Liver Investigations

Liver Investigations

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Liver function tests (LFTs) are readily available and are often included as a baseline investigation for a large number of different presentations. Liver function tests (LFTs), are a group of blood tests that detect inflammation and damage to the liver. They can also check how well the liver is working. Liver enzyme testing includes ALT, AST, alkaline phosphatase; true liver function tests (LFTs) include PT, INR, albumin, and bilirubin.

Doctor may conduct liver enzyme and liver function tests if:

Ÿ  Taking a medication that can harm the liver

Ÿ  Have liver disease

Ÿ  Have symptoms of liver or bile system disease (abdominal pain, nausea and vomiting, or yellow skin)

Ÿ  Drink alcohol excessively

The liver filters and processes blood as it circulates through the body. It metabolizes nutrients, detoxifies harmful substances, makes blood clotting proteins, and performs many other vital functions. The cells in the liver contain proteins called enzymes that drive these chemical reactions.

When liver cells are damaged or destroyed, the enzymes in the cells leak out into the blood, where they can be measured by blood tests. Liver tests check the blood for two main liver enzymes:

Aspartate Aminotransferase (AST), formerly called SGOT. The AST enzyme is also found in muscles and many other tissues besides the liver. Alanine Aminotransferase (ALT), formerly called SGPT. ALT is almost exclusively found in the liver. If a liver damage is most likely present ALT and AST are found together in elevated amounts in the blood.

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·         Alanine aminotransferase (ALT) or Aspartate aminotransferase (AST)

 Both these enzymes normally reside inside cells (in cytoplasm) so raised levels usually represent hepatocellular damage. ALT is more specific to the liver, as AST is also found in cardiac and skeletal muscle and red blood cells. Very high levels (>1000 IU/L) suggest drug-induced hepatitis (eg paracetamol), acute viral hepatitis (A or B) , ischaemic, or rarely, autoimmune hepatitis. The ratio of AST to ALT can give some extra clues as to the cause in chronic liver disease ALT >AST, once cirrhosis established AST >ALT. The extremes of the ratio of AST:ALT can also be helpful: >2 suggests alcoholic liver disease, and a ratio of <1.0 suggests nonalcoholic liver disease.

Another of the liver's key functions is the production of bile, which helps digest fat. Bile flows through the liver in a system of small tubes (ducts), and is eventually stored in the gallbladder, under the liver.

Alkaline Phosphatase is by far the most commonly tested of the three. If alkaline Phosphatase and/or 5' nucleotidase and GGT are elevated, a problem with bile flow is most likely present. Bile flow problems can be due to a problem in the liver, the gallbladder, or the tubes connecting them.

When bile flow is slow or blocked, blood levels of certain liver enzymes rise

                  Alkaline phosphatase (ALP)

 It comes mainly from the cells lining bile ducts but also in bone. Marked elevation is typical of cholestasis (often with elevated GGT) or bone disorders (usually normal GGT). Isoenzyme analysis may help identify source. It is physiologically increased when there is increased bone turnover (eg adolescence) and is elevated in the third trimester of pregnancy (produced by the placenta).

 Gamma-glutamyl transferase (GGT)

It also related to the bile ducts. Typically elevated in cholestasis (with elevated ALP) but, if ALP normal, suggests induction of hepatic metabolic enzymes (e.g alcohol or enzyme-inducing drugs).

  5' Nucleotidase

Bilirubin:

Bilirubin is derived from the breakdown of haem in the red blood cells within the reticuloendothelial system. The unconjugated bilirubin then binds albumin and is taken up by the liver. In the liver it is conjugated which then makes it water-soluble and thus allows it to be excreted into the urine. Normally total serum bilirubin is measured; however, the unconjugated and conjugated portions can be determined by measures of the fractions of indirect bilirubin and direct bilirubin respectively. Albumin - sensitive marker of hepatic function, but not useful in the acute stages as it has a long half life (20 days).

Total protein.

Interpreting abnormal liver function tests (LFTs) and trying to diagnose any underlying liver disease is a common scenario in Primary Care. Abnormal LFTs may be asymptomatic, and are often inadequately investigated - which may miss an early opportunity of identifying and treating chronic liver disease.

The primary problem may be the liver, or the abnormal results can be secondary to other problems in the body.  Alternatively, there may be nothing wrong with the liver at all!  Traditionally 'normal' values are defined as being within ± 2 standard deviations meaning that 2.5% of a healthy population will have LFTs outside the normal range. However, as liver disease is frequently asymptomatic, such a 'healthy' population may have significant numbers of people with undiagnosed liver disease, and thus this argument should not be used as an excuse for inadequate investigation.

