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J Clin Pathol. 2006 December; 59(12): 1229–1237.
Published online 2006 May 19. doi:  10.1136/jcp.2006.037754
PMCID: PMC1860526

Best practice in primary care pathology: review 5

Abstract

This fifth best practice review examines three series of common primary care questions in laboratory medicine: (1) minor liver function test abnormalities; (2) laboratory monitoring of patients receiving lithium; and (3) investigation of possible venous thromboembolism. The review is presented in question–answer format, referenced for each question series. The recommendations represent a precis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence‐based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most are consensus‐based rather than evidence‐based. They will be updated periodically to take account of new information.

This is the fifth in a series of reviews which answers several questions that arise during the use of pathology in primary care.

Each topic is introduced with a brief summary of the type of information found and is handled separately.

Although the individual topics are not related because they cover the disciplines of clinical biochemistry, microbiology, immunology, haematology and cellular pathology, they are designed, once completed, to form a resource that will be indexed and cover a wide range of the most common issues in the primary care laboratory, to be made available to users.

In instances where the new UK General Medical Services (GMS) contracts make specific reference to a laboratory test, the indicator or target is appended at the end of the answer.

Minor liver function test abnormalities (WSAS, SR)

Biochemical tests of liver function are used to investigate a wide range of symptoms and for various purposes in asymptomatic people. This raises the potential to discover significant disease at an early stage in its natural history, but also produces abnormal results in apparently healthy people. This is particularly so in the “statin prescribing” era.

The usual liver function tests include two separate types of tests. Serum albumin and bilirubin provide a true measure of hepatic function, although both can be abnormal for several non‐hepatic causes. The remaining tests are of liver enzyme levels, usually alanine aminotransferase (ALT) or aspartate transaminase (AST) in combination with alkaline phosphatase (ALP) +/− γ‐glutamyl transpeptidase (GGT).

These answers attempt to allow the user to identify situations in which values of one or more of these tests outside the 95% population reference range (mean (2 standard deviations (SDs)) for the population) may indicate the presence of clinically significant disease.

In view of the statistical phenomenon of regression to mean,1 the principle of interval retesting to establish one‐off from stable and progressive increases seems sound. There is guidance, but limited evidence, on retesting intervals, although in the asymptomatic context and in view of the slow time course of the potential underlying diseases, the retesting interval of months rather than weeks seems reasonable for minor increases, commonly described as up to 3–5 times the upper limit of normal (ULN). Indications for further investigation of persistent rises commonly refer to 1.5 ULN. The limitations of reference ranges are further compounded for liver tests by the fact that population results are not normally distributed and exhibit a right skew effect.

How should I investigate an isolated slightly raised alkaline phosphatase in an asymptomatic adult?

We recommend:

  • Checking of liver and bone profiles if not already carried out, to exclude other raised indices.
  • Isolated raised values up to approximately 20% above the ULN (typically 120 IU/l) are more likely to reflect a statistical rather than clinical finding.
  • If <1.5 ULN: recheck in 1–3 months.
  • If >1.5 ULN (2 measurements, 6 months apart): further investigation indicated.
  • If >3 ULN (single measurement): further investigation indicated.

Reference ranges of ALP are age and sex‐related, being lower in women than men, but rising in women beyond middle age. In addition, bone‐specific ALP is higher in black women than in white.2 Laboratory methods and reference ranges unfortunately vary by method, and users should acquaint themselves with local ranges. The laboratory reference range contains 95% of the population values. Notwithstanding exceptions described earlier, 2.5% of people would therefore be expected to have activities above the ULN, and, in view of the low prevalence of disease in patients with minor rises just over the mean (up to approximately 20%), this is more likely to represent a statistical rather than a clinically relevant finding. Using a typical local reference range of 35–104 IU/l, approximately 2.5% of a normal population will be expected to have values >104 IU/l (mean (2 SDs)), compared with approximately 0.1% >121 IU/l (mean (3 SDs)).

ALP has two main sources in the non‐pregnant adult: liver and bone.

Higher ALP activities are also seen as a normal variant3 and are associated with a range of medical conditions (congestive heart failure, hyperthyroidism, pregnancy) and certain drugs (ibuprofen, acetaminophen, cefotaxime) (reviewed in Aranda‐Michel and Sherman2).

Liver

ALP is an intrahepatic cannalicular enzyme, which when raised because of liver disease reflects intrahepatic or extrahepatic obstruction rather than hepatocellular damage, although both may coexist.

In addition to clinical assessment of possible risk factors for, or indicators of, liver disease to distinguish potential hepatic risk factors from bone disease, GGT4,5,6,7,8 (or 5′ nucleotidase when used as an alternative9) offers the best means of identifying a hepatic origin.

Recommendations distinguish isolated from paired or multiple‐enzyme abnormalities as an initial indicator of potentially significant disease. Although not evidence‐based, a threshold of 1.5 times ULN is cited by several authors as an indication for further investigation at 1–3 months if raised <1.5 ULN4 with further investigation if >1.5 ULN on two occasions at least 6 months apart.5 This is consistent with a review in the Journal of Insurance Medicine6 describing the threshold as a means of distinguishing potentially significant disease, although the same review highlights the paucity of direct clinical data relating liver enzyme abnormalities to mortality. On the basis of mathematical calculation of mortality associated with biopsy diagnoses, this review concluded that, if alcohol and hepatitis were excluded, background mortality was “fairly low” for patients with mild to moderate liver profile abnormalities.

Although the reference range for women rises with age, the prevalence of primary biliary cirrhosis also rises. Measurement of antimitochondrial antibodies in cases of persistently increased ALP >1.5 times ULN of liver origin would therefore seem appropriate.

Bone

Raised ALP without a concomitant rise in GGT in a non‐pregnant adult is likely to be of bone origin.4,5,6,7,8 Formal distinction can often, but not always, be achieved by isoenzyme analysis if uncertainty remains in the presence of marked abnormalities.

Calcium studies combined with the clinical filter will help in the diagnosis of treatable bone disease due to osteomalacia and parathyroid disease, and therefore seem clinically justified. However, the most common reason for raised bone ALP in older people is (often subclinical) Paget's disease.

Paget's disease is estimated to have a prevalence of 2–6% in the UK,10 and to have autosomal dominant inheritance with variable penetrance in some families.11 ALP activity is reported to correlate with disease activity, and the relative risk of Paget's disease in patients with raised ALP is 10.9, although Paget's disease was also found in 2.3% of people with normal ALP.12

The currently established indications for treatment of Paget's disease are based on symptoms and preparation for orthopaedic surgery.13 Presently, in the absence of these situations, a further investigation on minor bone‐related ALP would seem unwarranted in an asymptomatic patient with normal calcium studies.

