I also had drug-induced liver injury (DILI). Mine was caused by green tea extract. Like this gentleman, I had stopped taking the green tea extract. While he seemed to not have symptoms, I did - high ammonia, elevated clotting times, very high bilirubin, inability to eat, pain, nausea. I started showing symptoms about a week or two after stopping the supplement. My liver biopsy confirmed the diagnosis and I was put on high-dose steroids to stop my immune system from continuing the damage.
I eventually recovered fully, thankfully. But I might not have and could have either died or needed a liver transplant. While this man's liver failure self-corrected, it won't always. And believe me, you miss your liver when it's gone!
6
@Susan
Thank you for writing about your liver injury. Reading your story makes me leery about taking (so-called) health supplements. I googled 'green tea extract' and found this:
"Consuming too many of the supplements can have a harmful effect on your liver, according to the European Food Safety Authority (EFSA). ... Researchers have determined that consuming more than 800 mg of the antioxidants naturally present in green tea can lead to higher health risks, including liver damage."
Your letter is a public service, thank you.
7
I want to know the name/family of antibiotics the man was given for Strep—that is a common enough illness—and sounds like the antibiotic has this side effect enough for it to be KNOWN for causing bile duct issues...EVERYONE should be aware of that!
4
Your columns are always enlightening. It's almost always like a 2 page mystery.
Your latest, about the liver scare, was par for the course, always a good read.
So why did this one in particular cause me to ask: what did all of this cost? Not what insurance paid or any of the many finance-related medical issues but what did this very high end hospital and the several rounds of [obviously necessary] doctors actually charge?
This should not be taken to mean you shouldn't pursue these medical stories or that the price is the object or should be part of your consideration when treating us to the history and resolution or that the patient shouldn't get the best result that the American medical system can offer.
Still....
2
@Bob
With Medicare for all, the inevitable outcome of socialized medicine is rationing of services. Finances preclude treatment for patients like the one in the article. Dialysis for diabetics will be limited. Surgeries will be postponed until a slot in the schedule occurs. More emphasis will be placed on lifestyle changes to eliminate many of the illnesses that fill our hospitals, but we must still expect longer waits for treatment. Ethics will play an important role when deciding who lives or dies. Shall we spend the money on premature infants, the aged, drug addicted emergency room recyclers, or would a young college graduate needing breast cancer treatment be first on the list for care? It's a brave new world we are entering.
@Daphne As someone who has lived my whole life in a country with a single-payer Medicare system for everyone, I find your post very misleading. Nobody in my extended family and none of my friends have ever had to wait very long for medically necessary treatment. We certainly don’t have to wait while the rich are treated first! Like the man in this article, my family doctor found elevated liver enzymes in my blood during routine testing and ordered the test repeated. When the levels were still high he sent me for an ultrasound which revealed a diagnosis. Treatment was begun immediately and my doctor will monitor my condition every three months henceforth. All of this took less than two weeks and didn’t cost me a penny out of pocket! I know that if further investigation or treatment is required they will be done in a timely manner at no cost to me. I find that people who complain about wait times are often those who expect to receive “service” rather than “care”. They expect to be waited on as if they were at a hotel or restaurant. Of course it is stressful waiting a week or two for test results but not nearly as stressful as going bankrupt over medical bills! Canadians receive medically necessary healthcare in a timely, efficient fashion at lower overall cost to the system, and in relation to the severity of their medical conditions. You Americans should try it!
18
I also took an antibiotic for a minor infection (sinus). Three years later my liver enzymes are nearly normal. After all of the tests listed in this article and more, I learned much more than '..the outcome would have been the same if he’d never known about the liver injury. It was discovered because of an incidental blood test. The only real difference was the worry it caused." Four doctors into it I learned that the antibiotic caused vanishing bile duct syndrome which is not treatable and not usually reversible. Each subsequent exposure to entire class of antibiotics that caused this reaction can produce a similar or worse response. The man in this article should likely never take the antibiotic again and he should warn his children of the possibility of a similar response in them. The type of liver response is dangerous - far beyond what is indicated in this article.
18
Fortunately for this man, things worked out in his favor. As someone who has specialized in high-risk life insurance for 20+ years, the outcome could have been much different. I've had a number of clients over the years who were declined due to elevated liver functions, only to learn with follow-up testing that the reason why liver functions were elevated was due to hepatitis.
