Posted in Checkpoint Tutorials, Online Classes

End Cell Edition (ECE) ~ MTLE Final Coaching

END CELL EDITION –
THE FINAL COACHING SESSION

This course aims to polish you on each board exam subject using a brief in-depth review with Q&A sessions.


AUGUST 2022 BATCH (AUGUST 2 to 19, 2022)

  • Review Fee: P4500
  • Activities and Inclusions:
    1. Brush Up Sessions ~ In-Depth Review of all board subjects
      • Live: 9 am to 4 pm
      • Replay option is available thru ThePhoenixxApp
        (NOTE: Newly recorded live lectures may be accessible 1 to 2 days after the live schedule)
    2. Run Down Sessions ~ Practice Q&A for all board subjects
      1. To be done live (no recorded session)
    3. Printable and annotatable soft copy of personalized END CELL EDITION (ECE) NOTES (Online Final Coaching Notes)
    4. Co-Memory-Ate Session (Mini Online Final Coaching of Must-Memorize Values)
    5. Online Mock Board Exam (August 2 and 3, 2022)
    6. Group studies (with Memory Cell Edition students)
    7. Bible studies/Worship sessions – optional
  • Deadline of Enrollment: August 1, 2022 to be able to join the live MBE
    • If you cannot enroll before this date, you may still do so anytime before the August 2022 MTLE dates
    • You may still avail the activities you may have missed (e.g., MBE or brushup sessions)
  • Orientation: August 4, 2022, at 9am
  • Distribution of ECE Notes: July 25, 2022

Click here to see the ECE Schedule of Activities

How To Register:

1) When you join, YOU AGREE TO THE FOLLOWING TERMS & CONDITIONS.
a. No recording in any form (audio, video, screenshot) will be allowed. Programs are in place to monitor your in-app activity and once you’ve violated our agreement, we will be compelled to file charges against you.
b. Your personal information will be kept strictly confidential and will not be sold, reused, rented, loaned or otherwise disclosed.
c. Only fully paid students will be allowed to join. Please BE HONEST and DO NOT invite students to join without paying individually.

2) To proceed with enrollment, please pay first using the following modes of payment. Fees are NON-REFUNDABLE and NON-TRANSFERABLE.

BANK DEPOSIT
BANCO DE ORO (BDO)
ACCOUNT NAME: Krizza-Almond S. Aguilar
ACCOUNT NUMBER: 00 732 001 4669

BANK OF THE PHILIPPINE ISLANDS (BPI)
ACCOUNT NAME: Mark Anthony N. Salido (account of my husband)
ACCOUNT NUMBER: 2349 2711 52

SECURITY BANK (SB)
ACCOUNT NAME: Krizza-Almond S. Aguilar
ACCOUNT NUMBER: 00000 17563681

GCASH (See QR code below).
If GCASH to GCASH or GCASH to bank, no extra fee
If kiosk (i.e., 7-11, palawan) to gcash, please add the required service fee to the amount to be transferred
GCash via PALAWAN: add 2% service fee
GCash via 7-11: add 3% service fee


PAYMAYA (See QR code below).

PLEASE DO NOT SEND PAYMENT VIA PALAWAN PERA PADALA.
HUWAG MAGPADALA SA PALAWAN EXPRESS PERA PADALA.
MODES OF PAYMENT
GCASH
PAYMAYA

CLICK THIS FOR THE ECE ENROLLMENT FORM

3) Register ECE FORM Please make sure you have the proof of payment ready as well as a decent photo which we will be using for your digital ID.

4) Wait for confirmation via text or email along with the instructions. Sir Axel will assist you. Kindly wait for his message.

If you still have any questions or clarifications, please contact me.
Thank you very much and looking forward to meeting you online. 😊

Posted in Checkpoint Tutorials

#CheckPoint Tutorials for Medical Technologists

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MUST KNOWS (or not? XD)

FIRST, if you are too lazy to read everything here, then my tutorial is not for you. I’m sorry.

SECOND, if you are a fresh graduate/first timer, I suggest that you try in a review center first. But if you insist to join us, you are more than welcome.

THIRD, I do not accept everyone. I only want to do this for those who are fully willing to help themselves too. If you are looking for spoon feeding type of learning then I’m not the one who can help you.

FOURTH, please be aware that this is NOT the usual tutorial set-up nor the usual review center set-up you know…As in everything is NOT the usual.

FIFTH, please bear in mind that I am not forcing you to join. If you find it in your heart that you really want to do your review with us, then we are waiting for you. But if you don’t like any of the above rules, then thank you for your time.

There are a lot to explain (and some are really not explainable by words) but here’s a runthrough of #CheckPoint tutorials.

  • CheckPoint Tutorials for March 2019 will start on November 2019. Actual dates will be announced when PRC releases the final board exam dates.
  • We are currently having the tutorials in 2 areas. 
    • CheckPoint Manila version 10.0
    • CheckPoint Davao version 3.0
  • We don’t meet everyday.

Our schedule is not fixed since we (the tutors) are also working and so we will be developing a schedule that fits everybody.

