Alcohol and the central nervous system.

Ethanol use is common to most cultures but with varying doses and to varying extents. While research has focused on the effects on the liver, alcohol exerts a range of actions on the function and structure of the nervous system. In the central nervous system (CNS) it can provoke or exacerbate neurological and psychiatric disease; its effects on the peripheral nervous system are not included in this review. Sustained alcohol intake can predispose to acute neurochemical changes which, with continued ingestion and incomplete treatment, can lead to chronic structural changes in the CNS: these include generalised cortical and cerebellar atrophy, amnesic syndromes such as Korsakoff's syndrome, and specific white matter disorders such as central pontine myelinolysis and Marchiafava-Bignami syndrome. Alcohol in pregnancy commonly and significantly affects fetal health, though this receives less medical and political attention than other causes of fetal harm. This review looks at the range of disorders that can follow acute or chronic alcohol use, and how these should be managed, and we provide a practical overview on how neurologists might diagnose and manage alcohol addiction.

Peri-ictal responsiveness to the social environment is greater in psychogenic nonepileptic than epileptic seizures.

OBJECTIVE: To look for evidence of peri-ictal social interaction in psychogenic nonepileptic seizures (PNES) and epileptic seizures exploring the notion of PNES as a form of nonverbal communication. METHODS: Video recordings of typical seizures experienced by patients with epilepsy and PNES were obtained in a naturalistic social setting (residential epilepsy monitoring unit). Video analysis by three nonexpert clinicians identified 18 predefined semiological and interactional features indicative of apparent impairment of consciousness or of peri-ictal responsiveness to the social environment with assessment of interrater reliability using Fleiss κ. Features were compared between epileptic seizures and PNES. RESULTS: One hundred eighty-nine seizures from 50 participants (24 epilepsy, 18 PNES, eight combined) were analyzed. At least fair (κ > 0.20) interrater agreement was achieved for 14 features. The PNES and epileptic seizures compared were of similar severity in terms of ictal impairment of consciousness (κ = 0.34, odds ratio [OR] = 1.11, 95% confidence interval [CI] = 0.62-1.96) and responsiveness (κ = 0.52, OR = 1.01, 95% CI = 0.55-1.86). PNES were more likely to be preceded by attempts to alert others (κ = 0.52, OR = 12.4, 95% CI = 3.2-47.7, P < .001), to show intensity affected by the presence of others (κ = 0.44, OR = 199.4, 95% CI = 12.0-3309.9, P < .001), and to display postictal behavior affected by the presence of others (κ = 0.35, OR = 91.1, 95% CI = 17.2-482.1, P < .001). SIGNIFICANCE: Nonexpert raters can, with fair to moderate reliability, rate features characterizing ictal impairment of consciousness and responsivity in video recordings of seizures. PNES are associated with greater peri-ictal responsiveness to the social environment than epileptic seizures. These findings are consistent with a potential communicative function of PNES and could be of differential diagnostic significance.

Chronic kidney disease presenting acutely: presentation, clinical features and outcome of patients with irreversible chronic kidney disease who require dialysis immediately.

BACKGROUND: Patients with irreversible chronic kidney disease who require dialysis immediately are a subset of ultra late referrals for whom the term chronic kidney disease presenting acutely might usefully be applied. Although well known to nephrologists and recognised as a specific group with considerable problems, little has been written about them. OBJECTIVE: To describe the presentation, clinical features and outcome of irreversible chronic kidney disease presenting acutely, with particular reference to nausea and vomiting as presenting symptoms. METHOD AND RESULTS: Review of 202 consecutive patients with irreversible chronic kidney disease who had dialysis between 1996 and 2006 showed that 15 (7%) had required dialysis immediately or within 7 days of presentation. Analysis of 14 available case records showed eight avoidable late referrals: previous evidence of renal failure in six, and two patients with diabetes who had not had their renal function checked. Gastrointestinal symptoms were common and led to further delays in diagnosis, with three patients having endoscopy requested before their bloods were checked. Physical and psychological morbidity associated with this form of presentation was high. CONCLUSIONS: Chronic kidney disease presenting acutely is not uncommon, often avoidable and associated with adverse outcomes. The identification, follow-up and appropriate referral of patients with raised serum creatinine is likely to reduce its incidence. Nausea and vomiting may occur sufficiently frequently in advanced renal failure to justify measuring renal function before proceeding to endoscopy when patients present with gastrointestinal symptoms.