Okay, so good day to everybody, so welcome to our first official lecture for the semifinal period. So what we're going to discuss today is all about patient preparations. So we're actually traversing the different analyzes already. So before we dig into your carbohydrates or lipids and even your proteins, it is first very important for us to talk about and discuss the basic and the important patient preparation that we need to ensure and provide to our patient for accurate results in the laboratory. So for today, we'll be talking about patient preparation. So you've heard me say many times before, especially when we were discussing about your quality management that patient preparation is included in the preanalytical phase. And as you all know, in the preanalytical phase, most of your errors are happening because there are a lot of variables that we need to consider. One of those is how your patient's prepared. So how your patient's prepared can drastically affect the result of your test because there are tests that would require fasting, there are tests that would require special preparation and that's what we're going to discuss for today. So again, good morning to everybody. So I do hope that all of you will be learning a lot in our discussion for today. So let's dig in and move on to our next slide. So this will be the outline of my discussion for today. So as you all know, we'll be discussing patient preparation and patient safety, which will be the second part of our video in the coming lecture. So we'll be discussing, of course, we need to review patient preparation and safety specifically, the different physiologic factors or parameters that can actually affect your patient's result. Okay. So there are different analytes as we all know in clinical chemistry. There are a lot of things, a lot of analytes that we do need to check. So we'll be discussing them one by one for today. And aside from that, we're also going to discuss the effect of bio rhythm, specifically your diurnal variation in your circadian rhythm. How do they affect some of the tests, some of the analytes inside your body? We're all going to discuss that for today. But before anything else, before digging into the different physiologic factors and parameters that might affect your different analytes, I just want to introduce us a very important terminology to everybody, which is what we call your basal state. So basal state in a simplest form refers to the resting metabolic state of the body early in the morning after fasting for approximately 12 hours. So basal state, let's assume that your basal state is the metabolic resting state of our body. So when you say metabolic resting state, imagine when you go to bed at night, your body would be performing its duty. As you all know, there are a lot of things that are happening while we are asleep. Metabolism, catabolism, anabolism of different biomolecules, all of those things are happening inside our body. So basal state meaning, basal state means that you are on a resting metabolic state. So somehow there is homeostasis within your body, all your hormones, all of your hormones equilibrate in that case. So when we talk about basal state, when we talk about basal state, there are no other factors, external factors, if you may say so. External factors that may not play a role in your different analyte. So in its simplest term, when we say basal state, your analytes are on their normal, somehow normal state because there is no factor coming from your exercise, no factor coming from your posture. It really is the basal state or the normal or the resting state of our body. And that's actually the perfect time. That's the perfect time for us to measure this analyte. So beat your glucose, your lipid cholesterol triglyceride, whatever that may be. The ideal state or ideal time for us to collect blood is during our body's basal state. Why basal state? Again, because your body is free from other variations. When you say variation, of course, when you wake up, you'll have your coffee, you'll have all other things, you'll drink your water, you'll eat, you'll do other things, you'll smoke, so you'll drink your vitamins, your medicine, your drugs. So there are now a lot of factors that might affect your analyte. But when we talk about basal state, it is your body's resting state, resting metabolic state. And in our laboratory, it is the most ideal phase to collect your blood. So remember that when we collect your blood at the basal state, we eliminate a number of fission logic variables from your patient. So those will be able to be eliminated and will be controlled when we try to collect our samples. But of course, that's why we have what we call your basal state specimen collection. And your basal state specimen collection is ideal in establishing reference ranges on inpatient because the effect of diet, exercise, and other controllable factors on the test are minimized or much more eliminated. So remember that when we talk about basal state specimen collection, we collect the blood early morning before rising. Again, let me repeat that when we collect your sample at the basal state, we collect your blood early morning before rising. So why early morning? So I'll go back to the first point here. We mentioned that it is indeed early morning because it is our body is still on its resting metabolic state. But why is it important for me to include before rising? Remember that posture also affects your analyte. So it affects your analyte. It does cause some changes in your analyte. So it's very important for us to also take note that in basal state specimen collection, we need to collect the blood early morning before rising. So to encapsulate everything before I move on to the next slide, when we talk about basal state, it is your body's resting metabolic state after sleeping and after fasting for approximately 12 hours or so. So when you talk about basal state, the good thing about basal state is that it is free from external or extrinsic factors such as, of course, your diet, your exercise and other controllable factors, physiological factors that we need to eliminate or we need to minimize for us to have the most accurate measurements of our analyte. Although, I just also want to remind everybody that during basal state, there's still factors such as your age and your gender in other condition of your body that cannot be eliminated. Only those extrinsic factors may eliminate natin. And finally, when we say basal state specimen collection, we collect the blood early morning before rising. So later on, I'll discuss more. Why is it important to collect the blood before rising in an ideal world? In an ideal situation, why is it important? So we'll be discussing that in a short while. But for now, I just want to show you the different fishologic factors and parameters that we are going to be discussing for today, that we're going to discuss for today. So as you guys can see, we have here the different fishologic factors and parameters.  