The other thing to point out is that if an insured had elevations as high as you mentioned, he would be uninsurable until he went through all the tests you had him complete. Without the biopsy in his case, he would not be able to protect his family which after all was the reason why this all started in the first place.
From an underwriting standpoint, elevations that are 2-3 times the normal limit may still be insurable without all those tests but when results are in the thousands there is no chance to get life insurance until addressed.
5
@RiskQuoter Oh, so his risk was to be uninsured? Well, than the insurers should make explicit that they use random requirements to insure people. Understandably, your name is not published because this doesn't sound legal.
2
@Heloisa Pait life, disability, and long term care insurance have different regulations than medical insurance. Companies can have individually set guidelines regarding medical impairments including declining.
1
Allow me to share the following true story: A 65 year old friend was advised to acquire additional life insurance by his financial planner. The medical testing required by the insurance company revealed kidney issues. Follow-up testing revealed that my friend had been born with only one kidney and that this kidney was approximately 35% functional. Subsequently, my friend made major life style changes. He had no indication of his kidney failure prior to this physical-no symptoms and he did not get regular physicals. Some commenters will condemn routine bloodwork as having the potential for false positives or identifying minor anomalies that will correct themselves without the need for medical intervention. However, there are symptomless serious issues with dire consequences that may go undetected until medical crisis occurs. Any by the way, my friend is an orthopedic surgeon.
17
Read the book called "Overdiagnosed" and you'll see a definitive answer on why this unnecessary testing is going on, the money it costs, and the emotional turmoil it causes in your life. after I read that book, I never had another physical, and I never had another screening test. but you have to read the book to understand it.
8
@buddy
You sound (in attitude) like my father -- avoided diagnostic tests because he thought they were scams. For this reason, he never had a colonoscopy. When he had blood in his stool, then he went to the doctor, and yes, it was colon cancer. He had surgery to remove two cancerous tumors, and luckily recovered. He also completely stopped eating deli cold cuts, which was his normal lunch.
(This was 10 years ago; he's now 83.)
Another real difference would be the 100's of thousands of dollars worth of testing and specialist consulting.
Not to say that it was not worth it, but at any time did the guy feel really sick?
2
Ifr you think you're healthy, you haven't had enough tests
34
for me, a non-American, this story emphasizes that our European system of NOT testing yearly for no other reason than that a year has passed is a sound idea.
Yearly testing leads to lots of worries, lots of costs, and no guarantee of a longer life. I take my chance of living till well in my nineties like most of my relatives have done, without going into the worries of testing when you are not sick
29
Interesting the nod to hemochromatosis. My father and older brother both died of that. My dad passed in ‘71, long before it was a diagnosis in ‘94, but my brother’s diagnosis came late in his illness. He had a pulmonary before it was caught and gotten under control in 2005. Just saying.
16
@Tom Hayden Dear Lord, I have been dealing with hemochromatosis for about a decade and have phlebotomy done around once a month. My hematologist has never suggested it could be fatal. I'm going to inquire about that on the next visit. Also, I hope you were tested and found to be negative. Best wishes.
11
I am always amazed disturbed when people ask, as the Times does in its front page subheading, is it worth knowing because of the worry that results from knowing. Such people are doing nothing other than championing for ignorance.
I am also disgusted by the casual way that the author of this article, a physician, in so light hearted and accepting manner wrote:
"Although illness is indifferent to time and holidays, doctors and medical staff are not."
I think that it shows lack of ethics to selfishly make patients wait for testing of such serious threats to health (and possibly life itself) as liver damage. The author's casual acceptance of such behavior by those in her own profession shows deficiency in her ethics, too.
21
@Errol Not a doctor, but I think it's odd that you would oblivious to reality in that it was the holidays--of course doctors will have time off. To couch the situation as a matter of ethics is ludicrous. It's the real-world.
Of course, it would have been better for the patient's frame of mind, had the pathologist been on-call, but the hospital doesn't revolve this patient.
18
@Errol
What even-more-entitled-than-here planet are you from? Does it have unlimited money and staff for every medical contingency 24/7/365? For you? For everyone in the concierge practice? For anyone with a regular job or no insurance?
