ChronoBiologyletter

November 2011 ▎ 10th Edition

Diagnos-Techs™ Medical Support Group doctoral courses in pharmacology, Clinical & Research Laboratory gastroenterology, clinical diagnosis, and Quar ter ly Newslet ter John J. White, MD, CM gynecology. She also practices privately, specializing in functional medicine and HIGHLIGHTS IN THIS EDITION Recent callers for advice and endocrinology, with particular expertise 2 Bone Health interpretation of results have probably Diagnos-Techs Bone Health noticed two new voices in our Medical in hormonal restoration and fertility Panel™ (BHP™) Support group at Diagnos-Techs™. As optimization in both men and women. 4 Educational Pathways well, you certainly would have been Dr. Webb has authored health-related -Medical Support as pleased and impressed with them as articles, delivered community-wide -Telephone Consultations lectures, and been featured in local and Office Visits we are to have them with us. They are: -DTI On the Road radio programs and national print publications. 5 Hormones in Cosmetics Brandy Webb, ND An Update Dr. Webb received Cycling Female Hormone Andrew Allshouse, ND Panel™ (FHP™) her Doctorate Timing of Collection of Naturopathic After majoring in Announcing the New Medicine from biochemistry at Diagnos-Techs™ Catalog Bastyr University the University of 6 Laboratory Adviso after earning her biochemistry Washington, Dr. -GI Panel degree from Seattle University. Allshouse earned his -Salivary IgA While pursuing her pre-medicine Doctorate of Naturopathic Medicine Green Topped Collection studies, Dr. Webb worked at the Fred from Bastyr University with a focus on Tube Confusion Hutchinson Cancer Research Center homeopathic medicine, diagnostics, 6 Resources for You -Insurance Billing studying allogeneic bone marrow and mental health. Dr. Allshouse is -Technical Services transplantation. Following medical an experienced Emergency Medical -Shipping & Contact Info school, Dr. Webb promptly became a Technician and has volunteered at the Back Flexi-Matrix™ Panel teaching fellow, clinical resident, and Seattle Crisis Clinic for 6 years. While Page “Build Your Own Panel” ultimately an instructor at Bastyr and leading the anatomy department at other institutions teaching advanced Everest College, he received national recognition. He developed a locally broadcast television show, The ™ Naturopathic Perspective, wherein Diagnos-Techs he fielded health-related telephone is going Paperless! calls from the public on live TV. Dr. Allshouse also has established his In an effort to be more mindful of the environment, we will now own insurance-based private practice be distributing an electronic version of our quarterly newsletter, specializing in preventative counseling ChronoBiology Letter. If you do not have an email address listed on and mental health. Since joining your account, please call Client Services at 1.800.878.3787 to add the Medical Support department at your email address. Diagnos-Techs™ he continues to If you prefer to receive a printed copy of our ChronoBiology Letter, practice, remains active in his church, please email us at [email protected]. and volunteers with The American Red Cross. ChronoBiology LETTER Bone Health and Diagnos-Techs™ Bone Health Panel™ (BHP™) John J. White, MD, CM Andrew Allshouse, ND Kamal Henein, MD