  • Venues
    • CheckPoint Manila: OUR HOME at SAN MIGUEL (or PALATIW), PASIG CITY
      • We have a room for tutorials just in front of our home. I am very sorry if I cannot grant your request to do the tutorial anywhere other than this venue.
    • CheckPoint Davao: No permanent venue as of yet, we usually do tutorials in different coffee shops around Davao. 🙂
  • I do the teaching but I also get help from my colleagues.
    • CheckPoint Manila: I do most of the teaching but there’ll be subjects to be handled by Sir Ross Axel Rufino (Unciano Colleges).
    • CheckPoint Davao: Most subjects will be handled by Sir Jayson Sanchez (Davao Doctors College) while I teach certain subject/s whenever I have a schedule in Davao.

We have a tradition not to move to another topic until everyone in the group understands. And yes, you can tell us everything you want to understand and we will try our best to explain but we don’t guarantee being all-knowing. If we don’t know the answer to your question, then we are willing to study again for you. 

  • If you want an easy life and would just want to rely on recall questions, then you’re in the wrong place. 

You will pass because you understood the topics, not because you remember the recalls. But if you believe otherwise, then I can’t help you. That’s not how I roll.

  • We will also have a lot of practice exams with explanations why this and not that is the answer moments.
  • There will be unpleasant moments (typhoon, super traffic, dysmenorrhea days) to teach personally so that we’ll just have an online review.
  • I will require at least 50% downpayment for our expenses.
    • FEE: Manila – P11,000 & Davao – P12,000 (already inclusive of P1,860 worth of personalized #CheckPoint Notes – all available subjects)

I am not rich, I cannot support our growing #CheckPoint family with just my usual budget so, please pay. Haha. Usually, I use the money for our refreshments (food and coffeeeeee) and enjoyment (like ice skating, karaoke, arcades, haha, no kidding).

  • I DO NOT ACCEPT QUITTERS.

If you are joining us, make sure that you are not a quitter or if you really are, be prepared to change. To tell you the truth, I’m not willing to do this for someone who will QUIT on me, so, let’s have a contract as early as now.

  • I do this because I live to teach.

This has been my passion ever since and has been a part of my promise to my God (long story, you’ll know on the way). I choose to teach MedTech students who are willing to sacrifice, change for the better, believe in themselves and fight for their dreams. Even if it is hard, we will not quit.

SO, are you ready to be like us? ^^,

If yes, then SEND ME A MESSAGE, like right now. 🙂

P.S.
For those who’d like to know the in-between-experiences of the previous #CheckPointees, you are free to contact them.

CheckPoint v1.0

Ross Axel Rufino, RMT

Erwin Pagkatipunan, RMT

Kayla Lara, RMT

Josel Losada, RMT

Fatima Yao, RMT

CheckPoint v2.0

Hillary May Cuizon, RMT

Ahrjay Atienza, RMT

RF dela Cruz, RMT

Davicca Hwang, RMT

Chrismari Sison, RMT

CheckPoint v3.0

Wilfred Lawas, RMT

Mark Salvador Mabesa, RMT

Princess Alyssa Suerte, RMT

CheckPoint v4.0

Mia Cortez, RMT

Shirley Mae Magadang, RMT

Maria Corazon de Villa-Obnamia, RMT

John Gabriel Pagsanghan, RMT

CheckPoint v5.0

Patricia Inocencio, RMT

Sharmane May Almazan, RMT

Dette Nuñez, RMT

CheckPoint v6.0

Dexter de Vera, RMT

Dafy Macalalad, RMT

Aianna Valenton, RMT

CheckPoint v7.0

Michelle Reyes, RMT

Julia Aira Marie Sanchez, RMT

CheckPoint Manila v8.0

Alicia Abril, RMT

Lara Mae Ganaden, RMT

Jam Shane Supan, RMT

Georgina Belo, RMT

CheckPoint Manila v9.0

Gene Tulawie, RMT

Theodor Carandang, RMT

Almira Felias, RMT

CheckPoint Davao v1.0

Francis Jade Labatos, RMT

Geric Sam Lopez, RMT

Rey Marcelo Caupayan, RMT

Elspeth Katherine Luig, RMT

Denden Espero, RMT

CheckPoint Davao v2.0

Jamaica Cadorna, RMT

Shedney Mae Kawaling, RMT

Fauziyah Pagayao, RMT

Joanna Marie Guiraldo, RMT

Caryl Anne Abeto, RMT

GJ Gaetos, RMT

TO GOD BE ALL THE GLORY!

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Tara, aral? 🙂 Or manga na lang. Hehe!

Posted in Lecture Notes

My Med Tech Notes in PDF for FREE!

Disclaimer: The notes I’m sharing may not be currently updated (as I’ve used some of them in my past lectures/reviews), so please always refer to textbooks if you encounter conflicting information.

Password protected.
If you’re new here, please ask for it thru private message. Click this.

ALL NOTES MAY BE USED FOR
UNDERGRADUATE, LOCAL BOARD EXAM OR INTERNATIONAL EXAMS (i.e., ASCPi)

— This list will be updated from time-to-time, so check back regularly. Click DOWNLOAD BUTTON to access each file below. —

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SEE STUDY TIPS & TECHNIQUES

ERRATUM FOR THIS: For the action of insulin, please change GLYCOGENOLYSIS to GLYCOGENESIS. Insulin lowers glucose and so it should increase conversion of glucose to glycogen (GLYCOGENESIS).

NOTE: Watch FREE ONLINE REVIEW (FOR) You discussion of the notes above here.

NOTE: If you want to watch the video lecture for the CM notes above, please see instructions here.

