An epidemiological study of the association of coffee with chronic liver disease.

BACKGROUND AND AIMS: Chronic liver disease affects 855 people per million in the UK. Previous studies have reported that coffee appears protective against the development of abnormal liver enzymes, hepatic fibrosis and cirrhosis. The aim of this study, the first in a Scottish population, was to compare coffee consumption in patients with liver disease and that of control populations to determine correlations between coffee intake and the incidence of non-cancerous liver disease and with Child's-Pugh and model for end-stage liver disease (MELD) scores. METHODS AND RESULTS: Two hundred and eighty-six patients attending the liver outpatient department at the Royal Infirmary of Edinburgh completed a questionnaire regarding coffee consumption and lifestyle factors. Control questionnaires were also completed by 100 orthopaedic outpatients and 120 medical students. Patients with cirrhosis (n = 95) drank significantly less coffee than those without cirrhosis (p = <0.001). There was no correlation between Child's-Pugh (-0.018) and MELD scores (-0.132) with coffee consumption. CONCLUSION: Coffee drinking is associated with a reduced prevalence of cirrhosis in patients with chronic liver disease. However, there was no significant difference in the amount of coffee drunk by liver patients and the control groups. It is possible that by changing the amount of coffee drunk, the development of cirrhosis in liver disease could be postponed.

Acute liver failure in Scotland between 1992 and 2009; incidence, aetiology and outcome.

AIM: To describe incidence, aetiology and outcome data for Scotland since the inception of the Scottish Liver Transplant Unit (SLTU) in 1992. BACKGROUND: Acute liver failure (ALF) is a rare but frequently fatal condition. Few studies have adequate patient numbers to draw convincing conclusions over demographic features, aetiology and outcome. DESIGN: Statistical analysis of prospectively collected data on aetiology, demographic, clinical and outcome of all admissions, including those with ALF, to the SLTU. METHODS: Incidence data presented for admissions and ALF. Descriptive frequencies for aetiology, clinical, demographic and outcome data presented; including split analysis for paracetamol and non-paracetamol aetiologies. Univariate and multivariate analysis of admission factors predictive of outcome is described. RESULTS: Nine hundred and forty-nine patients were admitted to the SLTU between 1992 and 2009. Five hundred and twenty-four patients had ALF. The annual incidence of ALF in the Scottish population is 0.62 per 100,000 and paracetamol overdose (POD) was the largest causative factor; responsible for 0.43 cases of ALF per 100,000 population per year. The odds ratio (OR) of transplantation or death was 0.47 in the POD group compared to other aetiologies; yet of not being a transplant candidate having met the Kings College Hospital poor prognostic criteria OR was 4.9. Of admissions listed for transplant 76.0% were transplanted. Of those listed and not transplanted mortality was approaching 100% and 76.1% of those transplanted survived to discharge. CONCLUSION: This large, prospective, single centre study with a defined geographical area and well-recorded population provides accurate data regarding ALF between 1992 and 2009.

Review article: omega-3 fatty acids - a promising novel therapy for non-alcoholic fatty liver disease.

BACKGROUND: Non-alcoholic fatty liver disease affects 10-35% of the adult population worldwide; there is no consensus on its treatment. Omega-3 fatty acids have proven benefits for hyperlipidaemia and cardiovascular disease, and have recently been suggested as a treatment for non-alcoholic fatty liver disease. AIMS: To review the evidence base for omega-3 fatty acids in non-alcoholic fatty liver disease and critically appraise the literature relating to human trials. METHODS: A Medline and PubMed search was performed to identify relevant literature using search terms 'omega-3', 'N-3 PUFA', 'eicosapentaenoic acid', 'docosahexaenoic acid', 'non-alcoholic fatty liver disease' and 'NAFLD'. RESULTS: Omega-3 fatty acids are important regulators of hepatic gene transcription. Animal studies demonstrate that they reduce hepatic steatosis, improve insulin sensitivity and reduce markers of inflammation. Clinical trials in human subjects generally confirm these findings, but have significant design inadequacies. CONCLUSIONS: Omega-3 fatty acids are a promising treatment for non-alcoholic fatty liver disease which require to be tested in randomized placebo-controlled trials.

Are selective serotonin re-uptake inhibitors associated with an increased risk of self-harm by antidepressant overdose?

