Patient perspectives of epilepsy

This paper reports the results of a pilot survey testing patient perspectives of epilepsy in 51 epileptic patients attending the neurology service of The Queen Elizabeth Hospital, Adelaide. The questionnaire used dealt specifically with patient identification, diagnostic information, management and attitudes. The information identifying the sample was compared with existing epidemiological data and shown to be representative of the epileptic population. The patients' views about their condition highlighted areas of concern both in their management and in their place in society.

Evaluation of therapists by patients with epilepsy

Fifty-three patients were asked to nominate the most important person treating their epilepsy and asked to give suggestions for improving treatment. One-third of patients named the neuro-specialist as the prime therapist, although there was considerable dissatisfaction expressed concerning the neuro-specialists' manner of communicating. The majority of suggestions for improving treatment reflected a desire for greater rapport between doctor and patient. More open communication would form the basis for increased patient knowledge of epilepsy and greater opportunity for the doctor to consider the important psycho-social aspects of his patients' condition.

The neurological aspects of atrial myxoma

2 cases of left atrial myxoma are presented, with a review of the recent literature on the topic, in order to bring this rare condition to the attention of clinicians. Both cases presented to the Neurological Unit of the Queen Elizabeth Hospital during 1978. The cases helped to emphasise the role of echocardiography in the routine appraisal of the stroke patient, especially if there are multiple lesions or if the patient concerned is young. The second case raised interseting questions regarding electrocardiographic changes associated with altered states of consiousness. Until recently cardiac myxomas were usually a postmortem diagnosis, but now with the effective combination of echocardiography and cine-angiography, cases are being effectively diagnosed and treated. It is hoped that with an increased awareness of the condition, diagnosis will be made sooner and thus prevent more severe sequelae occuring.

Medical management of epilepsy

The treatment of epilepsy depends on an accurate diagnosis of the specific type of epilepsy. Where possible it is important to prescribe the minimum amount of medication for seizure control, preferably with monotherapy. The ultimate aim of treatment is to achieve maximal improvement in the quality of life for the patient.

Legal and ethical obligations to conduct a clinical drug trial in Australia as an investigator initiated and sponsored study for an overseas pharmaceutical company

Most multi-centre trials are both financed and sponsored by the pharmaceutical company involved. What follows will map the path adopted for an investigator initiated and sponsored study for a new indication of an established medication. The chief investigators of a company-sponsored, investigator-initiated, multi-centre, placebo-controlled study of an established medication, Pharmaceutical Benefit Scheme (PBS) listed for treatment of one condition but trialled in the management of another condition (trial of off-label use), were approached to submit a protocol to repeat the type of study with a different compound. The new study would test a different agent, also PBS listed, for the same condition as in the initial study and with the same off-licence application. The company would finance the study, provide the medication and matched placebo but only review the investigator-initiated protocol which would be sponsored by the principal investigator. This required the investigator to implement the trial, as would normally be done by the pharmaceutical company, yet also act as its principal investigator. The principal investigator, with colleagues and a Clinical Research Organisation (CRO), developed a protocol, adapted for the new agent, and submitted it for approval. Upon acceptance a contract was negotiated with the pharmaceutical company which had to overcome jurisdictional conflicts between common law and civil law legal systems. A CRO was contracted to undertake administrative functions which dictated special contractual agreements to overcome possible conflicts of interest for a sponsor/investigator to protect patient interests. There was need to find indemnification insurance with jurisdictional problems, co-investigators, ethics committee approvals and finance management as just some of the difficulties encountered. The paper will outline how these obstacles were overcome and how ethical and legal issues were respected through compromise. The ethical and legal obligations were addressed in a fashion which allowed the conduct of a trial adopting a proven methodology but novel infrastructure such that it was a totally independent study with regards conduct and reporting of final data, irrespective of the results being either positive or negative. This may represent a more acceptable way to ensure that future clinical trials are devoid of undue influence from the pharmaceutical industry which may still fund the study.