When basic LFTs are abnormal, ensure a full history and examination is performed:

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History and examination of a patient with abnormal LFTs

Full history - include:

·         Recent travel.

·         Transfusions.

·         Drugs, including paracetamol overdose and herbal remedies.

·         Tattoos.

·         Unprotected sexual intercourse.

·         Drug history (including herbal remedies).

·         Alcohol.

·         Occupation.

·         Diabetes mellitus, obesity, hyperlipidaemia (all associated with fatty liver disease).^[5^]

·         Family history.

Full examination - look especially for:

·         Stigmata of chronic liver disease, eg icteric skin and mucous membranes, palmar erythema, bruising, spider naevi, gynaecomastia.

·         Hepatomegaly.

·         Splenomegaly.

·         Ascites.

·         Obesity (associated with a fatty liver).

·         Any clues to the underlying cause, eg lymphadenopathy.

·         Features suggestive of hepatic encephalopathy.

Further tests will also be needed to try to find out the underlying cause:

·         The other transaminase - ie ensure you have both ALT and AST results. The ratio of AST to ALT may be useful for distinguishing fatty liver due to alcoholic and nonalcoholic aetiologies (see above).

·         Prothrombin (INR) - sensitive marker of hepatic synthetic function.

·         Viral serology, eg hepatitis B and C, cytomegalovirus (CMV), Epstein-Barr virus and possibly HIV.

·         Autoantibody screen, eg antimitochondrial antibody, anti-smooth muscle antibody and antinuclear antibody.

·         Immunoglobulins (if not available, raised immunoglobulins may be suggested by a raised globulin fraction (total protein minus albumin)).

·         Serum ferritin and transferrin saturation.

·         α-fetoprotein.

·         Copper/ceruloplasmin.

·         α1-antitrypsin.

·         Imaging: ultrasound is noninvasive and helpful to detect structural abnormalities.

·         Patients should be identified for Jaundice, Dubin-Johnson Syndrome, Gilbert's Syndrome and Rotor's Syndrome

Interpretation

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Once results are obtained, determine which of the following scenarios they fit in to:

1.      Rise in bilirubin alone:

Need to know if unconjugated hyperbilirubinaemia or conjugated hyperbilirubinaemia. Usually due to defects of hepatic excretion. It can be detected by measuring the direct bilirubin component of the total bilirubin (>50% confirms the presence of conjugated hyperbilirubinaemia).

Unconjugated hyperbilirubinaemia is usually due to Haemolysis – (check reticulocyte count, blood film, haptoglobins, LDH and may need direct Coombs' test. Liaise with haematologist). Drugs, Gilbert's syndrome or Crigler-Najjar syndrome are the other posibilities.

Conjugated hyperbilirubinaemia is usually due to Dubin-Johnson syndrome, Rotor syndrome, Chronic liver disease, (usually associated with other liver function test (LFT) abnormalities).

·         Rise in ALP and GGT more than AST and ALT

Is an indication of Obstructive picture or cholestasis . This may be intrahepatic (Primary biliary cirrhosis,Drugs) or extrahepatic (bilirubin will also be raised).

Extrahepati conditions:

·         Gallstone in common bile duct.

·         Head of pancreas neoplasm.

·         Drugs, eg erythromycin, tricyclic antidepressants, flucloxacillin, oral contraceptive pill and anabolic steroids.

·         Cardiac failure - improves with treatment.

·         Primary biliary cirrhosis - more common in women and the first sign is a rise in ALP.

·         Primary sclerosing cholangitis.

·         Neoplasm - primary (rarely) and secondaries.

·         Familial (benign).

·         Rise in AST and ALT more than ALP and GGT

It shows a Hepatitic picture.

·         Alcohol - fatty infiltration and acute alcoholic hepatitis (usually associated with markedly deranged liver function).

·         Cirrhosis of any cause - alcohol being one of the most common.

·         Medications, eg phenytoin, carbamazepine, isoniazid, statins, methotrexate, paracetamol overdose, amiodarone. (Transaminases may be >1000 IU/L).

·         Chronic hepatitis B and C.

·         Acute viral hepatitis, eg hepatitis A, B and C and CMV infection.

·         Autoimmune hepatitis.

·         Neoplasms - primary or secondaries.

·         Haemochromatosis.

·         Metabolic - glycogen storage disorders, Wilson's disease.