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QUIZZES/EXAMS


REVIEW STUFF SHARED BY STUDENTS

MISCELLANEOUS

MGA WALANG KWENTANG MNEMONICS

Posted in Lecture Notes

Clinical Chemistry – Carbohydrates

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WHAT’S IN HERE?

  • Carbohydrates
  • Glucose and Its Metabolism
  • Hyperglycemia
  • Hypoglycemia
  • Genetic Defects in Carbohydrate Metabolism
  • Laboratory Analysis of Glucose
  • References

DEFINITION

  • Compounds containing C, H and O with general formula Cx(H2O)y
  • Contain C=O and –OH functional groups
  • Derivatives can be formed by addition of other chemical groups such as phosphates, sulfates and amines
  • Commonly called “SUGARS” and use the suffix –ose

CLASSIFICATION

  • Based on four different properties
  • SIZE OF THE BASE CARBON CHAIN
    • TRIOSES: with three (3) carbons
    • TETROSES: with four (4) carbons
    • PENTOSES: with five (5) carbons
    • HEXOSES: with six (6) carbons
  • LOCATION OF THE CO FUNCTION GROUP
    • ALDOSE: has a terminal carbonyl group (O=CH) called an aldehyde group
    • KETOSE: has carbonyl group (O=CH) in the middle linked to two other carbon atoms called a ketone group
  • STEREOCHEMISTRY OF THE COMPOUND
    • STEREOISOMERS: have the same order and types of bonds but different spatial arrangements and different properties
    • ENANTIOMERS: images that cannot be overlapped and are non-superimposable
      • L-isomer: if the configuration of the highest-numbered asymmetric carbon is on the LEFT or if hydroxyl group farthest from the carbonyl carbon is on the LEFT
      • D-isomer: if the configuration of the highest-numbered asymmetric carbon is on the RIGHT or if hydroxyl group farthest from the carbonyl carbon is on the RIGHT
  • NUMBER OF SUGAR UNITS
    • MONOSACCHARIDES
      • Simple sugars that cannot be hydrolyzed to simpler form
      • Examples: glucose, fructose, galactose
    • DISACCHARIDES
      • Formed by two monosaccharides joined by glycosidic linkage
      • Hydrolyzed by disaccharide enzymes (i.e., lactase) produced by the microvilli of the intestine
      • Examples:
        • Maltose = 2 β-D-glucose in 1→4 linkage
        • Lactose = glucose + galactose
        • Sucrose = glucose + fructose
      • OLIGOSACCHARIDES
        • Chaining of 2 to 10 sugar units
      • POLYSACCHARIDES
        • Linkage of many monosaccharide units
        • Yield more than 10 monosaccharides upon hydrolysis
        • Examples: starch, glycogen

 MODELS USED TO REPRESENT CARBOHYDRATES

  • FISCHER: linear formula where the aldehyde or ketone is at the top of the drawing and can be depicted in the D- or L- form
  • HAWORTH: cyclic form that is more representative of the actual structure and is formed when the carbonyl group reacts with an alcohol group on the same sugar to form a ring and can be depicted in the α or β form

CHEMICAL PROPERTIES

  • REDUCING SUBSTANCES
    • Contain a ketone or aldehyde group
    • WITH FREE ANOMERIC CARBON
    • Can reduce other compounds
    • Examples: glucose, maltose, fructose, lactose, galactose
  • NON-REDUCING SUBSTANCES
    • Do not have an active ketone or aldehyde group
    • NO FREE ANOMERIC CARBON
    • Will not reduce other compounds
    • Example: sucrose (table sugar)
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Glucose and Its Metabolism