Cerebrovascular Disease Profiles of Culturally and Linguistically Diverse Communities in South Western Sydney and New South Wales

INTRODUCTION

Culturally and linguistically diverse (CALD) communities are growing globally. Understanding patterns of cerebrovascular disease in CALD communities may improve health outcomes through culturally specific interventions. We compared rates of transient ischaemic attack (TIA)/stroke (ischaemic stroke, intracerebral haemorrhage) and stroke risk factor prevalence in overseas and Australian-born people in South Western Sydney (SWS) and New South Wales (NSW).

METHODS

This was a 10-year retrospective analysis (2011-2020) of SWS and NSW age-standardized rates per 100,000 person-years of TIA/stroke. Data were extracted from Health Information Exchange and Secure Analytics for Population Health Research and Intelligence systems. Rates of hypertension, type 2 diabetes mellitus (T2DM), atrial fibrillation (AF), smoking, and obesity were also calculated.

RESULTS

The SWS and NSW age-standardized rate of TIA/stroke for people born in Australia was 100 per 100,000 person-years (100/100,000/year). In SWS, 56.6% of people were overseas-born compared to 29.8% for NSW. The age-standardized rate of TIA/stroke for Polynesian-born people was more than double that of Australian-born people (p < 0.001). Hypertension (33 [SWS] vs. 27/100,000/year [NSW]) and T2DM (36 [SWS] vs. 26/100,000/year [NSW]) were the most common risk factors with rates >50/100,000/year (hypertension) and >80/100,000/year (T2DM) for people born in Polynesia, Melanesia, and Central America. Rates of T2DM, AF, and obesity for Polynesian-born people were over threefold greater than people born in Australia.

DISCUSSION/CONCLUSION

Greater rates of TIA/stroke were observed in specific CALD communities, with increased rates of cerebrovascular risk factors. Culturally specific, targeted interventions may bridge health inequalities in cerebrovascular disease.

Chronic kidney disease prevalence and clinical outcomes in anterior circulation acute ischemic stroke patients with reperfusion therapy: A meta-analysis

AIM

Chronic Kidney Disease (CKD) is a common comorbidity among acute ischaemic stroke (AIS) patients undergoing reperfusion therapies, including intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). Acknowledging CKD's prevalence in this cohort and understanding its influence on outcomes is crucial for prognosis and optimizing care. This study aims to determine the prevalence of CKD among anterior circulation AIS (acAIS) patients undergoing reperfusion therapies and to analyse the role of CKD in mediating outcomes.

METHODS

A random-effects meta-analysis was conducted to pool and examine prevalence data. A total of 263 633 patients were included in the meta-analysis. The study assessed CKD's association with functional outcomes, symptomatic intracranial haemorrhage (sICH) and mortality.

RESULTS

The overall pooled prevalence of CKD among acAIS ranged from 30% to 56% in IVT-treated patients and 16%-42% for EVT-treated patients. CKD was associated with increased odds of unfavourable functional outcome at 90 days in both IVT (OR 1.837; 95% CI: [1.599; 2.110]; p < .001) and EVT (OR 1.804; 95% CI: [1.525; 2.133]; p < .001) groups. In IVT-treated patients, CKD was associated with increased odds of 30-day mortality (OR 6.211; 95% CI: [1.105; 34.909]; p = .038). CKD in IVT-treated patients exhibited increased odds of sICH, albeit statistically non-significant (OR 1.595; 95% CI: [0.567; 3.275]).

CONCLUSIONS

The high prevalence of CKD and its significant impact on outcomes in acAIS patients treated with reperfusion therapies underscore its clinical significance. This insight can guide personalised care strategies and potentially improve the prognosis in the management of acAIS.

