Marika Holmqvist

Long-term follow-up of patients with NAFLD and elevated liver enzymes.

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of elevated liver enzymes in patients of developed countries. We determined the long‐term clinical and histological courses of such patients. In a cohort study, 129 consecutively enrolled patients diagnosed with biopsy‐proven NAFLD were reevaluated. Survival and causes of death were compared with a matched reference population. Living NAFLD patients were offered repeat liver biopsy and clinical and biochemical investigation. Mean follow‐up (SD) was 13.7 (1.3) years. Mortality was not increased in patients with steatosis. Survival of patients with nonalcoholic steatohepatitis (NASH) was reduced (P = .01). These subjects more often died from cardiovascular (P = .04) and liver‐related (P = .04) causes. Seven patients (5.4%) developed end‐stage liver disease, including 3 patients with hepatocellular carcinoma. The absence of periportal fibrosis at baseline had a negative predictive value of 100% in predicting liver‐related complications. At follow‐up, 69 of 88 patients had diabetes or impaired glucose tolerance. Progression of liver fibrosis occurred in 41%. These subjects more often had a weight gain exceeding 5 kg (P = .02), they were more insulin resistant (P = .04), and they exhibited more pronounced hepatic fatty infiltration (P = .03) at follow‐up. In conclusion, NAFLD with elevated liver enzymes is associated with a clinically significant risk of developing end‐stage liver disease. Survival is lower in patients with NASH. Most NAFLD patients will develop diabetes or impaired glucose tolerance in the long term. Progression of liver fibrosis is associated with more pronounced insulin resistance and significant weight gain. (HEPATOLOGY 2006;44:865–873.)

Alcohol consumption is associated with progression of hepatic fibrosis in non-alcoholic fatty liver disease.

Objective. Moderate alcohol consumption has been reported to be inversely associated with cardiovascular disease and total mortality. The importance of non-alcoholic fatty liver disease (NAFLD) is increasing and many NAFLD patients suffer from cardiovascular disease. In these patients, moderate alcohol consumption could be beneficial. The aim of this study was to investigate whether low alcohol intake, consistent with the diagnosis of NAFLD, is associated with fibrosis progression in established NAFLD. Material and methods. Seventy-one patients originally referred because of chronically elevated liver enzymes and diagnosed with biopsy-proven NAFLD were re-evaluated. A validated questionnaire combined with an oral interview was used to assess weekly alcohol consumption and the frequency of episodic drinking. Significant fibrosis progression in NAFLD was defined as progression of more than one fibrosis stage or development of endstage liver disease during follow-up. Results. Mean follow-up (SD) was 13.8 (1.2) years between liver biopsies. At follow-up, 17 patients (24%) fulfilled the criteria for significant fibrosis progression. The proportion of patients reporting heavy episodic drinking at least once a month was higher among those with significant fibrosis progression (p=0.003) and a trend towards higher weekly alcohol consumption was also seen (p=0.061). In a multivariate binary logistic regression analysis, heavy episodic drinking (p<0.001) and insulin resistance (p<0.01) were independently associated with significant fibrosis progression. Conclusions. Moderate alcohol consumption, consistent with the diagnosis of NAFLD to be set, is associated with fibrosis progression in NAFLD. These patients should be advised to refrain from heavy episodic drinking.

Approaches to assessment of alcohol intake during pregnancy in Swedish maternity care-a national-based investigation into midwives' alcohol-related education, knowledge and practice

OBJECTIVE to evaluate how much education midwives in Sweden have undertaken to help them assess alcohol intake during pregnancy, and what tools they use to identify women who may be at risk of drinking during pregnancy. DESIGN a national survey was conducted in March 2006, using a questionnaire constructed by a Swedish team of researchers and clinicians. SETTING maternity health-care centres in Sweden. PARTICIPANT 2106 midwives. FINDINGS nearly all midwives stated that they had excellent or good knowledge concerning the risks associated with drinking during pregnancy. They considered themselves less knowledgeable about detecting pregnant women with risky alcohol consumption before pregnancy. The majority of the midwives had participated in some education in handling risky drinking. Almost half of the midwives assessed womens alcohol intake before pregnancy. Important facilitators for increased activity concerned recommendations and decisions at different levels (national, local and management) on how to address alcohol with expectant parents and work with risky drinkers. KEY CONCLUSIONS more education was associated with more common use of a questionnaire for assessment of womens alcohol intake before pregnancy, and more frequent counselling when identifying a pregnant woman whose pre-pregnancy consumption was risky.

Linking drinking to injury--causal attribution of injury to alcohol intake among patients in a Swedish emergency room.

This study analysed the drinking patterns and motivation to change drinking behaviours among injury patients who acknowledged alcohol as a factor in their injuries. A cross-sectional study was conducted over 18 months at a Swedish emergency department. A total of 1930 injury patients aged 18 – 70 years were enrolled in the study (76.8% completion rate). Of those who reported drinking, 10% acknowledged alcohol as a factor in their injury. A patient was more likely to report a causal attribution of the injury to alcohol the higher the weekly intake and the higher the frequency of heavy episodic drinking. The motivation to change variables showed a similar pattern of increased likelihood of attributing a causal link of alcohol and injury with increasing discontent with drinking behaviours and increasing desire to change drinking behaviours. The findings suggest that the ability to measure causal attribution of alcohol to injuries could be a promising tool to help patients explore the association between their injuries and alcohol use and motivate patients to modify drinking behaviours in order to avoid future injuries.