  • End product of carbohydrate digestion in the intestine
    • Enzymes involved
      • AMYLASE (salivary & pancreatic) – digests nonabsorbable polymers to dextrins and disaccharides
      • MALTASE (from the intestine) – digests disaccharides to monosaccharides
      • SUCRASE & LACTASE – hydrolyze sucrose & lactose respectively
    • FUNCTIONS:
      • Provides energy for life processes
      • The only CHO that can be directly used for energy or stored as glycogen
    • FORMS: ~35% alpha & 65% beta
    • MAJOR METABOLIC PATHWAYS
      • EMBDEN-MEYERHOFF PATHWAY or GLYCOLYSIS
        • Substrate: D-glucose
        • End-products: 2 moles of PYRUVIC ACID, 2 moles NADH and 2 moles of ATP
        • Can occur aerobically or anaerobically
          • If aerobic, pyruvate is formed
          • If anaerobic, lactate is formed
        • Other substrates can enter this pathway at various points
          • Glycerol (from TAG) enters at 3-phosphoglycerate
          • Fatty acids, ketones and some amino acids are converted to acetyl-CoA
          • Other amino acids enter as pyruvates or as deaminated α-ketoacids and α-oxoacids
        • HEXOSE MONOPHOSPHATE SHUNT OR AEROBIC/OXIDATIVE PATHWAY
          • G6P is converted to 6-phosphogluconic acid which permits the formation of NADPH (important to red cells because they lack mitochondria thus incapable of TCA cycle)
          • End-products: pentose phosphate, CO2 and NADPH
        • GLYCOGENESIS
          • Stores glucose as glycogen
          • Converts G6P to G1P
          • G1P → uridine diphosphoglucose→ glycogen by glycogen synthase
          • GLYCOGENOLYSIS – conversion of glycogen to G6P
PATHWAYS IN GLUCOSE METABOLISM
GlycolysisMetabolism of glucose molecule to pyruvate or lactate for production of energy
GluconeogenesisFormation of G6P from noncarbohydrate sources
GlycogenolysisBreakdown of glycogen to glucose for use as energy
GlycogenesisConversion of glucose to glycogen for storage
LipolysisDecomposition of fats
LipogenesisConversion of carbohydrates to fatty acids
  • MAJOR HORMONES CONTROLLING BLOOD GLUCOSE
    • PANCREATIC HORMONES
      • INSULIN – primary hormone for DECREASING blood glucose levels
        • Responsible for the entry of glucose into the cells by enhancing membrane permeability to cells in the liver, muscle and adipose tissues
        • synthesized by β-cells of the pancreas
          • released when glucose levels are high/increased
          • not released when glucose levels are low/decreased
        • EFFECTS:
          • increases glycogenesis, lipogenesis, and glycolysis
          • inhibits glycogenolysis
        • INSULIN IS THE ONLY HORMONE THAT DECREASES GLUCOSE LEVELS and can be referred to as a hypoglycemic agent
      • GLUCAGON – primary hormone for INCREASING blood glucose levels
        • released in response to stress and fasting states
        • synthesized by α-cells of the pancreas
          • released when glucose levels are low/decreased
          • not released when glucose levels are high/increased
        • EFFECTS:
          • increase glycogenolysis and gluconeogenesis
        • can be referred to as a hyperglycemic agent
      • SOMATOSTATIN
        • produced by δ cells of the pancreas
        • EFFECTS: inhibition of insulin, glucagon, growth hormone, and other endocrine hormones.
      • ADRENAL HORMONES
        • CORTISOL
          • produced by the adrenal cortex on stimulation by ACTH
          • EFFECTS: decreases intestinal entry into the cell and increases gluconeogenesis, liver glycogen and lipolysis
        • EPINEPHRINE
          • produced by the adrenal medulla
          • EFFECTS: inhibits insulin secretion, increase glycogenolysis and lipolysis
          • Released during times of stress
        • ANTERIOR PITUITARY HORMONES
          • GROWTH HORMONE
            • EFFECTS: decreases the entry of glucose into the cells
          • ACTH
            • EFFECTS: stimulates the adrenal cortex to release cortisol, increases glycogenolysis and gluconeogenesis
          • THYROID HORMONES
            • T3 & T4
              • EFFECTS: increases glycogenolysis, gluconeogenesis and intestinal absorption of glucose
HORMONAL ACTIVITY AFFECTING SERUM GLUCOSE LEVELS
HORMONESOURCEEFFECTACTION
Insulinβ cells of pancreasstimulates glucose uptake by cells
Glucagonα cells of pancreasglycogenolysis
ACTHAnterior pituitaryinsulin antagonist, glycogenolysis & gluconeogenesis
Growth HormoneAnterior pituitaryinsulin antagonist & glycolysis
CortisolAdrenal cortexinsulin antagonist, gluconeogenesis & lipolysis
HPLPlacentainsulin antagonist
EpinephrineAdrenal medullainhibits insulin secretion, glycogenolysis & lipolysis
T3 & T4Thyroid glandglycogenolysis, gluconeogenesis & intestinal absorption of glucose
Somatostatinδ cells of pancreasinhibits insulin, glucagon, GH

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Hyperglycemia

  • Increase in plasma glucose levels caused by imbalance of hormones
  • DIABETES MELLITUS
    • Group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both
    • Categories of Diabetes (According to the ADA/WHO guidelines)
      • Type 1 Diabetes
      • Type 2 Diabetes
      • Other specific types of diabetes
      • Gestational Diabetes Mellitus (GDM)
  • PRIMARY DIABETES MELLITUS
Points of DifferenceTYPE 1TYPE 2
Former namesInsulin Dependent Diabetes Mellitus (IDDM)

Juvenile Onset DM

Brittle DM

Ketosis-prone DM

Non-Insulin Dependent Diabetes (NIDDM)

Maturity Onset DM

Stable DM

Ketosis-resistant DM

Receptor Deficient DM

OnsetBefore 20 y/oOver 40 y/o
Measurable circulating insulinNONELow
Insulin receptorNormal↓ or ineffective
Beta cell massMarkedly ↓Moderately ↓
C-peptide levelsUndetectableDetectable
Incidence10-15%85% (common)
Ketoacidosis*CommonRare
Physique/Stature**Normal or thinOften overweight
Pathogenesis -β-cell destruction

-Absolute insulin deficiency

-Autoantibodies

-Insulin resistance with insulin secretory defect

-Relative insulin deficiency

TreatmentParenteral insulin administraionOral hypoglycemic agent
  • SECONDARY DIABETES MELLITUS – associated with secondary conditions
    • Genetic defects of β-cell function
    • Pancreatic disease
    • Endocrine disease
      • Cushing syndrome – excessive cortisol
      • Pheochromocytoma – epinephrine excess
      • Acromegaly – growth hormone excess
    • Drug or chemical induced
    • Insulin receptor abnormalities
    • Other genetic syndromes
      • Maturity onset diabetes of youth (MODY) – rare; autosomal dominant
  • GESTATIONAL DIABETES MELLITUS (GDM)
    • any degree of glucose intolerance with onset or first recognition during pregnancy
    • due to metabolic or hormonal changes
    • Infants born to mothers with this kind of diabetes are at increased risk to respiratory distress syndrome, hypocalcemia & hyperbilirubinemia

