Myofascial Triggger Point Essay Example for Free

Myofascial Triggger Point Essay This chapter is the review of the available literature concerning the theoretic content that is necessary to understand the trapezius muscle and its role in the symptoms associated with upper back pain. Particularly the issues about the types of trigger points, including a discussion of myofascial trigger point therapy and acupuncture trigger point therapy. More importantly the awareness and understanding on how to improve the quality of life by learning about the alternative options, making changes and applying self-help strategies on myofascial trigger points. Given this points, a brief description of the topics are noted: It is painful to say that about 23 million persons, or 10 percent of the U. S. population, have one or more chronic disorders of the musculoskeletal system (Imamura, Fischer, Imamura, Teixeira, Tchia Kaziyama, (1997). The most common reason for the breakthrough of pain and rigidity in the head, neck and shoulder is the development of myofascial trigger points (MTrPs) activity in those areas. Factors responsible to set in motion trigger point in the muscles of the neck and shoulder region include postural disorders, drooping of the shoulder girdle, direct and indirect overloading of the neck muscles, acute trauma to the neck and anxiety (Baldry, 2002). For instance, the muscle most often affected by MTrPs is the trapezius muscle. Any position or task that requires the shoulders to carry out the weight of the upper extremities repeatedly or for prolonged periods of time overloads the upper trapezius muscle, and strongly boosts the development of MTrPs (Mense, 2001). Incidentally, MTrPs extremely common and became a painful part of nearly everyone’s life at one time or another. ), the upper trapezius active MTrPs are common in patients presenting neck pain (Simons Travell 1999). Surprising statistics suggested that neck pain has a lifetime incidence of 45%-54% in the general population (Fernandez-de-las-Penas, Alonso-Blanco Mangolarra, 2007). Trigger points are tender to direct pressure or squeezing, they are painful and they are palpable as hard nodules. Rachlin, 2005). In fact, Simons Travell (1999) has described pain due to TrPs is a cause of pain in all parts of the body and it has been reported as a source of pain in numerous medical conditions. Patients presenting mainly with upper body pain or headaches are more likely to MTrPs pain than patients presenting with pain located elsewhere (Rachlin, 2005). Indeed, therapy for MTrPs has been used by Bilkstad and Gemmell, (2008) with anecdotal success in patients with non-specific neck pa in. Gemmell and Allen’s (2008) study also proved that a session of trigger point therapy, has a clinical meaningful effects in the treatment of acute trigger points of the upper trapezius muscle. Certainly acupuncture for MTrPs is an effective and efficient technique for the treatment of myofascial pain and dysfunction. That is, an acupuncture needle is inserted through the skin and moved gently up and down through the MTrPs. The effect is to de-activate the trigger point and relax the muscle according to Travell and Simons (1999). Furthermore, studies of neck pain have proposed that manipulation is an effective therapy, especially when combined with exercise (Rubinstein, Leboeuf-Yde, Knol, de Koekkoek, Pfeifle van Tulder, 2008). Gatterman (2005) stated that chiropractic treatment of the spine has a relaxing effect on the spinal muscle and a loosening effect on spinal articulations, hence making a difference in a number of ailments drawn by cervical structure. Historical Background Review  Back to 1816, British physician Balfour, as cited by Stockman, described â€Å"nodular tumors and thickenings which were painful to the touch, and from which pains shot to neighboring parts† (Stockman, 1904 p. 107-116). In 1841, trigger points have been documented in western medicine research. In the European literature, regional musculoskeletal pain conditions have been documented since the 18th century (Reynolds, 1983). Dr. Janet Travell (1901-1997) is generally credited for bringing MTrPs to the attention of healthcare providers. MTrPs have been described and rediscovered for several centuries by various clinicians and researchers as far back as the 16th century, de Baillou (1538-1616), Ruhmann (1940) described what is now known as myofascial pain syndrome (MPS). Bron Dommerholt, ( 2012, p. 1) acknowledges, myofascial pain syndrome is defined as the â€Å"sensory, motor, and autonomic symptoms caused by Mypfascial Trigger Points†, and has become a recognized medical diagnosis among pain specialists. The first trigger point manual was published in 1931 in Germany nearly a decade before Dr.  Janet Travell became interested in MTrPs These early descriptions and other historic papers did illustrate the basic features of MTrPs quite accurately (Simons, 1975). In 1966, Dr. Travell founded the North American Academy of Manipulative Medicine, together with Dr. John Mennell, who also published several articles about MTrPs (Mennell, 1976-1989). In the early 1960s, Dr. David Simons was introduced to Dr. Travell and her work, which became the start of a fruitful collaboration eventually resulting in several publications, including the Trigger Point Manuals (Simons Travell 1999). The Trigger Point Manuals are the most comprehensive review of nearly 150 muscle referred-pain patterns based on Dr. Travell’s clinical observations, and they include an extensive review of the scientific basis of MTrPs. Both volumes have been translated into several foreign languages. These books are considered the definitive reference on myofascial pain and locating trigger points. Trapezius Muscle This diamond shape muscle is situated in the neck and upper part of the back and lies most superficially (Moore Dalley, 2006). It was given its name because the muscles of the two sides form a trapezium. The main action of the trapezius is to aid in head, neck and the clavicle movement. The trapezius commonly contains trigger points, and referred pain from these trigger points bring patients to the office more often than for any other problem. Figure 2. 