 Okay. So again, good afternoon to everyone. Let's continue our discussion now with your ESR. So, ESR is also known as your erythrocyte sedimentation rate. So, ESR, I just want it to be very, very clear at this point of time ha, ESR is a non-specific marker of underlying inflammation. So, when I say non-specific, your ESR could be a screening test but never as a confirmatory test. So, a lot of different conditions in our body, both pathological and it is order and diseases, some type would have ESR that is abnormal. Okay. That is abnormal. So, ESR, as you can see, is the sedimentation rate. So, what do we mean by that? This is the rate of fall of every RBC that will now settle from the top of your tube going to the bottom of the tube. So, the sedimentation rate, please remember this, is directly proportional to the weight of the cell aggregate and inversely proportional to the surface area. Directly proportional to cell aggregate and inversely proportional to your surface area. So, why do we perform ESR? Okay. Why do we perform ESR? So, as you can see, ESR is a non-specific marker. So, when I say marker, an abnormal ESR result would actually signal that there is something abnormal inside your body. Okay. There is something going on in your body that is actually not aligned with the usual scenario or the usual pathophysiological processes in your body. Okay. In your body. So, with regards to ESR, you would hear it even in immunology. You would hear it in hemacology because it can actually give you a reflection of both anemia and also inflammation. But before we dig deeper into the different conditions and the different considerations in performing your erythrocytes sedimentation rate, let us first discuss the stages of your ESR, which are, number one, the log phase, the LAG phase. Or di ba parang yung growth lang ng ating mga bacteria during poulture, di ba? May log, may log, may platu, di ba? Same thing with erythrocytes, we also have different stages. Okay. The first one is the log phase, the decantation phase and the last phase would be the sedimentation phase na. Okay. So, the first phase, which is the log phase, happens in the first 10 minutes. Okay. And then the decantation phase happens in the next 40 minutes. And the last stage, which is the sedimentation phase, happens in the last 10 minutes. And if you're going to add all of this, ilang minutes lahat, this is 60 minutes for a total of one hour. Which would now lead me to the answer that into another point that I want to make, that your erythrocytes sedimentation rate is the rate of your RBC sedimenting within an hour. Within an hour. So, that is one hour. That's why, kapag sa laboratory, ESR cannot be considered or should not be stopped. Okay. Hindi pwede niya stat yung ESR. Ano to halogin mo? Bilisan nyo. Yung siya cheer up mo yung mga ESR. Okay. ESR, let's go. Let's do this. Let's do this under 30 minutes because doc will get mad. Hindi ganan nyo. Okay. You have to really wait for one hour. But later, as we go along, may isy-share ako sa inyo ng mga advances in ESR na dati one hour ngayon 45 minutes na lahat. So, moving forward, let's talk about the different stages. So the lab phase will now be the rollu formation. Hindi to rollu formation. What happened during rollu formation? Your RBC now will start to aggregate or at magdidikit-dikit na sila to one another. Okay. They will be joined together na. And then the decantation phase, which is the next 40 minutes, would be a more rapid and constant sedimentation. So meaning to say, after your RBC already have formed rollu, it would now be easier for them to fall down. Gravity. Okay. And then the last 10 minutes would now be a slow. Why? Why slow? Because almost all of the RBC have accumulated in the bottom of your tube already. Okay. Bottom of your tube already. So please take note that using a longer tube, okay. If you're using a longer tube, the longer the decantation phase would be. Okay. The longer the decantation phase would be. So those are the three. Lab, decantation, and sedimentation phase. Okay. Let us now move forward to the different factors that would affect your sedimentation rate. Okay. Your sedimentation rate. Let's now talk about the intrinsic first. When we say intrinsic, something is wrong in the RBC. Something is wrong with the blood or the plasma. That is the reason why there is an abnormal ESR. Okay. There's an abnormal ESR. So let's