So let's go and discuss the first one, which is your diurnal variation. So these are your bio rhythm. So I'll be discussing diurnal variation and at the same time, your circadian rhythm. So your diurnal variation, your diurnal and your circadian rhythm is very important for you to understand that there are the levels of many blood components in our body. They do exhibit your diurnal or your circadian rhythm or their circadian variation or fluctuation. So when we say diurnal, it is happening daily. Okay? It is happening daily. And when we are talking about your circadian rhythm, they have a 24-hour cycle variation. So most of our analytes have diurnal variation. So when we say diurnal variation, they vary in the morning and they vary in the evening. So for you guys to be able to understand this better, I have a snippet here coming from Henry's. Okay? Coming from Henry's. The different tests that are affected by diurnal variation. I just want you guys to focus on the different analytes affected by diurnal variation. But so when we say diurnal variation, their levels vary in the morning, in the afternoon and even in the evening. So imagine there are, you have AM morning, afternoon and evening. So those three compartments, they do change over time. Some of your analyte change over time. So one example of those are your hormones. Your hormones, they are higher in the morning, some are higher in the morning, some are higher in the evening. Depending on the time that you need them and depending when your body release them. Okay? So let's take a good example here, which is your cortisol. So your cortisol, remember your cortisol is a stress hormone, a type of a stress hormone. So it peaks, okay? It is highest at 4 to 6 AM. So it's high, it is very high in the morning and it starts to lower down and over the day, okay? It starts to lower down over the day and it would have its lowest level at 8 PM to 12 midnight, okay? So for coffee drinkers like me, so this is a good way on how you should schedule your coffee. Because early morning, when you wake up, you would have an influx of cortisol in your body. So your adrenal gland will be releasing your cortisol early morning. That's why it is actually not advisable to have your coffee first thing in the morning. Why? Because naturally, your body would actually be awakening your cell, awakening your body through the help of your cortisol. So when your cortisol is released from 4 to 6 PM, it will actually take effect and wake up your body, okay? And it will help your body get up in the morning. So that's the job of your cortisol. Of course, there are a lot of things, a lot of functions in the body that cortisol is controlling. One of those is your glucose metabolism, which is another story for another time. So your cortisol, again, it peaks at 6 to 46 AM. That's why if you guys would know, okay? It is actually best to drink your coffee around noon, okay? It is best to drink your coffee around noon because that's the time that your cortisol will start to lower down, okay? Or start to go down. By its level, okay? So it's important for you to also identify that. Okay, so 50% lower at 8 PM than 8 AM. So increase in your cortisol also increases with stress. So what we're trying to discuss here are just the urinal variation, not stress. So because there's another part for that. So an example of urinal variation is AM. Morning, afternoon, and evening, a perfect example of that is cortisol. Aside from that, there are also a number of hormones that are also affected by the urinal variation like your adrenal corticotropic hormone that is lower at night and are increased in your stress, okay? Your plasma renin activity, which is lower at night, okay? And as you can see, there are also some that are higher because of your posture. So this would now explain why I was mentioning a while back that in your racial state specimen collection, it's best to collect your blood early morning before rising, okay? Before rising so that we could prevent any postural changes, okay? That might affect your test. Aldosterone is also lower at night. Enchiline is also lower at night. Your growth hormone is higher in the afternoon and in the evening. So for those people who have been disobeying their parents to sleep in the afternoon and the evening, well, there's actually a science behind that. So growth hormone is higher in the afternoon and higher in the evening. And the release of your growth hormone, just a quick information to everybody, the release of your growth hormone is stimulated by deep sleep, okay? Deep sleep, okay? So DEEP sleep, okay? Yung lalim ng tulog mo, okay? So that's why most of the people actually, most of the people who actually sleep in the afternoon and in the evening, they would actually are taller. So there's a science behind that, okay? There's a science behind that. So in the future for your sons and daughters, you need to explain it to them and elaborate to them the reason behind, the science behind, okay? Because I myself did not follow my parents, okay? My guardians when they told me to sleep or when they told me to sleep in the afternoon until I got to college and read about this one and it's actually just too late, okay? So for your siblings or anybody, would still want, okay? Would still want to grow taller.  So aside from your growth hormone, also we also have your acid phosphatase higher in the afternoon and in the evening, tyroxine, it increases with exercise. So it's actually a good thing, okay? It will help you with your metabolism. You have your prolactin. Your prolactin is higher with stress but higher levels at 4 and 8 a.m. So prolactin is one of the hormone that would actually require a special preparation for your patient. So prolactin, please take down note. I want you guys to take note of this one. So prolactin when we're instructing our patient for prolactin testing, we tell them that they need to have their blood collected six hours after rising, okay? So when they wake up, when they get up from bed within six hours, their blood should be collected already, okay? Again, within six hours, their blood needs to be collected already. Why? Because we're playing on that specific margin that from 4 a.m. to 8 a.m., your prolactin is at its highest. So we'll be able to measure if there is really an abnormal increase or if the prolactin levels are just normal. Aside from that, as you guys can see, there are two electrolyte and trace element that is included in this list. So almost everything are hormones, okay? Except for your iron and your calcium, okay? Except for your iron and your calcium. But specifically your iron, your iron is affected by the urinal variation. So meaning to say, it differs from the morning and it differs from the later time of the day. So iron peaks early to late morning and decreases up to 30% during the day. So it starts to go down, the level start to go down as the day goes back. So remember that all of these hormones and trace elements and electrolytes are very important to be considered when it comes to the urinal variation, okay? When it comes to the urinal variation. So why the urinal variation? Because their levels would vary. Their levels would vary day by day.  Some of your circadian rhythm also would affect specifically when you have changes on your 24-hour cycle. Take for example, if you're moving from at the different side of the globe. So take for example, you're coming from America to Asia. So there might be some changes when it comes to your, some changes when it comes to your body. That's why if you guys would know, people coming in from other country to the Philippines, they would sometimes experience jet lag because their bodies also adjusting to the 24-hour cycle of their body on a different place already, okay? So that is the urinal variation. I hope I get to explain the effect of the urinal variation. So in a nutshell, when we talk about the urinal variation, there is a variation when it comes to the levels of your analytes because of the time of the day. So if it is a morning or in the evening, things would change, okay? Analyze may be affected, okay? So moving forward, of course, aside from your urinal variation, one of the most common factor that we need to consider when it comes to testing is your fasting requirement. Or in a nutshell, these is your diet, okay? Remember that your diet can greatly affect laboratory test results because whatever you eat, whatever you put inside your body, can go to your bloodstream, can affect and can interfere in the testing of your analytes. So most common analytes that are greatly affected by diet are your glucose and your triglycerides. So your glucose and triglycerides are absorbed from food and thereby increasing after eating. So when you take, for example, you ate chocolates or you ate your breakfast early in the morning and you have a test for your fasting