1 shows the trapezius- a large kite-shaped muscle, covering much of the back and posterior neck. There are three main parts to the muscle: the Upper, middle, and lower part. Each part has its own actions and often different functions. Figure 2. 1 Trapezius Muscle Namely the upper portion of the trapezius muscle laterally flexes the head and the neck towards the same side, and assists in extreme rotation of the head so that the face turns to the opposite side. It can draw the clavicle backwards and raise it by rotating the clavicle. It usually helps to carry the weight of the upper limb during standing, or support a weight in the hand with the arm hanging. Acting bilaterally, the upper fibers extend the head and the neck . The upper trapezius can reflect headaches on the temples, dizziness, severe neck pain, intolerance to weight on your shoulders. While the middle trapezius reflects pain on the mid-back, headaches at the base of your skull and superficial burning pain close to the spine. On the other hand lower trapezius on the mid-back refers pain to the neck, and/or upper shoulder region (Simons Travell, 1999). Figure 2. 2 Trapezius Trigger Points Myofascial Trigger Points The word myofascial means muscle tissue (myo) and the connective tissue in and around it (fascia). According to the most commonly accepted theory, a myofascial trigger point ( Figure 2. ) is an area of hypersensitivity in a taut band, or contraction knot of skeletal muscle with respect to pain (Simons, et al. , 1999), as opposed to healthy muscle, which does not contain taut bands or trigger point (Shah, et al. 2005). The trigger point feels like a pea embedded within the muscle to the touch. A trigger point is always tender and becomes painful, like contracted knots that refers pain and tightness upon direct compression and is mediated by a local twitch response (Hong, 2006; Simons et al. , 1999; Simons, 2004). Auleciems (1995) furthermore researched the incidence of MPS, reported to be as high as 85% at certain American pain clinics. Figure 2. 3 Myofascia Trigger Point Taut Band Myofascial Trigger Point Development There are existing studies to account for the development of trigger points and subsequent pain patterns, but scientific evidence is lacking. Many researchers concur that an acute injury or repetitive small injuries may lead to the development of a trigger point which creates some degree of tissue damage (Rachlin, 2005). The damage to muscle and connective tissue can befall several ways. From lack of exercise, prolonged poor posture, vitamin deficiencies, sleep disturbances, and joint problems (Simons Travell, 1999). Examples of predisposing activities such as typing/moussing, handheld electronics, gardening, home improvement projects, work environments, holding a telephone receiver between the ear and shoulder to free arms; prolonged bending over a table; sitting in chairs with poor back support, improper height of arm rests or none at all (Simpson McCarthy, 2001); sustained loading as with heavy lifting, carrying babies, briefcases, boxes, wearing body armor or lifting bedridden patients. Injury from falling down stairs or whiplash injury in a motor vehicle accident (Lavelle, Lavelle, Susti, 2007). Myofascial Trigger Point Classification Trigger points are classified as being active or latent. The active, painful phase of the trigger point is the one which motivates people to seek relief. The active trigger point hurts when pressed with a finger and causes pain around it and in other areas. (Hong, 2006; Simons, 2004). The active trigger point referral symptom may feel like a dull ache, deep, pressing pain, burning, or a sensation of numbness and fatigue. If unaddressed or ineffectively treated, eventually other muscles around the dysfunctional one become stressed and develop secondary trigger points. It is not unusual for chronic pain patients to have multiple, overlapping referred pain patterns, making diagnosis and treatment more complex. Trigger points can also lie quietly in muscles, sometimes for years. This type of trigger point is called latent. Latent trigger points are very common. Probably one wont know they are there for the fact that they cause pain unless it is compressed. Latent trigger points cause restricted movement, distorted muscle movement patterns; stiffness and weakness of the affected muscle (Fricton, Kroening, Haley Siegert, 1985). When firm pressure is applied over the trigger point in a snapping often causes the muscle to â€Å"jump† or briskly contract a â€Å"local twitch response† (Simons et al. , 1999). The reaction of a twitch response during palpation of a trigger point, or during a trigger point release procedure, is a reliable confirmation that the trigger point has been accurately located. When a trigger point in one muscle can create pain in another area it is known as referred pain. This referred pain is felt not at the site of the trigger-point origin, but remote from it (Mense Schmit, 1977). For example (Figure. 2. 4), a primary trigger point in the upper trapezius muscle refers pain to the temple region of the head. All muscle tissue is potentially prone to developing trigger points. Fig. 2. 4 Referred Pain from Trapezius Trigger Points Treatment of Myofascial Trigger Points As a matter of fact treating each trigger point is relatively simple. Treating the whole myofascial pain syndrome so that pain fully goes away is a more complicated process. Pharmacologic treatment of patients with chronic muscle pain includes analgesics and medications to induce sleep and relax muscles. Antidepressants, anti-inflammatory drugs are often prescribed (Imamura et al. , 1997). The long-term clinical efficacy of various therapies is not clear, because data that incorporate pre- and post-treatment assessments with control groups are not available. No laboratory test or imaging technique has been established for diagnosing trigger points (Fricton et al. , 1985). However, the use of ultrasonography, electromyography, thermography, and muscle biopsy has been studied. A variety of hands-on skills, such as stretching, massage, manipulation, mobilization and strengthening (Simons, 2002), and a wide variety of modalities namely, diathermy, transcutaneous electrical nerve stimulation, ethyl chloride Spray and Stretch technique, dry needling, and trigger-point injections with local anesthetic, saline, or steroid heat, ice, ultrasound, electrical stimulation, mechanical pressure and light energy, are available to physicians and therapists for the treatment of trigger points (Edward Knowles, 2003). For instance trigger point therapies can help specifically a number of health issues such as: 1) Relieve migraine and headache 2) Alleviate low-back pain and improve range of motion Ease dependence over the counter or prescription medication 3) Release endorphins that work as the bodys natural painkiller 4) Enhance immunity by stimulating the bodys natural defense system. 