ne of the lesser known and Major Factors in the Pathogenesis of Osteoporosis Table 1 appreciated tests offered Low Levels of: High Levels of: Other: Oby Diagnos-Techs™ is the 17-B , , low body weight, Bone Health Panel™. It utilizes saliva , parathyroid hormone, celiac disease, samples to assess pertinent hormone testosterone, calcitonin, glucose load (diabetes), alcoholism, vitamin C, vitamin D, thyroid hormone, rheumatoid arthritis, levels and an aliquot of urine to assay physical activity FSH multiple myeloma Pyrilinks-D. No trips to a laboratory or radiation exposure are involved, and into the general circulation. The final These processes progress inevitably costs are considerably less. The test is step in the cycle is the mineralization starting age 30-40 and appear accurate and can be used to monitor of the matrix protein by calcium to be more severe in women. They the effects of any bone health program. salts. Additional mechanical bone result from a dynamic chronic As background, the interplay between tensile strength is attained through the imbalance among a variety of factors bone formation and resorption is a formation of pyridinium cross-links (see Table 1, above). continuous, lifelong process that favors (pyridinoline [Pyd] and deoxypyridi- Although the pathogenic events bone formation in the early years noline [DPD]) between the neighboring involved in the development of of life, leading to a peak bone mass mature collagen fibrils. osteopenia, and its progression to at approximately 20 to 30 years of Alteration in the activity of osteoblastic osteoporosis, are relatively irreversible, age. From then on, total bone mass and osteoclastic cells represents the they can be slowed down and gradually declines in both men and final pathway through which diverse ameliorated by early detection and women. Women generally experience stimuli, including hormones, affect bone intervention. Traditionally, diagnosis an increased rate of bone loss in balance. Successful bone maintenance has relied on bone densitometry the post-menopausal years, largely requires continued attention to factors (mineralized bone mass assay) using due to declining levels. The that influence bone acquisition: diet, radioactive or radiographic techniques cycle of bone remodeling starts with physical activity, and performed at a referral facility. osteoclasts (resorption cells) eroding status, with possible deficiency of one Noninvasive methods to estimate bone bone surfaces and forming cavities. not compensated by the others. mineral density are now available to The collagen peptides that result from identify high-risk patients who have not bone resorption have pyridinoline Osteoporosis is defined as yet sustained a fracture. They include structures that can be assayed in urine a number of specific urinary assays of as a measure of bone resorption rate. “reduction in bone mineral bone resorption markers for the diagnosis At the same time, osteoblasts density, leading to fractures and follow-up of osteoporotic patients. (bone-forming cells) secrete bone after minimal trauma,” and Assays of Pyrilinks-D, pyridinoline, matrix proteins. Ninety percent of these osteopenia as “any decrease and N-terminal cross-linked peptides are collagen type I with other minor (NTX) in urine have been advanced as proteins; osteocalcin, the isoenzyme in bone mass below normal.”(1) sensitive and specific markers for bone alkaline phosphatase, and procollagen resorption. Pyrilinks-D is specific I extension peptides are also secreted

