Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
Acute blood pressure asymmetric dimethylarginine in patients with chronic heart failure order mildronate mastercard treatment lung cancer. Nitrite anion provides potent cytoprotective and anti- acid activates dimethylarginine dimethylaminohydrolase in cul- apoptotic effects as adjunctive therapy to reperfusion for acute tured endothelial cells discount mildronate 500 mg mastercard medications for migraines. Effects of alpha-lipoic acid on the sion of sodium nitrite protects brain against in cheap mildronate 250mg on line symptoms for bronchitis. Two different approaches to restore renal nitric ox- Assymetric Dimethylarginine in Clinical Setting Current Medicinal Chemistry, 2015, Vol. Olive oil polyphenols decrease blood pressure and ing treatment with tumour necrosis factor-alpha antagonists is not improve endothelial function in young women with mild hyperten- accompanied by changes in asymmetric dimethylarginine in pa- sion. Lack of association between asymmetric dimethy- Improvement of endothelial dysfunction in atherosclerotic rabbit larginine and in. Metabolism, 2009, 58(3), tic study of a class of protein arginine methylation inhibitors. Elevated plasma asymmetric dimethyl-L- tive stress in cardiovascular diseases: possible therapeutic targets? L- tonin improves cardiovascular function and ameliorates renal, car- arginine as a nutritional prophylaxis against vascular endothelial diac and cerebral damage in rats with renovascular hypertension. Long-term L-arginine supplementation improves larginine in young rats with bile duct ligation. Melatonin blocks oxidative stress-induced in- ers in cardiovascular disease: a novel therapeutic target. Nitric Oxide, 2010, larginine attenuates the association of melatonin secretion with 23(1), 34-41. Pharmacoki- Resveratrol supplementation: Where are we now and where should netic and pharmacodynamic properties of oral L-citrulline and L- we go? Short-term effects of L-citrulline supple- methylaminohydrolase/asymmetric dimethylarginine pathway. Effects of oral L-citrulline resveratrol in restoring endothelial cell dimethylarginine dimethy- supplementation on lipoprotein oxidation and endothelial dysfunc- laminohydrolase expression and activity after high-glucose oxida- tion in humans with vasospastic angina. Liver X receptor and farnesoid X receptor as therapeu- tor cells in patients with type 2 diabetes mellitus: role of dimethy- tic targets. Coordinated regulation of dimethylarginine di- in human blood vessels: relationship to endothelial dysfunction, methylaminohydrolase-1 and cationic amino acid transporter-1 by clinical and genetic risk factors. Assymetric Dimethylarginine in Clinical Setting Current Medicinal Chemistry, 2015, Vol. Is asymmetric larginine-dimethylaminohydrolase1 is reduced in cirrhosis and is a dimethylarginine responsible for the vascular events in patients un- target for therapy in portal hypertension. Unexpected effect of rosclerosis risk due to the homocysteine-asymmetric dimethy- proton pump inhibitors: elevation of the cardiovascular risk factor larginine-nitric oxide cascade in children taking antiepileptic drugs. Vitamin B6 intake and supplementation improve some immune Vitamin B6 functions in vitamin B6-deﬁcient humans and experimental animals. A possible mechanism involved is Inﬂammation Kynurenines mobilization of vitamin B6 to the sites of inﬂammation where it may serve as a co-factor in pathways Sphingosine 1-phosphate producing metabolites with immunomodulating effects. Animal products mostly contain tissues or cells or passing the bloodebrain barrier. Most reactions are part of amino acid synthesis to these parameters in healthy controls (Huang et al. As well as functioning as a co-factor, vitamin B6 has been associated with indices of immune response (Huang et al. Supplementation of critically ill patients who had Isolated dietary vitamin B6 deﬁciency is rare in developed systemic inﬂammation with high dose pyridoxine caused no countries, but lowcirculating vitamin B6 has been reported in users (Quasim et al. However, it has been conjectured that sys- have been investigated in well-controlled metabolic settings as a temic inﬂammation, as measured by elevated C-reactive protein function of variable vitamin B6 status. The immune indices were normalized upon vitamin B6 including cancer of the ventricle (Eussen et al. The association was sociations were essentially upheld after supplementationwith high strongest for lung cancer (Zuo et al. Glucocor- the main enzyme responsible for catabolism of dietary Trp and ticoids may have profound effects on vitamin B6 metabolism and maintenance of Trp homeostasis (Ball et al. Vitamin B6 and inﬂammatory pathways with a similar genomic structure (43% homology) and adjacent chromosomal localization, but with different tissue distribution 7. The pathway includes a variety of metabolites, collectively termed kynurenines, some of which are neuroactive compounds and some have immunomodulatory effects. Biological effects from metabolites Early hypotheses suggested that activation of Trp catabolism 16 P. Kyn has speciﬁc roles, such as being an endothelium- neurons and astrocytes, and induction of seizures. Kynurenine pathway metabolites and vitamin B6 status superoxide anions and peroxynitrite (Lugo-Huitron et al. Kynurenine pathway metabolites and chronic diseases transmission/neuromodulation (Gobaille et al. It is a metal- conditions characterized by involvement of immune activation in chelating (Murakami et al. Such activation causes Trp (Roberts, 2001) compound with antioxidant (Christen et al. These properties have been related to its numerous disorders, including neurodegenerative diseases (Parrott possible role in cataractogenesis (Roberts, 2001), lens epithelial cell and O’Connor, 2015), depression (Meier et al.