·         Ischaemic liver injury, eg severe hypotension,

·         Fatty liver disease (mild elevation in transaminases <100 IU/L).

·         Non-hepatic causes: coeliac disease, haemolysis and hyperthyroidism.

·         Isolated rise in individual enzymes

Isolated rise in GGT:

·         This is most commonly due to alcohol abuse, or enzyme-inducing drugs.

·         An isolated rise can occur even if there is no major liver disease.

·         The rise is not related to the amount of alcohol intake.

·         Also, many heavy alcohol users may have normal GGT.

·         Stopping alcohol for 4 weeks should rectify the abnormality.

Isolated rise in ALP:

·         Third trimester of pregnancy (comes from the placenta - a normal finding).

·         If isolated rise in ALP, consider other sources, eg bone or kidney.
In the elderly consider:

·         Fractures

·         Paget's disease of bone

·         Osteomalacia

·         Bony metastases

ALP is not usually raised in myeloma or osteoporosis (without a fracture).

·         Occasionally, the liver enzymes, eg ALP, GGT, AST or ALT may all be similarly elevated making it difficult to determine whether it is a cholestatic or hepatitic picture.

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Management plan

Any liver abnormalities with evidence of hepatic dysfunction, eg low albumin, raised INR, should be referred to a specialist.^[7]

·         If slightly abnormal rise in liver function tests (ie less than twice upper limit of normal):

·         Repeat liver function tests (LFTs) in 6 months' time.

·         If you suspect the cause to be alcohol-related then inform the patient and ask them to abstain, and repeat the tests.

·         Other lifestyle changes may help, eg good diabetes mellitus control and weight loss.

·         If still abnormal, perform further tests, eg viral serology or ultrasonography.

·         If remaining abnormal for longer than six months then consider referral to a specialist.

·         If the patient is unwell despite slightly abnormal LFT's then they may need to be referred more urgently.

·         Very abnormal LFTs (ie more than twice the upper limit of abnormal):

·         Organise further blood tests and imaging.

·         Refer to outpatients - if you suspect the cause may be malignancy then an urgent cancer referral should be made.^[7^]

Consider urgent referral for hospital admission if a patient is unwell; for example:

·         Severe jaundice

·         Severe ascites

·         Encephalopathy

·         Septic

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Barriers to Effective Learning

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To become a good learner, every student must recognize their own strengths and weaknesses in how they learn. We have already identified individual learning strengths and successful study tips using the Learning Styles Assessment. Now we can begin to look at our potential weaknesses by identifying barriers to effective learning. There are a variety of different things that can prevent each of us from being the best learners we can possibly be.

These barriers can be divided into three general groups:

●     Emotional Barriers

●     Motivational Barriers

●     Learning Disabilities

Every student faces their own unique challenges when it comes to learning, and identifying those barriers is the first step to overcoming them and becoming a better learner. A description of each of the three categories of learning barriers is given below.

Emotional Barriers to Learning

One of the primary problems students, especially in high school, have to deal with is their emotions. The four major emotional barriers for high school students are:

●     Fear

●     Shame

●     Emotional Sensitivity

●     Adjusting to Change

Each of these emotional barriers affects every student in a different way. Many students encounter more than one of these barriers. Understanding and knowing where emotional barriers come from, is the first step to getting over them and continuing your

growth.

Fear

“To conquer fear is the beginning of wisdom”    Bertrand Russell

“Fear is what prevents the flowering of the mind.”    Jiddu Krishnamurti

A major emotional barrier to learning is fear. Some people express their fears as anxiety or anger. Others suffer from lowered confidence, withdrawal or self-isolation. Understanding the reasons behind a fear of learning is important in confronting it. For most people, their fear arises for one or more of the following reasons;

●     A fear of what people say, fear of criticism and judgement

●     A fear of not succeeding, fear of failure·

●     A fear of rejection

It is important to know the causes and results of each of these emotional barriers. Read the descriptions of the causes and consequences of the various fears that follow.

Fear of Criticism and Judgement

“Judgments prevent us from seeing the good that lies beyond appearances.”              Wayne Dyer

Students are often afraid of the criticism they will receive from their teachers, classmates or parents if they do not do a good job or get high marks in school. For some students, this fear is so great that they would rather not try to succeed than risk having to take this criticism. For many such students, the criticism they receive from other people is seen as being a personal attack, and they internalize these criticisms to mean that they themselves must be dumb or lazy.