start with the intrinsic factor. So intrinsic factors are any inherent factors that comes along with your specimen, either your RBC or your plasma. So number one, okay, is the number of RBC per cubic millimeter. So this is inversely proportional to your ESR. Okay. RBC count down. Okay. What happened in your polycythemia vera? Increase, decrease, thumbs up, thumbs down. Increase or decrease RBC count in your polycythemia vera. Increase, decrease, increase, correct. Increase sa PV. In your anemia, it is decreased, obviously. Okay. So meaning to say, slower ang ESR, kapag polycythemia vera, the anemia is faster ESR. As you can see, kaya siya ang gamit natin adjective is either slower or faster because we're talking about rate. Okay. We're talking about the rate. Okay. Hindi ko sinatabin increase, decrease, because we're talking about rate. Okay. Mas mapilis, okay. Kung narin, pag sinabi natin faster, that would be around 40 millimeter per hour, ganon. Okay. So slower and faster yung parameter natin dito, ha? So in your RBC count, okay, the more RBC, the slower, which is, bakit ganon, sir? Okay. Bakit pag mas madami, mas mabagal? Kasi siyempre, siksikan sila, nisila agad makakababa. Unlike your anemia, okay. Parang mag-isa lang siya dun, babagsak talaga siya agad papunta sa baba. Okay. Papunta sa baba. So that is for your RBC number or RBC count. Okay. Let's talk about RBC size. Let's talk about RBC size. RBC size is directly proportional naman. Okay. Directly proportional with ESR. What do I mean? The bigger the cell, the faster the ESR. Okay. RBC ya. The bigger the RBC, the faster the ESR. The smaller the RBC, the slower the ESR. Bakit ako ko ha? The slower the ESR. Question. What parameter can I use to check if your cell are macrositic or mormositic or micrositic? What can I use to check if? Ay, mabigilis. Okay. It's your MCV. What is the upper limit? Okay. I can say it is macrositic. Kapag ilan? I may naglagay ng 100. Okay. The answer is? But why 100? Okay. May naglagay. May naglagay. Ataman ang pala. 100. Okay. Greater than 100. Okay. Greater than 100 femtoliter. Would mean it is macrositic. Okay. Normal yan. Normal yung less than 100. Okay. It should be greater than. Okay. Greater than 100 femtoliter. Pag less than 80 femtoliter. That is your microsity. Okay. Very good. So again ha, RBC size is inverse, is directly proportional. Mas malaki, mas mabilis. Mas maliit, mas mabagal. Bakit mas malaki? Di ba ang saka mabagakagad? So yan. Talk about RBC shapes. Okay. What do we call the variation in your RBC shape? What do we call the variation in your RBC shape? We call it shape? Okay. The answer is? Okay. Point kilo cytosis. Okay. Point kilo cytosis. Correct. Okay. Question. In the RBC indices. Okay. Tingan natin kung may nakakatanda pa. RDW would reflect A. Point kilo cytosis. B. Anisochromia. Or letter C. Anisocytosis. ABC. Dancer is? Okay. Ang sagot po ay? Anisocytosis. Okay. RDW, guys. Ayan. May very good. RDW, anisocytosis. Okay. Anisocytosis. Sir, ano yung anisochromia? Anisochromia. Difference in the color of your RBC. Okay. Difference in the color of your RBC. Tatang nang obatan na. What is the last stage capable of mitosis? Pero masado ng malayo. Okay. Bakit isumpan nyo nako ng turu yan? Okay, yung pro-base o poly-ortho natin palatandaan sa RBC maturation series. But let's go back here. Okay. In the shape of your RBC, any abnormal or irregular shape would hinder rollu-formation. So kapag pinigilan mo yung rollu-formation, matatagalan ka. Okay. So ibig sabihin any point kilo sites, any presence of point kilo cytosis would now cause a slower ESR rate. Okay. Slower ESR rate. Okay. Are we clear? So far? Clear? Clear, clear, clear? Okay. My next slide will be the marriage of clean chem and hematology somehow. Why? Okay. Your plasma proteins. Remember, your plasma proteins Okay. As you all know, sabi ko nga, your ESR are usually used to check inflammation. These are usually done. Your ESR is done to check the presence of inflammation. So as you can see in your plasma proteins, we have acute phase reactants. Okay. We have acute phase reactants. So as you are now seeing right now, albiumin lesitin all, okay, would slow down your ESR. Okay. Would slow down your ESR. Question. Is albiumin a positive or a negative acute phase reactant? Positive or acute phase reactant? Okay. Negative. Okay. Correct. Ay. Nagaral na sila. Okay. Correct. Aside from aside from albiumin