How should I investigate an isolated case of slightly raised bilirubin in an asymptomatic adult?

We recommend:

  • Values up to 20% above ULN are likely to be statistical rather than clinical abnormals.
  • Values <1.5 times ULN: interval retest in 1–3 months unless clinical suspicion of disease.
  • Values >1.5 ULN: confirm proportion of indirect (unconjugated) bilirubin.
  • If >70%, unconjugated, probable Gilbert syndrome: no further testing needed if non‐progressive on interval retesting, unless haemolysis is clinically suspected. If rising on restesting, consider haemolysis and test haptoglobin, lactate dehydrogenase and blood count with reticulocyte count.
  • Values >3 times ULN: clinical disease probable, further investigation required. Consider ultrasound (conjugated >50%) or haemolysis (unconjugated >70%).

As a product of the degradation primarily of haem, and excreted in bile, circulating bilirubin concentrations are determined by the balance of production and excretion.

Production is increased principally in disorders of red blood cell metabolism and excretion in disorders of hepatic conjugation (producing unconjugated or indirect bilirubin) or removal (producing conjugated or direct bilirubin). Laboratory discrimination of direct from indirect bilirubin becomes less reliable at lower total bilirubin concentrations (typically < approximately 40–50 mmol/l).

Using the same principles as for ALP and a typical range of 5–21 mmol/l, 2.5% of a population would be expected to have a total bilirubin >21 mmol/l and 0.1% >25 mmol/l. Users should again check their local ranges.

The clinical assessment should logically seek to exclude drugs that interfere in the bilirubin reaction (propranolol, oxytetracycline, methotrexate and levodopa)2 and take this into account in the decision to investigate further for stable raised bilirubin.

As described earlier, a raised bilirubin in conjunction with other liver function test abnormalities will prompt further investigation directed by predominant pattern of hepatocellular (transaminases) or cannalicular (GGT and ALP) changes.

The most common cause of “slight” isolated rises in bilirubin is Gilbert syndrome, a benign untreated congenital defect of glucuronide conjugation, present in up to 5% of the population.14 This produces unconjugated raised bilirubin (particularly during intercurrent illness or fasting) usually not exceeding 68 mmol/l9,15 (or up to 85 mg/dl2,16). Although diagnostic investigations may be used to diagnose this, reassurance will in most cases be sufficient.9,15

Identification of raised bilirubin in conjunction with raised cannalicular enzyme (ALP or GGT) should prompt consideration of potential intrahepatic or extrahepatic cholestasis and is not described further in this answer.

Saturation of the conjugation process by excess production of bilirubin will lead to a predominance of unconjugated bilirubin. One review describes raised bilirubin >50% conjugated and raised bilirubin >70% unconjugated as representing direct and indirect hyperbilirubinaemia, respectively.2 If the rise is isolated, and predominantly unconjugated, exclusion of increased haem turnover leaves a highly probable diagnosis of Gilbert disease. No further investigation is recommended if bilirubin concentrations fall or do not continue to rise on interval retesting. The British Columbian guideline recommended interval retesting of 1–3 months for rises in any liver test <1.5 ULN. This is consistent when there is a small bilirubin rise in an asymptomatic patient, particularly in light of the bimodal serum decrease time, which has a long terminal phase (due to δ‐bilirubin formation17). Common sense would suggest that, in this period, retesting be carried out in the earlier part for larger rises and later for smaller rises. It would be unlikely to see large rises in bilirubin—for example, > 3 ULN—in the absence of other changes, and a laboratory opinion would seem reasonable in this instance (author interpretation).

Haemolysis is conventionally diagnosed by the laboratory appearances on a blood film, combined with reduced haptoglobin, reticulocytosis and raised lactate dehydrogenase. There is no clear evidence as to whether one or all of these tests are required.

If evidence of haemolysis is found, further investigation will be determined by the clinical context, usually in conjunction with secondary‐care advice or referral.

Resorption of large haematomas can produce a similar pattern of hyperbilirubinaemia; this should be clinically apparent provided requesters of tests are aware of this as a possible cause.

Several recommendations for liver function testing are focused on patients with risk factors for, or clinical evidence of, suspected liver disease.4,5,8 None recommend general population screening, an approach that is also not considered to be cost effective.18

How should I investigate abnormal transaminases in asymptomatic patients without risk factors for, or clinical features of, liver disease?

  • If raised <3 ULN: recheck in 1–3 months
  • If still raised (two measurements, 6 months apart): further investigation indicated as shown in table 11.
    Table thumbnail
    Table 1 Investigations in asymptomatic patients with increased liver enzyme level
  • If >3 ULN (single measurement); further investigation indicated as shown in table 11.

AST and ALT are sensitive markers of hepatocyte injury but both, particularly AST, are also found in decreasing concentration in cardiac muscle, skeletal muscle, kidney, brain, pancreas, lung and blood cells. As transaminases are present in highest concentrations in the liver, large increases are usually due to hepatocyte injury.

Serum ALT activity varies with age, sex, race, body mass index, acute illness and exercise (reviewed in Gianni et al8 and Giboney19), and compelling evidence from diseases such as hepatitis C, non‐alcoholic fatty liver disease (NAFLD) and haemochromatosis suggest that considerable liver injury may be present with normal transaminase levels.20,21 Perhaps the most impressive evidence that ALT normal ranges are misleading comes from trials of treatment of hepatitis C virus infection (HCV) in patients with normal transaminase levels. These showed that if HCV was eradicated, the previously normal levels fell further.22

The normal population reference range is therefore very approximate for clinical purposes. Certain chromogenic drugs may also interfere analytically (acetaminophen, tetracycline and aminosalicylic acid), independently of liver injury.23

The American Gastroenterology Association24 defines a mild transaminase abnormality as up to 5 times ULN but does not define a lower limit for investigation. Several guidance documents refer to persistently raised transaminases of >1.5 ULN as warranting investigation. It has been suggested that increased levels of transaminases should either be investigated after 1–3 months4 or 3 months,25 or that there should be a staged approach to investigation over 0–6 months.24,26 Some expert reviews suggest treating the most likely cause of the abnormal transaminases—that is, alcohol (by abstinence), hepatotoxic drugs (by drug cessation) and NAFLD (by weight reduction and diabetes or triglyceride control, where applicable) before more detailed investigation if transaminases remain abnormal after a period of observation24,26 with a referral (biopsy) threshold of 2.5 ULN.5

All the guidance found emphasised the importance of clinical history and examination to identify possible causes (particularly NAFLD, which is described in one study as prevalent in 23% of American adults27) before proceeding to further investigation in these cases.