The Value of Concurrent Electrocardiography When Performing an Electroencephalograph

Introduction. The use of concurrent, single lead electrocardiograph (ECG) recording, when performing a routine electroencephalograph (EEG), has been standard practice for many years. Previous studies have reported on the usefulness of concurrent EEG in assessing syncope and the detection of newly identified cardiac dysrhythmia but have relied on specialist cardiologist interpretation of the ECG trace. This study expands the understanding of concurrent ECG and provides demographic information regarding the incidence, nature of ECG changes and diagnostic utility of ECG interpretation, during routine EEGs, as evaluated by neurologists. Methods. A single center, retrospective study of routine concurrent EEG and ECG recordings was performed. All routine EEGs, performed within a 12 month period were analysed. Demographic data, underlying comorbidities, reasons for referral and ECG changes were assessed. Results. ECG abnormalities were identified in 147 (13.5%) of concurrent ECG/EEG routine recordings. The presence of ECG abnormalities was significantly associated with the reason for referral, namely being assessed for the evaluation of seizure activity and with increasing patient age. Thirty-eight patients (3.5%) had newly identified ECG abnormalities, of which atrial fibrillation (AF) (12 patients) and sinus bradycardia (9 patients) were the most common. Five patients (0.5%) had a change in their management consequent to the identified ECG changes. Conclusions. These findings support the value of neurologists' interpretation and need for ongoing concurrent ECGs, during routine EEG recordings. The study raises concern about the requesting clinician's response to the identification of newly diagnosed cardiac dysrhythmias.

Forensic neuropsychiatric aspects of epilepsy

Epilepsy may be associated with automatisms that are classed as 'insane 'as they are deemed to have originated within the mind. 'Sane automatism' is said to occur from external factors, such as physical trauma, while 'insane automatism' is said to be innate to the individual experiencing them. To claim automatism within the context of a criminal matter requires a detailed evaluation of the behavior demonstrated and a questioning of the volitional and purposeful nature of this behavior. It is insufficient to rely upon past behavior in association with these seizures to justify the defense of automatism within a specific event. Epilepsy is often considered to be associated with an increase in violence. Proper epidemiological research, both in long-term, large population control studies and hospital-based studies, has suggested that epilepsy, per se, is not associated with an increase in violence when compared to the population at large and controlled for other familial and environmental factors.

Clinical relevance of therapeutic drug level estimation with respect to clonazepam and carbamazepine: preliminary report

This paper compares the results of plasma drug level estimations for 30 patients receiving clonazepam and 39 patients taking carbamazepine (assessing total and free carbamazepine concentrations together with carbamazepine epoxide levels) with the clinical features of seizure control. Owing to the small numbers of seizure-free patients, the power of the study was insufficient to justify absolute conclusions being drawn. However there appeared to be a trend which suggested that drug level estimations in both situations had virtually no clinical relevance. This causes one to question the growing reliance on plasma drug level estimation in the treatment of epilepsy and, because of the low power of the study, demands extension of the work to confirm its significance. This type of research in epilepsy, based exclusively on a secondary and tertiary referral source, has inherent difficulty in that a conspicuously low number of well controlled patients is included. Acknowledgement of this fact should lead one to appraise critically other papers giving dogmatic statements regarding therapeutic ranges of anticonvulsant plasma levels.

Frequently asked questions and answers on Visually-Provoked (Photosensitive) epilepsy

Clinical experts associated with national epilepsy-related societies, led by the Epilepsy Foundation, collected, collated and answered "Frequently asked questions (FAQ)" of broad interest pertaining to visually-provoked seizures. Questions emerged from people with epilepsy, caretakers and healthcare professionals from different countries around the world. Focus is on practical implications of visually-provoked seizures. The top 5 most frequently asked questions were.1.How does a doctor make a diagnosis of visually-provoked seizures?2.What can I do in general to prevent visually-provoked seizures?3.Will I need antiseizure medications for my visually-provoked seizures?"4.Will I outgrow visually-provoked seizures? How will I know if I've outgrown them?5.How do I enable safety features to block content that could trigger seizures on social media, websites, phones, laptops and tablets?Answers were based on scientific evidence, where such information was available [1] and expert opinion when formal evidence was insufficient. Key answers included distinction of photoparoxysmal EEG findings versus light-provoked seizures. Typical provocation is by flashes at 10-25 per second or certain moving patterns. There is a genetic risk, which is outgrown in about half. Covering one or both eyes can prevent a light-provoked seizure. TV, videogames, virtual reality and 3D images are not in themselves provocative, but their content can be. Topics covered included: 1. Photosensitive epilepsy diagnosis; 2. Preventing visually-provoked seizures; 3. Do treatments help; 4. Life and behavioral decisions; 5. School; 6. Multi-media; 7. Children and youth.