Laboratory Findings in Hyperglycemia

  • INCREASED glucose (plasma & urine), urine specific gravity, serum and urine osmolality
  • Ketonemia and ketonuria
  • DECREASED blood and urine pH (acidosis)
  • Electrolyte imbalance (↓Na+, Cl and ↑K+)
DIAGNOSTIC CRITERIA FOR DIABETES MELLITUS
RPG                    ≥200 mg/dl (11.1 mmol/L) + symptoms of diabetes
Fasting PG         ≥126 mg/dL (7.0 mmol/L)
2-h PG               ≥200 mg/dl (11.1 mmol/L) during OGTT
CATEGORIES OF FASTING PLASMA GLUCOSE
Normal fasting glucose         FPG <110 mg/dL
IMPAIRED fasting glucose     FPG ≥110 mg/dl but <126 mg/dl
Provisional diabetes dx         FPG ≥126 mg/dl
CATEGORIES OF ORAL GLUCOSE TOLERANCE
Normal glucose tolerance   2h PG <140 mg/dL
Impaired gluc. tolerance     2h PG ≥140 mg/dl but <200 mg/dl
Provisional diabetes dx      2h PG ≥200 mg/dl
  • Screening test for GDM
    • Only high-risk patients should be screened for GDM
      • Age older than 25 years
      • Overweight
      • Strong family history of diabetes
      • History of abnormal glucose metabolism
      • History of a poor obstetric outcome
      • Presence of glycosuria
      • Diagnosis of PCOS
      • Member of an ethnic/racial group with a high prevalence of diabetes (e.g. Hispanic American,  Native  American, Asian American, African American, Pacific Islander)
    • METHODS:
      • ONE-STEP APPROACH – immediate performance of a 3h OGTT without prior screening
      • TWO-STEP APPROACH – initial measurement of plasma glucose at 1-hour postload (50g)
        • IF value ≥140 mg/dL (7.8 mmol/L) then do 3-hour OGTT using 100g glucose
        • GDM is diagnosed when any two of the following values are met or exceeded:
          • Fasting: >95 mg/dl
          • 1 hour: ≥180 mg/dl
          • 2 hours: ≥155 mg/dl
          • 3 hours: ≥140 mg/dl

Hypoglycemia

  • Decrease in plasma glucose levels
    • 65-70 mg/dl (3.6-3.9 mmol/L) – plasma glucose concentration at which glucagon and other glycemic factors are released
    • 50-55 mg/dl (2.8-3.0 mmol/L) – symptoms of hypoglycemia appear
    • Warning S/S are all related to CNS
  • Types of Hypoglycemia (Old)
    • Post-absorptive (Fasting) – MORE SERIOUS
      • Islet cell insulinoma
      • Insulin-producing tumors
      • Ethanol induced
      • Propanolol & salicylate
  • Post-prandial (Reactive) – MILD FORM
    • there is spontaneous recovery of glucose level as a result of insulin level returning to normal
    • Excessive release of insulin
    • Gastro-intestinal surgery
CAUSES OF HYPOGLYCEMIA
Patient Appears Healthy 
No coexisting diseaseDrugs

Insulinoma

Islet hyperplasia or NESIDIOBLASTOSIS

Factitial hypoglycemia from insulin or sulfonylurea

Severe exercise

Ketotic hypoglycemia

Compensated coexistent diseaseDrugs
Patient Appears ILL 
Drugs

Predisposing illness

Hospitalized patient

 
  • Diagnostic criteria for INSULINOMA
    • Change in glucose level of ≥25 mg/dl coincident with an insulin level of ≥6 μU/ml
    • C-peptide levels of ≥0.2 nmol/L
    • Proinsulin levels of ≥5 pmol/L
    • β-hydroxybutyric acid of ≤2.7 mmol/L
  • Diagnostic tests for HYPOGLYCEMIA
    • 72 hour fast which requires the analysis of glucose, insulin, C-peptide and proinsulin at 6-hour intervals
    • POSITIVE RESULT: <45 mg/dl; hypoglycemic symptoms appear after 72 hours had elapsed
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Genetic Defects in Carbohydrate Metabolism

  • Glycogen Storage Diseases – deficiency of a specific enzyme that causes alteration of glycogen metabolism
TypesEnzyme DeficientClinical Features
von Gierke’s dse

Type I

Glucose-6-phosphataseSevere fasting hypoglycemia

Lactic acidosis

Pompe’s dse

Type II

α-1,4-glucosidaseAccumulation of ↑ amount of glycogen on all organs

Presence of abnormally LARGE LYSOSOMES

Forbe’s dse

Type III

Debrancher enzymeHypoglycemia, hepatomegaly, seizures and mental retardation
Andersen’s dse

Type IV

Brancher enzymeProgressive liver enlargement or cirrhosis and muscular weakness by age 2

Absence of storage glycogen

Unbranched AMYLOPECTIN

Other enzyme defects/deficiencies that cause hypoglycemia: glycogen synthase, fructose-1-6,biphosphatase, phosphoenolpyruvate carboxykinase and pyruvate carboxylase.