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When antihypertensive treatment leads to the regression of left ventricular hypertrophy order 250mg mildronate otc symptoms prostate cancer, the incidence of atrial fbrillation decreases generic 250mg mildronate otc medications and grapefruit. Hypertension in Special Groups 71 both symptom relief and prevention of cardiovascular events cheap mildronate 500mg otc symptoms 3 days after conception. Cilostazol has been shown to be useful especially in the elderly with disabling peripheral arterial disease. Hence all antihypertensives currently used can reduce cardiac hypertrophy through sustained control of blood pressure. Calcium channel blockers in particular, provided signifcantly better protection against stroke compared with diuretics and/or ß-blockers in Asian263(Level 1) and Caucasian115(Level 1) populations. In the elderly264(Level 1) and very elderly113(Level 1) hypertensives, diuretics has been shown to prevent stroke. Existing antihypertensive medications during the acute phase of stroke should be deferred until patients have suitable enteral access and are medically and neurologically stable. They were randomly assigned to blood pressure reduction with intravenous nicardipine to achieve systolic pressures in the range of 140 to 179 mmHg (standard care) or 110 to 139 mmHg (intensive blood pressure lowering). Unfortunately, it did not show any signifcant outcome in mortality and functional recovery. There were signifcantly more renal adverse events within 7 days after randomisation in the intensive-treatment group. Of those who survived at 10 years, almost a third had poor range of clinical outcomes. The defnition of hypertension in the older adult (>65 years old) is the same as that of the general adult population. Hypertension is an increasingly important public health concern as our population ages. The prevalence of hypertension in adults >65 in Malaysia has been reported to be 71. The term ‘hypertension in older adults’ itself causes some diffculty as it encompasses the age groups of the ‘young- old’ (65-70 years) to the ‘old-old’ (>80 years). This group of patients is extremely heterogeneous with regards to comorbidities, frailty, and physical and cognitive functioning. There are numerous challenges including multiple comorbidities, postural hypotension, falls, functional and cognitive impairment and frailty. There is limited evidence from randomised controlled trials to guide management of hypertension in this group of patients. Hypertension in midlife (40-65 years old) has been found in longitudinal studies to be a risk factor for developing cognitive decline in later life. Hypertension predisposes mainly to development of vascular cognitive impairment, but has also been found to be a risk factor for Alzheimer’s pathology. Observational studies have also demonstrated the importance of frailty status on hypertension and outcomes. We advocate multiple readings using an automated offce blood pressure monitor after up to 3 minutes of quiet rest. Evaluation of older patients with hypertension should not differ from that of younger adult populations. In cases of resistant hypertension, secondary causes such as atheromatous renal artery disease should similarly be ruled out. Hypertension in Special Groups Where appropriate, one should consider a formal frailty assessment using one of the validated tools. Individualised decision in the context of comorbidities and patient tolerance to medication(s) is important. Therapy should be started cautiously with monotherapy at a low dose and titrated upwards slowly. Initiation with combination therapy is not encouraged and considered only after failure of initial therapy. There is evidence that de-prescribing does not result in an increase in mortality in this group of patients. Non-pharmacological Management (refer to chapter 4) Non-pharmacological interventions, particularly sodium restriction and weight loss, have been proven to be effcacious in the older adults. Managing blood pressure in isolation is not conducive to achieving a patient-centered approach. Healthcare providers must be mindful that in older adults, additional aspects must be considered before starting therapy. These include frailty, physical and cognitive functioning, and tolerance to treatment. Nevertheless, this warrants close observation, especially if proteinuria and hyperuricaemia are also present. Liver disease: raised transaminases and/or severe right upper quadrant or epigastric pain iv. Gestational hypertension is defned as hypertension detected for the frst time after 20 weeks gestation. Chronic hypertension is hypertension diagnosed prior to 20 weeks gestation or presence of hypertension preconception, or de novo hypertension in late gestation that fails to resolve three months postpartum. An obstetrician should lead the joint management of women with hypertensive disorders in pregnancy. Preconception counseling and adjustment of treatment in women with chronic hypertension.