OBJECTIVE: To investigate likelihood of self-harm by overdose with antidepressant drugs of different types by examining hospital admission data and poisons inquiries and relating them to prescribing. DESIGN: Retrospective analysis of prospectively collected data on overdose admissions, poisons inquiries and prescribing of antidepressants in Edinburgh and Scotland. SETTING: Poisons treatment unit of the Royal Infirmary of Edinburgh and its surrounding catchment for overdose cases and Scotland for poisons inquiries. PARTICIPANTS: All patients admitted to the Royal Infirmary of Edinburgh between 1 January 2000 and 31 December 2002 with an overdose involving an antidepressant. MAIN OUTCOME MEASURES: Overdose admissions (patients) in relation to prescribing in Edinburgh and poisons inquiries in relation to prescription rates in Scotland. RESULTS: There were 1656 admissions involving 1343 patients. The likelihood of admission for an individual patient in relation to volume of prescribing (likelihood ratio: 95%CI) in the catchment was somewhat smaller for amitriptyline (0.83:0.74-0.92) and sertraline (0.79:0.63-0.99), and somewhat greater for mirtazapine (1.99:1.57-2.51), trazadone (1.30:1.09-1.54) and venlafaxine (0.97:1.81-1.16) [corrected] For poisons inquiries in Scotland, the excess for venlafaxine and mirtazapine was confirmed and likelihood of an inquiry lowest for selective serotonin re-uptake inhibitors (SSRIs). CONCLUSIONS: There was no evidence of an excess likelihood of presentation with overdose with SSRIs, and the likelihood was reduced with sertraline. There was a small excess of both admissions and poisons inquiries for mirtazapine and venlafaxine. This is a concern in view of the increased toxicity of venlafaxine in overdose in comparison with SSRIs.

Referral patterns and social deprivation in paracetamol-induced liver injury in Scotland.

Paracetamol overdose is the commonest cause of acute liver failure in the UK, which has led to measures to restrict its sale. We aimed to establish whether changes in the referral of patients with paracetamol-induced acute liver failure have occurred since the introduction of legislation. We compared data from patients admitted to the Scottish Liver Transplantation Unit in 1992-98 with those admitted in 1998-2001. The incidence of paracetamol-induced liver failure, severity of patients' illness, and outcome did not differ between the groups. Patients with paracetamol-induced acute liver failure had higher Carstairs scores (1.99 [95% CI 1.33-2.65]; n=190) than patients with non-paracetamol acute liver failure (0.02 [-0.79 to 0.84]; n=68). We have shown an association between paracetamol-induced acute liver failure and social deprivation.

Psychological factors associated with delay in attending hospital following a myocardial infarction.

OBJECTIVE: There is wide variability in latency to attend hospital following a myocardial infarction (MI). The present study assessed possible psychological factors that may be implicated in delayed presentation. METHOD: Seventy-two patients who had experienced a confirmed MI were interviewed in hospital, 3-5 days post-MI. They completed a series of psychological measures of cardiac denial, cardiac threat, alexithymia, health locus of control, neuroticism and mood. RESULTS: Those patients who believed that they were having a heart attack sought help quicker than those who did not, and those who waited over 4 hours prior to seeking medical help had significantly lower scores on neuroticism, and higher scores on denial and health locus of control (chance). Confirmatory multiple regression analysis using an alternative estimate of delay in seeking help confirmed that health locus of control (chance) was the best predictor of delayed attendance. CONCLUSION: The present study confirms that the belief that one is having a MI is associated with prompt attendance, and additionally that the belief that health outcomes are largely due to chance factors is associated with delayed presentation following a MI. This delay could prove fatal. Modification of such beliefs may reduce response times and, thus, increase survival rates.

Variceal haemorrhage and post-traumatic stress disorder.