  • Galactosemia – a cause of failure to thrive syndrome in infants; congenital deficiency of one of three enzymes involved in galactose metabolism, resulting in increased plasma galactose levels
    • Galactose-1-phosphate uridyl transferase – MOST COMMON enzyme deficiency
    • Fructose-1-phosphate aldolase deficiency

Laboratory Analysis of Glucose

  • SPECIMEN COLLECTION AND HANDLING
    • Glucose concentration in whole blood is approximately 15% lower than in plasma or serum.
    • Glucose levels decrease approximately 10 mg/dL (7%) per hour in whole blood.
    • Serum or plasma must be separated within 1 hour (Bishop) to prevent substantial loss of glucose by the cellular fraction, particularly if WBC count is elevated. (within 30 minutes – Henry)
    • Glucose is metabolized at a rate of 7 mg/dl/h at room temperature; and 2 mg/dl/h at 4°C
    • Refrigerated serum or plasma is stable up to 48 hours.
    • Sodium fluoride (2 mg/mL) prevents glycolysis (gray top tube) for up to 48 hours.
    • Glycolysis decrease serum glucose by approximately 5-7% per hour (5-10 mg/dl) in normal, uncentrifuged coagulated blood at room temperature.
    • Fasting blood glucose should be obtained after an approximately 10-hour fast (not >16 hours)
    • Fasting plasma glucose values have a diurnal variation with the mean FBG higher in the morning than in the afternoon.
    • Fasting reference range for serum or plasma is 70-110 mg/dL
    • In the fasting state, arterial (capillary) values are 5 mg/dL higher than the venous concentration.
    • Urine glucose analysis (in 24h urine glucose) may be stabilized by addition of a preservative; should be stored at 4°C during collection because 40% of glucose is lost after 24 hours at room temperature.
    • CSF glucose analysis (if will be delayed) must be centrifuged and stored at 4°C-20°C
    • In normal CSF, values are two-thirds (approximately 60-70%) of plasma level.
    • RENAL THRESHOLD for glucose: 180 mg/dl
  • TYPES OF SPECIMEN FOR GLUCOSE ANALYSIS
    • Fasting Blood Sugar – blood collected after 8-10 hours of fasting (NV: 74-106 mg/dl)
    • Random Blood Sugar – test for INSULIN SHOCK (NV: <200 mg/dl)
    • 2 hour Postprandial Blood Sugar
      • Standard load of glucose: 75 grams
      • Glucose measurement taken 2 hours later
      • (NV : <120 mg/dl)
    • Glucose Tolerance Test – multiple blood and urine glucose test
      • Oral GTT
        • Janney-Isaacson (Single Dose)
        • Exton Rose (Divided Oral dose or Double Dose)
        • Not recommended for routine use
        • Fasting and 2h sample are measured except for pregnant patients
        • Adult load is 75g; children: 1.75 g/kg to 75g
        • Factors that affect tolerance
          • Medications (salicylates, diuretics, anticonvulsants, oral contraceptives and corticosteroids)
          • GI surgery
          • Vomiting
          • Endocrine dysfunction
        • Requirements:
          • Patient should be ambulatory
          • Patient must be in unrestricted diet of 150 grams CHO/day for 3 consecutive days prior to the test
          • Patient must be free from undue stress or severe illness
          • Alcohol intake and smoking are not allowed prior to the test
          • Patient should be fasting at least 10 hours and not more than 16 hours
          • Test should be performed in the morning because of hormonal diurnal effect on glucose
        • IVGTT – blood sample is collected every 10 minutes for 1 hour
          • 5g glucose/kg body weight (given within 3 minutes) administered intravenously
          • fasting is also required
          • NV: 1.4 – 2.0 %
          • Indications of IVGTT
            • Patients who are unable to tolerate large CHO load
            • Patients with altered gastric physiology or GI d/o
            • Patients with malabsorption syndrome
  • Self-Monitoring of Blood Glucose (SMBG)
    • Type 1 DM – should monitor blood glucose 3-4 times per day
    • Type 2 DM – optimal frequency is unknown
  • Glycosylated hemoglobin/Glycated hemoglobin/HbA1C
    • hemoglobin compound formed when glucose reacts with amino group of hemoglobin
    • test for long term diabetic control
    • reflects the average blood glucose level for the previous 2-3 months
    • for every 1% change in HbA1c value there is 35 mg/dl (2 mmol/L) change in the mean
    • in presence of hemoglobinopathies, there will be less time for glucose to
    • binding of glucose to HbA1 is irreversible
    • preferred anticoagulant is EDTA
    • NV: 4.5-8.5%
Methods of HBA1c Measurement
Methods based on STRUCTURAL DIFFERENCES
ImmunoassaysPolyclonal or monoclonal antibodies toward the glycated n-terminal group of the β chain of Hgb 
Affinity chromatographySeparates based on chemical structure using borate to bind glycosylated proteinsNot affected by temperature and other hemoglobins
Methods based on CHARGE DIFFERENCES
Ion-exhange chromatographyPositive-charge resin bedHighly affected by temperature and hemoglobinopathies