The prevalence of abnormal transaminases will therefore vary with the type of population studied, the threshold used to define “abnormal” and the time interval over which the results are studied. For example, when transaminases are measured as part of routine preoperative assessment for elective surgery, 0.1–0.3% of patients are found to have abnormalities if abnormal is defined as transaminases >2 ULN but 3.5% if any degree of transaminase elevation outside the population “reference” range is considered to be abnormal.28 Most data that are available deal with abnormal AST or ALT levels in subsections of American populations, based on single transaminase measurements.

There is evidence that increasing transaminase levels (AST and ALT) are directly associated with increased liver‐related mortalities.29 In the UK, there is also evidence that the causes of abnormal transaminases are often not investigated. When a thorough investigation is carried out, however, most patients are found to have significant disease warranting treatment or follow‐up.30

No single study has compared the clinical or histological diagnoses carried out at a certain degree of transaminase abnormality with those at a different level of abnormality. There is no great difference between the percentage of abnormal liver biopsies found when investigating patients with transaminases any degree above the normal range, above 1.5 times or above twice the ULN. Investigating patients with a greater than threefold increase in transaminases may result in fewer normal liver biopsies—that is, fewer false positives—but will clearly result in an underdiagnosis of significant liver disease (table 22).31,32,33,34,35,36,37 The only reason to set a threshold for investigating abnormal transaminases seems to be one of expedience. Sherwood et al30 investigated patients with abnormal transaminases >2 times the reference range because lowering this threshold would have resulted in six times more patients to investigate, “well beyond our means of investigation”.

Table thumbnail
Table 2 Findings on liver biopsy for abnormal transaminases

Table 11 shows an appropriate panel of initial investigations. There is no evidence to suggest that the level of enzyme abnormality in asymptomatic people has any influence on this risk of finding appreciable abnormalities on further investigation. In view of the poor correlation between the level of rise and biopsy findings, we do not recommend a lower threshold for carrying out basic investigations as shown in table 22 on persistently abnormal results.

As non‐alcoholic and alcoholic fatty liver diseases are the predominant causes, these can reasonably be sought from the clinical history before proceeding to more detailed (level 2) investigations.

How should I investigate abnormal transaminases in patients with risk factors for, or clinical features of, liver disease?

  • Further investigations are advised for any enzyme rise associated with risk factors for, or clinical evidence of, liver disease except where an apparent cause is found (hypertriglyceridaemia, diabetes, alcohol and overweight) for which a 6‐month trial of appropriate intervention is recommended.

An asymptomatic person found to have abnormal liver enzymes should have a history taken for specific factors that may predispose to liver disease or suggest another cause. Alcohol consumption, prior medical interventions, such as surgery or transfusion, intravenous drug use or tattooing should be included, as should a detailed drug history, including non‐prescribed or herbal remedies.

Physical examination aims to detect stigmata of chronic liver disease, spider naevi, clubbing, hepatomegaly or splenomegaly. If present, these suggest significant liver disease, as these signs are rarely present in the absence of hepatic cirrhosis.

The history and examination should also aim to exclude non‐hepatic causes for liver enzyme increase. The most common causes that may be difficult to diagnose clinically are right‐sided heart failure or constrictive pericarditis, which can cause considerable hepatomegaly and abnormal liver tests with relatively modest symptoms, and endocrine disorders, notably obesity, diabetes and thyroid dysfunction.

There is good evidence that obesity38 and diabetes39 cause abnormal liver enzymes via fatty liver, and the risk of death from liver disease was increased in the Verona Diabetes Study39 in patients with abnormal liver function tests. The condition is benign in those with simple steatosis40 although 10–30% of patients with considerable inflammation and particularly with fibrosis on index biopsy may progress to cirrhosis in 10 years.40,41 As yet, there is no specific medical treatment for NAFLD. Progressive weight loss can normalise liver enzyme levels and although there is no evidence that this improves long‐term outcome, it seems logical from a general health perspective. Note, however, that starvation dieting can also cause fatty liver.42

Risk factors for development of NAFLD, such as hypertriglyceridaemia and diabetes, should be dealt with, and a programme of exercise and weight reduction tried before liver biopsy is offered.

Further investigation is recommended if abnormal liver enzymes of any level are found in the presence of a major risk factor for liver disease or in particular if patients have stigmata of chronic liver disease.4,5,19,24

How should I investigate abnormal GGT in asymptomatic patients without risk factors for, or clinical features of, liver disease?

  • GGT has limited use as a primary liver test. Its use is recommended in particular to establish the likely origin of a raised ALP.
  • No clear consensus is found on thresholds for further investigation.

In the absence of guidance we recommend that:

  • Mild rises (<3 ULN) justify interval retesting.
  • Rises >5 ULN justify consideration of ultrasound if the cause is not apparent.

GGT is found in hepatocytes and in biliary epithelial cells. Its main use is in the diagnosis of biliary tract disease, in combination with ALP. It is widely and incorrectly regarded as a sensitive and specific marker of alcohol misuse.

The same statistical considerations apply to transaminases as to ALP, bilirubin and transaminases. Likewise, the actions to take in patients with risk factors for, or clinical evidence of, liver disease are the same, from the same documents. Some evidence, however, suggests that the yield from investigating raised GGT may be different from that for ALT or AST. The myth that a raised GGT is sensitive and specific for alcohol excess persists despite considerable evidence to the contrary. Studies have shown that the sensitivity of raised GGT for alcohol varies between 52% and 94%,43,44 depending on the population under study. Evidence also shows that the reference range for GGT is misleading; if a true reference range is established in non‐drinkers, ULN values of 45 for men and 35 for women are obtained.45 In a group with moderate alcohol intake, the levels rise to 66 and 40, respectively.

