Copyright Nick Sheron Alcohol and the liver nick

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Copyright Nick Sheron Alcohol and the liver nick. sheron@soton. ac. uk

Copyright Nick Sheron Alcohol and the liver nick. sheron@soton. ac. uk

Copyright Nick Sheron

Copyright Nick Sheron

Copyright Nick Sheron

Copyright Nick Sheron

Copyright Nick Sheron

Copyright Nick Sheron

Copyright Nick Sheron

Copyright Nick Sheron

Of total 9559 500 All Men Alcohol > 15 units / week 2660 166

Of total 9559 500 All Men Alcohol > 15 units / week 2660 166 Copyright Nick Sheron BMI > 30 70% beer 1 u = ½ pint in 1968 Scottish Midspan study BMJ 2010

Copyright Nick Sheron BMJ million women 2010

Copyright Nick Sheron BMJ million women 2010

Many people with alcohol related cirrhosis are not alcohol dependant Copyright Nick Sheron Soton

Many people with alcohol related cirrhosis are not alcohol dependant Copyright Nick Sheron Soton 2006 n= 96 Soton 2009 n= 213 SADQ Smith et al alcohol and alcoholism 2006, data updated 2009

Drinking diaries in consecutive liver patients over 6 months Copyright Nick Sheron Drinking days

Drinking diaries in consecutive liver patients over 6 months Copyright Nick Sheron Drinking days / week With one exception these had all cut down from daily drinking

It’s quite difficult to drink enough to damage your liver, you have to be

It’s quite difficult to drink enough to damage your liver, you have to be fairly dedicated to it Copyright Nick Sheron

Copyright Nick Sheron We identified 4 drinking patterns from lifetime drinking histories n =

Copyright Nick Sheron We identified 4 drinking patterns from lifetime drinking histories n = 236 subjects with liver disease Hatton et al Addiction 2009

Lifetime drinking history data Copyright Nick Sheron

Lifetime drinking history data Copyright Nick Sheron

Lifetime drinking history data Copyright Nick Sheron

Lifetime drinking history data Copyright Nick Sheron

Mortality at first presentation – published data Variceal bleeding 25% 30 day Jaundice 25

Mortality at first presentation – published data Variceal bleeding 25% 30 day Jaundice 25 -50% 30 day Ascites 35% 1 year Liver disease develops silently, But presents fatally Copyright Nick Sheron

100 consecutive patients with biopsy proven ALD + cirrhosis Copyright Nick Sheron Early mortality

100 consecutive patients with biopsy proven ALD + cirrhosis Copyright Nick Sheron Early mortality 20% 5 year survival 50%

Copyright Nick Sheron Early deaths – solution is taxation Late deaths – solution is

Copyright Nick Sheron Early deaths – solution is taxation Late deaths – solution is to stop drinking (and taxation) Subjects abstinent one month after diagnosis have increased survival (p<0. 003)

Copyright Nick Sheron Preventing late deaths Changing drinking behaviour is the key to survival

Copyright Nick Sheron Preventing late deaths Changing drinking behaviour is the key to survival

UKATT v SUHT nurse led clinic Copyright Nick Sheron 60% abstinent or much improved

UKATT v SUHT nurse led clinic Copyright Nick Sheron 60% abstinent or much improved cw 40% previously ©Unpublished data – Tull, Sheron 2004

Copyright Nick Sheron

Copyright Nick Sheron

2 UK NHS Hospital Trusts in NW of England treatment site (N=100) control site

2 UK NHS Hospital Trusts in NW of England treatment site (N=100) control site (N=100) Copyright Nick Sheron 100 50 -u w llo Fo tm ea Tr m ea t Tr en t ol tr on C p e el in B llo Fo B ol tr on as w as el -u in p e 0 C Daily Alcohol Units 150 Lynn Owens unpublished data

Copyright Nick Sheron N Sheron Clinical Medicine 2010

Copyright Nick Sheron N Sheron Clinical Medicine 2010

Copyright Nick Sheron N Sheron Clinical Medicine 2010

Copyright Nick Sheron N Sheron Clinical Medicine 2010

Copyright Nick Sheron

Copyright Nick Sheron

Copyright Nick Sheron

Copyright Nick Sheron

Copyright Nick Sheron

Copyright Nick Sheron

Copyright Nick Sheron N Sheron Clinical Medicine 2010

Copyright Nick Sheron N Sheron Clinical Medicine 2010

Globalisation of Copyright binge drinking Nick Sheron Speculation on why wine consumption has fallen