HbF – ↑

HbS and C – ↓

ElectrophoresisSeparation is based on differences in chargeHbF values >7% interferes
Isoelectric focusingType of electrophoresis using isoelectric point to separatePre-hb A1c interferes
HPLCForm of ion-exchange chromatographySeparates all forms of glycol Hb (a,b,c)
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  • METHODS FOR ANALYSIS
    • CHEMICAL
      • REDUCTION
        • Cupric Ion Reduction
          • FOLIN-WU – measure of ALL REDUCING SUBSTANCES in the blood
            • Reagent that binds with Cu+: phosphomolybdic acid
            • End product: phosphomolybdenum blue
            • End color: blue
          • NELSON SOMOGYI – MEASURE OF TRUE GLUCOSE
            • Reagent that binds with Cu+: arsenomolybdic acid
            • End product: arsenomolybdenum blue
            • End color: blue
          • NEOCUPROINE
            • Reagent that binds with Cu+: neocuproine
            • End product: cuprous-neocuproine complex
            • End color: yellow/yellow orange
          • Ferric Ion ReductionInverse Colorimetry – reduction of yellow ferricyanide to a colorless ferrocyanide by glucose
            • HAGEDORN JENSEN
    • CONDENSATION
      • Orthotoluidine (DUBOWSKI method)
        • can be also used for urine and CSF without protein precipitation
        • Absorbance: 630 nm
        • Reagent: aromatic amine, glacial acetic acid
        • End color: green
        • Interfering substances: galactose and mannose
    • Polarographic Glucose Oxidase
      • measures oxygen consumption with PO2 electrode (Clark)
      • used to avoid interference made by strong oxidizing agents in GOD
      • Molybdate – catalyzes the oxidation of iodide to iodine by H2O2
      • Catalase – catalyzes oxidation of ethanol by H2O2 forming acetaldehyde and H2O
    • Hexokinase
      • Generally accepted as the REFERENCE METHOD
      • MORE ACCURATE THAN HEXOKINASE
        • coupling reaction using G6PD is highly specific
      • Measured by quantitating reduced NADPH formation
      • NADPH is measured directly at 340 nm or coupled to chromogen and measured in visible range
      • Interfering substances: gross hemolysis & extremely elevated bilirubin (cause ↓ values)
      • May be performed using serum or plasma (heparin, EDTA, fluoride, oxalate & citrate)
      • Excellent for glucose determination in urine, CSF and serous fluids

OTHER IMPORTANT TESTS

  • KETONES
    • Produced by the liver through metabolism of fatty acids to provide ready energy source from stored lipids at times of low carbohydrate availability
    • THREE KETONE BODIES
      • Acetone (2%)
      • Acetoacetic acid (20%)
      • Β-hydroxybutyric acid (78%)
    • Causes of increased ketone levels
      • Diabetes Mellitus
      • Starvation/fasting
      • High-fat diets
      • Prolonged vomiting
      • Glycogen storage diseases
    • KETONEMIA – accumulation of ketones in the blood
      • KETONURIA – accumulation of ketones in the urine
      • MEASUREMENT OF KETONES
        • For patients with Type 1 Diabetes, it is recommended during acute illness, stress, pregnancy, or elevated blood glucose levels above 300 mg/dL or when patients have signs of ketoacidosis
        • SPECIMEN: FRESH SERUM or URINE tightly stoppered and analyzed immediately
        • METHODS FOR ANALYSIS:
          • GERHARDT’S TEST – historical test
            • Used FERRIC CHLORIDE reacted with ACETOACETIC ACID to produce a RED color
    • SODIUM NITROPRUSSIDE – more common method
      • Uses SODIUM NITROPRUSSIDE which reacts with ACETOACETIC ACID in an ALKALINE pH to form a PURPLE COLOR
      • If GLYCERIN is also added, ACETONE will be detected
      • Used in urine reagent strips and Acetest tablets
    • ENZYMATIC – newer method adapted in some automated intstruments
      • Uses β-HYDROXYBUTYRATE DEHYDROGENASE to detect either β-HYDROXYBUTYRIC ACID or ACETOACETIC ACID depending on the pH of the solution
        • pH of 7.0 causes the reaction to proceed to the right (decreasing absorbance)
        • pH of 8.5 to 9.5 causes the reaction to proceed to the left (increasing absorbance)

MICROALBUMINURIA

  • Defined as persistent albuminuria in the range of 30 to 299 mg/24 h or an albumin-creatinine ratio of 30 to 300 g/mg
  • Clinical proteinuria or macroalbuminura is established with an albumin-creatinine ratio of ≥300 mg/24h or ≥300 µg/mg
  • Powerful predictor for future development of diabetic nephropathy
  • Annual assessment of kidney function by the determination of urinary albumin is recommended for diabetic patients
  • METHODS FOR MICROALBUMINURIA SCREENING
    • RANDOM SPOT TEST – preferred method
    • 24-HOUR COLLECTION
    • TIMED 4-HOUR OVERNIGHT COLLECTION
  • A patient is determined to have microalbuminuria when two of three specimens collected within a 3- to 6-month period are abnormal.
  • Factors that may elevate the urinary excretion of albumin include exercise within 24 hours, infection, fever, congestive heart failure, marked hyperglycemia, and marked hypertension

ISLET AUTOANTIBODY AND INSULIN TESTING

  • Not currently recommended for routine screening for diabetes diagnosis but in the future it might identify at-risk, prediabetic patients
TESTS FOR CARBOHYDRATE DISORDERS
DIAGNOSTIC TESTSACTION
Fasting Blood SugarNormal – 70-110 mg/dl