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for bone resorption and does not Cortisol(14,15) the Institute of Medicine recently measure collagen degradation;(2,3,4) it •  directly inhibit bone reported on dietary reference has a 96-98% range of accuracy.(5,6) formation by decreasing cell proliferation intakes for calcium and vitamin D, Pyrilinks-D assay has demonstrated and the synthesis of DNA, proteins, emphasizing their real benefit for and collagen. precision and accuracy equal or skeletal health but inconsistent and superior to cross-linked N-telopeptides • -induced bone loss results inconclusive affect on extra-skeletal from lower activity and higher death (NTX) and linear C-telopeptides of rate of osteoblasts on the one hand, and health problems (e.g., cancer, type I collagen (CTX).(2,6) It is a better from increased bone resorption due to cardiovascular disease, diabetes, and predictor of bone loss than invasive prolonged life span of osteoclasts on the autoimmune disorders).(19) The Endocrine serum osteocalcin measurements.(4) other. Society has presented practice guidelines As well, Pyrilinks-D measurements • Glucocorticoids may potentiate the for the evaluation, treatment, and proresorptive actions of parathyroid correlate well with treatment.(4,6,7) For prevention of vitamin D deficiency.(20) hormone and vitamin D on bone, which these reasons, Diagnos-Techs™ has contribute to net bone resorption. selected the Pyrilinks-D assay as a DHEA/DHEA-S(16) meaningful assessment of bone loss • Enhances bone deposition and and its treatment. In men and women remodeling. 40-80 years of age, a Pyrilinks-D • Decreases bone resorption and increases (DPD) value exceeding 7.3 nmol/mmol bone formation. creatinine signals osteopenia or FSH(17,18) osteoporosis. • Bone loss during or after menopause has Although the Pyrilinks-D urinary been attributed to a drop in estrogen assay may be ordered separately, levels. Recent studies show that high FSH REFERENCES the Bone Health Panel™ (BHP™) is associated with hypogonadal bone loss. 1. Dorland’s Illustrated Medical offered by Diagnos-Techs™ includes • In early menopause, FSH levels show a Dictionary. 32nd Edition. an assessment of those hormone sevenfold increase over values found in (2012)1347-1348. Elsevier. young menstruating women. values of a patient that underlie bone 2. Ross PD, Knowlton W. Rapid • In perimenopause and postmenopause, Bone Loss is Associated with . They include: FSH is correlated with: Increased Levels of Biochemical (10,11) Markers. J Bone Miner Res. Estradiol - Bone loss and osteoporosis (1998)13:297-302. • Limits bone elongation in adolescents - Sleep disturbances 3. Fassbender WJ, Gödde M, and prevents bone loss in adults. - Hot flashes and night sweats Brandenburg VM, et al. Urinary • After menopause, very small amounts Bone Resorption Markers The information provided by the Bone (deoxypyridinoline and C-terminal (if any) of are secreted by Health Panel™ (BHP™) constitutes telopeptides of type I collagen) the ovaries. in Healthy Persons, Postmeno- a valuable data base upon which to • Low estrogen levels cause diminished pausal Osteoporosis and Patients bone deposition. construct an appropriate treatment with Type I Diabetes. Adv Med Sci. (2009)54:1-6. • Low estrogen levels increase the number plan for patients with osteopenia or 4. Lenora J, Ivaska KK, Obrant KJ, and activity of osteoclasts. osteoporosis. Appropriate correction et al. Prediction of Bone Loss Using Progesterone(12) of hormonal imbalance, coupled with Biochemical Markers of Bone calcium and vitamin supplementation Turnover. Osteoporos Int. • Promotes new bone formation and (2007)18:1297-1305. or pharmacological intervention, deposition. 5. Al-Awadi A, Olusi SO, Al-Zaid can provide the under-pinning of Testosterone(13) N, et al. Serum B2-Microglubulin successful therapy. Concentration Correlates with • Helps reduce bone loss and has a role in Urinary Concentrations of Type I bone formation. Follow-up assessments every six to Collagen Cross-linked N-telopeptides and Deoxypyridinoline twelve months can provide ready in Rheumatoid Arthritis. evaluation of the selected therapy. Ann Saudi Med. (1998)18:113-116.