As a side anecdote I will just share my gratitude for the ER, cardiology, and internal medicine teams on call at Mt Sinai West hospital in NYC this past July 4. I had an unexpected and worrisome “health event”, but was still concerned that an ER visit on a major holiday was like the set up for a bad medical school “new residents “ joke. In fact I was treated promptly and efficiently and thoroughly and coherently. (Yes, maybe over-tested? Yes maybe that’s because I’m among the fortunate well-insured, for now. Still grateful.) Just wanted to share a good hospital on a holiday tale.
4
This story puts me in mid of the classic definition of a healthy person: someone who has not yet had a complete work up.
43
This story brings to mind the classic definition of a healthy person: one who has not yet had a complete work up.
3
why is celiac disease classified as an inherited disease rather than an autoimmune disease in this article?
4
@NYer
It's both. It can be inherited, and it is an autoimmune disease.
10
I think it is likely the events of this story are not unrelated to the high cost of healthcare in the US. We demand near perfection from our bodies and when that does not happen we demand that medicine tell us why not. We demand near perfection from the medical industry to give us immediate and perfect answers, and solutions, to our health problems. It is a lot to ask for and certainly a more than one could expect even 20 or 30 years ago. As the tests get more sophisticated, the bar is going to be raised even further as to what we all want out of medicine, and as the bar rises, so will the costs. This really should not be a surprise to anyone. In the face of this it is hard for me to see how we can realistically dial back the costs of healthcare.
8
@Scott Werden
I think you are correct that we will demand ever more healthcare, and therefore the necessary cost of healthcare will rise. But that does not mean that the current prices of each unit of healthcare are not greater than reasonable and not unfair. For example, just prohibiting all price discrimination by producers and sellers of drugs would result in a great increase in fairness as well as lower drug prices for Americans.
Nor does it mean we should not demand ever more healthcare. I think more healthcare is far more valuable to us than spending our money on more booze or more marijuana or more political campaign donations.
14
Having a single buyer- Pharmac, the government pharmaceutical agency which passes on much lower costs due to ultra-bulk buying- results in much lower charges for prescription medicine in NZ than I have experienced elsewhere. Having a single payer- again, the government- resulted in high quality healthcare in Canada that saved my life after multiple hospitalisations and surgeries as a child due to a health condition that developed when I was a toddler. My parents paid nothing directly; instead, they continued to pay their income taxes. I have much to be grateful for, clearly. But my point is: your medical costs could be reduced, in a range of ways, while still providing good health care. You could start by changing your private health insurance set up.
5
Yes the outcome for this man would have been the same if he never knew about it. But the outcome would have been very different if he never was evaluated and he had autoimmune disease, cancer, or some other condition that required immediate treatment. He may have escaped from a bad outcome but the next patient may die if he does not know. His worry is a small price to pay for being sure. I congratulate this man’s doctors for being thorough and professional
55
What surprises me in this story is the delay in ordering imaging for the liver. An ultrasound is a relatively inexpensive, easily scheduled, completely noninvasive procedure. After two blood tests showing abnormal liver values, it seems to me an ultrasound would be the logical next step.
I’ve had lab results showing abnormally high lymphocytes, and have been told to get the tests redone because the measurements are often wrong (blood sample mishandled, etc.). But two high readings and you need imaging.
Incidental findings can indeed cause unnecessary worry, as well as outrageously high out-of-pocket expenses. But they have to be investigated. Because I have had many injuries, I have had abnormalities (nodules and and cysts that could be tumors) show up on x-rays, MRI and CAT scan. I’ve also had some scary things come up with MRI scans related to migraine. I’ve gone through the weeks of fearful waiting, only to find out that I’m okay. It’s the “okay” part that matters.
14
It’s not just worry...
This took time and resources, the testing causes discomfort/pain and was not without risk. During the interval the family has to put its life on hold—how do you make plans if you are waiting to hear if you have a life threatening disease?
Emotions are the least of the problems with overtesting.
18
Mt Sinai's liver service is the best! Thirty or so years ago doctors at St. Vincents which was the time was in Greenwich Village insisted I needed to have the right lobe of my liver removed. I changed doctors and hospitals. After one of the early laparoscopic biopsies at Mt Sinai, I still have my the late Dr. Fenton Schaffner who was my doctor.
7
@KBM and you still have that part of your liver?
2
I felt run down and tired for a few weeks and finally saw my doctor. Routine blood work showed my liver enzymes were sky high (1400) and followup testing showed hepatitis b. By the time I knew I had hep b I felt fine so I feel lucky I found out, quit drinking, and eventually got on antivirals.