Make sure before you do surgery that the menorrhagia who don’t suffer from infertility or woman does not have cervical cancer purchase mildronate online medicine ball core exercises, because the recurrent miscarriage (as these groups would profit surgery can become disastrous if she has! Pelvic anatomy for abdominal hysterectomy and myomectomy (Figure 3) Surgical treatment Important surrounding structures which are prone Indications for surgical treatment are the following: to injury and thus have to be identified are: • Menorrhagia unresponsive to medical treatment • Urinary bladder anteriorly generic 500mg mildronate with visa medications used to treat schizophrenia. Supporting structures of the uterus are the follow- • Other symptoms interfering significantly with ing mildronate 500 mg on line medications known to cause pill-induced esophagitis. It is important to ovarian ligaments with ovarian branch of the thoroughly examine women with recurrent preg- uterine arteries. The most important ones are listed below: • Intraoperative blood loss with the need of blood Myomectomy transfusion. Myomectomy means the excision of fibroids from • Postoperative infection with consecutive tubal the myometrium without removing the uterus. Depending on the site, number and Although this seems to be a rare event with a size of the fibroids, a vertical incision might be low incidence of around 0. If you feel, however, risk depends on: that a vertical incision is necessary due to size and N number, site and size of fibroids number of fibroids you should consider again N surgical technique whether you have the skills to do the operation as N perioperative infection these myomectomies need advanced experience N intraoperative opening of the uterine cavity and skills. N the capability of healing of the patient’s tissue Fibroids easily accessible to abdominal myo- N time elapsed since operation. These figures, however, are for mural part, as otherwise they can’t be located laparoscopic surgery, a method which will be abdominally during the operation. It is very important to consider that for patients All other patients becoming pregnant after myo- with infertility, recurrent miscarriage and desire for mectomy have to deliver in hospital, with theatre future pregnancies, a lot is at risk when undertaking facilities available 24 h, under any circumstances. If a the operation, since you are never sure if you can woman is not ready for this prior to surgery, myo- avoid a hysterectomy beforehand. Please be aware of the fact that the biggest cause of subfertility in low-resource Adverse events settings is tubal blockage and you should rule this Although the uterus is preserved, myomectomy is a out before surgery in patients who come with major abdominal operation and has as such adverse fibroids and a history of infertility (see Chapter 16). It is always wise to examine the patient yourself as the intraoperative placement of tourniquets is a surgeon, before the operation and again while she an effective method but you have to be sure of the is already anesthetized. This method should only be chosen and position of the fibroids and the uterine mobi- where misoprostol or bupivacaine/epinephrine are lity you will have to decide whether you can use a 14 not available. The technique for applying tourni- transverse or vertical incision of the abdominal wall quets for reduction of hemorrhage in myomec- for your operation. Here it is important to consider tomy is as follows: the aim of the operation: most patients for myo- mectomy undergo the operation in order to be- • Incise the anterior part of the peritoneum come pregnant and deliver safely. Thus, you will between the bladder and the uterus and reflect need the best access to the fibroids and the uterus to the bladder inferiorly. Therefore it is some- side of the uterine isthmus cranial to the uterine times wise to consider a vertical incision especially arteries. If you are • Pass a 20-cm length part of sterile infusion set more experienced you can choose a horizontal in- through the holes and tie it tightly anteriorly cision like a Pfannenstiel or Joel Cohen incision. If around the cervix at the level of the internal there are few or a single smaller fibroid which is cervical os. A mini-lap is cheaper and needs a shorter hos- a small forceps to occlude the ovarian vessels. The final approach to the fibroids is not dependent the most important complication in myo- on the choice of skin incision or method for mectomy is hemorrhage with consequent anemia. Here is a stepwise approach: Intraoperatively this may impair your access to the former fibroid capsule and hamper uterine recon- • Increase access to the uterus by either packing struction resulting in a weak scar. Thus, you must the bowel with damp