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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.

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.'

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.

The Kurtzke system and overall disability scales (KS) for multiple sclerosis were adapted to questionnaire form (QKS). A qualified nurse recorded Kurtzke ratings, by QKS, from 36 multiple sclerosis patients and 11 healthy controls. These scores were compared with ratings obtained by a doctor with neurological training using the conventional history/examination technique. The results obtained by these 2 methods were closely comparable. The use of a questionnaire appears to be a valid and accurate approach to the determination of disability in multiple sclerosis and may be of particular value in epidemiology and therapeutic trials in this condition.

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.

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.

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.

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.

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

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.

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.

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.