and transtyritin, what else is the negative acute phase reactant? Aside from pre-albiumin, aside from transtyritin, aside from pre-alb. Okay. It's your transferring. It is your transferring. Okay. Trilang po sila. Or tatlonga lang sila. Your pre-albiumin or transtyritin, albiumin in your transferring. Okay. So only three. So moving forward, okay. Moving forward with that. As you can see now here, guys, pag may inflammation, faster ang ating, okay. Pag may inflammation, faster ang ESR. Pag walang inflammation, normal yung ESR obviously. Okay. Normal yung ESR obviously. And as you can see, globulins faster. Why? Globulins in general are your alpha one, alpha two beta and your gamma. Your fibrinogen, which is abeta globulin also causes faster ESR. So nakikita ninyo ha that the positive acute phase reactant would increase your, would increase your ESR. Pwede paulit kong mabilis po kapag may inflammation. Um, your ESR rate is faster in the presence of inflammation. Okay. And siguro tatanungin ninyo ako. Sir, pano naman po naging mabilis dahil sa inflammation? At sasagutin ko kayo, this is because of the presence of your positive acute phase reactant. Make sense now? Okay. So at least alam yung ngayon na yung ESR mo mabilis dahil may inflammation. But what about that inflammation that increases my ESR? It is because of the presence of your acute phase reactant. Okay. It is because of the presence of your acute phase reactant. Am I clear now? Okay. Am I clear? Okay. Thank you. Okay. Okay. So those are the plasma proteins. So remember daloong plasma proteins lang ang nagpapabagal less citin and albumin. Okay. Let's move forward with the viscosity. Okay. Viscosity of your plasma is inversely proportional to your ESR. Again, your RBC viscosity is inversely proportional to your ESR. The more viscous, the slower the ESR. Paralang yang take for example water. Water would move faster in your capillary ang capillary motion ng less viscous natin would flow faster. Unlike in your unlike in your in a more viscous solution, mas mabagal magfuflo yan. Okay. Kasi nga viscous siya. Okay. So in your viscosity with regard to your viscosity inversely proportional sila. Wait, wait, wait. Parang ternosilanino. Ternosilani RBC count. Okay. Ni RBC count. Bakit? In polycythemia vera ladies and gentlemen, polycythemia vera is also characterized not only with increased RBC but also with increased blood viscosity. Okay. Okay. Okay. So polycythemia vera increase yung RBC mo increase pa yung viscosity. Okay. So moving forward. Okay. Kani nakapamooving forward, sir. Hindi ka naman nagmooving forward. Okay. So moving on. Okay. We also have extrinsic factors. Okay. Extrinsic and intrinsic factors. Children, magmarilito ha. Kasi last time yung pinagusapan natin intrinsic and extrinsic factors ng hemolysis. Iba ito sa ISR. Ha. Yung mga pinagusapan natin kanina intrinsic factors. RBC count, presence of plasma proteins, poikilosytosis, what else pa ba? Your the size of your cell and then we also included din sa discussion natin your viscosity. So all of those are intrinsic factors. Let's talk about extrinsic factors this time. Okay. When I say extrinsic factors, ito yung mga nagawa nung medtech habang pinapreform yung ISR. Ito yung nangayari sa tube. Ito yung manner ng collection. Okay. Number one. Okay. Extrinsic factors is the length of tube. Okay. The longer the tube, the faster the ISR. Okay. Again. The longer the tube, the faster the ISR. Okay. The faster the ISR. Sir, parang may naalala kung note mo kanina ba ba? Okay. The faster the ISR. When I say faster ISR, that's equivalent to elevated ISR. Pero why am I saying it again faster or slower? Because I'm talking about rate. Okay. So faster ISR. The longer the tube, the faster the ISR. Why? Because in this sense, okay, kung note, this one. Ayan. Ito mas mahaba. Kung note, the longer this is, puha tayo ng isa. Okay. This one. Can you see? Which will have a faster ISR based on length of tube? Okay. Is it the stabilo? Okay. Or the moody pen? Okay. The answer would be the moody pen. Mas matas yung ISR, mas faster yung ISR nya because it's longer compared to this one. Okay. What about the diameter? Okay. What about the diameter of the tube? Normal diameter of your tube should be 2mm to 3.75mm. Okay. 2mm to 3.75mm. Before I move forward, question. What should be the distance of your 30K from the site of the puncture site during flibotomy? What should be the distance of your 30K? It should be 3-4 inches. What should be next question? What should be the distance of the drop of blood from the label in your PBS? Okay. Answer. Okay. Good. 1cm. Correct. What should be the diameter of the drop of blood? What should be the diameter? What should be the angle? Okay. What should be the angle of your needle insertion during flibotomy? Aga-aganya sumagot. Okay. What should be the angle? Okay. 15-30 pag flibotomy. But that's correct. 