Hepatic fibrosis is present in only 11% of cases of asymptomatic patients with a raised GGT alone who do not drink excessively.46 By contrast, patients drinking excess alcohol who have an isolated raised GGT rarely had considerable liver damage.47

The same reviews that handled transaminases, ALP and bilirubin cite the primary purpose of GGT assessment as the clarification of the likely origin of an isolated ALP,2,4,5,8,24 used as a second‐line test. The British Columbian guidelines also stated that an isolated non‐progressive rise in GGT seldom reflects considerable liver disease, and a second review2 referred to raised GGT as a common reason for mistaken diagnosis of viral hepatitis or inappropriate referral for liver biopsy, which often shows no abnormality in cases of an isolated minor GGT rise.46 This point also appears in a Journal of Insurance Medicine review, drawing the same conclusions as above and offering little support for the utility of isolated GGT levels for actuarial predictive purposes.6 Conversely, however, GGT is raised in 50% of cases of NAFLD.48

Therefore, there seems to be limited enthusiasm in the same reviews, which recommend the investigation of other slightly raised liver enzymes for the use of GGT levels in isolation, and consensus emerges that its main use lies in the clarification of a raised ALP. Differences in practice exist between laboratories: some do not include GGT in a liver profile, reserving it for second‐line use, whereas others do. As highlighted by Aranda‐Michel and Sherman,2 it is important that requesters recognise the limitations of this test.

When should I refer for secondary assessment and possible liver biopsy?

In the absence of clear guidance, we recommend:

  • Laboratory results >2 ULN (unexplained by laboratory tests);
  • Or following disease‐specific protocols if laboratory results show an underlying cause, to stage disease where applicable.

For most patients with abnormal liver enzyme levels, the pattern is non‐specific, commonly raised ALT, ALP and GGT. The only investigation likely to produce a diagnosis if the above investigations are normal is liver biopsy.

The pathological effects of alcohol, drugs and the non‐alcoholic fatty liver variants can only be diagnosed on liver biopsy. Percutaneous liver biopsy does, however, entail a finite risk, primarily of haemorrhage, and the decision to offer liver biopsy is therefore a balance between the potential benefits of a treatable diagnosis to prevent hepatic fibrosis and risk. This benefit is clear in conditions such as autoimmune hepatitis but less so in conditions such as alcoholic liver injury. Conditions with a specific treatment that can change the natural history of the liver injury are found in between 7% and 18% of patients undergoing biopsy for abnormal liver enzymes.

Transaminase of twice the ULN are only associated with a histologically normal liver in around 6% of cases.37 The most common diagnosis made on liver biopsy in this setting is either NAFLD or non‐alcoholic steatohepatitis37 (table 33).). This diagnostic group accounts for two thirds of unexplained increase in liver enzymes. As above, however, clinical intervention data lacking the merits of liver biopsy in these situations are uncertain. Other important diagnoses include conditions such as antimitochondrial antibody‐negative primary biliary cirrhosis and autoimmune hepatitis. A marked fibrosis on biopsy is common (table 22).). An isolated mild, isolated, non‐progressive rise in GGT is often not linked to liver disease and is rarely a reason for liver biopsy.

Table thumbnail
Table 3 Findings on liver biopsy for unexplained abnormal liver enzyme increase in 354 patients37

GMS contract indicator: None.

Lithium safety monitoring (WSAS, IDW)

Guidelines for safety monitoring in patients receiving lithium do not differ greatly qualitatively although a few differences in testing intervals are found. Several publications are available, indicating that management of this patient group often does not comply with published guidelines, and in view of the low toxicity threshold and potential severity of toxicity, there would seem to be a need for initiatives to improve monitoring.

When should I measure blood lithium concentrations and what additional testing is recommended?

We recommend:

  • Testing at 3‐month intervals;
  • Testing in any patient presenting with potential signs of lithium toxicity;
  • Testing a sample taken at least 12 h after the previous lithium dose, if possible at the same time after the dose;
  • Measurement of renal function annually and in conjunction with any unexplained rise in serum lithium concentration;
  • Measurement of thyroid function once 6 months in the initial years of treatment, annually thereafter if stable;
  • Separate advice should be sought for pregnant women.49

Although consensus‐based rather than evidence‐based, several guideline sources recommend routine monitoring of lithium in stable patients at intervals of 1–3 months,50 2 months,51 3 months,52,53,54 3–6 months55,56 or at least once in 6 months.57,58 Most guidance recommending intervals of more than 3 months advocates more frequent testing in certain situations or use the qualifier “at least”, and we consider the 3‐month recommendation to be the most representative for the average patient. The 3‐month interval also appears in several locally derived guidelines.52,59,60 Despite these, there is good evidence that medical systems and practices often result in inadequate monitoring.61,62,63,64 Lithium has also been a topic of several large medical negligence claims.65 Lithium toxicity can produce death and long‐term sequelae and can occur as a result of a wide range of factors including drug treatment, concomitant illness and age‐related renal changes.66 Monitoring has been shown to reduce the risk of toxicity.67,68 Shared care management has been proposed as a means of reconciling the greater compliance with monitoring guidelines reported in secondary care with the success of joint primary and secondary care in mental illness.62,69

Guidelines on when a sample should be taken for lithium measurement (in the non‐acute situation) vary slightly from at least 10 h to 12–18 h after the last dose. The British National Formulary (BNF) advocates 12 h,62 consistent with historical recommendations, based on the fact that lithium concentrations vary little between 12 and 24 h after a dose in healthy people.70,71 The 12‐h recommendation would therefore seem simple and logical and appears in several other guidelines. As the half life of elimination of lithium in young patients with normal renal function may be only 8–10 h, it would also seem logical to keep as close as practicable to the same timing for successive samples to limit variability.52

Although the guidance found does not refer to monitoring for the possible development of nephrogenic diabetes insipidus in long‐term use, prescribers should be aware of this possibility in any patients presenting with polyuria.

When should I measure blood lithium concentrations after a change in dose or after starting treatment?

We recommend:

  • Remeasurement after 3–4 days but within 1 week after changing a dose.

As the half life of elimination of lithium is approximately 8–40 h in human beings depending on age and renal function, steady‐state conditions would be expected between 2 and 8 days after starting or increasing a dose.62 The same review of lithium prescribed advocates retesting after 1 week. This is consistent with the known pharmacokinetics of lithium and should allow the steady state to have been reached in most people, but similarly highlight the risk of accumulation in those in which the half life of lithium is prolonged.

Few consensus recommendations exist on retesting policies after a dose change, although we advocate rechecking if doses are changed as a result of a trend of low or high results but do not stipulate a retesting interval.59 Although not evidence‐based, this would seem prudent in view of the serious consequences of overdosage or underdosage and the narrow therapeutic margin. Where minor dose titrations are being made, it would seem reasonable to recommend a period of 3–4 days after changing a dose in most patients, as the steady state is likely to have been reached in patients with normal renal function, noting that, in elderly people or those with impaired renal function, a further check may be required to ensure that the steady state has been reached, particularly as the time taken to reach the steady state will increase with increasing half life, as seen in renal impairment. This would also allow earlier detection of accumulation in patients with renal dysfunction or in elderly people, rather than waiting for a potentially toxic steady‐state concentration to be reached.