Globalisation of Copyright binge drinking Nick Sheron Speculation on why wine consumption has fallen in France Health campaigns and the Loi Evin EEC wine lakes and CAP – move to quality Health awareness, links between wine and cirrhosis Urbanisation, death of the rural idyll and ze long luuurnch Improving incomes 1960 1970 1980 1990 2000 N Sheron Clinical Medicine 2010

Liver deaths Copyright Nick Sheron Wine consumption N Sheron Clinical Medicine 2010

Liver deaths Copyright Nick Sheron Wine consumption N Sheron Clinical Medicine 2010

Copyright Nick Sheron Value of wine market has increased through quality N Sheron Clinical

Copyright Nick Sheron Value of wine market has increased through quality N Sheron Clinical Medicine 2010

World Health Organisation modelling of evidence based alcohol policy Copyright Nick Sheron Chisholm et

World Health Organisation modelling of evidence based alcohol policy Copyright Nick Sheron Chisholm et al 2004

World Health Organisation modelling of evidence based alcohol policy Copyright Nick Sheron More effective

World Health Organisation modelling of evidence based alcohol policy Copyright Nick Sheron More effective Early intervention Drink driving Increased tax Advertising and availability Chisholm et al 2004

World Health Organisation modelling of evidence based alcohol policy Copyright Nick Sheron More expensive

World Health Organisation modelling of evidence based alcohol policy Copyright Nick Sheron More expensive Early intervention Drink driving Increased tax Advertising and availability Chisholm et al 2004

World Health Organisation modelling of evidence based alcohol policy Copyright Nick Sheron Early intervention

World Health Organisation modelling of evidence based alcohol policy Copyright Nick Sheron Early intervention Drink driving Increased tax Advertising and availability Chisholm et al 2004

Copyright Nick Sheron -How do you signalize/diagnose alcohol related liver diseases -Can you describe

Copyright Nick Sheron -How do you signalize/diagnose alcohol related liver diseases -Can you describe the average patient with a fat liver, a hepatitis and / or a cirrosis -How do you start a confrontation with a 'suspected patient" -What kind of methodology do you use in this confrontation (I suppose a kind of a motivational interview) -How do patients react usually? -How do you try to guarantee a behavioural change of these patients? -Do you cooperate with addiction centres? and if yes how, which and what results -Do you have lessons to be learnt from other hospitals c. q. colleagues?

Copyright Nick Sheron Alcohol related harm in a hospital setting (15 years without a

Copyright Nick Sheron Alcohol related harm in a hospital setting (15 years without a psychiatrist)

Copyright Nick Sheron How do you diagnose alcohol related liver disease?

Copyright Nick Sheron How do you diagnose alcohol related liver disease?

Copyright Nick Sheron How do you diagnose alcohol related liver disease? “usually too late”

Copyright Nick Sheron How do you diagnose alcohol related liver disease? “usually too late”

Copyright Nick Sheron Patients present with: variceal bleeds ascites 25 -50% mortality jaundice from

Copyright Nick Sheron Patients present with: variceal bleeds ascites 25 -50% mortality jaundice from alcoholic hepatitis Audit of 94 first presentations of alc cirrhosis 67% never seen in hospital 33% seen in ED for an alcohol related problem mean of 7 yrs previously seen GP a mean of 9 -13 x / year in the 5 yrs prior to admission Verril – Subst Abuse Treat Prev Plicy 2006

Copyright Nick Sheron Early deaths 39% Late deaths 60% Claire Verril et al Addiction

Copyright Nick Sheron Early deaths 39% Late deaths 60% Claire Verril et al Addiction 2008

Copyright Nick Sheron Can you describe the average patient with a fat liver, a

Copyright Nick Sheron Can you describe the average patient with a fat liver, a hepatitis and / or a cirrhosis?