19
Great article. There is no evidence to support the routine checking of transaminases as part of a screening blood panel, as low-level elevations are very common and very rarely pathologic. It is not a good test for chronic hepatitis, fatty liver disease, iron overload, or even cirrhosis as it lacks specificity and sensitivity. For a healthy patient with no comorbidities, the evidence supports checking a lipid panel and either a fasting glucose or A1c, and consider a PSA in men 50-70. That's it. No CBC, creatinine, LFTs, or other chemistry components. If someone has symptoms, that's a whole different story. But from a screening standpoint, less is more. And don't be swayed by the rare person who had more extensive testing done and happened to catch something unlikely; anecdotal evidence is misleading and not a good basis for one's practice. Remember the ACP principles of testing: 1) Don't order a test that won't change your management. 2) A test for a disease with a low pre-test probability is more likely to give you a false positive than a true positive, and 3) The true cost of a test is not just the expense to the patient, but the expense to the system, the potential cost to the patient's peace of mind, the doctor's time and energy, etc.
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@Brent, maybe a blood test for life insurance should not be a complete blood panel. The insurance exams are often useless anyway (often the “doctor” doing the exam is someone who graduated from medical school but never qualified as a physician), and they don’t need as much information as they gather from an applicant. But after this man had strep throat he did have ongoing symptoms. The article says he had not felt well for a couple of months. The initial test that showed abnormal blood values was done before he got strep throat, but any initial blood test just acts as a baseline for comparison with the next one when a value is flagged. So when the next labs were also abnormal, the follow-up investigation was necessary. Certainly the patient had out-of-pocket expenses, but how is this an “expense to the system”? Would you rather the patient’s outcome was dire? Would that make the whole thing more worthwhile, in your mind?
My doctor orders a complete blood panel for me when I go in for a general physical, and she might order one if I come in at other times with symptoms like fatigue or dizziness. A complete blood panel is quick, convenient and not that expensive. It provides a lot of information for little effort. Good bang for your buck, I’d say.
6
@Brent
Compare the consequences of a false positive and a missed true positive. Sometimes the latter are much worse, and justify the risk and consequences (more testing) of a false positive.
2
@Jonathan Katz
Your perspective is understandable but misses the very serious and real consequences of false positives. You can look up "An Injudicious Request - Performing a Test that Is Not Indicated" from the Journal of the American Medical Association a few years ago for a particularly interesting example.
For years I had abnormal liver tests, not terrible but they had to be watched. I changed Internist and he used a different lab part of a hospital system. I was so surprised that my liver levels were now completely normal and have stayed normal for years now , this change in lab results happened immediately with changing doctors and labs. My internist was not surprised says it happens all the time when he gets new pts.
Also my new internist warned me to be careful of radiology reports, don't trust them if they show something new, always get another group to read your results. Radiologist are so over worked now they cmix up pts and make lots of errors.
Our medical system is not to be trusted.
39
@Chelsea, I think your last sentence is a massive overstatement.
My doctor told me that blood samples can easily be mishandled when vials are transferred from one location to another, as from a doctor’s office to the lab (shaking the sample can skew the values, for instance), so it’s always better to get your blood drawn in the same place where it will be tested.
I thought about this when I read about the shenanigans Theranos got up to (the company that supposedly had a magic machine that did a complete panel using one drop of blood). They were Fed-Exing their (standard-sized) blood draws from a huge number of Walgreens locations to their single lab. I wonder how many people got incorrect flags on their blood panels due to rough handling of their samples?
10
Liver enzymes are inside the cells of the liver and any inflammation causes them to leak out into the blood, so they are a non specific indicator of inflammation. They are very sensitive to numerous insults. There are viruses that we don't have tests for that can do this. Screening tests stumble across these transient lab abnormalities and set off a search for a cause as outlined here. There is some risk to some of these test (liver biopsy comes to mind) which is the bugaboo about screening tests.
A ten fold increase in liver enzymes is not in itself impressive but certainly deserves monitoring.
If you can't live with doubt don't go into internal medicine. Trying to be sure can get dangerous for the patient and the art of medicine is knowing when to go whole hog, crossing into risky procedures. A little gray hair helps.
33
It is great that the liver enzyme tests are back to normal, but something caused them to be so far out of line that there was serious concern. If you don't know what happened the first time you don't know that it won't happen again.