What is the target range for lithium and what action should I take for raised lithium concentration?

We recommend:

  • 0.6–1.0 mmol/l for most adult, non‐elderly patients;
  • 0.4–0.8 mmol/l for most elderly patients;
  • patients managed specifically outside of these ranges (normally not exceeding 1.2 mmol/l) should be individually identified and the reason for the decision clearly documented in patient records.

It is important to understand that a therapeutic range offers a guide to efficacy and potential toxicity, but is not an unequivocal target range, which must necessarily be achieved in all patients for reasons of physiological variability.

Lithium has a narrow therapeutic margin between efficacy and toxicity. Different target ranges have been proposed, although most people acknowledge the need for some flexibility in their interpretation. These vary within the extremes of 0.4–1.2 mmol/l. The range cited in the BNF is 0.4–1.0 mmol/l as compared with 0.4–1.2 for the American Psychiatric Association72. Values <0.6 mmol/l have, however, been reported to be associated with poorer functioning and higher relapse rates in adults,73,74 and it is probable that the lower target ranges of 0.4–0.6 mmol/l will be used more in elderly people, in whom standard maintenance concentrations of 0.4–0.8 are reported.75

However, these differences are of limited importance if the spirit of the guidance is correctly followed. Most point out that some patients may require concentrations slightly in excess of the more conservative ranges to achieve clinical stability, and conversely, some, particularly elderly, patients may be adequately controlled on doses below some ranges. This point is succinctly reviewed in the UK GMS Contract Quality and Outcomes framework guidance notes (target range cited 0.6–1.0, but qualified as above).76 Although a narrower target range is proposed in the UK GMS contract, the accompanying guidance acknowledges the need for this flexibility.

As the main purpose of monitoring in this case is to avoid potential toxicity (ie trigger interval retesting or a change in dose) while ensuring a sufficient dose to maintain clinical stability, the range cited in the BNF would seem, albeit not on evidence‐based findings, to offer a satisfactory balance between the need to predict toxicity and recognise the relatively wide range of doses required in clinical practice.

It follows from this that patients in whom a clinical decision has been made to maintain lithium concentrations outside of a target range should be clearly documented as such to avoid inappropriate change in dose by another practitioner.

The value of 1.5 is cited as a level at which the incidence of adverse events rises considerably,77 and as a threshold for at least temporarily stopping treatment. In view of this, it would not seem prudent to include higher values (eg >1.0 mmol/l) within the usual range.

GMS contract indicator: percentages of patients on lithium treatment with:

  • A record of lithium level checked in the preceding 6 months;
  • A record of serum creatinine and thyroid stimulating hormone checked in the preceding 15 months;
  • A record of lithium levels within the therapeutic range in the preceding 15 months (range cited as normal 0.6–1.0 mmol/l).

d‐dimer testing and deep venous thrombosis or pulmonary embolism (MJG, ACW)

The guidance mentioned below is taken largely from the British Committee for Standards in Haematology document: The diagnosis of deep vein thrombosis (DVT) in symptomatic outpatients and the potential for clinical assessment and d‐dimer assays to reduce the need for diagnostic imaging.78 This emphasises the need for testing, if carried out, to be combined with appropriate clinical assessment. Adoption of a suitable clinical scoring system should allow a standardised approach to primary (and secondary) care assessment of possible DVT.

In which patients with suspected DVT should a d‐dimer test be carried out in a primary care setting?

We recommend:

  • Testing patients with suspected DVT but Wells' probability score <2.
  • Patients with higher probability scores should be referred for diagnostic imaging after a clinical algorithm depending on local service provision.

d‐dimers are increased as a result of the degradation of fibrin, which may have formed as a result of a clot, but other situations giving rise to an increased fibrinogen will produce a high result. The use of this test allows a diagnosis of DVT to be excluded if the d‐dimer result is low but a positive test does not confirm a DVT, which requires other investigations. Adoption of a suitable clinical scoring system—a combination of a d‐dimer test and a pre‐test probability or clinical probability score—can be used to eliminate the need for diagnostic imaging as long as the combination gives a negative predictive value of >98%.78,79,80,81 The criteria listed by Wells81 are shown in figure 4. d‐dimers are of limited positive predictive value but can be used in clinical algorithms to exclude venous thrombosis. There are numerous causes of raised d‐dimers, which should be excluded before asking for the test (see below).

Which test?

Many different d‐dimer tests are available and the aim should be to use a test with a high negative predictive value.81 The results from the test should be used with a probability score and not in isolation. The test should be carried out by, or in conjunction with, an accredited laboratory with satisfactory quality assurance.82 Cut‐off values will vary depending on the method used and if possible should be audited locally. Old samples may give false‐positive results with some methods.

Who to investigate?

d‐dimers and probability scoring can be used to exclude DVT in patients presenting with clinical symptoms suggestive of a DVT as long as symptoms have been present for <14 days.81 Anyone who has already received heparin is excluded from this guidance,78,81 as are patients likely to have raised d‐dimers secondary to other conditions including the following:

  • Pyrexial
  • Grossly unwell
  • Bedridden
  • Obviously infected/septic
  • Recent surgery
  • Known malignancy
  • Inflammatory disease
  • Liver failure
  • Renal failure
  • Cardiac failure
  • Pregnant.78

d‐dimers may be raised in these situations, even in the absence of thrombosis. To avoid confusion, it would therefore seem appropriate to request imaging in these situations to establish whether the patient has a DVT or pulmonary embolism.

Table thumbnail
Table 4 Wells' criteria for likelihood estimation of lower extremity deep venous thrombosis81

Post‐test assessment

In patients with a low clinical probability score and a negative d‐dimer, DVT can be excluded78,79,80,81 and no further investigation is required. Those patients with an unlikely clinical score in whom the d‐dimer is positive or those patients classified as likely to have a thrombosis will require further investigation. Heparin should be given unless there is immediate access to diagnostic imaging,78 hence a sample for d‐dimers must be taken at this point if it is to be used in the clinical algorithm.

Compression ultrasound imaging is usually the main diagnostic tool used, although distal venous thrombosis can be missed. In high‐risk patients rescans may be indicated to exclude any progression of a previously missed distal thrombosis. The risk of embolic events from a distal thrombus that does not progress is extremely low.78

Clinical algorithm

A clinical algorithm needs to be designed according to resources and the local patient population. Many will already exist in the secondary care setting and require little modification for use in primary care or out‐of‐hours settings. One way these can vary is by changing the order in which tests are carried out. As long as the basic evidence‐based principles are applied it should be possible to establish an algorithm suitable for the local clinical service provision.