30-45 kapag peripheral blood smear. Okay. Napag peripheral blood smear. Okay. Lesson patapusin ng tanong. Okay. So moving forward. Sayon ngan. Lesson natin dun patapusin ng tanong. And changing with you guys. Okay. What's happening right now is not your fate. Okay. That's just a chapter of the season in your life. So, won't niyong tapusin lahat ngayon. Okay. Moving forward, let's go to the diameter of your tube. The less if you have as a what do you call this? If you have a smaller, if you have a smaller diameter slower siya. Slower diameter slower smaller diameter, slower than ESR. And then if it is a if it is a greater, your diameter is big. Okay. It's big. And that would mean that your ESR would be faster. Your ESR would be faster. Okay. So diameter of the tube 2 to 3.75 millimeter less than 2 slower greater than 3.75 that would be a faster ESR. So nakikita nyo na kong paning exams? Yes, sir. Okay. So increase or decrease makaganyan lang yun. Okay. With regards to your temperature, okay. The optimum is 22 to 27. Sir, bakit 22 to 27? This is sure room temperature. Okay. Less than 22, babagal. Diba parang ikaw pag normal yung temperature you can freely move. Like us here in the Philippines. But for Alberto and Kosen na na sa states ngayon, the colder mas restricted yung movement nila. Okay. So the higher the temperature the faster the ESR. Directly proportional temperature and ESR rate. The higher the temperature, the faster the ESR. The lower the temperature the slower the ESR. I clear. Can I see a race of hatch if I'm clear so far with all the things that we're talking about? Okay. Before I proceed, let me just clarify this one. Milaya has a question Longer tube, sabi natin kain nila ba? Longer tube, faster ESR which is still correct. Pero ang point lang dun sa kanin ang pinakita ko is elevated or longer yung ano niya. Longer yung decantation face niya. Kasi mas mahaba yung remember, Milaya, mas mahaba yung itatravel ng RBC mo so mas mahaba yung decantation mo but it's still faster. In a sense, it's still an elevated ESR. Okay. Hopefully I'm clear with that. Yung stage 2 lang yung decantation face yung mas mahaba, longer than 40 minutes. Okay. But of course yung ang mag-adjust dun silag at siyong dulong side. Okay. Okay. So that's with temperature 22-27. Ginito ang gagawin ninyo guys. Specifically in certain cases like temperature sizes, meron siyang optimum. So anything below the optimum and above the optimum dun maglalaro if it is faster or slower. Okay. So inclination of the tube. Okay. This is very important for you to remember because still think the tube is a straight ESR. Let me show you a picture of ESR. Parang kaya yung palang meron na kayong idea kong pano siya ginagawa. As you can see, lahat ng ESR straight. Okay. Lahat ng ESR straight siya vertical siya na oriented. Okay. Why? Because any tilt in your ESR any tilt dyan, any baliko any tilt in your ESR would cost what? Tilting or inclination of your tube would cost okay, an error up to 30%. Okay. Even a slide 3-degree angle tilt would now cost an error of 30% 30% error. Specifically, what error it would accelerate or faster yung ESR. Nakukukuha ko ba ako. Konwara, example normal naman yung normal siyong bang nan dito. Konwara si Davis na lang. Sanag ising Konwara ay yung ESR okay, this is your ESR tube ni Davis. Normal yung dogo ni Davis, wala siyang inflammation, wala siyang condition. Pero nung nilagay ni nilagay ni RG yung kanyang tube, baka pabalik ko sabihin, ah okay kaya kaya Davis naman niya nilagay niya lang nakakaslan. Eventually faster yung ESR ngayon ni ESR results would now be faster ay nanong ayong resonada napag faster, faster ESR would mean there is a presence of inflammation and there is a presence of inflammation. So tilting would would cost now would now cost would now cost unabnormal results of your ESR. So before I go ahead, before I move forward, siguro nagtataka kayo sir what is the normal ESR? It is actually 0 to 30 for male, 0 to 40 for women. 