5) Increase blood flow to bring oxygen (Dommerholt Huijbregts (2011, p. 18 ). The proposed principle of treatment of MPS is to inactivate the active MTrPs through the use of various therapeutic modalities (Hong, C. 2000). However, the various treatments are beyond the scope of this study, the main focus here is to determine the efficacy of acupuncture and myofascial trigger point therapy for upper back pain. Acupuncture Trigger point pain may result from old or new injuries, excessive work out, incorrect body mechanics and poor body posture. In this light, acupuncture treatments can help return the balance to muscles. It is one of the safest ways to address physical problems. Using FDA-approved grade of acupuncture needles, it stimulates the muscle fibers, generating involuntary twitching of muscles located on the suspect trigger point (Figure 2. 5). Usually leads to an immediate reduction of the tightness as well as a reduction or elimination of the related problems (Scholar Hong, 2000. Aside from relieving muscles from stress, acupuncture treatment releases endorphins, boosts the nervous system, enhances the immune system, and causes a number of other biochemical and hormonal changes (Napadow, Webb, Pearson, et al. , 2006). Acupuncture is a time proven and safe method to optimize health. In restoring balance to brain and nervous system functions, it helps regulate blood pressure, blood flow and body temperature, which is indirectly beneficial to managing and relieving body stressor (Birch, Hesselink, Jonkman, et al. , (2004).

Education Beyond Undergraduate Essay -- Masters Graduate School Essays

Education Beyond Undergraduate Graduate or professional education is an often-debated topic for a large number of University seniors. Regardless of the undergraduate degree many students must decide whether to enter the job market or go to school for another couple of years. When these students are faced with this decision it is important to look at what they consider. Is it job satisfaction, future pay, or the mere fact that they want to spend a few more years in college? These issues are all very important to students in very different manners. An important reason students consider continuing their education beyond their undergraduate degree is job satisfaction. Through my marketing classes, I have learned that my generation (generation X) is more concerned with their job satisfaction than compensation or benefits. Was job satisfaction a motivator in my decision to continue my education beyond graduate school? Definitely, I feel that with the graduate degree I plan to receive will enable me to attain a job that will make me happy. I think that this is something all college students think about when they try to pick a major in college. If I am satisfied with my job when I get into the â€Å"real world,† it will not matter to me what pay I receive. Is it possible that there are students who decide to continue their education just for the difference in pay they receive? I truly think it is. It is important to consider how students that go beyond an undergraduate degree pay for their schooling. As a person who is planning to go through Law School, I think that whether or not a person goes beyond undergraduate depends on how hard they struggled financially during their undergraduate schooling. I feel that if th... ...hings are very important to a lot of people. A large number of people want to receive an education that gives them a better shot at being economically stable in the future. It is very important for students to consider an education beyond undergraduate. I believe that many students are faced with this decision at the end of each school year. It is also viable to believe that these three items in this essay are of great significance to these graduating seniors. When a student spends four to five years in undergraduate school, they feel worn out and feel that school is the last place that they want to be. But, after considering some of these facts, they may feel that a graduate or professional education is exactly what they should do whether they look at future job satisfaction, future compensation, or just want to spend a few more years with their friends.

Succubus Dreams CHAPTER 16

As I walked into my building after dropping Seth off, I was surprised to see the guy who staffed the front desk still working. He usually went home at dinnertime. A sheaf of papers in his hands indicated some sort of mandatory overtime. He brightened when he saw me. â€Å"Miss Kincaid! I have something for you.† I blanked for a moment, then remembered the daily Post-it reminders on my door. There'd been a total of three now. â€Å"Oh, yeah,† I said. â€Å"Sorry I haven't had a chance to pick it up yet. I keep forgetting.† He was already rustling around for something behind him on the other side of the window. I strolled over, just as he heaved a huge box up onto the counter. The printing on the side was upside down, but I could still make it out: Christmas Tree – Austrian Fir. â€Å"Oh, man,† I grumbled. â€Å"This is somebody's idea of a – â€Å" But the guy was busy hauling another box up to the counter, a smaller one with pictures on the side depicting the ‘pre-decorated fiber optic tree' inside. It was followed by another box, a bit smaller than the Austrian Fir, and a smaller one still that was about two-by-two feet. These last two boxes were wrapped in glittery green paper, with a wrapping job so perfect that only one being on earth could have managed it: Peter. The desk guy surveyed the boxes. â€Å"You must really like Christmas.