blood glucose, they will no longer allow you to do so because your body is, your body would have an increased level of your glucose and even your triglyceride. So remember that your glucose, your glucose, our main source of glucose comes from our diet, triglycerides. There are two types of triglycerides, the exogenous and the endogenous triglycerides. The one coming from your diet is what we call your exogenous triglyceride. This comes from the food that we eat on a day-to-day basis. So we'll be discussing more about triglyceride, the exogenous and the endogenous triglyceride as we go to your lipids and lipoproteins. So, but going back here, remember that your diet would affect your glucose and your triglyceride lipids. That's why it's important for us to actually require our patient to do their fasting, okay? To do their fasting. So in your hyperkylo-micronemia, okay? In your hyperkylo-micronemia, this usually happens if you just ate your food and then you would be tested for your triglyceride levels. Remember that your triglycerides are being carried by a lipoprotein, which we call your kylo-microns. Again, your triglyceride is specifically your exogenous triglycerides are being carried by your lipoprotein, kylo-microns, okay? So why do we say they are being carried by your kylo-microns? Remember that your triglycerides, your exogenous triglyceride are water insoluble. So they need a carrier protein, a carrier molecule to carry them around your body to be metabolized. And what is that? That is your kylo-microns, okay? That is your kylo-micron. So again, it's important for our patients to do their fasting because, okay, their glucose and triglyceride may increase. Not only that. There's also some reports in your journals that your bilirubin may also increase after 48 hours of fasting. So if you fasted for more than 48 hours, your bilirubin levels will also be increasing. That is if we measure it using your serum, okay? Your serum bilirubin may increase when your patients have fasted for more than 48 hours. And on the other hand, your plasma triglyceride can also increase after 72 hours of fasting. So what we're trying to say here is that overfasting and underfasting can both affect your patient's result. In Tagalog, we can say kapag sumobra at kapag kinulang sila ng fasting, it can affect the patient's result. So whether their fasting is over-due or their fasting is their fasting is cut short, those can affect your result. That's why it's important for your patient to be advised properly prior to specimen collection so that we can avoid such errors in our measurement. And it's actually a good thing that when it comes to fasting, we do follow a guideline right now. So the guideline coming from the CLSI, GP41-A6, mentions or requires that there are some tests that requires fasting.  In your triglyceride. So it's important for us to remember that. So time and restriction vary depending on the test. So when we say time, the fasting requirement may vary from different analytes. I take for example, this is not on the PowerPoint, but I want you guys to write this down. Take for example for your glucose. Your glucose, the minimum fasting hours for your glucose is eight hours to 12 hours. Eight hours to 12 hours for your glucose. Eight hours to 12 hours for your glucose. But on the other hand, we also have your triglycerides. Okay? Your triglycerides, the minimum fasting hours requirement for your triglyceride is 10 hours. 10 hours to 14 hours in some of the textbooks. Okay? 10 to 14 hours. So to tell you honestly, there is a there is really no a stand. There is in the Philippines and even all over the all over the globe. There is really no standardize fasting hours for a particular test. So when you go to other laboratory, you would see six to eight. You would hear 10 to 12. You'll hear 8 to 10, 8 to 12. So it really vary from one institution to the other. But if we're going to collate everything we've read from journals and from books, I can actually I can actually tell you guys that when it comes summarizing now, summarizing what we have from the books, what we have from from the books from the journals and even from an ongoing research that is being done in the ASEAN region right now. The fasting requirement for the best. Okay? The best fasting requirement that we can give to our patient is 10 to 12 hours. Why 10 to 12 hours? Because 10 to 12 hours would now cover the fasting hours that is needed for your glucose and the fasting hours needed for your triglyceride. So remember, your glucose can go as early as 8 to 12 hours and then your triglyceride is 10 to 14 hours. So if we're going to go on the middle, okay? Yung esakto, yung oras na hindi ko sa triglyceride at hindi din sobra for your glucose if I'm if I'm going to say it in English a perfect we actually found a perfect time range where your fasting for your glucose is not over fasting and you are not under fasting for your triglyceride. So that is 10 to 12 hours. Okay? Again that is 10 to 12 hours. Again, 10 to 12 hours. So take for example your your physician requested both glucose and also your triglyceride. You can just simply tell your patient that they need to fast for around 10 hours to 12 hours. They should not exceed 12 hours and they should also not be too early. Okay? Although when it comes to under fasting it's actually much easier to be resolved than over fasting because over fasting we automatically reject our patient with over fasting requirements. But if they um they um take for example they do lap ulang lang ng ilang oras we can um we can fix that we can remediate that um in the laboratory. Okay? But again let me just repeat and encapsulate when it comes to diet. Okay? When it comes to diet um when it comes to diet the the optimum okay? The optimum time in which both your triglyceride and your glucose will be covered is 10 to 12 hours. Again 10 to 12 hours. So moving forward 10 to 12 hours another thing that maybe a lot of people are asking what about your diet? What about fasting? Because a lot of people will be asking you guys. Okay? A lot of people will be asking you. When we say fasting are we required to drink water? Are am I am I allowed to chew gum? Am I required to smoke? Am I required to um take the communion for example because I in the past have patients like that. So let's clear out the air and explain them one by one. So let's go first with um fasting. Okay? When it comes to fasting there are specific requirement um there are specific requirement that we need to follow. So take for example for glucose okay? For glucose this will be part of your laboratory but I will be mentioning this in the lecture also as well. Um in your in your glucose okay? You are required to have a a high carbohydrate load three days prior to testing. So that is around 150 grams of carbohydrates per day. Okay? 150 grams of carbohydrates per day. So why do we need to have such load um of glucose three days prior to my test? That is to stabilize the different hormones inside your body. Okay? So when we say stabilize your insulin, your glucagon, epinephrine, tyroxine and even your growth hormone. They need to be stabilized inside your body. Okay? So that um your glucose will not be affected by these hormones. Okay? Yung level ng glucose or nang carbohydrate sa katawan mo. It's not because of any fluctuation or any um imbalances when it comes to your hormones. So that's one when it comes to your um diet restriction. Okay? Diet restriction. As for other um other testing in the clinical chemistry, um there's not uh there's we're no longer requiring any other or special preparation for others. Okay? Special preparation for others. I will not be including um other tests here because that is a part of your clinical k clinical microscopy na. Okay? But that's one for glucose. Again, remember for glucose you need to have a 150 grams of carbohydrates per day or in other textbook in other textbook they do not give the 150 grams per day kasi what they give you is that patients should have a high carbohydrate diet. So high carbohydrate diet 150 grams per day. So that's your that's your um preparation for glucose. So another question is that can I take the communion? Okay? Can I take the communion or can I chew gum? So I'll just discuss them all together. Remember that carbohydrates okay? Remember that your carbohydrates uh the digestion of your carbohydrates starts in your mouth. Remember that you have your salivary amylase that would break down complex sugars like your um like your um that will break down complex sugar like your starch okay?  