drapes or by putting the take measures to reduce bleeding. Although the • Inspect the uterus for size and site of the fibroids sample sizes of these studies were small, the in order to determine where to best place your Cochrane collaboration’s conclusion was that miso- uterine incision: prostol, bupivacaine with epinephrine, tranexamic N Incise where you will be able to ‘harvest’ the acid or a triple tourniquet have led to a significant most fibroids with one incision. N Posterior incisions might lead to intestinal Misoprostol is readily available in most resource- adhesions. In settings where spinal anesthesia know that for cesarean section scars a low in- is performed, bupivacaine 0. Inject 50 ml of bupivacaine ture15 but there is no stronger evidence for together with 0. Figure 4 Fibroid dissection from its bed Abdominal hysterectomy • If your incision is a low anterior incision, incise Definition the bladder peritoneum and reflect the bladder A hysterectomy is the removal of the uterus with or downwards. For uterine fib- • Incise the uterine serosa and myometrium at the roids this is usually done via an abdominal incision top of the protruding fibroid until you see its either transverse as the above mentioned Pfannen- particular whitish tissue. If an older lady has been fibroid to identify it and make sure you have postmenopausal for some years (i. How to remove your fingers and if necessary sharply with the dis- the ovaries and tubes is described in Chapter 28 on secting scissors or cauterizing forceps (Figure 4). The technique is described in Chapter 20 layers of interrupted single Vicryl-0 sutures to on the treatment of abnormal vaginal bleeding. There should be as little space left as mentioned indications for surgery in women with possible to reduce the possibility of hematoma a completed family planning history and no desire and further necrosis within the myometrium. In the case of high suspicion • Close the uterine serosa through running inverted of malignancy the latter criteria, however, can’t be Prolene (if not available: Vicryl-2–0 sutures). When fibroids are too numerous to remove, a hysterectomy can often not Vaginal myomectomy be avoided as reconstruction of the uterus will in- Occasionally a submucosal fibroid is ‘born’ through evitably fail. In this case a vaginal operation can be performed16: Adverse events • Put the patient in lithotomy position and dis- • Intraoperative blood loss with the need of blood infect vulva and vagina with iodine. Description of surgical technique of abdominal hysterectomy You should always stick to the operation steps described below until you are really experienced in this kind of operation. An interesting video clip on how to do an abdominal hysterectomy is available on the inter- net at:.
Whilst there was evidence that surgery was clinically beneficial in adults mildronate 250mg visa medications beginning with z, the committee did not feel it was appropriate to extrapolate these results to children and recommend its use without clinical evidence purchase mildronate us lanza ultimate treatment. In addition generic mildronate 500 mg visa medications causing hyponatremia, the committee expect that the better clinical outcomes demonstrated by surgery would be likely to lead to lower downstream medical costs due to better health and fewer complications. Therefore, the committee concluded that the additional costs of conducting surgery as the first-line treatment would be either partly or wholly compensated for by reductions in other costs, and any net increase in costs compared with current practice would be expected to be cost effective due to the better clinical outcomes for people undergoing surgery. Given the lack of clinical or economic evidence relating to children, the committee agreed to make a recommendation that further research be conducted. Other considerations the committee discussed what other considerations were important to highlight to clinicians; it agreed that people with hereditary pancreatitis and children with pancreatitis need to be looked at with special consideration and believe they should be discussed at a multidisciplinary meeting. The committee also wanted to highlight that it is important to discuss the use of endotherapy in a multidisciplinary meeting before using it as a treatment. The committee agreed that people with chronic pancreatitis being considered for intervention should be discussed and managed by a specialist pancreatic multidisciplinary team. Those with hereditary pancreatitis and children with pancreatitis present clinicians with a particular challenge. Subject to Notice of rights 256 Pancreatitis Management of small-duct disease in people with chronic pancreatitis 25 Management of small-duct disease in people with chronic pancreatitis 