Patients with a positive ultrasound should be fully anticoagulated initially with low‐molecular‐weight heparin followed by warfarin according to current guidelines.83,84 No other diagnostic investigations are required; however, consideration as to the cause of the thrombosis is essential, including the exclusion of underlying malignancy. Patients with DVT require full medical assessment. Thrombophilia screening may be recommended after anticoagulation is completed.85

One possible approach derived below (fig 1) is suggested from a previously published algorithm.81.

GMS contract indicator: None.

figure cp37754.f1
Figure 1 Proposed algorithm for patients with an intermediate or high probability of a deep venous thrombosis (adapted from Wells et al81).

Conclusion

This fifth review brings to a running total 66 question–answer sets written to provide an overview of current advice in use of laboratory tests in primary care. Answers to the first four question–answer sets can be found in Smellie et al.86,87,88,89 They have all used a common search method,90 although where recent systematic reviews have been carried out, the guidance also relies heavily on the findings of these reviews. For authors wishing to consult the UK GMS Contract91 and related Quality and Outcomes framework76 guidance, these can be found on their respective websites.

Acknowledgements

We thank Mrs Susan Richardson for typing this manuscript, Mrs G C Smellie for help in collating answers into this article and to the following people who reviewed the work: Professor I S Young, Dr D Housley (Association of Clinical Biochemists), Professor R Gama (Association of Clinical Pathologists), Dr E Logan (British Society for Haematology), Dr R Neal, Dr N Campbell (Royal College of General Practitioners), Dr D Gozzard, Dr D Freedman (Royal College of Pathologists), and other Council members of these Associations and Colleges who have assisted in recruiting reviewers.

This work has been supported (in alphabetical order) by the Association of Clinical Biochemists*, Association of Clinical Pathologists*, Association of Medical Microbiologists, British Society for Haematology, Royal College of General Practitioners, Royal College of Pathologists* and the Sowerby Centre for Health Informatics in Newcastle (SCHIN), representatives of which have contributed to the reviewing process. The opinions stated are, however, those of the authors.

* These organisations contributed direct funding to support the project start up.

Abbreviations

ALP - alkaline phosphatase

ALT - alanine aminotransferase

AST - aspartate transaminase

BNF - British National Formulary

DVT - deep venous thrombosis

GGT - γ‐glutamyl transpeptidase

GMS - General Medical Services

NAFLD - non‐alcoholic fatty liver disease

ULN - upper limit of normal

Footnotes

Competing interests: None declared.