Fear of Failure

“Failure is success if we learn from it”    Malcolm S. Forbes

Some students, rather than being afraid of the criticism that comes with not succeeding, are afraid of the failure itself. Sometimes, if a student has experienced failure in school repeatedly in the past, they get “stuck”, because of the idea that they will always fail. They reason that because they have failed in some of their efforts in school, they themselves are failures, and do not bother trying. Sometimes, this fear of failure can grow to include not trying in sports, social activities and other parts of life.

Fear of Rejection

“Human beings, like plants, grow in the soil of acceptance, not in the atmosphere of rejection”     John Powell

Besides the fear of criticism or the fear of failure, many students are much more afraid of rejection by their peers. Some students feel that if they do well, they will not be as “cool”, and people will not like them as much as if they failed. They are terrified of being called a “brainer” or a “nerd”. It is important that students feel pride when they are rewarded with high grades for their work, rather than worrying what their friends will say.

“I must not fear. Fear is the mind-killer. Fear is the little-death that brings total obliteration. I will face my fear. I will permit it to pass over me and through me. And when it has gone past I will turn the inner eye to see its path. Where the fear has gone there will be nothing. Only I will remain."   Frank Herbert, Litany Against Fear

Shame

Shame, like fear, is another emotional barrier that prevents learning. Many students who feel they are not doing well in school feel a sense of shame. They are afraid of what people will think when they see their work. These students feel they will never be as good as the brightest students, and so do not even try to succeed. Shame is perhaps the most self-destructive barrier to a student’s learning.

Emotional Sensitivity

Teenagers, just like adults, have a variety of personalities, strengths and weaknesses. Some people have strength in organizing and calculating, and others’ strength lies in their emotions. Students in high school can be especially emotionally sensitive.

Although emotional sensitivity helps a person understand their own and other people’s feelings, it can also at times overwhelm a person. People that are very passionate in this way can sometimes lose control of their emotions. They may sometimes be more easily brought to tears than others when exposed to their own or other people’s pain. This passion can also turn to aggression, however, even when the person did not mean to become upset or angry.

Often emotional over-reactions can occur in school and have a negative impact on the person’s ability to learn.

 Adjusting to Change

"Change is hard because people overestimate the value of what they have—and underestimate the value of what they may gain by giving that up."

Change is scary for everyone, but for teenagers, change may be particularly difficult. Some students prefer procedures to stay the same and have a hard time moving from one activity to another.

Many students have trouble moving from one task to another without completely finishing the first task before moving on to the next one. These students are sometimes  described as inflexible when it comes to considering another person's viewpoint or a different way of doing something.

In general, teenagers are less prepared for the unexpected than adults, since they have to at the same time cope with new emotions, responsibilities and school settings. The unexpected may bring new learning hurdles, new demands or new social challenges.

Motivational Barriers to Learning

“People who are unable to motivate themselves must be content with mediocrity, no matter how impressive their other talents.”    Andrew Carnegie

Motivation is the drive inside an individual to channel their energy towards a goal. Many people, especially teenagers experiencing their first adult freedoms and overcoming emotional and social challenges, find it difficult to do this. When it comes to school, real difficulties can arise if homework does not get done on time or tests are not studied for. Getting motivated is hard work, and presents many challenges for a high school student. There are three major motivational barriers typically encountered by teenagers. Each of the three is discussed in further detail below.

The three major motivational barriers to learning most often encountered by teens

include:

●     Lack of a goal

●     Procrastination

●     Improperly arranged learning environment

Lack of a Goal

“Without goals, and plans to reach them, you are like a ship that has set sail with no destination.”     Fitzhugh Dodson

In order to achieve a goal, you have to first know what that goal is. It is important to have a clear idea of what it is you want. In high school, your ultimate goal should be to get your diploma and graduate. This goal, however, is difficult to keep in your mind on a day-to-day basis.

Set out short-term and medium-term goals to help you stay motivated. For example, some of your focus can be placed on doing well on the math quiz tomorrow in the short-term and an English essay next week in the medium-term. Having clear-cut objectives for the near future will allow you to track your progress through school and feel like you are getting somewhere. 

                                                                                                                                                     

Procrastination

"Procrastination is the grave in which opportunity is buried."    Author Unknown

Like most students, you have no doubt put off doing homework or studying for a test, only to find that when you try to do it later, you do not have enough time. In school, just as in the workforce, or at home with chores, saying “I didn’t have enough time” is rarely accepted as a good excuse for not doing your work.

