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.

Six-day clotrimazole therapy in vaginal candidosis.

Two hundred and two patients with symptoms, signs and mycological evidence of Candida vaginitis were entered in a single-blind trial comparing 6-day clotrimazole therapy with a control group receiving 6 days' nystatin therapy. Adequate data was collected on 69 clotrimazole and 72 nystatin treated patients for analysis. Judged by both the severity of symptoms and signs and the number of patients with negative mycological findings, 6-day clotrimazole therapy produced statistically significantly better results than obtained in the control group. When reviewed 4 weeks after starting therapy, 93% of the clotrimazole treated patinets had culturally negative results for Candida compared with 74% of the patients treated with nystatin. It is concluded that 6-day clotrimazole therapy is effective in the treatment of Candida vaginitis.

The behavioural characteristics of local authority home residents referred to a geriatric psychiatry service.

With increasing demands upon a geriatric psychiatry service, the priorities for day care and long-term hospital care have had to be re-examined. As a result, old people already in local authority residential care are receiving lower priority than those still in the community. In this study we suggest that certain behavioural characteristics and, in particular, incontinence, may present the caring staff of residential homes with special difficulties. We conclude that adequate assessment is essential to ensure that residents are suited to the level of facilities supplied.

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.

General practice consultation patterns before and after intentional overdose: a matched control study.

This study investigated the general practice consultations of 46 patients during the year before and 13 weeks after hospital admission for deliberate self-poisoning. These were compared with data for controls matched for age, sex, family structure and area of residence. The frequency of consultations increased as parasuicide approached but this effect was due to large increases in a few patients. The greatest increase in the number of consultations and an increase in subjects consulting for physical problems occurred four to six months before the event. The seriousness of the attempt assessed by suicidal intent was unrelated to consulting pattern either before or after overdose. The rate of default from appointments was less than for controls, although this was not significantly different. Because of the problems in identifying when intentional self-harm will occur and the common presentation being psychosocial distress rather than mental illness, intervention to prevent parasuicide is likely to prove even more difficult than for suicide.

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 validity of emergency recommendations for compulsory psychiatric care.

Retrospective scrutiny of the documents authorising 240 consecutive emergency detentions to a Glasgow psychiatric hospital over a three-year period revealed that 15 per cent were incorrectly completed. Fourteen documents (5.8%) failed to meet a list of minimum requirements supplied by the Central Legal Office and were therefore invalid. Invalid documentation was associated with a failure to use the recommended form. In practice, these documents were recognised at the hospital of detention and patients were either properly detained, informally admitted, or in three cases, discharged. It is suggested that doctors who make Emergency Recommendations without using the printed form should always discuss the wording of their letter with the receiving psychiatrist who should in turn be familial with the six minimum requirements of the Central Legal Office.

Factors determining the use of the emergency recommendation for compulsory psychiatric care.

The factors determining the use of Section 31 admissions and reclassifications at a district psychiatric hospital were investigated prospectively over an eight month period. Thirty-six per cent of patients failed to meet the criteria laid down for full detention and, particularly with reclassification, Section 31 was invoked to secure treatment. While the Emergency Recommendation is not used as the legislators intended, a seven day detention order appears more relevant to modern psychiatric practice than the full detention procedure.

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.

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.

Incontinence in the Social Services' residential homes for the elderly.

The residential homes for the elderly run by the British Social Services contain approximately 25,000 frequently incontinent residents, the disorder having a prevalence of 17 per cent. Frequent incontinence has been consistently demonstrated to be the behaviour disability which best discriminates between suitable and unsuitable residents, in the staff's opinion. The Social Services' response to the problem is hampered by the inappropriate design of their accommodation, the lack of incontinence aids, the low levels and lack of training for staff, the poor primary health-care cover, the low priority given by hospital services, and by their own philosophy and policy for the elderly.

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.

Supervising lithium. A comparison of a lithium clinic, psychiatric out-patient clinics, and general practice.

Supervision of lithium treatment among three groups of patients treated in different settings - at a lithium clinic, as hospital out-patients, and by a GP - was studied. The lithium clinic maintained lower levels and checked these more frequently. Elevated lithium levels were most frequent in the GP-supervised group, which also included the 13 patients with the most impaired glomerular filtration. In hospital settings GFR-impaired patients received a lower daily dose of lithium; in general practice, affected patients had a higher mean serum lithium level and were more frequently prescribed lithium once daily. We conclude that patients with glomerular impairment who require lithium should be supervised by a specialist, or at least prescribed lithium in divided daily doses.