References

1. Bland J M, Altman D G. Regression towards the mean. BMJ. 1994;308: 1499, http://www‐users.york.ac.uk/ ˜mb55/talks/regmean.htm (accessed 7 Jul 2006)
2. Aranda‐Michel J, Sherman K E. Tests of the liver: use and misuse. Gastroenterologist 1998. 634–43.43. [PubMed]
3. Wilson J W. Inherited elevation of alkaline phosphatase activity in the absence of disease. N Engl J Med 1979. 301983. [PubMed]
4. Guidelines and Protocols Advisory Committee Evaluation and interpretation of abnormal liver chemistry in adults. British Columbia: BC Health Services, http://www.health.gov.bc.ca/msp/protoguides (accessed 7 Jul 2006)
5. Minuk G Y. Canadian Association of Gastroenterology Practice Guidelines: evaluation of abnormal liver enzyme tests. Can J Gastroenterolhttp://www.pulsus.com/Gastro/12_06/minu_ed.htm (accessed 5 Oct 2005) [PubMed]
6. Titcomb C P. Liver function tests: what is the risk? J Insur Med 2003. 3526–35.35. [PubMed]
7. Pratt D S, Kaplan M M. Evaluation of abnormal liver‐enzyme results in asymptomatic patients. N Engl J Med 2000. 3421266–1271.1271. [PubMed]
8. Giannini E G, Testa R, Savarino V. Liver enzyme alteration: a guide for clinicians. CMAJ 2005. 172367–379.379. [PMC free article] [PubMed]
9. Green R M, Flamm S. AGA technical review on the evaluation of liver function tests. Gastroenterology 2002. 1231367–1384.1384. [PubMed]
10. Cooper C, Dennison E, Schafheutle K. et al Epidemiology of Paget's disease of bone. Bone 1999. 243S–5S.5S. [PubMed]
11. Sofaer J A, Holloway S M, Emery A E. A family study of Paget's disease of bone. J Epidemiol Community Health 1983. 37226–231.231. [PMC free article] [PubMed]
12. Vellenga C J, Pauwels E K, Bijvoet O I. et al Untreated Paget disease of bone studied by scintigraphy. Radiology 1984. 153799–805.805. [PubMed]
13. Kotowicz K K. Paget disease of bone. Diagnosis and investigation for treatment. Aust Fam Physician 2004. 33127–131.131. [PubMed]
14. Bosma P J, Chowdury J R, Bakker C. et al The genetic bases of the reduced expression of bilirubin UDP‐glucuronosyltransferase 1 in Gilbert's syndrome. N Engl J Med 1995. 3331171–1175.1175. [PubMed]
15. Tomsen H F, Hardt F, Juhl E. Diagnosis of Gilbert's syndrome. Scand J Gastroenterol 1981. 16699–703.703. [PubMed]
16. Hultcrantz R, Glaumann H, Lindberg G. et al Liver investigation in 140 asymptomatic patients with moderately elevated activities of serum aminotransferases. Scand J Gastroenterol 1986. 21109–113.113. [PubMed]
17. Van Hootegem P, Fevery J, Blanckaert N. Serum bilirubins in hepatobiliary disease: comparison with other liver function tests and changes in the postobstructive period. Hepatology 1985. 5112–117.117. [PubMed]
18. Quinn P G, Johnston D E. Detection of chronic liver disease: costs and benefits. Gastroenterologist 1997. 558–77.77. [PubMed]
19. Giboney P T. Mildly elevated transaminases levels in the asymptomatic patient. Am Fam Physician 2005. 711105–1110.1110. [PubMed]
20. Gholson CF Morgan K, Cantinis G. et al Chronic hepatitis C with normal transaminases levels: a clinical histologic study. Am J Gastroenterol 1997. 921788–1792.1792. [PubMed]
21. Mofrad P, Contos M J, Haque M. et al Clinical and histologic spectrum of nonalcoholic fatty liver disease associated with normal ALT values. Hepatology 2003. 371286–1292.1292. [PubMed]
22. Keating G M, Plosker G L. Peginterferon alpha‐2a (40KD) plus ribavirin: a review of its use in the management of patients with chronic hepatitis C and persistently ‘normal' ALT levels. Drugs 2005. 65521–536.536. [PubMed]
23. Young DS. Effects of drugs on clinical laboratory tests. Washington, DC: AACC Press, 1990.
24. American Gastroenterological Association Medical position statement: evaluation of liver chemistry tests. Gastroenterology 2002. 1231364–1366.1366. [PubMed]
25. Limbi J K, Hyde G M. Evaluation of abnormal liver function tests. Postgrad Med J 2003. 79307–312.312. [PMC free article] [PubMed]
26. Theal R M, Scott K. Evaluating asymptomatic patients with abnormal liver function test results. Am Fam Physician 1996. 532111–2119.2119. [PubMed]
27. Harrison S A, Kadakia S, Lang K A. et al Nonalcoholic steatohepatitis: what we know in the new millennium. Am J Gastroenterol 2002. 972714–2724.2724. [PubMed]
28. Smetana G W, Macpherson D S. The case against routine preoperative laboratory testing. Med Clin N Am 2003. 877–40.40. [PubMed]
29. Kim C H, Nam M C, Jee S H. et al Normal serum aminotransferase concentration and risk of mortality from liver diseases: prospective cohort study. BMJ 2004. 328983–986.986. [PMC free article] [PubMed]
30. Sherwood P, Lyburn I, Brown S. et al How are abnormal results for liver function tests dealt with in primary care? Audit of yield and impact. BMJ 2001. 322276–278.278. [PMC free article] [PubMed]
31. Hultcrantz R, Glaumann H, Lindberg G. et al Liver investigation in 149 asymptomatic patients with moderately elevated activities of serum transaminases. Scand J Gastroenterol 1986. 21109–113.113. [PubMed]
32. Mathiesen U L, Franzen L E, Fryden A. et al The clinical significance of slightly to moderately increased liver transaminase values in asymptomatic patients. Scand J Gastroenterol 1999. 3485–91.91. [PubMed]
33. Hultcrantz R, Gabrielsson N. Patients with persistent elevation of aminotransferases: investigation with ultrasonography, radionucleide imaging and liver biopsy. J Intern Med 1993. 2337–12.12. [PubMed]
34. Hay E J, Czaja A J, Rakela J. et al The nature of unexplained chronic aminotransferase elevations of a mild to moderate degree in asymptomatic patients. Hepatology 1989. 9193–197.197. [PubMed]
35. Daniel S, Ben‐Menachem T, Vasudevan G. et al Prospective evaluation of unexplained chronic liver transaminase abnormalities in asymptomatic and symptomatic patients. Am J Gastroenterol 1999. 943010–3014.3014. [PubMed]
36. Sorbi D, McGill D B, Thistle J L. et al An assessment of the role of liver biopsies in asymptomatic patients with chronic liver test abnormalities. Am J Gastroenterol 2000. 953206–3210.3210. [PubMed]
37. Skelly M M, James P D, Ryder S D. Findings on liver biopsy to investigate abnormal liver function tests in the absence of diagnostic serology. J Hepatol 2001. 35195–199.199. [PubMed]
38. Nomura F, Ohnishi K, Satomura Y. et al Liver function in moderate obesity—study in 534 moderately obese subjects among 4613 male company employees. Int J Obes 1986. 10349–354.354. [PubMed]
39. de Marco R, Locatelli F, Zoppini G. et al Cause‐specific mortality in type 2 diabetes. The Verona Diabetes Study. Diabetes Care 1999. 22756–761.761. [PubMed]
40. Teli M R, Day C P, Burt A D. et al Determinants of progression to cirrhosis or fibrosis in pure alcoholic fatty liver. Lancet 1995. 346987–990.990. [PubMed]
41. Teli M R, James O F, Burt A D. et al The natural history of nonalcoholic fatty liver: a follow‐up study. Hepatology 1995. 221714–1719.1719. [PubMed]
42. British Liver Trust Fatty liver. Liver diseases. http// www.britishlivertrust.org.uk/content/diseases/fatty_liver.asp.
43. Moussavin S N, Becker R C, Pipmeyer J L. et al Serum gamma‐glutamyl transpeptidase and chronic alcoholism: influence of alcohol ingestion and liver disease. Dig Dis Sci 1985. 30211–214.214. [PubMed]
44. Orrego H, Blake J E, Israel Y. Relationship between gamma‐glutamyl transpeptidase and mean urinary alcohol levels in alcoholics when drinking and after alcohol withdrawal. Alcohol Clin Exp Res 1985. 910–13.13. [PubMed]