† â€Å"I thought each of those notes was a reminder for the same package.† â€Å"Nope. New one each day. Want some help?† We hauled the trees up to my apartment and deposited them on the living room floor. I thanked him, and as soon as he left, Aubrey emerged and began stalking the boxes. â€Å"That's a lot of tannenbaum,† a voice behind me suddenly said. I jumped and turned around. Yasmine. â€Å"Don't do that. Carter does exactly the same thing.† â€Å"Sorry,† she said, looking sheepish. â€Å"Wasn't intentional. I just got here.† She walked over to the boxes, tilting her head to read them. She wore jeans and an LSU sweatshirt, her black hair pulled into the trademark ponytail that made her look seventeen. â€Å"What's up with all these?† I took off my coat and flounced onto the couch with a sigh. â€Å"My friend Peter started this whole buzz that I needed a Christmas tree after Carter burned mine down. So I guess everyone made good on it.† â€Å"Wait,† she said. â€Å"Did you say Carter burned down your Christmas tree?† â€Å"Yeah, it's a long story.† â€Å"He must feel bad.† She pointed to the little fiber optic tree, the one that was already decorated. Words were scrawled on the side of the box in spidery, nearly illegible writing: G – Figured you could handle this one. Ready and decorated! – C P.S. – And flame retardant. â€Å"Hmm,† I mused. â€Å"‘C' could be Cody too.† â€Å"Nah. I recognize the poor attempt at penmanship. It's Carter.† â€Å"Okay, so the angel repents. But who are the rest from?† We soon found out. The wrapping job on the two matching boxes had already given Peter away. The larger box contained a very beautiful, very expensive tree with ‘winter moss green' needles that were lightly dusted with silver glitter. The smaller box contained a matched set of lights and ornaments all done in purple and fuchsia. Peter apparently hadn't trusted me to decorate his gift myself. The Austrian Fir turned out to be from the bookstore staff. A card from Maddie read: Surprise! We all pitched in for it. Now you can't be a Scrooge. It was signed by other store workers, as well as Seth. I looked back and forth between the boxes. â€Å"It's a Christmas miracle. I had no tree. Now I have a forest.† â€Å"C'mon,† said Yasmine. â€Å"I'll help you set them up.† I looked at her in surprise. â€Å"Aren't you here to meet up with Vince or something?† She shook her head. â€Å"I'm here to talk to you.† Uh-oh. I didn't really want to set up the Christmas trees, but a being vastly more powerful than me did, so I set to it. Carter's tree was the easiest since all I had to do was plug it in. I placed it in a window sill, one with an outlet right underneath. The tree's fiber optic needles lit up to pale pink, then purple, then teal, then white. â€Å"Good God,† I said. â€Å"It's the Christmas tree equivalent of a lava lamp.† â€Å"I like it,† declared Yasmine. â€Å"It's got moxie.† She looked really excited. She could have been a kid on Christmas morning. You'd think after seeing so many Christmases (and trees) in her existence, they'd get kind of old. She pointed at Peter's tree. â€Å"Let's do the prissy one now.† We were stringing purple lights on the ‘winter moss green' tree when she finally started The Talk. â€Å"So. Vincent told me what happened.† She paused as she looped the lights over a branch. â€Å"I'm glad your guy is okay.† â€Å"Me too. He was lucky†¦if Vincent hadn't been there†¦Ã¢â‚¬  More silence. I didn't entirely know where Yasmine was going with this. My guess was that she was concerned I'd tell someone about Vincent. I felt absolutely certain, however, that she wasn't going to threaten to break my kneecaps or anything to keep me silent. In fact, I realized then that what she wanted was reassurance. It was a crazy and startling idea. She was an angel, after all. A being of hope and peace, a being that others prayed to for comfort. Yet, here she was, seeking it from me – a creature of Hell. â€Å"I meant it,† I told her. â€Å"What I said to him. I'm not going to tell anyone.† â€Å"I believe you,† she said, confusion all over her face. Angels knew when others were telling the truth. â€Å"But I don't understand it. Why? Why wouldn't you? You could get into big trouble if your superiors – if Jerome – found out you knew and weren't telling.† Vincent had said the same thing. It was true. â€Å"Your people tend to get pissed off over stuff like that.† â€Å"What, and yours don't? Would they be forgiving if they found out?† She looked away from me, diverting her attention to hanging a pink glass dove. â€Å"Look,† I said. â€Å"I work for Hell, but I don't, like, delight in others' suffering. Especially since I like both of you. I don't want to see you get into trouble. I don't even think what you're doing is wrong. Dangerous, maybe, but not wrong.† â€Å"Which part? The loving part or the nephilim part?† I shrugged. â€Å"It's all risky.† She smiled at me. â€Å"You talk about nephilim pretty calmly. Most people – in our circles – go running for the hills.† â€Å"I met one once. Dated him.† I hung a bejeweled purple orb on the tree. â€Å"He was scary as hell, yeah. Had this whole homicidal revenge thing going on, which kind of negated his sexiness a little. But at the end of the day†¦I don't know. He wasn't much of a monster. He couldn't help being born what he was.† I was glad to be free of Roman, glad he was somewhere far away from me. He'd posed too much of a threat to both me and those I loved. Still, there had been something in him I found appealing. It was why we'd connected before things literally blew up. I understood his weariness with the games Heaven and Hell played. He'd offered to take me away and free me from it all, and there were days I would still wake up and long for that. â€Å"No,† Yasmine agreed. â€Å"They can't help what they are. And it's not their fault. But their existence is a reminder of our faults†¦of our weaknesses.† She held her hands open in front of her, studying them as though they held answers. â€Å"None of us higher immortals want to be shown that we're weak. That's our hubris, I guess. Especially the angels. No one's perfect, but we like to play that we are.† She sighed and let her hands drop. â€Å"I should walk away from this. I should have a long time ago.† I jerked my head up. â€Å"But you love him.