Tuesday, April 24, 2018

Blog #93: DRIVING AND EPILEPSY: COMPARING USA AND UK


            In the United States of America, only the states of California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania require physicians by law to report persons with epilepsy. California mandates physicians report such patients to the state health authorities. The health department then reports such persons to the Department of Motor Vehicles (DMV). The DMV obtains information on the person’s medical condition from the patient and from the physician. The DMV decides if the license is revoked for a period of observation. If the person remains seizure-free due to effective medications or because the epilepsy has become inactive for 6-24 months the driving privilege can be reinstated. The DMV makes this decisionnot the physician!

            If the driving privilege is reinstated but then another seizure occurs it’s the responsibility of the patient AND of the physician to report this to the DMV for re-evaluation.

            In the 44 American states that do not have a mandatory physician-reporting law, it’s up to the patient to voluntarily stop driving and to report to the DMV. Emotional constraints and ethical challenges are rife: who wants to stop driving if their livelihood depends on it and especially if there is a paucity of public transportation in their area? Some of my own patients challenged me: “Don’t send that report in, Doc. Are you going to pay my mortgage if I can’t work at my driving job?

            EPILEPSY ACTION, a website in the United Kingdom (England, Scotland, Wales and Northern Ireland), advises people who have had a seizure of any kind to stop driving and report their seizure-condition to the driving agency. 1 In the UK, unlike in the United States, reporting is not necessary “on the understanding if the seizures are nocturnal, i.e., the seizures occur only during sleep. In nocturnal-type seizures in the United States physicians in those six mandatory-reporting states still must report. But, physicians may support driving for these people by stressing that their seizures occur only during sleep and not while drivingnocturnal epilepsy. Sleep lowers the resistance on seizures in people with epilepsy.

            If one continues to drive in the UK they are breaking the law; significant financial fines can be levied. Car insurance is unlikely to cover the person.

            Personal responsibility, ethical behavior and common sense are challenged; abiding by the law often is abandoned as a part of our common humanity.

            My recent blog # 92 on this LanceFogan.com website (Citizens Influence New York State Law:Driving with Epilepsy, March 26, 2018) reviews how a deadly driving accident occurred during an apparent seizure in Brooklyn, NY in March, 2018. It led to a mandatory physician-reporting law being introduced in the New York State Legislature. If passed, New York would be the seventh American state making mandatory physician reporting of epilepsy. More lives then could be protected. 


1.    Epilepsy Action is a UK based charity providing information, advice and support for people with epilepsy. The organisation was founded in 1950 as the British Epilepsy Association and adopted Epilepsy Action as its working name in 2002. Epilepsyaction.org.



Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Tuesday, March 27, 2018

Blog #92: Citizens Influence New York State Law: Driving With Epilepsy

      A few weeks ago I saw a TV report: a Brooklyn driver ran a red light and killed two children, ages four years and one year old and injuring others, including a pregnant woman — “It was something you see in a horror movie,” a witness said. The car dragged one kid’s stroller more than 350 feet at Ninth St. and Fifth Ave. in Park Slope, Brooklyn, N.Y.
      According to reports, this auto accident was caused by a driver afflicted with multiple sclerosis, seizures and a heart condition. After the accident she said she didn’t recall the red light or hitting anything. On-sight witnesses reported that she seemed oblivious to what had just happened. That strongly suggests that this person’s epilepsy caused a seizure.
      Neurologists evaluate and treat people who experience altered and loss of consciousness.  In contrast to the epilepsy type that causes falling to the ground with convulsive shaking, I had to include the non-convulsive type epilepsy as a possible cause of a person’s altered behavior. This form of epilepsy can be difficult to recognize. The non-convulsive forms include complex partial seizures and petit mal seizures. People suffering these common forms of blank-outs may walk about, converse in a confused manner, turn on water faucets and eat at a table with other people all the while they are in a mental fog—out of contact with their environment and without memory of their actions.
      Children may suffer these seizures but teachers, families and even medical workers may miss the correct diagnosis. These people may be considered to be “slow learners,” or have hearing problems, attention-deficit disorders (ADD) or autism. The prime diagnostic tool, the electroencephalogram (EEG), commonly is normal because the epileptiform abnormalities may not occur in the brain during the hour or so that the person is connected to the brain-wave-detecting equipment. Brain scans routinely are normal, too. The diagnosis can be made by speaking with observers who note these patients’ “foggy” mind-states. My novel, DINGS, is a medical mystery story of just such a bright third-grader who is failing school because of his unrecognized complex partial seizure-blank outs. He’s just not “keeping up.”
      Upon seeing this report on TV two weeks ago I recognized Brooklyn’s Park Slope as a neighborhood in which my cousins live. I sent them my opinion that the driver must have had a seizure causing the accident of which she had no memory. “It was murder,” they told me.
     Why was this woman with epilepsy driving?
      I related that my state, California, is only one of six states where state law requires physicians to report people with altered consciousness. New York is not one of those six states. The other 44 states hope that people with epilepsy will report themselves to the Department of Motor Vehicles (DMV). That’s a problem. Some of my California epilepsy patients would become understandably belligerent when I would caution them of their driving responsibilities and to stop driving until sanctioned by the DMV; they were endangering their families, passengers, the public and themselves. “No, Doc. Don’t send that report in. Are you going to pay my mortgage?” Personal insight, personal economics and ethics all swarm in their minds as they make decisions of giving up their driving privilege, i.e., their DMV license.
     Upon learning my information my Brooklyn cousin asked if he could share it with a New York State legislator’s office. That same week Brooklyn State legislators unveiled a bill to create a mandatory reporting system and to authorize the DMV to evaluate pe  I shall be following New York’s action.


Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Monday, February 26, 2018

Blog #91: Non-Drug Treatments for Epilepsy



            Many patients whose epilepsy responds poorly to antiseizure medications (20-30% of the three million American epilepsy population) may benefit from non-drug treatments. A study presented at the 71st American Epilepsy Society Annual Meeting showed evidence that Vagus Nerve Stimulation (VNS), the ketogenic diet and a surgical procedurecorpus callosotomymay reduce generalized and focal seizures. Among patients who failed three anticonvulsive medications between ages 8 months to 20 years, with a mean age of 10 years, underwent one of these treatments. Most of the patients’ parents were pleased with the results.1 Sixty-three percent of patients who went on the ketogenic diet reported 50% or greater  reduction of their  generalized seizures. Fifty-four percent of patients who underwent corpus callosotomy and 52% of patients who received vagus nerve stimulation reported 50% or greater reduction in their generalized seizures.

            A very important benefit in withdrawing multiple anticonvulsive medications is that drug side effects are minimized: drowsiness, poor concentration, weight control problems, blood testing, teratogenic risks for women among other effects.

  • Vagus Nerve Stimulation is sometimes referred to as a "pacemaker for the brain." A stimulator device is implanted under the skin in the chest. A wire from the device is wound around the vagus nerve in the neck. A person with a VNS device is usually not aware it's operating.

  • The ketogenic diet is a special high-fat, low-carbohydrate diet that helps to control seizures in some people with epilepsy. It is prescribed by a physician and carefully monitored by a dietitian. It is extremely strict, with calorie, fluid, and protein measurements. Ketones are formed when the body uses fat for its source of energy. The body usually uses carbohydrates (such as sugar, bread, pasta) for its fuel, but because the ketogenic diet is very low in carbohydrates, fats become the primary fuel instead. Higher ketone levels often lead to improved seizure control but the precise reason is not understood.

  • Corpus callosotomy The corpus callosum is the most important connection between the two halves of the brain. Callosal surgical sectioning is quite effective in reducing seizure frequency in patients who have generalized epilepsy with drop attacks. It is generally reserved for this selected population. It is an epilepsy surgery procedure that is considered palliative only. It mediates communication between the two hemispheres of the brain. Seizures may spread rapidly from one hemisphere to the other by way of the corpus callosum; thus seizure spread is reduced and control is increased.  Serious complications are exceedingly rare.

