity, Socioeconomic Status, and Geographical Factors

BACKGROUND

Reperfusion therapies, such as intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT), are crucial for improving outcomes in patients with acute ischemic stroke (AIS). However, access to these treatments can vary significantly due to ethnicity, socioeconomic status (SES), and geographical location, impacting patient outcomes.

OBJECTIVES

The Disparities in Access to Reperfusion Therapy for Acute Ischemic Stroke (DARTS) study aims to systematically assess disparities in access to IVT and EVT on the basis of ethnicity, SES, and geographical location.

METHODS

A comprehensive meta-analysis was conducted, incorporating data from 38 studies involving 5,256,531 patients with AIS. The analysis evaluated IVT and EVT utilization rates across ethnic groups, SES levels, and geographical locations.

RESULTS

The findings reveal substantial disparities in access to reperfusion therapies. IVT and EVT utilization rates varied significantly by ethnicity (9% ethnic, 11% non-ethnic for IVT; 7% ethnic, 6% non-ethnic for EVT), SES (13% low SES, 16% high SES for IVT; 7% low SES, 10% high SES for EVT), and geography (9% rural, 12% urban for IVT; 1% rural, 4% urban for EVT). Black patients had significantly lower odds of receiving IVT (OR 0.69, p = 0.001) and EVT (OR 0.87, p = 0.005) compared with white patients. Similarly, patients with low SES and those from rural areas faced reduced odds of receiving IVT (OR 0.74, p < 0.001; OR 0.72, p = 0.002) and EVT (OR 0.74, p < 0.001; OR 0.39, p < 0.001). Rural patients also had significantly lower odds of timely hospital arrival (p < 0.001), posing a barrier to accessing reperfusion therapies.

CONCLUSIONS

The DARTS study (and this meta-analysis) reveals significant access disparities in AIS treatment related to ethnicity, geography, and SES, particularly affecting Black communities, low SES individuals, and rural populations. Despite advances in reperfusion therapies, suboptimal implementation rates persist. To address these issues, we recommend the EQUITY framework: Educate, Ensure Quality, provide Universal Access, Implement Inclusive Policy Reforms, Enhance Timely Data Collection, and Yield Culturally Sensitive Care Practices. Adopting these recommendations will improve access, reduce disparities, and enhance stroke management and outcomes globally. Equitable access is essential for all eligible patients to fully benefit from reperfusion treatments.

The ethics of post-marketing surveillance of therapeutic agents

Trials of new therapies have strict codes of conduct which expect the highest of ethical practice. Local ethics committees review protocols, patient information, consent. National research councils delineate guidelines for minimum standards regarding subjects in such trials. Once medications enter the market place, there is less definition of minimal codes of conduct. Clinical trials are designed to meet regulatory demands to access commercial markets. Prior to marketing, there is a usual drug trial exposure of less than 5,000 individuals which diminishes identification of rare adverse events. Australian case law has found negligence for not warning of a 1:14,000 risk of sympathetic ophthalmia and more recently, in Chappel v Hart, even a speculative risk was grounds for negligence. Recent reports of serious adverse events for conditions such as epilepsy or depression resulted in companies appearing to expend considerable effort to suppress concern rather than to seriously investigate these complications in the post marketing period. This paper will explore such cases and discuss approaches to improve post marketing surveillance and patient protection.

The Right to Biological Truth versus Stability of the Family

This article reports on a 2019 Lithuanian case of disputed paternity. The judgment highlights the challenges of requiring deoxyribonucleic acid (DNA) testing of a family, where the infant is already part of an established family unit. The decision turned on the refusal of the putative parents to undergo imposed DNA testing. Ultimately, the Lithuanian Supreme Court (LSC) decided the matter according to the basis of the best interests of the child.

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.

Legal implications of public health guidelines

Medical guidelines aim to provide stylised procedures to manage illnesses. Doctors might believe that conforming to guidelines provides protection within legal proceedings. Guidelines were deemed inadmissible evidence in Regina v Ross Gillett, raising some concerns. Gillett was a middle aged man who denied having epilepsy when applying for a driver's licence and was involved in a car crash which killed three people. He had confirmed epilepsy yet expert witnesses testified he was within AUSTROADS Guidelines for fitness to drive. The judge refused to admit these Guidelines into evidence, finding the defendant guilty of dangerous driving occasioning death. The Guidelines were endorsed by all Australian and New Zealand traffic authorities, seven medical colleges, two sub-specialty faculties, seventeen illness-related organisations plus the Australian Medical Association. Their purpose was to achieve "...best practice for the safe and effective management and use of the road system...". The judge rejected them when considering his verdict. Precedence demands the judiciary consider all relevant data although the Guidelines were deemed irrelevant and could not be admitted into evidence. Guidelines cannot bind the court unless enforced by legislation. It is difficult for doctors to comprehend how Guidelines, designed to determine optimal road usage, can be excluded when analysing a road accident. Doctors need to be circumspect about applying Guidelines in the wake of Gillett.

Cervical ependymoma presenting with brainstem and cerebellar signs: case report

This case report demonstrates cervical spinal cord pathology which presented with brainstem and cerebellar signs consequent to the peritumoural oedema that extended rostrally to the pontomedullary junction. A Medline search of the literature back to 1960 failed to produce any previous report of a cervical ependymoma presenting with brainstem and cerebellar signs purely consequent to oedema. This case highlights the need to look further afield when presented with the scenario of clinical features of a brainstem lesion with only oedema apparent on cranial imaging. It indicates the need to include cervical imaging well below the foramen magnum in these circumstances.