† â€Å"Sometimes loving someone means you have to do what's ultimately good. What you need instead of what you want.† â€Å"I suppose. But ending it seems so extreme. There must be a way to†¦I don't know, have it all.† The door opened, and Vincent walked in. He didn't look surprised to see either of us, but then, he would have sensed our auras. His eyes met Yasmine's, and it was like lightning crackling through the room. Both of them lit up, shining in a way that I doubted my succubus glamour could even begin to compete with. He expressed surprise over my Yuletide Forest but jumped in to help us, appearing just as excited as Yasmine over the activity. The two of them never touched, but I noticed the same thing that I had at breakfast: an intimacy in the way they interacted with each other. They didn't need to touch. Their relationship was obvious, and I wondered how it was possible none of the other angels had ever noticed this. Maybe it was like what Yasmine had mentioned about angels and hubris. Maybe angels always assumed they were perfect and were too blind to see flaws in each other, whereas someone like me – who exploited weakness – knew what to look for. We finished Peter's tree, and then I found my ornaments from last year – the ones that hadn't been destroyed in the fire – and used them on the bookstore's tree. When my woodland paradise was finally complete, Yasmine and Vincent made their farewells and left. I still had no idea what their divine mission in Seattle was, but I assumed it had universal consequences. I felt a little weird that it had been put on hold to decorate my home. As I cleaned up the boxes, I kept thinking about what Yasmine had said about needing versus wanting. In some ways, that was what Seth and I did. We wanted to have sex. We needed to avoid it. I also found myself recalling Andrew again, that annoyingly good priest who'd caused me so many headaches. I hadn't thought much about his story since last week, but as my body mindlessly completed chores, the images began replaying in my mind. Despite my best efforts, he'd remained a bastion of purity and willpower. While frustrating, it nonetheless continued to make the game fun. And although I didn't appreciate it as much back then as I did now, I sort of took pleasure in just hanging around him. He was good company, and he came to mean more to me than just a sexual conquest. It was obvious he cared about me too. It would figure that things went bad between us on a beautiful, sunny day. I remembered it distinctly. I had wandered over to the church he ministered out of and sat with him in the vegetable garden. I stayed clear of the dirt, conscious of the yellow silk dress my bishop had just had made for me. Andrew, less concerned, worked on his knees, unhesitatingly digging in – literally – and cultivating the church's small crop. â€Å"Don't you have other people who could do this for you?† Squinting up at me in the bright light, he smiled. â€Å"Nothing compares to the satisfaction of doing something yourself.† â€Å"If you say so.† He returned to his work, and I continued to sit quietly, watching him and the lazy vista of that golden afternoon. Not far away, the sounds of daily hustle and bustle carried over. I liked this town – it was a nice break from the large, busy cities I'd spent most of my succubus time in. Eventually, though, I knew I'd grow restless and move onto some place with a little more excitement. I turned back to Andrew. â€Å"Thomas Brewer just got back from Cadwell. He says they're all getting sick there.† Andrew nodded. â€Å"People are getting sick everywhere. There have been outbreaks in a lot of the western towns.† â€Å"Are you worried?† He shrugged. â€Å"What comes will come. None of us can change God's will.† I grimaced. I'd heard about this illness, what later generations would call the Black Death. The rapid onset. The blackened skin. The swollen lumps. Even if it couldn't technically hurt me, I didn't want to see it spread here. â€Å"I don't think God can be as merciful as you say in mass if He's inflicting something like that on his people.† â€Å"It's a test, Cecily. God is always testing us. It makes us stronger.† â€Å"Or dead.† He didn't respond. â€Å"What will you do if it comes?† I pushed. â€Å"Geoffrey says he'll leave. Will you go with him?† His dark eyebrows rose in surprise, like I'd asked if the sun would take tomorrow off. â€Å"Of course not. I mean, as bishop, I'm sure Geoffrey must†¦do what is necessary to continue fulfilling his duties, but me? I serve the people. I will continue to serve the people. If they're sick, I'll tend them.† My sarcasm gave way to shock, and I leapt to my feet, striding toward him. â€Å"You can't do that! Haven't you heard about this? People don't come back from it. The only thing to do is get out and let it run its course.† It was true. Call it cruel, but as I'd told Liam on our post-auction date, that was the way the world had dealt with epidemics for a lot of human history. Certainly, some people cared and ministered unto others, but when disease grew really terrible, with no clear answer in sight, ignorance and fear reigned supreme. Most people of that era saw the simplest solution as putting as much distance as possible between them and the illness. Andrew stood up as well, wearing an expression so annoyingly wise and serene as he faced me. â€Å"If that's what you must do, then you must do it. My place is here.† I didn't even have seduction on my mind when I reached out and grabbed his hands. He flinched with surprise but didn't let go. â€Å"It's stupid,† I told him earnestly. â€Å"You can't stop it. You'll die, and I – I can't watch that.† â€Å"Then go. Go with Geoffrey. Or go†¦out to the convent. It's isolated. You'd be safe there.† I scowled. â€Å"Not that again.† â€Å"I just want what's best for you, that's all.† One of his hands reached up and cupped my chin. â€Å"I don't want to see you suffer either.† It occurred to me then how close we stood. The heat building between our bodies rivaled that of the sunshine pounding down on us from above. Andrew, realizing this too, started and tried to pull away. I held on to his hand, anger flaring up in my chest. â€Å"So that's how you'll let it end then? You spend your whole life living in poverty and chastity, only to die in a pile of stinking corpses with oozing sores and rotting skin?