Diabetes – >126 mg/dl

2hr Post Prandial Blood Sugar (PPBS)Normal – <126 mg/dl

Diabetes – >200 mg/dl

Post-Loading GlucoseSimilar to PPBS

*Glucose load is standardized

*Diabetics ≥200 mg/dl

Glucose Tolerance Test (GTT) Standard dose = 75g*Diagnostics of diabetes mellitus

>150 mg/dl after 2 hours

>200 mg/dl after 2 hours

*Perform if FBS and PPBS are normal

Intravenouse Glucose Tolerance Test (IVGTT)*Poor absorption (flat curve with OGTT)

*Patient who cannot tolerate large glucose load (vomiting)

O’Sullivan Test

(for gestational diabetes)

*Standard dose 50g

*Probable gestational diabetes

>150 mg/dl at 1 hour

*Follow up with OGTT

TESTS FOR MONITORINGNOTES
Glycosylated hemoglobin*Assessment of long term control

*Average glucose level over 60 days (1-2 months)

Microalbumin*Detects small amounts of protein in urine of diabetic patients to assess renal damage
C peptide of Insulin

(reflects pancreatic insulin secretion)

Normal 1:1 (insulin:C-peptide)

Diabetes > 1:1

C-Peptide ↓after insulin injection

REFERENCES:

  1. Bishop, Michael L., et.al., Clinical Chemistry Techniques, Principles, Correlations, Sixth Edition
  2. PER Handbook
  3. Theriot, Betty, Clinical Laboratory Science Review: Bottom Line Approach
  4. McPherson, Richard, et.al., Henry’s Clinical Diagnosis and Management by Laboratory Methods, 22e
Posted in Lecture Notes

Water Bacteriology

Source: Alba’s Medical Technology

Water-Borne Diseases

  • Salmonella – typhoid & parathypoid fevers
  • Shigella – bacterial dysentery
  • E. histolytica – amebic dysentery
  • Vibrio – cholera

The bacteriological examination of water usually consists of

  1. Estimating the number of bacteria present by TOTAL PLATE COUNT
  2. Detecting the presence or absence of coliforms & estimation of the number of coliforms present by the “MOST PROBABLE NUMBER” (MPN) method

DRINKING WATER STANDARDS

U.S. Public Health Service Drinking Water Standards publication

  • standard for public water supplies
  • states that NO MORE THAN 10% OF ALL THE STANDARD 10 ml PORTIONS OF WATER EXAMINED IN A MONTH SHALL SHOW THE PRESENCE OF COLIFORM BACTERIA

Sampling

  • collected in sterile glass containers with ground glass stoppers
  • should be packed in ice or stored at 6-10°C
  • examination of contents should be done within
    • 6 hours – IMPURE WATER
    • 12 hours – PURE WATER
  • 20-50 mg of sodium thiosulfate is added to sample bottle when testing water from swimming pools to NEUTRALIZE RESIDUAL CHLORINE and prevent chlorine from killing bacteria in the interval between collection and testing

Two (2) Procedures carried out routinely:

  1. TOTAL BACTERIAL PLATE COUNT – report as number of bacteria (each colony is counted as one bacterium) per mL of undiluted H2O. When bacterial total plate count exceeds 100 organisms/mL at 37°C, the water is usually CONSIDERED UNSAFE FOR HUMAN CONSUMPTION.
  2. TESTS FOR COLIFORM GROUP OF BACTERIA

Coliform group – all AEROBIC & FACULTATIVE ANAEROBIC GRAM NEGATIVE NON-SPOREFORMING BACILLI which FERMENT LACTOSE WITH GAS FORMTION WITHIN 48 HOURS at 35°C.

PRESUMPTIVE TEST

  • LACTOSE BROTH or LAURYL TRYPTOSE BROTH
  • POSITIVE: Formation within 48± 3hours of GAS in ANY AMOUNT IN THE FERMENTATION TUBE
  • NEGATIVE: Absence of gas formation at the end of 48± 4hours incubation

CONFIRMED TEST

  • BRILLIANT GREEN LACTOSE BILE BROTH FERMENTATION TUBES
  • POSITIVE: Formation and presence of gas in any amount within 48± 3hours
  • ENDO or LEVINE’S EMB AGAR PLATES
    • Results on Endo or Levine’s EMB
      • Typical nucleated with or without metallic green sheen
      • Atypical, opaque, unnucleated after 24hour incubation. PINK.
      • Negative (others)
  • POSITIVE: Growth of TYPICAL COLIFORM COLONIES with 24± 2 hours
  • NEGATIVE: Growth of NEGATIVE COLONIES

COMPLETED TEST

  • BRILLIANT GREEN LACTOSE BILE BROTH FERMENTATION TUBES showing gas used for confirmed test
  • POSITIVE: Formation of acid and gas in Lactose broth; demonstration of Gram Negative non sporeforming bacilli in the agar
  • NEGATIVE: Absence of gas formation or failure to demonstrate Gram Negative non sporeforming bacilli in a gas forming culture
  • THE detection of the coliform group in significant number is takes as evidence of FECAL CONTAMINATION.

Fecal origin: E. coli IMViC (++–)

Non Fecal origin: E. aerogenes IMViC (–++)