Strategic and principled approach to the ethical challenges of epilepsy monitoring unit triage.

Electroencephalographic monitoring provides critical diagnostic and management information about patients with epilepsy and seizure mimics. Admission to an epilepsy monitoring unit (EMU) is the gold standard for such monitoring in major medical facilities worldwide. In many countries, access can be challenged by limited resources compared to need. Today, triaging admission to such units is generally approached by unwritten protocols that vary by institution. In the absence of explicit guidance, decisions can be ethically taxing and are easy to challenge. In an effort to address this gap, we propose a two-component approach to EMU triage that takes into account the unique landscape of epilepsy monitoring informed by triage literature from other areas of medicine. Through the strategic component, we focus on the EMU wait list management infrastructure at the institutional level. Through the principled component, we apply a combination of the ethical principles of prioritarianism, utilitarianism and justice to triage; and we use individual case examples to illustrate how they apply. The effective implementation of this approach to specific epilepsy centres will need to be customised to the nuances of different settings, including diverse practice patterns, patient populations and constraints on resource distribution, but the conceptual consolidation of its components can alleviate some of the pressures imposed by the complex decisions involved in EMU triage.

The effects of a multiday (10-14 days) subanesthetic dose IV ketamine infusion in the treatment of refractory chronic pain.

Aim: Ketamine is an anesthetic agent that at lower doses can be a potent analgesic. There has been an interest in the use of low dose ketamine in treatment of chronic pain syndromes. Patients & methods: We report the results of a retrospective observational study for patients diagnosed with a chronic noncancer pain syndrome receiving a 2-week continuous subanesthetic IV ketamine infusion. Results & conclusion: We conclude that a 10-14 days of subanesthetic ketamine infusion in chronic patients results in clinically significant lowering of patients' numerical pain score. Further studies looking at subanesthetic ketamine infusion in a prospective trial of multi-day IV ketamine infusion in chronic refractory chronic neuropathic pain are needed to further assess the efficacy of ketamine.

Ketamine is a pharmacological agent that was developed in the 1960s. There has been an increase in interest in the use of ketamine at low doses in the treatment of chronic pain syndromes. In this study, we report the results of a study that investigated patients diagnosed with a chronic noncancer pain syndrome that received a 2-week continuous ketamine infusion. We hypothesized that patients receiving IV ketamine infusion will experience acute and chronic lowering of pain intensity on the numerical rating pain level scale and reduce patient's opioid requirements. We concluded that a 10­14 day of subanesthetic ketamine infusion in chronic patients results in clinically significant lowering of patients' numerical pain score during the ketamine infusion.

Updates in the Treatment of Post-Stroke Pain.

PURPOSE OF REVIEW: To provide an overview of the current treatment strategies for common subtypes of post-stroke pain. RECENT FINDINGS: There is growing research interest in non-pharmacological treatment approaches for chronic pain, including neurostimulation as well as lifestyle and psychosocial interventions. Newer pharmacotherapy research includes cannabinoids and NMDA-receptor antagonists as well as bee venom. Persistent post-stroke headache is an increasingly appreciated entity, though the role of novel chronic migraine treatments for post-stroke headache is not known. Overall, most treatment approaches to post-stroke pain lack high-quality evidence. Stroke survivors are in need of effective treatments based on methodologically sound evidence. To address the interplay of clinical and psychosocial factors that contribute to post-stroke pain, it may be reasonable to adopt a multimodal treatment strategy incorporating both lifestyle interventions and conventional therapies.

Affect-induced reflex seizures (AIRS): A case series based on a systematic literature review.

Seizures are commonly thought to occur in a spontaneous, unpredictable manner. However, it is well-established that a subset of patients with epilepsy can experience reflex seizures that are consistently elicited by a specific stimulus. While various forms of reflex epilepsy have been documented in the literature, acute affective states have not been commonly described as a potential reflex seizure trigger. We performed a systematic literature review to determine if acute emotional states can trigger reflex seizures. We included any case in which reflex seizures repeatedly occurred in response to a patient-specific stimulus that was reported as emotionally relevant by the authors. This yielded our case series of ten patients who have been described to have reflex seizures in response to emotional stimuli. We characterized features of these cases including the following: age, gender, developmental and psychiatric history, seizure semiology and duration, emotional triggers, other reflex triggers, relationship between reflex triggers and seizures, investigations, localization, final diagnosis, treatment, and outcome. Considerable variability was found between cases. A trend toward limbic seizure semiology with psychic aura originating in networks involved in emotional processing was noted, with temporal lobe epilepsy being the most common, although without clear laterality or gender predominance. In addition, the report of a significant life stressor occurring at epilepsy onset in three of ten patients as well as the initial suspicion that reflex epileptic seizures were psychogenic in three cases both emphasize the role of electroencephalography in assessment of such presentations to avoid missing a diagnosis of epilepsy. Findings from these ten cases suggest that a patient-specific affective stimulus may trigger reflex seizures in a subset of patients, and that this could be underrecognized or mislabeled as nonepileptic. We encourage future studies with larger numbers to further characterize this phenomenon. Insights gained may enhance our understanding of seizure localization and bear potential treatment implications.