0 to 30, 0 to 40. So ibig sabihin sir pwede akong mag-ESR nilagay ko yan ng isang oras pero wala nang yayari pwede pero normal pa rin yung 0, 0 lang siya. Later papakita ko sa inyong kung paano siya binapasa. So let's move forward from those things. We still have this tree, last tree nalang to. So wet glassware. Take for example, this is your tube basayong luog, it will cause hemolysis, faster ESR. What about the presence of bubbles? Presence of bubbles meaning to siguro ibig sabihin pag may mga bubbles ka yan in between, konti lang yung dubo na nailagay mo. That's why it would also cost faster ESR. Sir paano naman po pag anticoagulant? Masyadong madami yung anticoagulant na nalagay ko na dilute ng anticoagulant yung blood what will happen? Faster ESR. Sir in what way? Remember this improper ratio of blood in anticoagulant would cost the shrinkage of your RBC. Meaning to say that is a poikilo, cytosis. In short, kapag meron kang kapag nag-crenate, wag hindi ko na tatawagin poikilosite. Kapag nag-crenate yung cells mo kapag nag-crenate yung cells mo or nag-rupture yung cells mo, it would also cause hemolysis. Therefore increase din yung ESR. Hindi ko na tatawagin poikilosites baka malito kayo kasi poikilosites is different, slower than ESR. Nag-gets ba ko? Higher concentration ng anticoagulant, lahat elevated or faster ESR. Delay in ESR, for example you did your ESR for more than 2 hours mag-suswell naman this time yung RBC mo. Mag-suswell yung RBC mo RBC would start to swell and remember when your RBC start to swell, when your RBC start to swell poikilositosis na ryan magiging spherosite sila magiging slower yung ESR. Slower yung ESR. Siguro what I want you to do then, I've seen some of your IG stories which I really want to upload. Some of you are summarizing my notes. Some of you are summarizing my notes tapos nakalagay yung names nila doon. Nakalagay yung mga names nila doon which I really... yun yung sinasabi ko sa batch ninyo, matagal na. Pagpatulin yung ganyan. Syempre, ganyan din naman sa men's school may mga talagang tagawa ng trance. Tapos trance nalang yung babasahin ang buong batch. Ayun nga, with regards to that I want you to make sure that you have a table. Kasi meron ng table, kagay nung pass, yung pressure, angle, speed, tapos yung eska nina yung eska nina sa ulo. Pagdating doon sa anan natin, pinagusapan natin yung tawag dito. Pinagusapan natin yung peripheral blood smear. Pass. Pressure ay halay yung utako na wawala na. Pressure, yung angle, yung size, size of the drop and speed. Okay. So moving forward, question. What color of test tube is being used for ESR? What color of tube is being used for ESR? Ay, very good. It is your may sumagot ng lavender, may sumagot ng black. The correct answer is both. Why? Because I did not specify what type of ESR method. What type of ESR method. You can use your purple, but never your light blue. Okay. Not your light blue. Okay. Not your light blue. You can use your purple. You can use your black, but never your light blue. Okay. Never your light blue. Not your light blue. Okay. So to be specific, okay. Your black is for your Westergren ESR or your Westergren sedimentation brain. Let us talk about those two. We have two types. We have your Westergren and we have your windthrobe. Okay. Your windthrobe and your lance bird, you have to read it after one hour. It uses a double oxalate as an anticoagilan. Okay. As an anticoagilan. Okay. As an anticoagilan. So these are the normal values for your ESR. Again, we have your windthrobe, windthrobe and lance bird. Okay. Windthrobe and lance bird. And we also have your Westergren method, which is the most sensitive method. Why? Because di ba orignally, you only have to read your ESR after one hour. ESR, take an extra lip. After one hour, hindi ka paulit ng isang oras. Okay. Two readings siya. I want you to remember that. Windthrobe, one reading, two readings. Two readings. In addition to that, your Westergren uses your 3.8 sodium citrate as an anticoagilan. Found in your black top tube. Found in your black top tube. Are we clear? Okay. Let me just talk about your windthrobe first. Your windthrobe, you can use double oxalate or you can use your EDTA on it. Your lavender. Your windthrobe in lance bird is actually we call the tube windthrobe tube. We call it windthrobe tube. And your windthrobe tube can be used into two tests. Your