† â€Å"If that's what God – â€Å" â€Å"Stop it,† I said, leaning forward. â€Å"Just stop it. Don't you get it? God doesn't care. He's not even paying attention.† â€Å"Cecily – â€Å" I didn't let him finish. Instead, I pressed my mouth against his mouth, molding my body to his. I don't know if he'd ever kissed anyone else before, but if not, he was a quick study. He didn't break from me. In fact I would have sworn there was an eagerness to his lips as they explored mine, willingly letting my tongue stroke and dance with his. And oh, God help me, he was so very good and noble that I tasted a sunburst of energy just from that kiss alone. It poured into me like honey, glorious and sweet. And surprisingly, it was me who finally broke the kiss, though I still stayed pressed against his body, my arms encircling him. â€Å"Don't you see how stupid it is?† I whispered, our lips so close we shared each other's breath. â€Å"Are you going to die without having lived? Without having tasted everything that's out there? Are you really just going to rush into death like that?† His eyes weighed me, his own hands resting on my waist. â€Å"I don't need fleshly pleasures to complete my life.† â€Å"You're lying,† I told him. â€Å"You want to.† â€Å"Wanting and needing are two different things.† He stepped away from me, and I suddenly felt incomplete without his body against mine. I had a fleeting flash of some connection bigger than both of us, and then it was gone. â€Å"A long life means nothing if it's empty and has no purpose. Better to live a short one filled with the things that are important to you.† â€Å"You're a fool,† I snapped. â€Å"I'm not going to stay and watch you die.† â€Å"Then go.† And I did.

Liver function tests - Free Essay Example

Sample details Pages: 9 Words: 2563 Downloads: 6 Date added: 2017/06/26 Category Health Essay Type Essay any type Did you like this example? Introduction The liver is the largest internal organ in the body. In adult the liver weighs approximately 1-2.5 kilograms. It is â€Å"wedge-shaped†, soft and reddish-brown in colour. Don’t waste time! Our writers will create an original "Liver function tests" essay for you Create order It is situated underneath the diaphragm. The liver is divided into right and left lobes by the middle hepatic vein. The right lobe is bigger and consists of caudate and quadrate lobes. The blood is supplied to the liver constitute 25% of the resting cardiac output and through two major blood vessels: hepatic artery and portal vein. Blood leaves the liver via the hepatic vein, which drains directly into the inferior vena cava. Bile is formed in the liver and it is collected in the bile capillaries which drain into the right and left hepatic ducts. The liver is organised in lobules within which blood flows past hepatic cells via sinusoids from branches of the portal vein (bringing absorbed materials from gastrointestinal tract) to the central vein of each lobule. Hepatic artery blood (providing oxygen needed for many of the metabolic processes carried out by the liver) also enters the sinusoids. The central veins coalesce to form the hepatic veins which drain into the inferior vena cava. Each liver cell is also apposed to several bile canaliculi. The canaliculi coalesce to form the right and left hepatic ducts, which join outside the liver to form the common hepatic duct. The cystic duct drains the gallbladder. The hepatic duct unites with the cystic duct to form the common bile duct. The common bile duct enters the duodenum at the papilla. Ganong, (1995) Hepatocytes or parenchymal (liver cells) which further classified on the basis of their site in the lobule comprise about 60% kupffer cells lining the hepatic sinusoids comprise 30% of the liver cells and the remaining 10% of cells consist of vascular and supporting tissue and bile ducts. The significant important of the liver came from the ability of this organ to perform a wide variety of functions which contribute in the body homeostasis, in particular regulation of blood sugar. When there is an excess sugar, the pancreatic cells secret the hormone insulin that converts excess sugar into glycogen (st orage form of glucose). Glycogen provide rapid accessible source of energy for the body when blood glucose decrease. Also gluconeogenesis (formation of new glucose) from amino acids such as alanine and ascorbic acid take place in liver. The coagulation factors which are required for blood clotting, albumin and various lipoproteins which are required for transport of lipid in blood stream are synthesized in the liver. The only exception of protein synthesis is the synthesis of immunoglobulin. Cholesterol which serves as precursor of steroid hormones is mostly synthesized in by the liver. Also liver has the ability to excrete and detoxify e.g. ammonia formed from the breakdown of amino acids or microbial action in the gastrointestinal tract converted to urea. Steroid hormones which are inactivated by conjugation with glucuronate and sulphate excreted into urine as water soluble forms. A wide range of medications (drugs) inactivated by endoplasmic reticulum enzymes and some are excr eted in the bile. Kupffer cells in the hepatic sinusoid extract toxins absorbed from the gastrointestinal tract. Other important excretory function is the excretion of bile acid formed from cholesterol in the liver to gall bladder where it stored until required for lipid digestion in the small intestine. The ability of liver to carry out its excretory function of the metabolism end products depends on, healthy functioning hepatocytes, adequate blood flow through the liver and patent biliary duct. The other important function of liver is Storage of vitamins such as vitamin A, D and vitamin B12. In addition, metabolism and excretion of bilirubin is one of the major functions of the liver. Bilirubin is an ecteric waste product pigment formed from the breakdown of haemoglobin (Hb) in the red blood cells in the lymph reticular system at the end of their life span which is approximately 120 days. Normally an adult produces about 450 umol/L daily. Gaw et al, (1999). Hb contains four hae m group, an iron atom and prophyrin ring attached