Legal medicine implications of a multidisciplinary approach to managing Traumatic Encephalopathy Syndrome in Australia

The medical profession has a fundamental obligation to accurately diagnose and effectively treat a range of diseases and conditions. In the case of Traumatic Encephalopathy Syndrome (TES), where there are no universally accepted clinical diagnostic criteria, a clear clinical diagnosis can pose significant challenges for healthcare providers and for subsequent appropriate management. "Nihilism" or an uncertain working diagnosis is not acceptable in the medical field and deserves further consideration. This paper explores the legal obligations that are placed upon healthcare professionals, both individually and as a part of a multidisciplinary team. This article analyses the responsibilities and expectations of medical professionals in diagnosing and treating complex medical conditions, such as TES. The authors address legal issues that must be considered for an effective operation of integrated medicine to enhance the overall quality of care and improving patient outcomes for those affected with underlying Chronic Traumatic Encephalopathy (CTE).

Fitness to drive and seizures - Recent medicolegal considerations to tell or not to tell? - THAT IS THE QUESTION!

This paper reviews a Coroner's inquest into the deaths of two people. The deaths were caused when a driver had a seizure, and lost control of his car, which then plowed into a café. The Coroner reviews the roles and responsibilities of primary and tertiary caregivers, with special focus on the question of who has the responsibility to inform the Drivers' Licensing Authority of a patient's unfitness to drive - the patient or the practitioner? The Coroner recommends the establishment of a multi-agency committee to advance work in this area. The paper notes a separate but parallel development - a review of AUSTROADS Assessing Fitness to Drive Guidelines, which may achieve the outcomes sought by the Coroner.

Analysis of Part 1 of the latest Austroads Guidelines, June 2022

The Austroads Fitness to Drive Guidelines were updated in 2022. Most of the focus to date has been on Part 2 of the Guidelines, which provide guidance as to specific medical conditions. Less attention has been paid to Part 1 of the Guidelines, which cover a medical practitioner's ethical and legal obligations. This paper addresses the imbalance by considering and amplifying the obligations discussed in Part 1 of the Guidelines.

Management of chronic headache

BACKGROUND

Headache remains the most common cause of neurological consultation in clinical practice for which correct diagnosis and treatment are essential.

OBJECTIVE

This article provides a review of headache presentation and management, with an emphasis on chronic headaches and the differentiation between migraine and tension-type headache (TTH).

DISCUSSION

By far the most important diagnostic tool for proper headache diagnosis is the taking of a concise and representative history of the headaches. Migraine and TTH exist along a continuum and identification of the patient's position on this continuum has important implications for management.

Automatisms--the current legal position related to clinical practice and medicolegal interpretation

The interface between medicine and the law is an area which demands further investigation. There can be no criminal capability for an act unless the perpetrator had both the will to so act and the capacity to differentiate and choose whether or not to conform the particular behaviour to that dictated by the law. The capacity for choice must remain the fundamental issue. The range of conditions which can raise volition as a defence include: Somnambulism; post-traumatic syndromes; epilepsy; arteriosclerosis; or acts secondary to cerebral neoplasia. There is need to differentiate between reflex actions and automatisms and it is imperative that terms such as automatism or automatic behaviour are not perverted to allow an excuse for that which is inexcusable. Cases such as that of Cogdon, who was acquitted of murdering her daughter; Ramsbottom who was found guilty of causing a traffic accident despite having a stroke; Dennison in which a driver was found guilty despite epilepsy or Jenkins where the driver was initially found innocent of dangerous driving because of the unpredictable nature of diabetes are discussed. Special attention will be focused upon the case of Sullivan, a landmark in consideration of automatism in epilepsy. The paper examines insane verses non-insane automatism and the Australian legal system as it affects modern neurological practice. Suggestions are proffered as to how the law should be modified to better reflect justice as required within the context of modern medical knowledge. 'The social and psychological pressures that shape our criminals also shape-those who make and remake the laws which aim to control, punish or rehabilitate them, and those who try to change their behaviour.'