Implementation of a computerized alcohol advice concept in routine emergency care

BACKGROUND There is a growing body of evidence for computer-generated advice for many health behaviours. This study evaluated the implementation of a computerized concept to provide tailored advice on alcohol in a Swedish emergency department (ED). AIM The aim was to evaluate the usage of the concept over 12 months: participation rate among the ED population; representativeness of the participants; and participation development over time. METHODS The target population was defined as all patients aged 18-69 years given a card from ED triage staff with a request to conduct a computerized test about their alcohol use. After completing the 5-10-min programme, the patient received a printout, containing personalised alcohol habit feedback, as calculated by the computer from the patients answers. Data for this study were primarily obtained from the computer programme and ED logs. RESULTS Forty-one percent of the target population completed the computerized test and received tailored alcohol advice. The number of patients who used the concept showed a slight decreasing trend during the first half of the year, leveling off for the second half of the year. CONCLUSION A computerized concept for provision of alcohol advice can be implemented in an ED without unrealistic demands on staff and with limited external support to attain sustainability.

Is questionnaire-based alcohol counseling more effective for pregnant women than standard maternity care?

OBJECTIVE To compare current standard maternity care in Sweden concerning provision of alcohol advice with a more comprehensive questionnaire-based counseling model. METHODS The study population included pregnant women in Linköping who were registered at a maternity care center during a 2-year period and whose pregnancies resulted in liveborn infants without birth defects, representing 93% of all pregnant women. Anonymous questionnaires were mailed to the women. The first cohort (registered April 2005 1, to March 31, 2006) received standard care according to a procedure that is common practice in Sweden. The second cohort (April 1, 2006 to March 31, 2007) received alcohol advice based on a comprehensive counseling model, incorporating the use of the three-item Alcohol Use Disorders Identification Test (AUDIT-C) questionnaire and tailored counseling based on the AUDIT-C score. RESULTS The response rate was 61% in the first cohort (standard care) and 70% in the second cohort (questionnaire-based counseling). The cohorts were similar in sociodemographic variables and prepregnancy drinking characteristics. The proportion of women who continued drinking alcohol during the pregnancy was 6.0% in cohort 1 and 5.8% in cohort 2. Women in cohort 2 were more favorable to the advice and, to a larger extent, perceived the main message to be abstinence from drinking during pregnancy. CONCLUSIONS The questionnaire-based counseling model was more favorably perceived than the standard care model, but the new model was not more effective in terms of its impact on the proportion of women who abstained from drinking during pregnancy.

Towards improved alcohol prevention in Swedish antenatal care

OBJECTIVE to evaluate an education effort and revised alcohol-preventive routine in Swedish antenatal care; to generate more knowledge for further development of alcohol issues in antenatal care. DESIGN two national cross-sectional surveys of Swedish midwives were conducted. Baseline data were collected in 2006 and follow-up data in 2009. SETTING antenatal care centres in Sweden. PARTICIPANTS 974 midwives in 2006 and 1108 midwives in 2009. MEASUREMENT amount and content of continuing professional education, work with alcohol-related issues, identification of women with risky consumption of alcohol, and action after identifying women with risky consumption. FINDINGS the amount of continuing professional education undertaken by midwives on handling risky drinking increased significantly between 2006 and 2009. The routine to detect risky drinking changed between the baseline and follow-up data collection, as nearly all midwives reported the use of an alcohol screening questionnaire in 2009. The most confident midwives in 2009 had taken part in more days of education, more often stated it was their own initiative to participate, and had more often taken part in education regarding MI, provision of advice and information on the health risks associated with alcohol and, screening. KEY CONCLUSIONS our results indicate that a broad, national education effort can be successful in enhancing knowledge and changing antenatal care practice. However, generalisation to other countries or cultures may be limited because the usage of new routines is affected by many organisational and contextual factors.

Alcohol prevention activity in Swedish primary health care and occupational health services : Asking patients about their drinking

Aims To investigate the alcohol preventive activity in Swedish Occupational health services (OHS) and Primary health care (PHC) in relation to education in handling risky drinking, perceived skill ...

National education and implementation initiatives in the field of alcohol and their effect on perceived competence and clinical practice in Swedish primary care.

To encourage health professionals to raise the issue of alcohol among patients and to provide better advice to reduce hazardous drinking, Swedish health authorities implemented the Risk Drinking Project (RDP) between 2004-2009. The main activities were training seminars focusing on teaching motivational interviewing and screening for risky drinking. To evaluate the impact of RDP, baseline and follow-up surveys (in 2006 and 2009) were conducted. Participants were general practitioners (GPs) and district nurses (DNs). They were asked how often they discussed alcohol with their patients, and how they estimated their skill at providing advice about drinking and their effectiveness in helping patients reduce risky drinking. We triangulated the results with two population surveys where patients reported whether they had been asked about alcohol when visiting their primary health care (PHC) provider. We also studied changes in the number of alcohol-related diagnoses in PHC in western Sweden between 2005- 2009. Fifty-five percent of PHC providers in the 2009 follow-up survey reported participating in alcohol-related education in the past three years. For all three parameters analyzed (frequency, skill, and effectiveness), there were significant increases during the three years, particularly among DNs. However, the population surveys showed no change in patients being asked about their alcohol consumption. Further, there was only a small increase in alcohol-related diagnoses over this time-period (9%). The RDP is a likely cause of enhanced self-perceived competence among nurses and GPs. Using a combination of data sources to evaluate the impact of RDP raises uncertainty as to whether the educational effort alone was sufficient to increase screening and brief intervention.