So in short um fast day um communion and chewing your gums or chewing can be um prior to test is also not allowed they are not allowed X okay? Another thing that um is commonly being asked is smoking okay? Smoking so um perhaps you already have heard of NPO NPO or non per OREM okay? When you say non per OREM and in English it translates to nothing by mouth okay?  You cannot put anything in your mouth and that includes your cigarette or that includes your E-cigarette or whatever you are using because smoking is not is also not allowed I'll have a different slide for smoking which will be discussed shortly so I'll go back to that and explain more about smoking why is it not included so when we say fasting in included po okay? When we say fasting you're not just allowed we are not just restricting your patient from eating we're also restricting them from smoking okay?  According to DOH even according to I've been to series of seminars from BD and other pre-analytical master class they actually mentioned that drinking water is allowed okay? drinking water is allowed but there are some nuances okay? some some things that we just need to discuss about drinking water with respect to fasting number one if the patient is instructed by the doctor to have an NPO meaning non per orem okay? non per orem they are not allowed to drink water okay? again let me just rephrase my statement okay? rephrase what I am saying patients are allowed to drink water during fasting unless they are on an NPO instruction from their physician they can drink water kung hindi naman nang doctor nila na nothing by mouth sila or NPO sila but if they are doing procedures that are NPO even water is not allowed okay? again even water is not allowed but for normal patients okay? for normal procedures like take for example glucose and even triglyceride they can drink water but usually a cup of water lang is allowed okay? a cup or two of water is allowed so what hindi naman si nabing ano not because we allowed our patient to drink water it doesn't mean they will drink a litter of water they are only allowed to drink a cup or two of water and I want you guys to take note about this this is actually a very good thing about drink a very good parameter prior to this if your patient has an increase thirst okay? has an increase thirst and would consume more than one cup of water during their fasting state you need to record that because that might be sign of polydipsyat polydipsyat which is included in the early signs of your diabetes melitus okay? so again drinking water is allowed unless the physician instructed your patients of NPO or nothing by mouth okay? so it's very important to take note of that but if your patients are allowed to drink water you also need to take note how much how much water or how many cups of water were they able to consume within that 10 to 12 hour period of time because that could also be an early indication an early sign of your diabetes melitus which is polydipsyat okay? so I hope we're clear when it comes to fasting if you have any questions or clarifications feel free to send me a message or send me a a message through our TLC so aside from that aside of course from your fasting there are also other types of diet that might affect different types of analyte so let's go to that so take for example for your high protein diet okay? if you are having high protein diet which we call your Atkins diet okay? Atkins diet or high protein diet there will be an increase ammonia uric acid in urea so obviously you all know that proteins have their nitrogenous group so if you if you catabolize if you metabolize if you cut down okay? or if you break down rather if you catabolize your protein there will be your ammonia as it's by-product together with your urea caffeine okay? increased caffeine inside your body would also increase your cortisol your ACTH and your glucose remember that your caffeine okay? remember that your caffeine can increase your glucose that's why for patients that have diabetes mellitus we're requiring them not to drink coffee anymore because caffeine can increase your glucose okay? the increase in your glucose is just secondary because of the increase in your cortisol remember that when your cortisol increases it promotes your glucose neogenesis okay? your glucose neogenesis which in return uses non-carbohydrate sources like your amino acids your glycerol and even your triglyceride to create more to create more glucose that's why your glucose is also increased carbohydrates of course if you have increased load of carbohydrates in your diet that would also affect your glucose excessive drinking of water this is what we're talking about canina excessive drinking of water can also affect your hemoglobin in other electrolytes okay? remember that your electrolytes are being affected by being affected by your water so Alex I'm trying to prevent myself from over over sharing things about electrolytes because that will be part of your clinical chemistry too we also have your fats and oils okay fats and oils that can affect of course your cholesterol and your triglyceride meat and vegetables this one could affect your F-O-B-T or your fecal occult blood this so patients that are about to take your fecal occult blood are not allowed to eat red meat and also not allowed to drink vegetables that are having peroxidases like your horseradish okay your horseradish they are not allowed to eat them okay? so what we're trying to show you here is that if your diet is high protein this are the analyte that may me affected okay? so that's everything about diets so that took me very long because although it's very fine because in the laboratory a lot of our patients would really ask you about fasting what are the requirement for their diets who I highly suggest that if there are some parts of this discussion that were unclear to you you ask me questions or you go back to our recording so that when time comes you'll go and face your patients you'll be able to explain it to them very well specifically the reason behind why they will not be allowed to take the test because of over fasting so in reality there are a lot of people in the laboratory that might come into your lab over fasting and you should be able to explain it to them properly that their testing will not push through there will be rejected because we're trying to safeguard the quality of our tests so before I move forward to other parts or other parameters let's just settle it also what happens ba? okay, sabi ko nga kanina if your patient take for example if your patient came in too early you can just wait you can wait around or you can wait for an hour so that they will be able to meet the fasting requirement that's no problem they will just be able they will just wait so that we'll be able to have the required fasting hours but the problem really lies on patient that are over fasting so when we say over fasting they already exceeded the optimum or the ideal fasting requirement for their test like take for example your patient has a test for for your glucose and your triglyceride so the ideal fasting hour for that is what? I'll give you five seconds to think four three two one zero the optimum fasting requirement for that is 10 to 12 hours so take for example your patient came in after 14 hours so two hours