23
@W.A. Spitzer:
not only that but the world could end at any moment!
6
@W.A. Spitzer
To get “don't know that it won't happen again.” out of my head, it’s best to start drinking. Alcohol washes it all away.
2
@W.A. Spitzer
Good point...What was the result of the mono test? I had mono after a strep infection. Maybe he had several bouts of strep. The article just said he "didn't feel well". I had pain when doing situps and the MD found my liver felt enlarged. Had a positive mono-spot. 3 weeks in bed, I was good to go. This patient's timeline corresponds.
1
"The outcome would have been the same except for the worry..." and the financial drain. This guy apparently could afford it, but others might easily have been bankrupted by the hospital stay and all the testing. Fix our health care system!
149
Bankrupted, or perhaps dead, due to lack of ability to pay in the first place? Surely Americans deserve better?
4
Hope he had CPK done during the evaluation. Some of the enzymes could be coming from damaged muscles .
7
"The only real difference was the worry it caused."
And the cost of the medical procedures done.
90
In systems analysis, as one monitors things more closely, individual readings skew from the mean. Perfect example in biology. Monitoring blood pressure by taking 10 second averages over 60 seconds, produces (in the majority of seated or recumbent people) very consistent readings. but monitoring/averaging blood pressure every 10 milliseconds produces huge variability. This is part of the chaos effect applied to biological systems. Medical scientists and clinicians first saw the blood pressure effect when computers were applied to the analysis of biological systems. The more intensively they were studied, the more chaotic they appeared. The electrocardiogram (ECG) is another example. Take a reading of 20-30 ECGs (a function of heart performance) from a healthy individual, and the overwhelming majority will look normal. Take 100,000 ECGs from those same people, and abnormal ones will appear. And for the most part, the abnormal ones represent the chaos of the system, and are meaningless. Bottom line: you cannot compare the results from an intensely monitored biological phenomena to a result that just averages effects over a long period of time.
17
I recently had a series of blood tests ordered by my doctor in conjunction with my (somewhat) annual physical. I'm 53. The liver tests all came back normal. This was very alarming to me, though I did not express my concern to my doctor. You see, I am a self-proclaimed expert on American and Scottish whiskies. To further my education and solidify my place in the hierarchy of sippers and online reviewers, it is necessary for me to sample all manner of this product (usually after work). I then must take to the web in my relaxed state and wax on and on about that evening's dram. As you might imagine, this can cause one to be concerned about his (or her) one and only liver.
20
A moderate drinker can have normal liver test results but still have advanced cirrhosis--as I learned from a family member who recently died of cirrhosis.
For years he'd had two drinks per day, but in last 20 years had shifted to one drink per day (as measured in standard dosage units). His liver tests remained in the normal range until about a week prior to death, and even then were only very mildly elevated.
The hospital doctor said cirrhosis often (usually?) does not produce abnormal liver enzyme levels as measured by standard blood chemistry panels, but unfortunately, the normal results for all those years gave a false sense of security, so he continued drinking, only adding to the damage.
You may want to reconsider your conclusion about the health of your liver. Cirrhosis is quite a grim way to die, and every drink will add to the damage. Blood chemistry panels do not register the damage until it's far too late.
23
@kathleen - what an awful story about your family member. As someone who is 44 years sober, with rampant alcoholism on both sides of my family tree, I experienced some alarm bells when reading Mike’s comment. Cirrhosis is very grim indeed. Thank you for educating us about a dreadful condition exacerbated by even relatively small amounts of alcohol. I hope that Mike was exaggerating in order to be funny.
7
@Matt
No hepatitis and no NASH. But he was taking recommended amounts of NSAIDs to deal with severe arthritis. These probably did contribute since they're also hepatotoxic, but the death certificate gave cause of death as cirrhosis that was caused by ethanol. And given my close contact in recent years, the amount of ethanol used is known to be accurate, and once he knew and stopped drinking completely he did not miss it at all.
I'm sure there are some who would also dispute the cause of death of my other parent--smoking--since her COPD could have been caused by other things.
Drinking itself has another major symptom: denial. When that denial is compounded by the belief that all is well because the lab results say so, and no doctor bothers to suggest a cessation of all alcohol to a patient with obvious liver disease (gross ascites), it's clear that it's not just the patient who is in denial.