to each haem group. When Hb molecules metabolize, the iron atoms are removed and reused again in the processing of a new Hb molecule. The prophyrin ring breaks to form a open tetrapyrole derivative biliverdin chain which is further reduced to form unconjugated bilirubin (lipid soluble).Whitby, (1988). The lipid-soluble bilirubin can cross cell membrane include brain barrier and cause brain cell damage. Therefore it has to be transported by a special carrier called albumin in the plasma in order to be converted to water-soluble so that can be excreted into bile. The binding of albumin accomplished by being not enter cells readily and also not filtered through glumerulus unless there is glomerular proteinuria. When the albumin-bilirubin complex reach the liver, it dissociates by the receptors on the plasma at the same time. Inside hepatocytes, bilirubin molecules join to relatively non-specific anion binding proteins called ligandin (Y protein), is soluble transport protein in the smooth endoplasmic reticulum. Calbreath, (1992). The glucuronic acid molecules attach to unconjugated bilirubin molecules to form bilirubin glucuronides in a reaction mediated by uridine diphosphate (UDP). Bilirubin glucuronides complex is water-soluble conjugated bilirubin which then excreted into small intestine. The conjugation process depends on the active secretion of bile acids and therefore serum bile acids concentration are more sensitive index of hepatic transport function than the total bilirubin. Small amount undergoes reabsorption in the small intestine and the rest is degraded by bacterial action mainly in the colon where it is de-conjugated to form urobilinogen. Portions of urobilinogen re-enter the hepatic circulation and excreted by the liver into bile. Small fraction filtered by kidney into urine, but the majority is excreted in faeces providing its orange-yellow characteristic. If the bilirary tract becomes block ed, serum bilirubin concentration will rise as uncojugated bilirubin not excreted and the patient becomes jaundice. Jaundice is a yellow discoloration of the skin or the sclera of the eye. The yellowish coloration is caused by an excess amount of bilirubin in the plasma which is not detectable until the concentration is greater than 40 umol/L. gaw, et al (1999). The normal concentration is up to 20 umol/L. causes of jaundice classified into three categories including haemolytic (prehepatic) jaundice characterized by an increased breakdown of haemoglobin, hepatic jaundice due to failure of the conjugation mechanism and post hepatic or obstructive jaundice because of obstruction of biliary system. Most newborn babies are characterized with physiological or neonatal jaundice due to natural process of breaking down RBCs. As their livers are immature, they can not process bilirubin as quickly as when they are old. This increase in bilirubin concentration and has no significance to do wit h liver. Marshal, (2000). In clinical practice usually all the tests related to liver diseases are called liver function tests (LFT). Biochemical tests include measurement of bilirubin, the aminotransferases (ALT and AST), albumin total protein and alkaline pkosphatase in serum specimen. Albumin and total protein reflect the synthetic liver function. ALT and AST used to measure the severity of liver cells damage although they are not specific index of acute damage to hepatocytes, but they are sensitve indicators to cytoplasmic and mitochondrial membrane. Gaw, et al (1999). Increased conjugation bilirubin concentration and increased ALP activity at sinusoidal surface indicate cholestasis, a blockage in the bile flow. Prolonged cholestasis can result in severe jaundice with very high bilirubin concentration result in deposition of bile salts, characterized by itching, bleeding due to vitamin K malabsorption, cholesterol retention and dark urine with pale stool. The prothrombin time (PT) which is used to asses the synthetic function of liver is prolonged due to cholestasis. Measurement of ? glutamyl transferase can give an indication of hepatocellular enzyme induction due to drugs or alcohol. Materials and method Please refer to medical biochemistry practical book (BMS2). Result Calculation Determination of ALP The equation obtained from the graph is used to calculate the amount of phenol liberated by the action of ALP. The equation is: Y = 0.1753 The enzyme activity is measured in international unit per 1 minute (IU/1) therefore to obtain the activity, the result has to be converted first to umol/1 and then divided by the incubation time (15 minutes) as follow: (Value of phenol concentration in mmol/1 X 1000) / 15 = IU/L Patient 1: Result: 0.207 / 0.1753 = 1.18083 x 1000   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  = 1180.8 umol/L To get the enzyme activity in 1 minute: = 1180.8 / 15 = 78.7 IU/L ALP enzyme activity of patient 1= 78.7 IU/L Patient 2: Result: 0.215 / 0.1753 = 1.2264 x 1000   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  = 1226.4 umol/L To get the enzyme act ivity in 1 minute: = 1226.4 / 15 = 81.7 IU/L ALP enzyme activity of patient 2 = 81.7 IU/L Determination of bilirubin The concentration of bilirubin is calculated by using the following equation Absorbance of the test x STD concentration Absorbance of STD Result: Patient 1 = (0.413/0.431) x 350 = 335.3 umol/L Patient 2 = (0.037/0.431) x 350 = 30 umol/L The results of Aspartate transaminase (AST), albumin and total protein were provided by the tutor. Conclusion The biochemical finding shows that patient 1 may have haemolytic disease where as the other patient (patient 2) suffer from acute hepatitis. Discussion Liver function test are done to asses the integrity of the liver to carry out its normal synthetic and metabolic functions. This is achieved through series of numerical tests that reflect the healthiness of the liver when comparing the result obtained with normal reference ranges. The measurements of enzyme activities are very useful in following the progress of the liver disease once the diagnosis has been made. From the result it is obvious that patient 1 ha s got normal TP, ALB, AST and ALP results, which means that there is liver damage. Total protein is combined of immunoglobulin proteins