over June okay are we going to allow them or are we going to reject them? the sad answer to that is we're going to reject the test okay, we're going to reject the patient or we're not going to push through with the testing why? simply because as you all know your body can only hold up into a fasting state for quite some time and remember that have you ever experienced not eating for more than 12 hours and you wonder why is it that my body still is able to function that is because some of your hormones are starting now to release some of your glucose and so they're trying to catabolize now some of your stored fats or your adipose tissue in the triglyceride that can be used up as energy sources so that's the same reason why is over fasting not allowed in the laboratory because so much as the the analytes okay, the analytes now are being affected because of that over fasting in your over fasting your body now will try to use up your stored glucose your glycogen your stored fats and break them down okay and use them as energy sources in the body and when that happens your analytes will be affected that's why over fasting is not allowed so in mabilis na kwento our international students allow me to say this in Tagalog yung mga pasyentin natin kapag sumobran ng fasting normal lang nagagawin ng katawan mo ay gamitin yung mga stored fats and stored glucose or carbohydrates mo in the form of your glycogen so kapag nangyari yun nangyari yun na niris na nila yung mga stored nila the levels inside your body will no longer be accurate again when you do over fasting if your over if your fasting is overdue your body will start to use up its reservoir its stored glucose in the form of your glycogen in the stored adipose and break them down to triglyceride and use them as energy sources for your body and in that case your glucose and your triglyceride will now be affected I hope I am making sense and I hope that's clear because we're moving now to another parameter which is your exercise so we talk about your diet now let's talk about your exercise so exercise as you all know I don't know if you do this every day or twice a week or twice a week but exercise they do they do affect our analyte they affect our analyte in such a way that they cause a transient or a long term effects in our analyte so when we say transient these are just temporary temporary changes in our analyte and if they are long term it can go for the entire day or for the entire period before the testing so most of most of the tests that are actually affected by this one are your enzymes your hormones and some of your catabolic products so when you say catabolic product these are the catabolic byproducts when you say catabolism this is the breaking down of molecules so these are the byproducts or ways of our body so for you to be able to understand it better when it comes to exercise there are some enzymes like what I was mentioning enzymes, hormones, and catabolic products that are affected so most specifically remember when you exercise we're trying to move your body your skeletal muscles are very much active so some of the enzymes affected are your CKMM okay your CKMM is a specific creatin kinase isoenzyme found in your muscles your CKMM okay CK stands for creatin kinase that is the isoform for your muscles the isoenzyme for your muscles CKMM there are actually three okay let me just share it to you for your pabibo moment in the future so you have your creatin kinase you have your MB CKMM CKMB so there are three types CKBB are the one found on your brain okay CKBB creatin kinase concentrated in your brain your CKMB the one that is found on your heart okay the one found on your heart or in your carjack muscles and your CKMM are usually found or majority of them are found on your skeletal muscle okay so why do I have arrangement CKBB CKMB and CKMM because the fastest when we do your electrophoresis correct when you subject them to electrophoresis remember that in your polyacrylamide cell we will be able to separate them one from the other so if we're going to separate them the fastest is your CKBB and then your CKMB followed by your CKMM sa kasabihin sa pag-ibig ayang utak bago ang puso bago ang musils sa iyong katawan so CKMB and CKMM that's the arrangement again they are affected because of your exercise aside from that we also have your AST okay your AST your aspartate aminotransferase your LDH or your lactate dehydrogenase specifically LDH4 and 5 because there are LDH1, 2, 3, 4 and 5 the one found in your musils skeletal musils are LDH4 and LDH5 and finally for your enzymes also affected is your aldolase A that are also found in your skeletal musils so please do remember CKMM, AST, LDH4, LDH5 and aldolase A that are also affected because of exercise now going to your hormones going to your hormones, your growth hormones your prolactin and even your insulin are all affected because of exercise meaning to say they increase kapag nag-exercise ka atik uya mga kapatid kababayan okay your hormones also would increase your growth hormone, your prolactin and your insulin remember that the metabolic products that will also increase are your ammonia your lactate and your creatinine okay so ammonia from your protein protein metabolism, lactate because of your anaerobic glycolysis and also your creatinine from your muscle your muscle metabolism so aside from that other other analyte that may be affected because of your exercise are your protein and your collateral that can increase up to 6% in your body so in a nutshell everybody what I want you guys to remember or understand when it comes to exercise that when you do exercise it would affect some of your analyte such as these that are now presented on your screen when I was in practice I actually have a patient okay she is a zumba instructor why did I say so because when she went to the laboratory when I was about to collect her blood she was in her gym outfit okay and then I started asking mom did you just came from your exercise or from your workout and she told me that yes she actually did came from her zumba class because she was a zumba instructor at that time and I actually suggested to her that it would actually be better if we postpone her test some of the analyte might be affected because of her exercise why because some of her tests are actually these analyte okay some of her tests are these analyte so I suggested to her that it might actually be better if we postpone her test and she totally understand it and decided to postpone the test tomorrow so again the reason why we're studying and the reason why I'm explaining this hopefully very thoroughly is for you to be able to also explain this to your patient okay because sometimes if you don't explain it to your patient a lot of medtex would always would always resort to this is the protocol but you have to explain why is it the protocol okay so in this case you should be able to explain to them that when patients exercise prior to this there are some tests that might be affected and these are affected if they are increased they might be diagnosed of a disease that they actually do not have but because they did exercise before test then it would be a diagnosis at the end okay like take for example for your creatinine creatinine can be associated with your kidney function so if your creatinine is too high because you had a heavy exercise prior to test then that would affect the result and eventually your diagnosis so that's it for your exercise again remember that it can either cause a transient, a temporary or a long-term changes inside your body aside from exercise of course we also have your postural changes when we say postural changes again now where i will go back to your basal state remember your basal state specimen collection is collecting your blood early morning before rising sir why why before rising because we're trying to maintain the equilibrium within our body did you know that your postural