25. The pain is varied in nature, intensity, duration and severity along with acute exacerbations. Chronic pancreatitis related pain is also multifactorial, making it difficult to have a set standard regime of pain control that can work for every patient. This is further complicated by the long-term effects of pain at the spinal and central nervous system such as wind up and central sensitisation. Pain is not the only symptom people affected also develop gastro-intestinal symptoms and other psycho-social factors causing a reduction in quality of life such as unemployment, relationship issues, addiction to pain killers and financial difficulties. With time, they may develop a neuropathic component of pain in the form of viscero-somatic hyperalgesia. Pain secondary to pancreatic duct obstruction or small-duct disease may need to be investigated and treated with appropriate intervention such as endoscopy or surgery. Pain management starts with education on alcohol and smoking cessation and other life style changes. Opioids are commonly used in treating both chronic pancreatitis and acute exacerbation of chronic pancreatitis. The dose used in pancreatitis pain can be varied from “on demand” use to very high doses on a regular basis. There is strong emerging evidence that the long term use of opioids may cause harm. This is an online resource on appropriate use of opioids for patients, carers and healthcare professionals. The following reviews attempt to address the management of pain for people with chronic pancreatitis. Other interventions such as coeliac plexus blocks, splanchnic nerve blocks and radiofrequency denervation are currently utilised in managing this complex pain. Therefore, this aspect of pain management in chronic pancreatitis has not been addressed in this guideline. Evidence from this study is summarised in the clinical evidence summary below (Table 95) and data not suitable for meta-analysis are presented in Table 94. The aim of the study was to assess which intervention most effectively reduced pain and improved quality of life. The study was a non- randomised comparative study that compared the intervention arms of 2 different case–controlled studies. What is the most clinically effective and cost-effective intervention for recommendation managing small duct disease (in the absence of pancreatic duct obstruction, inflammatory mass or pseudocyst) in people with chronic pancreatitis presenting with pain? Relative values of the guideline committee noted the following outcomes to be critical: quality of life, different outcomes mortality, complications and pain. The committee also chose the following outcomes as important outcomes: length of stay, repeated procedures and pancreatic function. There was no evidence found for the following outcomes: mortality, serious adverse events, adverse events, return to usual activities and pancreatic function. Quality of the clinical One non-randomised controlled trial was identified for inclusion in this review. The evidence study compared videoscopic splanchnicectomy to neurolytic coeliac plexus block for the management of small-duct disease in people with chronic pancreatitis. The evidence provided by the non-randomised trial was graded as very low quality due to risk of bias and imprecision. Trade-off between the evidence provided by the study showed no important clinical difference clinical benefits and between the 2 interventions, but this was based on a small study with very low harms quality evidence that did not report all of the critical outcomes. Therefore, the committee felt it would be most appropriate to recommend further research into the most clinical and cost-effective method of managing small-duct disease in people with chronic pancreatitis. Trade-off between No relevant health economic evidence was identified for this question. Other considerations the committee discussed how difficult it would be to define the population included in the review for a clinical study, it noted that many people with small-duct disease may not be known to have chronic pancreatitis and this might be reflected by the lack of studies identified for inclusion in this review. Subject to Notice of rights 261 Pancreatitis Management of small-duct disease in people with chronic pancreatitis the committee discussed what other considerations were important to highlight to clinicians; it agreed that people with hereditary pancreatitis and children with pancreatitis need to be looked at with special consideration and believe they should be discussed at a multidisciplinary meeting. Subject to Notice of rights 262 Pancreatitis Management of pseudocysts 26 Management of pseudocysts 26.
250 mg mildronate fast delivery. Tri-State healthcare providers seeing more visits for flu symptoms.