erythrocyte sedimentation rate, which is on the left side, the red one. Yung mga red graduation lines later I'll show you. And on the right side, the white increments would now be for hematocrit. But I want you guys to be specific because next meeting we will talk about hematocrit, hemoglobin, and RBC indices. But for now, I want you to remember that when using your windthrobe tube we are measuring the macro hematocrit. Macro hematocrit. And not the micro hemat. Di ba may ron tayong micro hematocrit tube? Your windthrobe tube is your macro hematocrit tube. Why? Obviously kasi mas malaki siya. So this is your windthrobe tube. The red one. The 0 to 10 that is for your ESR the white graduation from 10 to 0 that is for your macro hematocrit. That is for your hematocrit. Am I still clear? Am I still making sense with you guys? Ha? Pwag yung patsin yung mong gula kong hair. Wala mga upload to pero para lang mais yung aking anong. Are we clear? Clear ba tayo? Okay. Thank you, thank you. So again windthrobe tube. Okay. So this is how your ESR look like. Kumapapansin ninyo sir, ba thread kasi haimolais yung RBC haimolais, haimolais. This is etong number four number four, white turbidity sabi niya doon, leukocytosis doon. But for me nga, hindi pa nag-start na ano. Hindi pa nags-start na sa ano pa lang yan, nag-dedecant na lang. Number five ayan. So accelerated. Doon naman yellowish yung kanyang plasma. So most probably mayroon yung liver disease. Ayan. My liver disease ayan, ecteric. Liver disease, see you tomorrow. Clean chem. May clean chem nga ba tayo tomorrow? Ayan. So how do we read it? Ganito siya. Okay. So meaning to say, sabi nga natin kanina, your RBC would sediment. Okay. Would start to would start to form sediment below the tube. And this is how it would apply. Okay. So take for example, ayan. Ecto siya. Okay. It will go down down down down down. Okay. Papabasya ng pababa. So from zero to ayan, ecto ecto yung ano ha. This is wind throw. So sand ka titingin. Right or left? Right or left? Sa left. Ecto siya. So this is your wind throw. So kung makikita ninyo zero, we're going to count that. So yubibilangan mo yung distance already. So nandito na siya. So this is around 0.5 yun. 0.5. So 1, 2, 3. 0.8. Okay. Na sa 0.8 na yung ano. This is actually 10. This is 8. Okay. So increment nyan 1. So 1 0, 1, 2, 3, 4, 5, 6, 7, 8, 9. 10 ito, 10. Unlike kasi sa wind throw, ayan kung makikita ninyo yung ano sa wind throw, 0 to 9, 0 to 20, 0 to 13. So 1 digit lang sila. Unlike the other ano na esr yung increments niya s by 10. So this one, bilangin natin. This is only 8. 8 millimeter per hour. So that is the value of your esr. So ganan yung siya ba basahin. Sir ganan din po ba sa ano, sa lab? Yes. May yung tub mo, kas ba basahin mo lang siya. Okay. So hopefully during your pre-internship ano, we will be able to do that. And so having said that now ako usually, siguro pag nasa ganagawin yung siyang practice na, pagdinig namin yung esr tube you would also ask for somebody else's opinion. Okay. Kung baga pa double check ninyo. Okay. So moving forward, ayan aside from Westergren, aside from your wind throw, we also have your Vesmatic. Your Vesmatic is a bench top analyzer for esr. So you can do 20 blood samples at once. Okay. So naka naka slant yung esr tube. Anong mga yari, pag naka slant yung esr tube? Faster or slower? Faster or slower? Ay, mga slow nang mga keyboard warriors. Okay. It is faster or slower. Faster. Okay. And having that in mind, di ba? That is the principle now that they use to hasten para pabilisin yung Westergren. So originally, di ba? Pansin ninyo, yung Westergren natin two hours, kasi this is the most sensitive. Two hours. One hour and then another hour. What they did is to slant the tube 18 degrees, which now would make it now. You would read the first instead now, one hour. You would now read it after 25 minutes. And then you would now in the second hour, you would read it after 45 minutes. So di ba ang galing na 25 and then 45. So instead na 1 and 2, 25 45. So how do we measure it? We measure the esr using your optoelectric sensors automatically that automatically reads your esr levels. So I am now down to the I'll give you a case study by the end of the day. Pero hindi nga naman nasasagotin na like in the TLC pa. Tasagotin din natin agan. So these are the different conditions. These are just the conditions. These are all on your notes na, ha, guys? So esr