changes can cause false increase in these bar use analytes like your enzymes your calcium and your albimine from supine to seating so take for example you're lying down and you just for your blood to be collected enzymes, calcium and albimine may falsely increase if you are seating and then you decided to okay i would want my blood to be collected while i'm laying down and you did change your posture so from seating to supine your proteins and your lipids might also be affected aside from that prolonged standing for 30 minutes can also increase your potassium and if we're going to your clinical microscopy did you know that it can also cause proteinuria okay your orthostatic proteinuria because of prolonged standing so if prolonged standing for 30 minutes take for example pumila ka di ba sa national ID sa comili and register ka or pumunta ka sa concert ng idol mo at 30 minutes kang nakatayo okay expect that your potassium will also falsely increase why falsely increase of course your water changes inside your body will be affected and that's actually the main reason when it comes to postural changes okay that's actually the main reason when it comes to postural changes postural changes usually is due to what it is due to the shift in your in your water compartments inside your body okay the water compartment in your body that might affect these analyte so to further okay changes in your possession before and during blood collection can actually influence your specimen collection specifically the analyte that I was able to discuss and mention a while back so according to the national cholesterol education program or the NCEP okay the national cholesterol education program they actually recommend that for lipid profile it should be collected in a consistent manner and the patient or okay after the patient has been lying down or sitting quietly for a minimum five minutes so take for example nakatayo from standing your patient will sat down we need to wait for around five minutes so that the water the water will equilibrate inside their body if the patient sat down from lying down we wait for five minutes okay again so in a nutshell okay if your patients are trying to change their posture before your testing you need to wait for five minutes before collecting the blood five minutes actually that would take long for your patient that would actually take long specifically if you're trying to extract a lot of a lot of samples from your different patients from different patients but roughly we can say that your phlebotomy could take around this time five minutes so you can do your patient identification on you can do your cleansing identification of the site for your extraction assembling your phlebotomy kit, your ETS and then verifying your patients patient preparation actually roughly for your blood collection it would actually take you around five minutes so the goal here is to take note that postural changes do affect some of your analytes such as the following so from supine to sitting sir can you teach us a trick on how we should memorize it so for me there's only three so supine to sitting sitting to supine and even for long standing remember the different analytes that are affected the advice from the national cholesterol education program the national cholesterol education program to have at least five minutes to wait for around five minutes before blood collection so what do we mean by this for five minutes if your patient would be lying down for the blood collection you should lie down for around five minutes or close to five minutes at least so do remember that when it comes to postural changes so we're actually done with the first first four we discussed about your diurnal variation fasting requirement, exercise, postural changes now let's go to 30k application so this is just a quick review when it comes to 30k application please do remember let's have a quick review even though we are having this asynchronously so i want you to answer on your own while listening write this down or answer aloud so first question what should be the distance what should be the distance of your 30k application from the site of puncture i'll give you five seconds five, four, three two, one the correct answer is three to four inches away from your blood collection or if we're going to put that if we're going to put that if we're going to put that into centimeters that is around 10 centimeters away approximately 10 centimeters away from your puncture site three to four inches or 10 centimeters away 10 centimeters away so that is the distance what about how long okay how long should be the 30k applied five seconds four, three two, one zero, okay how long it should be less than one minute less than one minute is the required or the optimum 30k application okay now when it comes to 30k re-application 30k re-application how many minutes should you wait five seconds four, three one zero and the answer is yes you're correct two minutes so you distance is three to four inches or approximately 10 centimeters away from the puncture site how long less than one minute and for the 30k re-application you need to wait for two minutes before re-applying your 30k so please do remember that that will be coming out in your quizzes and your exam now the problem when it comes to 30k application is that for long 30k application can actually cost chemo concentration for long 30k application can cost chemo concentration so it will increase your proteins your enzymes your protein bound substances your cholesterol your calcium and even your triglyceride and please also include here your electrolytes may also be increased because of prolonged 30k application that's why there's actually a question one time actually this was my question to the speaker I was asking I asked the speaker if they can actually just simply eliminate the use of 30k because not only is 30k costing chemo concentration it can also cost infection because your 30k can be a safe haven they can harbor a lot of bacteria even resistant bacteria so to eliminate that will there be a possibility that we will go we will be we'll stop using 30k and we'll just use your vain viewer or any device that will help us view the vain without your 30k possibility in the future specifically a lot of our preanalytical errors might actually occur because of 30k application take for example you have a patient with a difficult vain you're having a hard time looking or finding the vain already and remember the 30k application should only be for less than one minute and if it took you too long it will affect your results so there will be a time in the future that possibly will be we'll stop using 30k and we'll simply go with vain viewers and other devices okay visual devices that will help us identify and visualize your vain so that is for 30k application so please remember the distance how long and also the reapplication and before I go I'll just want to mention pabibo moment for our future classes do remember that there are there is one analyte in the laboratory that does not require again does not require 30k application and that is the collection of sample for lactate lactate testing do not require your 30k application aside from that ammonia will also not ideally will not use your 30k but if you would use you need to make sure that you will only be using it for less than one minute okay less than one minute for ammonia and then for lactate of course no 30k application so finally let's move forward okay another factor affecting your analyte from your 30k application or your gender and age yes ladies and gentlemen gender and age also play our role in the different or also play our role in your analyte so more specifically their analyte that are higher in newborn lower in adults and vice versa okay first let's talk about your first let's talk about your newborn in your newborn they have an increase ALP or alkaline phosphatase your creatinine and even your uric