It is important to set time aside in the day which is reserved for schoolwork. Many students find it helpful to make a chart or write down on a calendar due dates for their assignments. For big assignments or tests, mark down on your calendar how much work or studying you plan to have done by a particular day, and stick to it!                                                                                                                                                   

Learning Environment

A key to achieving success in school is having the right atmosphere at home in which you can study and do homework. Set aside a quiet place where you can be alone without any distraction. Avoid studying in a room with a TV or a computer, unless you are using the computer for schoolwork.

It is also important to have a plan on what you are going to study, when, and for how long. Try to set up a routine in which you study in the same place at the same time every day. Let your friends know not to call you or to come over at that time. It is far better to learn for half an hour each day than trying to cram for many hours on Sunday night!

Learning Disabilities

Learning disabilities are one of the barriers to learning that some students encounter. Having a learning disability does not mean that someone is dumb or lazy, it simply means that they have to put more effort into studying and behaving at school than others. All that this means is that they process information in a different way than other kids.

Students with learning disabilities are presented with a set of challenges including any of the following:

●     difficulty doing school work at their grade level

●     difficulty getting along with teachers and other students

●     behavior problems

●     depression

●     becoming sick due to personal or school problems

Students with learning disabilities are more likely to have poor marks, get into trouble because of their behavior and have trouble containing their emotions. These students can benefit from after-class or one-on-one help that recognizes their learning needs. The school can accommodate them and access additional help. How does one find out about having learning disabilities?

Students with LD may answer "yes" to most of the following questions:

●     Do you struggle in school?

●     Do you think you should be doing better than you are in school?

●     Is reading harder for you than it should be?

●     Does your head think one thing but your hand writes something else?

●     Is writing slow and tedious for you?

●     Do you make spelling and grammatical errors when you write?

●     Are you having difficulty with math?

●     Is it hard for you to keep your notebooks and papers organized?

●     Do you end up losing or forgetting them?

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Human Resources Planing

Human Resources Planning

The ongoing process of systematic planning to achieve optimum use of an organization's human resources. The objective of human resource (HR) planning is to ensure the best fit between employees and jobs, while avoiding manpower shortages or surpluses. 

The three key elements of the HR planning process are forecasting labor demand, analyzing present labor supply, and balancing projected labor demand and supply.

Essential Steps to Human Resources Planning

Human resources planning is the process of identifying current and future human resources needs. It involves securing the right people, building a supportive work environment and developing the capacity to ensure the organization’s success and a confident future for the Public Service.

STEP 1. Review Your Business Goals STEP 1. Determine your Business Goals First you need to have a clear understanding of where your organization is headed. q Review the government’s key priorities or emerging directions that could have an impact on your organization’s mandate q Review your organization’s business priorities, budget allocations and performance indicators

STEP 2. Scan the Environment   STEP 2. Scan the environment

Identify the external and internal factors that could affect your organization’s capacity to meet its objectives.

External Factors q Labour market trends q Current and projected economic conditions q Changes in legislation q Technological advancements q Cultural and social values	Internal Factors q Workforce composition (profile, trends, skills) q Changes in policy platform, guidelines, program delivery, organizational structure q Government-wide initiatives, such as diversity and employment equity; official languages; training,  learning and development; values and ethics; workplace well-being
STEP 3. Identify the Gaps   STEP 3. Conduct gap analysis Based on Step 1 and Step 2, determine your organization’s current and future human resources needs. q Identify possible skills shortages in specific occupational groups or potential need for new skills q Identify possible need for succession planning and management q Ensure that you have met your obligations related to diversity and employment equity; official languages; training, learning and development; and values and ethics
STEP 4. Develop Your Plan   STEP 4. Set HR priorities to help achieve business goals Based on steps 1 to 3, determine the major human resources priorities and the strategies you will use to achieve the desired outcomes. q Include human resources priorities and key planning issues in your organization’s Report on Plans and Priorities q Factor in budgetary considerations into your human resources plan q Communicate your human resources plan to all employees and stakeholders and engage managers in its implementation
STEP 5. Measure Your Progress   STEP 5. Measure, monitor and report on progress The human resources plan is an evergreen document. Key to successful implementation is constantly measuring, monitoring and reporting on progress, and responding to changing circumstances. q Ensure human resources performance measures are aligned with indicators in the Management Accountability Framework and the People Component of the same Framework q Establish a process that allows for regular review, adjustments and communication of changes Sri Lanka Society for Medical Laboratory Science http://slsmls.org/  kumudeshr@gmail.com