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Lecture for Year 3 Medical Students Faculty of Medicine King
Fahad Medical City on Sep 9, 2013 by Professor Omar Hasan Kasule Sr.
LEARNING
OBJECTIVES & KEYWORDS
·
Learning Objective: To understand
the major ethical issues associated with Epilepsy and its management
·
Key
words: epilepsy, seizure, convulsions, ethics / ethical, legal, disclosure, epidemiology,
prevention
EPIDEMIOLOGY
·
Epilepsy
is not one disease but a collection of disease syndromes with wide diversity[1].
·
A
world review revealed age-adjusted prevalence estimates from record-based
studies (2.7-17.6 per 1000), are lower than those from door-to-door surveys
(2.2-41.0 per 1000). ). Age-adjusted incidence ranged from 16 to 51 per 100,000[2].
·
Point
prevalence of epilepsy in Nigeria is 5.3-37 /1000[3].
·
Incidence
of 174 per 100,000 persons in 2001 was reported in a hospital-based study from
Qatar.
·
Prevalence
ranged between 0.9/1,000 in Sudan
·
Prevalence
was reported 6.5/1,000 in Saudi Arabia[4].
ETIOLOGY
·
Epileptogenesis
not well understood.
·
Most
epilepsy is idiopathic and a genetic basis is difficult to establish[7]
·
Specific
genes were associated with epilepsy[8].
SCREENING FOR HIGH-RISK OCCUPATIONS
·
Screening
airline pilots, bus drivers, machine operators, security operators? How
reliable is the screening test?
·
Screening
of children with risk factors eg head injury, encephalopathy
·
Discrimination
and stigmatization
·
Restriction
of some activities like swimming and diving
CONFIDENTIALITY & DISCLOSURE:
the need to train to deal with convulsions
·
Disclosure
to the employer
·
Disclosure
to family members
·
Disclosure
to teachers
·
Disclosure
to fellow workers
DIAGNOSIS: USE OF STIMULATION
·
Provocative
techniques (inductions) during EEG may uncover infrequent seizures of a
psychogenic nature. This has to be weighed against the disadvantage of false
positives[9].
·
Intraoperative electrocorticography and cortical
stimulation in children.used to localize lesions[10]
·
Transcranial magnetic stimulation
in research and treatment has few side effects mostly seizures[11]
SURGICAL TREATMENT:
·
Surgical
treatment used but we do not understand the pathogenesis of the disease.
·
Surgery
is resorted to when epilepsy is medically intractable.
·
High
frequency oscillations were used to guide cortical resections with some
improvement[12].
·
Use
of awake carionotimy was found associated with several ethical issues: : (1) lack of
data; (2) utilization; (3) conflict of interest; (4) informed consent; (5)
surgical innovation; and (6) surgical training.[13]
MEDICAL TREATMEMT
·
Anesthetic
and non-anesthetic agents can be used in persistent status epilepticus of
childhood[14]
·
Use
of generic antiepileptics may be associated with the problem of establishing
bioequivalence with the original drug[15]
·
So
far few well designed RCT on treatment of infantile spasms[16]..
·
Contribution
of pharmacogenetics to epilepsy treatment not yet clear[17]
·
Intensive
reminders needed to ensure drug compliance[18]
PHYSICAL TREATMENTS
·
Physical
treatments including electric stimulation, magnetic stimulation, and cooling
·
Physical
treatments have been found to have some effect in reducing tissue excitability but
there are ethical concerns about trials on these agents[19].
TREATMENT OF CHILDREN
·
No
clear cut evidence drugs vs hormonal treatment in childhood epilepsy[20]
·
Surgical treatment for children
raises even more ethical complications[21]
TREATMENT OF PREGNANT WOMEN
·
Treatment
of pregnant women is uncertain because we have no good clinical trials
·
Anti-epileptic
drugs may have teratogenic effects but not using them exposes the pregnant
woman to seizures[22].
·
Pregnancy
associated with hormonal changes. Estrogen facilitates while progesterone
inhibits the generation of epileptic seizures[23].
·
Antiepileptic drugs (AEDs) may
result in reproductive endocrine disorders, inhibition of sexuality, decrease
in oral contraceptive effects, or congenital malformations[24].
·
Results of a systematic
literature review suggest that the overall incidence of the congenital
malformations in children born to women with epilepsy is approximately three
times that of healthy women[25]
RESEARCH
·
We
need to know more about epilepsy to give better care yet developing countries
cannot afford to channel funds from direct epilepsy care to research[26].
·
To
prove definitively that drugs are effective we need RCT of the drug against
placebo but this raises the problem that the control patients are denied a drug
that could be effective[27]
·
Placebo
use in neurological research has ethical problems[28]
·
Monotherapy
trials against existing treatments may be a way out of the ethical dilemma of
having to use placebo. Patients will have to exit the study if seizures occur[29].
TRADITIONAL TREATMENT
·
Body-mind
dichotomy[30] and
the belief that convulsions are a touch from jinn
·
Can
we allow traditional healers in the hospital?
·
Can
we use ruqya for epilepsy?
REFERENCES