            Dr. Dave Clarke, Clinical Director of Epilepsy at Texas Children’s Hospital at the Baylor College of Medicine in Houston led a study with colleagues at the Dell Children’s Medical Center in Austin between January 2010 and November 2015. They compared seizure control, cognitive and behavioral factors, quality of life and parental satisfaction.

            Parents reported a 50%, or greater, reduction in generalized seizures in 63% of patients who went on the ketogenic diet, 54% of patients improved who underwent corpus callosotomy and 52% of patients improved who received VNS.

            “Many doctors keep trying medications without considering alternatives,” said Dr. Clarke. He suggests doctors introduce treatment alternatives after two anticonvulsive medications fail to control seizures.


1.      www.neurologyreviews.com: Jack Remaly in Neurology Reviews. January 2018, page 1, 45-46.




Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.

Friday, January 26, 2018

Blog #90: Which Patients with Epilepsy Can Safely Drive?

 
            The perennial question from our patients is, “Can I drive, Doctor?” Only California, Delaware, New Jersey, Nevada, Oregon and Pennsylvania throw this decision to the state’s Department of Motor Vehicles (DMV). These states’ laws make it mandatory for physicians to report persons who are diagnosed with epilepsy to the state DMV; however, it is the DMV that decides if the patient may drive, not the physician. Failure to report an epilepsy diagnosis opens the physician to liability if car accidents occur. The other 44 states request patients to report themselves to the DMV. Facing loss of jobs, income and losing their driving privilege makes it very tempting not to report their epilepsy diagnosis. But, this compromises their own safety, the safety of their passengers and of the public. I have had patients who had their driving licenses revoked for a period of observation of six to twenty-four months. If they were seizure-free the DMV returned their driving privilege. In my follow-up, I would query, “Have you had any seizures or spells?” Some had responded, “Would you have to report anything to the DMV?” When I affirmed that I would, they then told me, “No, I’m doing fine, Doctor.”

            The patient’s doctor, usually a neurologist, is asked on the DMV’s forms whether the patient is safe to drive: “yes, no or unsure.” Physicians base their judgement on the patient’s and observer’s histories if loss of awareness has occurred. The DMV’s medical consultant committee, however, makes the ultimate driving decision.  

            The EEG is normal in up to 50% of epilepsy patients on any one test. Abnormalities may not appear except during seizure activity in the brain. EEG abnormalities of other types are not always diagnostic. Brain scans and blood and cerebrospinal fluid testing are commonly normal, too. So, a normal EEG does not rule out epilepsy. The clinical history is how the diagnosis of epilepsy is made.

            Petit Mal, or Absence, seizure patients usually have no warning-prodrome or post-ictal (after the seizure stops) confusion state or any obvious physical changes during their seizure. Also, these patients are oblivious of their loss of awareness which usually last just 10-15 seconds. Observers who are unfamiliar with epilepsyoften their juvenile friendscommonly miss the brief seizure; they consider the patient “weird” and “different.” Complex partial seizures can be hard to identify because the person does not convulse but just seems to be confused and to have lost contact with their environment.

            The lack of data about driving performance during seizures, and during the post-ictal period, makes it difficult to determine driving safety. A study of patients who performed a driving simulation test during inpatient video-EEG monitoring was recently reviewed.1 Hal Blumenfeld, MD, PhD and colleagues studied 20 patients during simulated driving in the Yale New Haven Hospital Epilepsy Monitoring Unit. Patients “drove” an average of three hours. Some seizures showed obvious impairment and others showed none. Several of the patients’ seizures resulted in “crashes.” Seizures lasted an average of 75 seconds in those patients who crashed, compared with an average of 30 seconds in patients who did not crash. Blumenthal concluded that “…more data is required to learn if there are people with epilepsy who are driving who shouldn’t be driving, as well as those who are not driving who can safely drive.”

            Another similar study also questions the long-held belief of a protective role of reliable auras against motor vehicle accidents in people with epilepsy.2 


1.      “Which Patients with Epilepsy Can Safely Drive” Neurology Reviews: January 2017, page 8.

2.       Punia V, Farooque P, Chen W, et. al. Epileptic auras and their role in driving safety in people with epilepsy. Epilepsia. 2015 Nov; 56(11): e182–e185. Free at Epilepsia.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.