what are the things that would be increased? Your esr is increased in your inflammation, chronic in chronic acute what do you mean? Acute and chronic infections, rheumatic fever, rheumatoid arthritis, myocardial infarction, all of this increase yung esr. Siguro magtatangakayo sir in nephrosis isn't it sir that all of my almost all of my plasma proteins were out of my body because I have nephrotic syndrome. I have nephrosis. Question what would be the only plasma protein increase during nephrotic syndrome? What is the plasma protein increase during nephrotic syndrome, children? The answer is ala hindi ko makita yung chat. What is the answer? May sumagot? Ay, may nakita po kong albumin. May pre-albumin ako nakikita. May nakita kong macroalbumin. Anong macroalbumin? May tinuro ba ako sa inyong macroalbumin, ha? Okay. Hindi ko makita yung chat namin sa auto. Ayyan. May sagot na dito sa O2 at O1. Dito sa O3, O4. Okay. Anong sagot? The answer is it's your, ay may nakita ko beta 2, macroglobulin kontin-kontin na lang, but the answer is your alpha 2, macroglobulin. Okay. Alpha 2, AMG, right? Alpha 2, macroglobulin. Sir, anong beta 2, microglobulin is the plasma protein you see on the surface of the cell. Small shot, right? Microglobulin. Okay. Hindi siya prealbumin, ha? Hindi albumin. So in nephrotic syndrome, the only plasma protein increase is on the alpha 2 band which is your alpha 2, macroglobulin. Okay. Very good for those who answered correctly. Kaya, in nephrosis okay, elevated pa rin yung ESR. Bakit, sir? Because your alpha 2, macroglobulin is a positive acute phase reactor. Okay. Did it make sense? Okay, kung bakit sa nephrosis, wala man na akong natiti rang protein sa katawan. Matas pa rin yung ESR ko. Bakit? Kasi nga, isa sa mga rason, AMG mo, matas pa din. Well, aside from that, we can also attribute that to a lot of other things, like there is anemia due to chronic kidney disease. Okay, saan siya increase? Increase po siya. When I say increase gas, it's faster. Okay. Increase siya sa tuberculosis, ayat. Mwaldensthromacroglobulinemia, hepatitis, and the rest. Now, okay, now, natsabi nyo sa akin, sir, lagot ka, malika sa mga explanation mo. Bakit man dyan si poli sa'y? Bakit man dyan si spirocytosis? Bakit po siya kinoon si Dernay ESR is normal? Bakit siya kinoon si Dernay ESR is normal? Bakit siya kinoon si Dernay ESR is normal? Isabi nyo, sir, slower now. Mali si sir. Inakarekot si sir, paano niya papalitan yung sagot niya? Ano? Why? I would still stick up with my answer that it is slower in polycytemia vera, in your spirocytosis. Why? It's not about, inflammation faster. Inflammation in a cute face reaction, faster ESR. Why is it that in this such situations, normal yung ESR sabi ni sir, slower. Slower, pero within reference range. The answer is this. Very similar to what Jerry Cosette. Very similar to what Jerry Cosette. Remember, sa sobrang bagal niya, wala pa rin siya. Lumampating isang oras. Pwede na sa 0 pa rin siya. Or na nandun pa rin siya sa within the reference range. Gaya nang sabi ni Jerry. It's too slow. Na nandun pa rin siya sa 1R9 nakalipas. Hindi pa rin nagsediment yung RBC. Nakukuha ako. Kaya when I say slower, the slower things na sinabi ko kanina doon, still slower pa rin siya. Paglumalala bas yan in your results. It would appear as if it is normal. As if it is normal. And of course, for the last slide for today, for the last slide for today, we've been talking for 2 hours and 30 minutes na. So, guys, I want you to remember this. ESR, sabi natin kanina, that ESR is a nonspecific test. Nonspecific test siya. But there are two conditions. ESR is useful and is indicated in establishing the diagnosis and in the monitoring of two conditions, which is your polymyalgia, rheumatica, and temporal arteritis, where the rate of your ESR typically exceeds 90mm per hour. It's your polymyalgia, rheumatica, polymyalgia, rheumatica, and your temporal temporal arteritis. Temporal arteritis. Am I clear? Hello, guys. Are we clear? Can I see a raise of hands if I am clear? Okay, thank you so much. Okay, thank you, thank you. Now, for our um, for our case study. Case study number one. I want everybody to answer. I want everybody to answer. I will be calling I will be calling persons to answer. So, pag hindi alam, call a friend. So, ESR, because of lack of space in the laboratory, masikip kasi, the rack of sedimentation rate tubes was placed directly on top of