OBJECTIVE: Post-traumatic Stress Disorder (PTSD) is thought to be relatively common following extremely distressing life-threatening events. Patients with liver cirrhosis can experience severe brisk variceal haemorrhage during which they vomit litres of blood and may exsanguinate. We predicted that a significant proportion of survivors would suffer from PTSD. DESIGN: PTSD assessment of 30 patients who had a haematemesis of more than four units of blood secondary to variceal bleeding and were fully conscious at the time of the bleed. METHOD: Structured Clinical Diagnostic Interview (SCID-DSM-III-R) and self-report measures. RESULTS: Most found the experience distressing, but only 1 out of 30 patients fulfilled DSM-III-R diagnostic criteria for PTSD. CONCLUSIONS: PTSD in a sample of patients who survived life-threatening variceal haemorrhage is much rarer than might reasonably have been anticipated. Possible reasons for this low prevalence of PTSD are discussed.

Psychodynamic factors in the aetiology of compensation neurosis.

These three cases illustrate the importance of psychodynamic factors in the genesis of some cases of compensation neurosis, with the neurosis being seen as the expression of current and past rejections. These claimants had all experienced major early loss which they had denied; their rigid coping mechanisms focused upon hard work, reliability and providing, which enabled them to belong and feel valued. They decompensated when inability to work compromised these defences.

The neuropsychiatric sequelae of mercury poisoning. The Mad Hatter's disease revisited.

BACKGROUND: The detailed effects of mercury poisoning on cognitive function, brain anatomy and regional brain function are largely unknown. We report the case of a 38-year-old man who was exposed to toxic levels of inorganic mercury. METHOD: Four years after exposure, the patient was assessed using magnetic resonance imaging (MRI), single-photon emission computerised tomography (SPECT) and detailed neuropsychological evaluation. RESULTS: The patient developed a myriad of physical and psychiatric complaints, including stomatitis, muscle spasm, tremor, skin rash and the psychiatric syndrome known as 'erythism' (Mad Hatter's disease). Neuropsychological evaluation revealed marked and significant deficits of attention concentration, particularly when under time pressure. The MRI scan was unremarkable; however, SPECT revealed hypermetabolism of the posterior cingulate CONCLUSIONS: Mercury poisoning appeared to result in a dysregulation of posterior cingulate cortex, which was associated with attention/concentration deficits and marked anxiety/agitation.

Fatal poisonings attributed to benzodiazepines in Britain during the 1980s.

The fatal toxicity indices of benzodiazepines during the 1980s were calculated from national prescribing data and mortality statistics. The overall rate was 5.9 deaths per million prescriptions for benzodiazepines taken alone or with alcohol only, anxiolytics being less toxic than hypnotics. Diazepam appeared more toxic than average among anxiolytics (P < 0.05), and flurazepam and temazepam more toxic than average among hypnotics (both P < 0.001). It was shown that the finding for diazepam was probably explained by concurrent use of alcohol, which implies that other anxiolytics may be safer in cases where there is alcohol misuse; but the greater toxicity of flurazepam and temazepam remained unexplained. Benzodiazepines are indeed much less toxic than the barbiturates they superseded, but they are not innocuous and temazepam in particular requires further evaluation.

Munchausen's syndrome and organic brain disorder.

A case of Munchausen's syndrome was probably caused by brain damage sustained during a necessary cholecystectomy. Doctors should not be discouraged from seeking treatable disorder because of such patients' behaviour.

Parasuicide and the lunar cycle.

Admissions to hospital following parasuicide in one city over eighteen years exhibit a cyclical variation apparently synchronized with the lunar quarters. The effect would only account for approximately 0.7 out of the average of 46 parasuicides per 100,000 adults per lunar cycle (95% CI 0.6-0.8), and fails to reach statistical significance.

Monthly and seasonal variation in parasuicide. A sex difference.

In a total of 22,169 parasuicides over 19 years, there was evidence for a seasonal cycle in parasuicide admissions among women, with an increase during the summer and a fall over the winter, including a pronounced December nadir. Further analysis of the winter trough suggests a sociological explanation, the focal point being Christmas. There was no evidence for monthly or seasonal variation among men.

Psychiatric emergencies, Scotland and the World Cup finals.

Reductions in emergency psychiatric presentations to hospital occurred during and after the finals of the World Cup football competitions, an effect evident in women as well as men, and more marked among the mentally ill than those who were not. Increases in the numbers of schizophrenic and neurotic men presenting before, and alcoholic men during, the competitions can be attributed to the football. The generalised reductions during and after could reflect an indirect effect upon help-seeking, although actual relapse rates of mental illnesses might be affected. These changes could arise from enhancement of national identity and cohesion.