acid in your bilirubin in adults okay in adults there's an increase creatinine okay and remember creatinine and cholesterol can also vary not only with newborn and adult but also with that comes to sex or when it comes to gender okay so men have higher creatinine compared to women number one they have higher or yeah they have higher body mass okay or higher muscle mass mas maraming muscles ang kalalukihan kong para sa kababa ihan kaya mas matakasang creatinine ng mga lalaki kong para sa mga babae in english the creatinine levels of your men are higher than women because men have higher muscle mass or muscle weight compared to women aside from your creatinine another analyte that is also affected by is your cholesterol did you know that cholesterol levels of women are lower compared to men ang cholesterol po ng mga kababa ihan ay mas mga baba kong para sa cholesterol ng mga kalalakihan this also explain why a lot of men are actually suffering from cardiovascular diseases and die at an earlier age because they are generally they do have okay higher cholesterol and did you know ladies what's the reason behind a lower cholesterol in women specifically those that are under 40 years old so women under 40 years old has lower cholesterol compared to men because of their estrogen yes estrogen your estrogen helps in the production of your HDL which is a good cholesterol your high density lipoprotein for another time your estrogen your estrogen increases the level of your high density lipoprotein thereby decreasing the cholesterol of our women that's why women ages less than 40 years old has less than has less cholesterol lower cholesterol compared to men but take note for our menoposal women when you reach the age 40 you will start to have an increase in your cholesterol 2mg per deciliter per year so please take note of that again if you're going to sum it up cholesterol is higher in men and creatinine is higher in men as well creatinine is higher in men because of an increased muscle weight compared to women cholesterol is also increased in men because women has estrogen estrogen that helps in the production of HDL that also helps lower down your cholesterol so I hope I made myself clear when it comes to the variation due to age and gender so similarly if you guys would know in hematology you also have a different reference range for men and women and even for newborn and adult that's also the reason the very same reason in clinical chemistry because of their physiologic physiologic differences in the body so that's it actually for your gender and age now let's move forward to another physiologic factor aside from age and gender we also have your skin and deceptive oh, yung mga pinanlilinis mo sa balat mo, mga ka-affecto rin pala doon sa ating parameters the things that you apply in your skin before blood collection can also affect your parameters or affect your analyte an example of that as you all know ladies and gentlemen 70% isopropyl alcohol at the most commonly used antiseptic in our in the laboratory so if you try to cleanse the puncture site for your patient to use your 70% isopropyl alcohol with a contact time of 30 to 60 seconds 30 to 60 seconds is the optimum contact time of your alcohol to your skin so that the bacteria, the viruses and other microorganisms that are in your skin will be killed but the problem with aside from that aside from your isopropyl alcohol another thing that we all usually use in the laboratory are your iodine or your povidon iodine specifically if these are for aseptic technique like for example you're also collecting blood for bacterial culture, it would also highly suggest that you cleanse the site not only with 70% isopropyl alcohol but with also cleaning it or cleansing it with povidon iodine but did you know that the use of povidon iodine can also increase some of your analyte, it should be updated hindi na PKU but your povidon iodine can actually increase your burp not burp as in the burp that you do after you are satisfied with what you ate but burp stands for bilirubin uric acid, potassium and your phosphorous so those four your bilirubin, your uric acid and your phosphorous or your phosphate are all increased if you use your povidon iodine so mga kapatid, mga pamilya ladies and gentlemen, children do not use your povidon iodine in cleansing the site for blood collection because it can falsely increase your bilirubin, your uric acid your phosphorous and your potassium so maybe some of you are asking now sir if I cannot use my povidon iodine I use then then you can use your chlorhexidin gluconate or in some cases in some of the chemical formulation this is your chlorhexidin dibluconate your chlorhexidin dibluconate is a substitute for your povidon iodine again ladies and gentlemen your chlorhexidin dibluconate or your chlorhexidin gluconate is a substitute for your povidon iodine but there's also another thing that you need to consider if you're also testing for your ethanol so you want to measure the ethanol content in the blood of your patient you cannot use an alcohol because it can falsely increase your ethanol so sir how can I resolve this problem? simple in ethanol testing instead of using 70% isopropyl alcohol it is actually best to use your benzoconium chloride or in other formulation in a branded formulation that is your zephyran chloride your benzoconium chloride or your zephyran chloride is the substitute for your isopropyl alcohol makikitanda 70% isopropyl alcohol in case of ethanol testing is not allowed that's why you will be using your benzoconium chloride or your zephyran chloride in aseptic technique if in aseptic technique for bacteriology together with clinical chemistry testing you cannot use your povidin iodine because it can falsely increase your bilirubin your uric acid, your phosphorus and your potassium that's why you need to use your chlorhexidine gluconate or chlorhexidine di-gluconate so that is for your aseptic technique please remember the commonly used 70% isopropyl alcohol the contact time 30 to 60 seconds and also the substitute for your alcohol and your povidin iodine because of their interferences which are your chlorhexidine your chlorhexidine di-gluconate and your benzoconium chloride so that's it for your aseptic technique we're actually down to the last four factors that are affecting your analyte and let's now go to smoking I did mention smoking awalbak number eight, smoking na tayo I did mention smoking awalbak specifically if your patients are fasting of npo nothing by mouth, they cannot smoke even if sabihin natin ang fasting kasi sir, ba wal kumain but when your patients are instructed to do npo nothing by mouth, ba wal kahit anong ilagay mo sa mga mga mo or sa mouth mo, it's not allowed why? because smoking has an active ingredient that are found in your tobacco which are your nicotine your nicotine ladies and gentlemen can falsely increase your cholesterol, your cortisol, glucose growth hormone triglyceride red blood cells, hemoglobin and they can also increase the concentration of your carboxy hemoglobin inside your body carboxy hemoglobin is a hemoglobin variant because of an increase carbon monoxide or carbon dioxide inside your body what I want to highlight here is your cortisol and your glucose did you know that similarly to your caffeine anong sabihin natin kanina sa caffeine caffeine increases your glucose because your caffeine increases the process called gluconeogenesis by increasing your cortisol similarly to your nicotine also increases your glucose that's why patient that has diabetes are very much discouraged to stop their smoking they are very much encouraged to stop their smoking because your nicotine can also increase your glucose sir in what way remember that your nicotine your nicotine can also increase your what it can also increase your cortisol so if your nicotine increases your cortisol your cortisol will promote glucose neo-genesis or the process of making or