45. Hietala J, Puukka K, Koivisto H. et al Serum gmma‐gultamyl transferase in alcoholics, moderate drinkers and abstainers: effects on GT reference intervals at population level. Alcohol Alcohol 2005. 40511–514.514. [PubMed]
46. Ireland A, Hartley L, Ryley N. et al Raised gamma‐glutamyltransferase activity and the need for liver biopsy. BMJ 1991. 302388–389.389. [PMC free article] [PubMed]
47. Whitehead M W, Hawkes N D, Hainsworth I. et al A prospective study of the causes of notably raised aspartate aminotransferase of liver origin. Gut 1999. 45129–133.133. [PMC free article] [PubMed]
48. McCullough A J. Update on non‐alcoholic liver disease. J Clin Gastroenterol. 2002;34;255–62. [PubMed]
49. Williams K, Oke S. Lithium and pregnancy. Psychiatr Bull 2000. 24229–231.231.
50. Linder M W, Keck P E., Jr Standards of laboratory practice: antidepressant drug monitoring. National Academy of Clinical Biochemistry. Clin Chem 1998. 441073–1084.1084. [PubMed]
51. Micromedex Lithium. MICROMEDEX [CD‐ROM], 2005 (accessed 5 Oct 2005).
52. Nicholson J, Fitzmaurice B. Monitoring patients on lithium—a good practice guideline. Psychiatr Bull 2002. 26348–351.351.
53. Joint Formulary Committee British National Formulary. Vol 50. London: British Medical Association and Royal Pharmaceutical Society of Great Britain, 2005.
54. Delva N J, Hawken E R. Preventing lithium intoxication. Guide for physicians. Can Fam Physician 2001. 471595–1600.1600. [PMC free article] [PubMed]
55. American Psychiatric Association Practice guideline for the treatment of patients with bipolar disorder(revision). Arlington, VA: American Psychiatric Association, 2000 (accessed 5 Oct 2005,
56. Frances A, Docherty J P, Kahn D A. Treatment of bipolar disorder. The Expert Consensus Panel for Bipolar Disorder. J Clin Psychiatry 1996. 573–88.88. [PubMed]
57. Anon Using lithium safely. Drug Ther Bull 1999. 3722–24.24. [PubMed]
58. Royal Australian and New Zealand College of Psychiatrists Australian and New Zealand clinical practice guidelines for the treatment of bipolar disorder. Melbourne, Victoria: Royal Australian and New Zealand College of Psychiatrists, 2004, (accessed 30 Sep 2005)
59. Eagles J M, McCann I, MacLeod T N. et al Lithium monitoring before and after the distribution of clinical practice guidelines. Acta Psychiatr Scand 2000. 101349–353.353. [PubMed]
60. Darlington P C T. Monitoring drug therapy. Darlington Primary Care Trust, 2005. (accessed 13 Jul 2005)
61. Marcus S C, Olfson M, Pincus H A. et al Therapeutic drug monitoring of mood stabilizers in Medicaid patients with bipolar disorder. Am J Psychiatry 1999. 1561014–1018.1018. [PubMed]
62. Ryman A. Lithium monitoring in hospital and general practice. Psychiatr Bull 1997. 21570–572.572.
63. Murie J. Lithium monitoring audit highlights need for regular review. Guidelines Pract 2002. 589.
64. Butler J A, Taylor D. A survey of lithium monitoring and prescribing patterns. Int J Psychiatry Clin Pract 2000. 4135–138.138.
65. Medical Protection Society Psychiatric negligence. London: Medical Protection Society, 1989. 1–2.2.
66. Aronson J K, Hardman M. ABC of monitoring drug therapy. Why monitor drug therapy? BMJ 1992. 305947–948.948. [PMC free article] [PubMed]
67. Kehoe R F, Mander A J. Lithium treatment: prescribing and monitoring habits in hospital and general practice. BMJ 1992. 304552–554.554. [PMC free article] [PubMed]
68. Reid L D, Horner J R, McKenna D A. Therapeutic drug monitoring reduces toxic drug reactions: a meta‐analysis. Ther Drug Monit 1990. 1272–78.78. [PubMed]
69. Burgess S, Geddes J, Hawton K. et al Lithium for maintenance treatment of mood disorders (Cochrane Review). In: The Cochrane Library, Issue 3. Chichester: Wiley, 2005. [PubMed]
70. Amdisen A. Serum level monitoring and clinical pharmacokinetics of lithium. Clin Pharmacokinet 1977. 273–92.92. [PubMed]
71. Aronson J K, Reynolds D J M. ABC of monitoring drug therapy: lithium. BMJ 1993. 3051273–1276.1276. [PMC free article] [PubMed]
72. American Psychiatric Association Practice guideline for the treatment of patients with major depressive disorder. 2nd edn. Arlington, VA: American Psychiatric Association, 2000.
73. Gelenburg A J, Kane J M, Keller M B. et al Comparison of standard and low levels of lithium for maintenance treatment of bipolar disorder. N Engl J Med 1989. 3211489–1493.1493. [PubMed]
74. Solomon D A, Ristow W R, Keller M B. et al Serum lithium levels and psychological functioning in patients with bipolar I disorder. Am J Psychiatry 1996. 36175–181.181.
75. Tueth M J, Murphy T K, Evans D L. Special considerations: use of lithium in children, adolescent and elderly populations. J Clin Psychiatry 1998. 59(Suppl)66–75.75. [PubMed]
76. NHS Confederation Quality and outcomes framework. Accompanying guidance document. 2003. NHS Confederation. www.nhsconfed.org/docs/quality_and_outcomes_framework_guidance.pdf (accessed on 3 Oct 2005)
77. Ward M E, Musa M N, Bailey L. Clinical pharmacokinetics of lithium. J Clin Pharmacol 1994. 34280–285.285. [PubMed]
78. British Committee for Standards in Haematology The diagnosis of deep vein thrombosis in symptomatic outpatients and the potential for clinical assessment and D‐dimer assays to reduce the need for diagnostic imaging. Br J Haematol 2004. 12415–25.25. [PubMed]
79. Fancher T L, White R H, Kravitz R L. Combined use of rapid D‐dimer testing and etimation of clinical probability in the diagnosis of deep vein thrombosis: systematic review. BMJ 2004. 329821–831.831. [PMC free article] [PubMed]
80. Gardiner C, Pennaneac'h C, Watford C. et al An evaluation of rapid D‐dimer assays for the exclusion of deep vein thrombosis. Br J Haematol 2005. 128842–848.848. [PubMed]
81. Wells P S, Anderson D R, Rodger M. et al Evaluation of D‐dimer in the diagnosis of suspected deep vein thrombosis. N Engl J Med 2003. 3491227–1235.1235. [PubMed]
82. UK National External Quality Assessment Scheme Blood coagulation report on survey 154: D‐ dimer analaysis. UKNEQAS: Sheffield, 2005.
83. British Committee for Standards in Haematology Guidelines on oral anticoagulation; third edition. Br J Haematol 1998. 101374–387.387. [PubMed]
84. British Committee for Standards in Haematology Guidelines on oral anticoagulation. 3rd edn, 2005 update. http://www.bcshguidelines.com/ (accessed 15 Dec 2005)
85. British Committee for Standards in Haematology Investigation and management of inheritable thrombophilia. Br J Haematol 2001. 114512–528.528. [PubMed]
86. Smellie W S A, Wilson D, McNulty C A M. et al Best practice in primary care pathology: review 1.J Clin Pathol 2005. 581016–1027.1027. [PMC free article] [PubMed]
87. Smellie W S A, Forth J, McNulty C A M. et al Best practice in primary care pathology: review 2.J Clin Pathol 2006. 59113–120.120. [PMC free article] [PubMed]
88. Smellie W S A, Forth J, Bareford D. et al Best practice in primary care pathology: review 3.J Clin Pathol 2006. 59781–789.789. [PMC free article] [PubMed]
89. Smellie W S A, Forth J, Sundar S. et al Best practice in primary care pathology: review 4. J Clin Pathol 2006. 59893–902.902. [PMC free article] [PubMed]
90. Smellie W S A, Wilson D, Finnigan D I. et al Best practice in pathology. Methodology for constructing guidance. J Clin Pathol 2005. 58249–253.253. [PMC free article] [PubMed]
91. General Medical Services Contract Investing in general practice. The New General Medical Services Contract. http://www.nhsconfed.org/docs/contract.pdf (accessed 3 Oct 2005)

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