and other proteins. A persons total protein level gives information about the liver damage, kidney damage and nutritional health. Albumin is small protein made in the liver. If a person suffers from liver damage, the albumin concentration will drop because the liver can not maintain the normal production of albumin. Aspartate transminase (AST) is the enzyme found in the liver, heart and muscle. Levels of this enzyme are usually assessed in conjugation with reading for other liver enzyme to determine or monitor the liver involvement. On other hand the bilirubin is very high above the normal range (hyperbilirubiaemia) and normally the bilirubin which is present in plasma is unconjugated bilirubin. Since the unconjugated bilirubin is high it indicates that is excessive red blood cells (RBCs) destruction (haemolysis) which occurs in haemolytic anaemi a. Normally the red blood cells survival is 120 days, but in haemolytic anaemia is less. Because of that the RBCs are destroyed in large quantities in the RE system (particularly the spleen). When the RBCs are destroyed, the haemoglobin is released and bilirubin is produced. It is mainly produced from the haem moiety of the haemoglobin (it is also produced from myoglobin, cytochroms and peroxidase, which are widely distributed in the body). The liver can not conjugate and remove this large amount of unconjugated bilirubin and since it is protein bound the renal glomeruli can not filter it. That leads to overflow of unconjugated bilirubin in blood circulation. These mean that this patient may have haemolytic jaundice (prehepatic jaundice), because the protein synthesis is normal and ALP, AST are normal which means that there is no liver involvement. Haemolytic jaundice also occurs in haemolytic Disease of Newborn, transfusion of incompatible blood, hereditary spherocytosis and aut oimmune red cell destruction. Marshall,(2000). The results of patient 2 show normal total protein, albumin and ALP. There is a slight increase in bilirubin level (hyperbilirubinaemia) and AST is above the very high. AST is an intracellular enzyme and is mostly found in the cytoplasmic and mitochondrial membrane of hepatocytes. So it is a sensitive marker for the severity of damage hepatocytes. ALP concentration usually rises in cholestasis (this is by extra-hepatic obstruction of the bile duct) but in this patient was normal, which means that the kupffer cells and sinusoidal surface is not yet damaged. Total protein and albumin were also normal and that indicates that the metabolism and synthesis in the liver is not yet affected. Bilirubin was slightly high which support that there is liver disease and due to this, there is defect of bile salt and bile pigment excretion. In addition to that, conjugation and detoxification functions are well defected because of hepatic cells damag ed. These happen due to a condition called Hepatitis (liver inflammation). Hepatitis is the common cause of acute liver injury. Acute hepatitis usually occurs due to viral infection particularly with hepatitis viruses A, B, C, D and E, but also Epstein-bar virus and cytomegalovirus or toxin (e.g. alcohol and paracetamol). Marshall, (2000) In the early stages of hepatitis, increased plasma ALT and AST activities may be the only abnormal chemical finding. There will be also an increased level of urobilinogen and bilirubin in urine (the urine will be darkened). The stool may be very pale due to impaired biliary excretion of bilirubin and urobilinogen then disappears more or less completely from the urine. Marshall, (2000) The above results reveal that liver is functioning well but partly defected because of the early stage of the disease. This patient may have acute liver disease (Acute hepatitis). To confirm these results hepatitis virus profiles should be done. Question Jaundice in the newborn is common. Why? Jaundice in the newborn is called Neonatal Jaundice. It is common because before birth, an infant get rid of bilirubin through the mothers blood and liver system. After birth, the babys liver has to take over processing on its own. The activity of the hepatic conjugation enzyme is usually low at birth but increases rapidly thereafter. Almost all newborns have higher than normal level of bilirubin; because the immaturity of their livers. In most cases, the babys system continues to develop and can soon process bilirubin. However, some infants may need medical treatment to prevent serious complications which can occur due to the accumulation of bilirubin. There are at least two significant processes that predispose normal infants to jaundice: The rate of bilirubin production is higher in infants than adults because their red blood cells have half-life and turn over more rapidly. Infants have a relatively limited ability to conjugate bilirubin and conjugation in the liver is necessary for efficient elimination. Write short notes on Gilberts disease. Gilberts disease is a harmless inherited condition in which the unconjugated bilirubin level in the blood is increased. Bilirubin is an end product of haemoglobin breakdown and it is conjugated in the liver with glucuronate. This process is catalysed by specific enzyme called uidine diophosphate glucuronyl transferase which is found in endoplasmic reticulum, which helps the body to conjugate bilirubin and get rid of it. Thus Gilberts syndrome is a genetic disorder which means that there is slight deficiency of this enzyme. Patient with Gilberts disease can have intermittent bilirubin level but the values are often increased when blood is drown after a period of fasting or during a time of concurrent viral illness or when the person is stressed, either physically or mentally. People with Gilberts syndrome are not ill but they may complain of vague abdominal discomfort and general fatigue for which no cause found. The condition is not usua lly apparent until adolescence or early adult life. It is sometimes discovered incidentally, in the course of investigations done for related reasons. All liver function tests (LFTs) are normal, except for serum bilirubin which is raised. X-ray and liver biopsy show that there is no liver disease. Gilberts syndrome should not be regarded as a disease and people with the syndrome are not ill.