producing glucose from non-carbohydrate sources and it will just simply increase your glucose it will simply increase your glucose more glucose a set entire lifestyle smoking that's is that will be a combo for diabetes melip so please remember nicotine and caffeine both of them increases your cortisol at dahil sang increase yung cortisol ano paing isang nag increase the process of gluconeogenesis and in return because of the gluconeogenesis your glucose will pack increase okay I'm discussing more about gluconeogenesis when we go to your carbohydrates but that is it for your smoking hopefully you understood that smoking affect a lot of your a lot of your analyte and you need to take note of this in the laboratory okay and then you know even your even your medical technologist your medical technologist specifically if your patient's test is ammonia it should be free from not only does your patient is restricted to smoke even the medtech because sometimes the the ammonia is affected by the smoke okay the smoke that are in your head because of the combustor during your smoking okay so aside from that aside from smoking we also have your alcohol intake so that's number nine alcohol intake let's go and talk about alcohol intake so alcohol intake specifically your ethanol okay mga naging sessions there okay ethanol remember that they can falsely increase your lactate, your uracil, your triglyceride and even your gamma glutamyl transferase or your GGT remember GGT okay remember nyo ng GGT for future reference and for future pagpapabibo and clinical chemistry too because your gamma glutamyl transferase is a sensitive indicator for chronic alcoholism gamma glutamyl transferase for chronic alcoholism so ethanol increases your lactate, your uracil, triglyceride and even your gamma glutamyl transferase that's why kung impatient mo kaka tapos lang magnomu may toma okay bawal siya magpakuha ng dugop because this analyte might be affected excessive alcohol intake can also cause hypoglycemia okay again excessive alcohol intake can also increase hypoglycemia remember no glucose is very important for your brain and imagine kapag yung inong kanang inong may hypoglycemia kaya rin siguro din ahihilo pagkatapot at kapag nalalase okay so please remember that ethanol increases this analyte and remember ethanol is not allowed prior to testing okay prior to testing I would also would like to include in the ethanol as well from GGT it can also increase your AST your aspartate amino transferase and your alanine amino transferase or your ALT let me write that down on your screen for you as well from GGT ALT kasama po mga kababayan kapati kapanalig okay so ALT and AST okay so that's for your alcohol intake finally okay second to the last we also have your stress halapati pala stress yes may yes so stress remember stress whether it is a physical or mental stress it can increase your adrenocorticotopic hormone or your ACTH your cortisol your catecholamide even your I think this was mentioned in your hematology that your because of stress okay lactate and glucose can also increase because of stress so it's always important to actually build rapport when collecting samples from your patient so as much as possible we try to make it pain less we can never really have a pain free extraction but we can always improve our techniques so that it will be your patient would be experiencing less pain and will be avoiding increasing your ACTH cortisol and even your catecholamide including your leukocytes, lactate and your glucose so remember that when it comes to stress now finally finally for the last one we did talk about a lot today so we're finished talking about the urinal variation, diet, exercise potural changes ternike application gender and age skin antisepsit, smoking alcohol intake stress and even drugs okay we're already done talking about that now let's talk about your drugs na the last one for today so drug therapy remember that medication can affect your plasma volume that can already affect your protein your BUN, your iron and your calcium concentration most specifically there are also other there are different types drugs or medicines like your hepatotoxic drugs your hepatotoxic drugs can increase your liver function enzymes your liver function enzyme like your AST and your ALT the one that I mentioned in the ethanol canina so remember that hepatotoxic drugs even though your liver is the one that detoxifies your drug there are also drugs that can actually harm your liver that's why if you're taking for those who are taking medicines from time to time your doctor would check your liver by measuring your AST-ALT to see how your liver is doing in the midst of your treatment aside from that there are also diuretics such as there are different diuretics na ininom natin actually tea, caffeine are also diuretics so they decreases your sodium and your potassium level so you need to monitor those if you're taking in diuretics so for simple the idea here is that the analyzed that are secondarily affected by the drugs you need to monitor them like your liver function test sometimes you take drugs to treat a particular condition but in return it also costs problem with your liver that's why you have to check your liver from time to time similarly with your diuretics if you're taking diuretics you also need to check the levels of your sodium and potassium from time to time so that you'll be able to make sure that they're still within normal levels so according to the College of American Pathologists according to their guideline drugs that can interfere in your blood test should be stopped or avoided for to 24 hours prior to obtaining your blood so if it is a blood test pag blood test for to 24 hours but if the drug can interfere with your urine test like in your clinical microscopy for example like your vitamin C it should be avoided for to 48 to 72 hours prior to the urine sample collection again if it is your blood prior to test it should be stopped but if it affects some of your urine test it should be stopped for 48 to 72 hours but here's the thing ladies and gentlemen as medical technologists we are not allowed to advise our patient to stop their medication it should be subjected to your physician's instruction our doctor will be the one that will instruct our patient whether they are going to stop their medication because there are some medications that are actually crucial in our patient's lives so we cannot just simply tell our patient to stop their medication because she will be collecting blood no so remember for to 24 hours if it affects blood test if it does affect your urine test mention it to them that they need to stop it for 48 to 72 hours again subject for your physician's approval and it will be your physician to instruct the patient on how they would stop the medication prior to testing so that is it actually for today those are the different parameters so I hope that more than just memorizing I want you guys to take home from this is what I want you guys to remember the purpose or the reason behind it's like what I always tell you I'm not here to encourage you to memorize I want you to understand the concept so that in the coming days when we go to other analyze in the future you'll be able to know okay this is the reason why exercise is not allowed this and that this is the reason why fasting requirement should be 10 to 12 hours so we'll be discussing that in the near future in our succeeding lectures but for now that is it for today that is all about patient preparation with respect to all the analytes in clinical chemistry one so if you have any questions or clarification you can refer to these references so with that thank you so much for listening if you have any questions or clarification you can send me a message or you can ask me during our next synchronous class so if there's no question or clarification I'll see you on our next class and there you have it have a great day