a small refrigerator. What are the three possible effects on the ESR result? Will it be falsely decrease or slower, falsely increase or faster, or nothing at all? So, again, what are the three possible effects on ESR results? Based on everything that we talk about, both the intrinsic and the extrinsic, what could be the possible what could be the possible effects? So, una-una, will it be intrinsic or extrinsic? Intrinsic, extrinsic. Correct. So, let's take a look at the O1 and O2 if the answer is correct. It's extrinsic. Why extrinsic? It's not your problem. I'm the problem. Okay, sounds familiar. Okay, so extrinsic. So, now, what would be the effect in your ESR? Anyone who's the brave soul this afternoon can see answers on the chat box. I want somebody who would volunteer themselves. So, everybody, lower down your hands. Okay, lower your hands. Okay. So, anyone who wants to answer, just raise your hand or acknowledge yourself na lang sa chat because hindi ko makita yung iba. Ay si Louie. Louie, unmute your mic. What what is the possible effect in your ESR? Louie, nagtaska ba ng kamay? Is Louie speaking? Wala ko marining. Wala pa. Okay, baka nakamali lang si Louie? Nahil dyan tatawagin natin si kung ako natatawag ng friend ni Louie. So, okay, any volunteer any volunteer who want to answer Miss Alberto. Unmute your mic, Danny. Ay na wala siya. Hello. Good morning, sir. Good morning, there. Good evening, sir. Good evening, sir. If it's on a refrigerator temperature on top of the refrigerator temperature would affect the the tube. Yeah. It would be well, it would accelerate or it would go faster because it's on top of a refrigerator to the temperature. Okay. So, thank you, Miss Alberto. Okay. Thank you, Danny. I'll thank you, Danny. So, that's correct, okay? That's one. Why? Because the tube is on top of the refrigerator, the monitor, the heat of the motor, the motor of your refrigerator would cause falsely increase or it would accelerate your ESR. Very good, Alberto. What else? I can see chats over here talking about optimal temperature. It's a very specific scenario. Hindi yung general na optimal temperature. I want what's happening on the case. Okay. That's correct for Alberto. That's very good. Aside from that, I still have toos and I'm still waiting for two answers. Iba naging English ay Rubigla kasi tagay us yung ka-usap. Okay. What else? Okay. Daniel, sir falsely increase ESR po due to vibrations po brought by the first motor of the refrigerator because some refrigerator tends to have vibrations and vibrations po brought by the opening and closing of the refrigerator switch parang tagito results to aggregation of the sedimentation rate po. Okay. Thank you, Daniel. Iba parang nakita nyo na yung case na nyo na binigay ko sa inyo. Okay. Thank you, Daniel. So, tama yung sinabi ni Daniel because of the vibration. It would now falsely increase. Parang ano yan, parang konorin nilagay mo dito. Yung pag-group mo, yung lamesa. So, what will happen faster? So, what else? Last one. Last one, guys. Last reasons. Let's go for Goree. I saw Goree raise her hand kanina. Jella, what's your answer? Go Jella. Falsely decrease po. Why? Because sir since it's on top of the refrigerator their tendencies mo di ba when we open the refrigerator. The temperature that's within the refrigerator parang ano siya there. Tama po ba? There's sa near sa area where the tube is placed. Therefore, may in KSR. Okay. Thank you Jella. Funny thing, nilagay ko pala tong case study na sa power point masinyan ko sa inyo. So, yan pala sa power point niya. So, the answers, thank you guys, Alberto Jella and Daniel. So, the answers are here. Okay, number one. Babak, it would cause a slower ESR because the air, the cold air rushing out from the refrigerator or freezer would actually slow down your ESR. It could also increase it in two ways. It can increase your ESR because of the vibration ng pag open and close ng refrigerator or the freezer. And aside from that, the motor, the heat ng motor released by your refrigerator. Okay. So, there's another question here. I think na figure out naman na Niazzy yung sagot sa tanong niya. Okay. So, yeah. So, that is it actually for today. Guys, thank you so much for intent in listening amidst my very, very long power point. So, thank you so much to you guys tomorrow for our discussion on our discussion on Glen Kim and also in Hima. So, you'll see me again, Hima Tamaro.