Copyright Nick Sheron ALD detox Mean age 50 40 Stable relationship 41% 14% Unemployed

Copyright Nick Sheron ALD detox Mean age 50 40 Stable relationship 41% 14% Unemployed 41% 73% Alcohol (cl/week) 70 140 Patients with alcohol related cirrhosis are often heavy social drinkers, with jobs and families. Smith et al – Alcohol and Alcoholism 2006

Copyright Nick Sheron Smith et al – Alcohol and Alcoholism 2006

Copyright Nick Sheron Smith et al – Alcohol and Alcoholism 2006

Copyright Nick Sheron How do you start a confrontation with a 'suspected patient“? What

Copyright Nick Sheron How do you start a confrontation with a 'suspected patient“? What kind of methodology do you use in this confrontation? (I suppose a kind of a motivational interview)?

The 5 minute alcohol history What type of drink do you like to drink?

The 5 minute alcohol history What type of drink do you like to drink? Do you like to drink at home or in the pub? Do you drink in the evening or at lunchtimes or both? What time of day would you have your first drink? How many days a week do you have a drink? Do you drink more at weekends? How much would you have to drink in a typical session? How quickly do you get through a bottle of wine / vodka? Where do you buy your booze, how often do you buy it, how much would you buy at a time? Copyright Nick Sheron

The 5 minute alcohol history What type of drink do you like to drink?

The 5 minute alcohol history What type of drink do you like to drink? Do you like to drink at home or in the pub? Do you drink in the evening or at lunchtimes or both? What time of day would you have your first drink? How many days a week do you have a drink? Do you drink more at weekends? How much would you have to drink in a typical session? How quickly do you get through a bottle of wine / vodka? Where do you buy your booze, how often do you buy it, how much would you buy at a time? Copyright Nick Sheron

The 5 minute alcohol history What type of drink do you like to drink?

The 5 minute alcohol history What type of drink do you like to drink? Do you like to drink at home or in the pub? Do you drink in the evening or at lunchtimes or both? What time of day would you have your first drink? How many days a week do you have a drink? Do you drink more at weekends? How much would you have to drink in a typical session? How quickly do you get through a bottle of wine / vodka? Where do you buy your booze, how often do you buy it, how much would you buy at a time? Copyright Nick Sheron

“The Cirrhosis Talk” Copyright Nick Sheron Their liver problem is due to the alcohol

“The Cirrhosis Talk” Copyright Nick Sheron Their liver problem is due to the alcohol they have drunk over the last 10 years or so I’m not going to tell them what to do or how to live their lives, but I want them to listen and to think about what I am going to say, and I want them to make a decision about what they are going to do about their drinking… And I’m going to come back and ask them what that decision is… They have two choices If they stop drinking completely, then the liver can recover (no matter how bad their liver disease is), and it is possible that the liver will recover sufficiently for them to live out their lives and to die of some other cause.

Copyright Nick Sheron If however you continue to drink… The chance of being alive

Copyright Nick Sheron If however you continue to drink… The chance of being alive in one years time is 50% or one in two The chance of being alive in two years time is a half of 50%, or one in four In three years time it is a half of a half or one in eight and after that it is one in sixteen, and after that they may as well forget it You have used up all your drinking years, just like you use up petrol in tank and your liver cannot take any more.

Copyright Nick Sheron 4 A 4 B Laennec grade of cirrhosis 4 C

Copyright Nick Sheron 4 A 4 B Laennec grade of cirrhosis 4 C

The pathological degree of cirrhosis has no effect on survival Copyright Nick Sheron P=ns

The pathological degree of cirrhosis has no effect on survival Copyright Nick Sheron P=ns Claire Verril et al Addiction 2008

The only thing that we can change is drinking behaviour Copyright Nick Sheron 39%

The only thing that we can change is drinking behaviour Copyright Nick Sheron 39% 60% Claire Verril et al Addiction 2008

Copyright Nick Sheron How do patients react usually?

Copyright Nick Sheron How do patients react usually?

Copyright Nick Sheron Do you cooperate with addiction centres? And if yes how, which

Copyright Nick Sheron Do you cooperate with addiction centres? And if yes how, which and what results?

UKATT v SUHT nurse led clinic Copyright Nick Sheron ©Unpublished data – Tull, Sheron

UKATT v SUHT nurse led clinic Copyright Nick Sheron ©Unpublished data – Tull, Sheron 2004

Copyright Nick Sheron Same patients before and after cost saving £ 90, 000 with

Copyright Nick Sheron Same patients before and after cost saving £ 90, 000 with 1/5 WTE nurse ©Unpublished data – Tull, Sheron 2004