Page 4 of 9 Hepatitis B immunisations – Q&A Hepatitis B immunisation for travel 1 discount mildronate express medicine 4839. However buy 500 mg mildronate fast delivery treatment action campaign, it is common practice to give this immunisation privately (for further information see Focus on travel immunisations) purchase 250 mg mildronate free shipping medicine guide. Can I charge for a private immunisation despite the Green Book recommending hepatitis B immunisation? Any single hepatitis B immunisation for travel can be given privately (but not in combined form). If there is a lifestyle issue then this is dealt separately in the section below; however if the immunisation is given for travel alone then the practice may charge - whatever the Green Book say. For example, a man who has sex with another man should receive hepatitis B protection as a lifestyle issue. If a travel risk assessment highlights that both of these immunisations are required, then the practice may decide that the benefits of fewer injections and increased compliance may make this a sensible alternative. Patients who have had hepatitis A immunisation in the past should never be given the combined immunisation just because they will not have to pay. Whose responsibility is it to provide hepatitis B immunisation for occupational health? If that risk assessment indicates that the employee is at risk then the employer is responsible for arranging immunisation. There is no obligation and the patient should be advised that it is the responsibility of their employer to organise hepatitis B immunisation. The employer or medical school can enter into a private contract with the practice to provide this service if they choose, or make alternative arrangements. There is no obligation and the patient should be advised that it is the responsibility of their employer to organise hepatitis B immunisation. The employer or medical school can enter into a private contract with the practice to provide this service if they choose, or make alternative arrangements. If the patient’s employer states that their risk assessment indicates that their employee (your patient) is at risk of hepatitis B and requests that the practice contracts with them to provide such an immunisation, then the practice can choose to do so. It must be clear that this is an arrangement between the practice and the employer and that the patient is not being charged. Giving hepatitis B for those at lifestyle or medical risk is not part of the additional service component of the global sum, and commissioners should ensure that proper arrangements are in place for this service to be provided, either within practices or elsewhere. The Green Book details those who should receive hepatitis B immunisations (see Appendix 1). Practices should be alert for patients at risk (which may include family members) and ensure that immunisation is advised for this group. Practices in England and Wales can give the immunisation from stock and claim reimbursement. Page 6 of 9 Further reading Green Book (Immunisation against infectious disease): immunisation. The behaviours that place them at risk will include sexual activity, injecting drug use, undertaking relief aid work and/or participating in contact sports. Travellers are also at risk of acquiring infection as a result of medical or dental procedures carried out in countries where unsafe therapeutic injections (e. Individuals at high risk of requiring medical or dental procedures in such countries should therefore be immunised, including: ● those who plan to remain in areas of high or intermediate prevalence for lengthy periods ● children and others who may require medical care while travelling to visit families or relatives in high or moderate-endemicity countries ● people with chronic medical conditions who may require hospitalisation while overseas ● those travelling for medical care. This includes any staff who are at risk of injury from blood-contaminated sharp instruments, or of being deliberately injured or bitten by patients. Close contact and the possibility of behavioural problems, including biting and scratching, may lead to staff being at increased risk of infection. Similar considerations may apply to staff in day-care settings and special schools for those with severe learning disability. In settings where the client’s behaviour is likely to lead to significant exposures on a regular basis (e. Immunisation is also recommended for all prison service staff who are in regular contact with prisoners. Hepatitis B vaccination may also be considered for other groups such as the police and fire and rescue services. In these workers an assessment of the frequency of likely exposure should be carried out. For other groups, post-exposure immunisation at the time of an incident may be more appropriate (see below). Such a selection has to be decided locally by the occupational health services or as a result of appropriate medical advice. Under Health and Safety Regulations, your employer has a duty to provide a safe working environment and, therefore, appropriate health advice for those at risk of infection with hepatitis B. We advise you to contact your employer who will be able to make arrangements with an occupational health provider for the provision of any immunisation which you may require following an appropriate assessment of the risk to which you are exposed. Under Health and Safety legislation employers have a duty to provide a safe working environment. Employers should undertake a risk assessment and arrange protection for employees, including, where necessary, immunisation against hepatitis B. If an assessment reveals a risk the employer has a duty to act and should make arrangements with a suitably qualified medical service to meet the relevant obligations. It is therefore inappropriate for us to proceed with the immunisation and I have asked your employee to return to you so that you can deal with this appropriately. A diagnosis of hepatitis is usually made by detection of biochemical abnormalities in the blood, in particular measuring enzymes released from liver cells (hepatocytes) damaged by infammation. Hepatitis is usually diagnosed when one (or more) of these enzymes is raised above normal ranges in the context of other results. In recent years recommendations have emerged suggesting these ranges are too high and may miss individuals with mild hepatitis.