Alcohol is toxic to the liver (and other things like the brain). As such it is a chronic poison even in moderation. It takes some while before cellular damage manifests as organ damage--which I imagine is something that it taught in med school, as it is in cell biology.
7
so the lesson here is we need more regular screenings for everyone to have better baseline data of what is acceptable and what should be worrying.
3
Actually, I would take the complete opposite position: it was the unindicated screening of this asymptomatic patient which revealed what turned out to be an incidental finding. In the process of that workup, though, he incurred a number of costs (both financial and emotional) as well as the risks of a hospitalization and an invasive procedure.
It's one thing to check liver labs if a patient's having symptoms, has a chronic medical condition involving the liver, is taking a high-risk drug, is at higher risk 2/2 lifestyle factors (alcohol, drug use), or has an infectious disease that can affect the liver; the pre-test probability in those cases is sufficiently high enough that a positive test result is more likely to be significant. However, "more regular screenings for everyone" will simply lead to more overdiagnosis and risky, costly workups. More data does not necessarily equal earlier diagnosis or better health.
51
@MDinTraining It doesn't sound to me like Andrew was recommending regular screenings for the presumed benefit of individual patients. I believe he wrote, instead, of gathering a very large patient sample in order to improve the data for a national baseline.
The effect on individual patients's health of learning his or her results is certainly open to debate.
5
But the patient wasn’t asymptotic. He hadn’t felt well for months.
20
The herb milk thistle has a long, well-regarded history as an adaptogenic herb for the liver. Meaning it supports liver function (i.e., does not fight disease.) It is readily available in capsule and tincture form. Too bad, seems no one provided the patient with this information. One would think the liver specialist would have/should have known.
22
@kathpsyche
You are right on point with this....while there is indeed quackery in the herbs/supplements/alternative medicine world, milk thistle has proven ability to protect the liver and help it heal from injury. I am not proud of this, but here goes.....I drink more beer than I should and my ALT came back at 54. Slightly high but still high. I found a high-quality milk thistle and took it every day for six months with no change in beer consumption. My ALT dropped to 25 which is well within normal limits. This is not to say, "Hey folks, take milk thistle and you can drink as much booze as you want!" Rather, it is an example (albeit anecdotal) of how an herbal supplement may have produced demonstrable benefit. Dr. Andrew Weill recommends milk thistle for people afflicted with chronic hepatitis B and concentrated milk thistle is a recognized treatment following ingestion of poisonous mushrooms.
20
Our veterinarian prescribed milk thistle for our dog when she had liver disease, so some medical practitioners are aware of its effectiveness. And our sweet dog lived longer than expected with her diseased liver.
17
Amazes me that laypeople will turn to educating subspecialists and really believe that they are right.
50
The insurance blood test was a life saver for me.
My PSA (Prostate Specific Antigen) resulst had always been marginal, between 3,8 and 4.2, over a 20 year interval when an insurance blood test showed an increase to 5.9. A followup blood test two months later revealed a further increase to 7.5. A biopsy of the prostate revealed cancer in several of the samples, with one sample at 90%.
I had a radical prostatectomy a week later. Fortunately, there was no spread to the cancer to the adjacent lymph nodes. The timing of the insurance blood test detected the existing prostate cancer and prevented it from metastasizing and threatening the rest of my life.
79
@Pete
Congratulations on slaying the dragon. You are indeed fortunate because it's not just overall PSA levels that predict the aggressiveness of a prostate tumor, rather, the rate/speed of PSA rise. Your PSA rose 27% in two months which was likely due to the presence of high-Gleason cells. Left untreated, they could have metastasized. Congratulations again and to quote Mr. Spock, "Live long and prosper".
26
@Pete- The PSA test has shown to be another way for the medical community to make money. It has been proven over and over again not to be of any value than if you don't take the test. In fact most doctors stopped using it.
I fervently hope your cancer does not come back but whether it does or not it had nothing to do with your PSA test or procedure.
The good news for you is that prostate cancer is very slow growing and if you are a senior chances are you will die from something else even if it comes back.
8
@Paul
My possibly wrong understanding of PSA is that an individual result doesn't mean anything, but that a person's numbers over time might. He had 20 years of results within range and then one outlier. It was right that they checked him out.
28
And what were the charges billed, then paid by both the Patient and the Insurer for this entire course of "cryptic" transaminitis (hepatitis)?
There is an entirely parallel and equally important story here. Thanks.
96