With regard to therapeutic approaches, Continued on page 4

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Bone Health, REFERENCES Educational Pathways Continued from page 3 11. Thijssen JH. Progestins and Bone. @ Diagnos-Techs™ 1. Zentralbl Cynokol (1997)119 Suppl 2. Yu SL, Ho LM, Lim BC, et al. 2:70-74. Medical Support Urinary Deoxypyridinoline is a 12. Wang C, Cunningham G, Dobs useful Biochemical Bone Marker A, et al. Long-term Testosterone Diagnos-Techs’™ team of medical advisors for the Management of Postmeno - Gel (AndroGel) Treatment is available to assist our licensed health pausal Osteoporosis. Ann Acad Maintains Beneficial Effects on Med Singapore. (1998)27:527-529. care professional clients by answering Sexual function and Mood, Lean 3. Palomba S, Orio F Jr, Colao A, and Fat Mass, and Bone Mineral questions about our laboratory tests and et al. Effects of Estrogen Density in Hypogonadal Men. assisting with interpretation of test results. Replacement Plus Low-dose J Clin Endocrinol Metab. There is no additional fee to receive Alendronate Treatment on Bone (2004)89:2085-2098. this service. Our medical support team Density in Surgically Postmeno- 13. Wang C, Eyre Dr, Clark R, et al. pausal Women with Osteoporosis. Sublingual Testosterone consists of MDs and NDs offering over 100 J Clin Endocrinol Metab. Replacement Improves Muscle years of medical experience. To speak to (2002)87:1502-1508. Mass and Strength, Decreases medical support call 1-800-878-3787. 4. Mizunuma H, Taketani Y, Ohta Bone Resorption, and Increases H, et al. Dose Effects of Oral Bone Formation Markers in Estradiol on Bone Mineral Density Hypogonadal Men—A Clinical TELEPHONE CONSULTATIONS in Japanese Women with Research Center Study. J Clin & OFFICE VISITS Osteoporosis. Climacteric. Endocrinol Metab. (1996)81: with our Medical Advisors (2010)13:72-83. 3654-3662. Telephone Consultations offer an 5. Prestwood KM, Kenny AM, 14. Cauley JA, Ewing SK, Taylor BC, Unson C, et al. The Effect of Low et al. Osteoporotic Fractures in overview of our test panels and reports to Dose Micronized 17ss-estradiol on Men Study (MrOS) Research familiarize clients with how to use them Bone Turnover, Sex Hormone Levels, Group. Sex Hormones in and offer an opportunity to ask questions. and Side Effects in Older Older Men: Longitudinal Women: A Randomized, Double Associations with 4.5-year Change Office Visits provide local clients the Blind, Placebo-controlled Study. in Hip Bone Mineral Density–The opportunity to receive information on J Clin Endocrinol Metab. Osteoporotic Fractures in Men (2000)85:4462-4469. Study. J Clin Endocrinol Metab. testing and how to further integrate 6. Lufkin EG, Wahner HW, O’Fallon (2010)95:4314-4323. our lab into their practice. To schedule WM, et al. Treatment of Postmeno- 15. Ross AC, Manson JE, Abrams SA, an appointment, please email Jessica at pausal Osteoporosis with et al. The 2011 Report on Dietary [email protected]. Transdermal Estrogen. Ann Intern Reference Intakes for Calcium Med. (1992)117:1-9. and Vitamin D from the Institute 7. Cummings SR, Browner WS, Bauer of Medicine: What Clinicians Need D, et al. Endogenous Hormones to Know. J Clin Endocrinol Metab. and the Risk of Hip and Vertebral (2011)96:53-58. Fractures Among Older Women. 16. Holick MF, Binkley NC, Study of Osteoporotic Fractures Bischoff-Ferrari HA, et al. Research Group. N Engl J Med. Evaluation, Treatment, and (1998):733-738. Prevention of Vitamin D 8. Weitzmann MN, Pacifici R. Deficiency: an Endocrine Society Estrogen Deficiency and Bone Loss: Clinical Practice Guideline. J Clin ™ An Inflammatory Tale.J Clin Invest. Endocrinol Metab. (2011)96: Diagnos-Techs (2006)116:1186-1194. 1911-1930. 9. Imai Y, Youn MY, Kondoh S, et On the Road al. Estrogens Maintain Bone Mass by Regulating Expression of Genes Conferences & Tradeshows Controlling Function and Life Span If you are attending the event listed in Mature Osteoclasts. Ann NY below, please visit our booth. We look Acad Sci. (2009)1173 Suppl forward to meeting you in person! 1:E31-39. 10. Seifert-Klauss V, Prior JC. ● A4M— December 8-10, 2011 Progesterone and Bone: Actions 19th Annual World Congress on Promoting Bone Health in Women. Anti-Aging Medicine & Biomedical J Osteoporos. (2010)2010:845180. Technologies • Las Vegas, NV http://tinyurl.com/3zyp7ed

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cosmetic products from having the Hormones in term “hormone” appear anywhere Cycling Female Cosmetics—An Update on the label or ingredient list. This Hormone Panel™ prohibition created a paradox John J. White, MD CM wherein the FDA proposed that, Brandy Webb, ND (FHP™) while the presence of progesterone In the previous issue or was allowable in Timing of Collections of ChronoBiology cosmetics, apparently disclosing that Appropriate collection timing for Letter (August information to the consumer was not. the 11 vials in the Female Hormone 2011), we stated Ultimately, this proposal was that “face creams Panel™ (FHP™) may be challenging. withdrawn before it was formally and shampoos are classified legally as Each kit contains two proposed enacted due to the “regulatory cosmetics and, as such, are not under collection calendars: one for a backlog” that existed within the FDA, the close purview of the FDA. Not only but not until over a decade later on “regular” cycle of 28-32 days, and can manufacturers add progesterone to November 26, 2004 (69 FR 68831). one for an “extended” cycle of their products (up to 4%), but they are Moreover, during the period that 58 33-42 days. These are guidelines and not required to list it on their label.” FR 47611 was still in proposal status, Further research, including direct can be modified as necessary by a the stated safe upper limits regarding communication with the FDA, compels practitioner. For a woman with a short progesterone and pregnenolone were clarification of this statement. cycle, the timing of collections can promulgated within the FDA and Our original statement was partially eventually incorporated into the official be compressed to accommodate the informed by a Federal Drug Guide to Inspections of Cosmetic shortened time. At times, however, Administration advance notice of Product Manufacturers (available at despite the most careful planning, a proposed rulemaking (ANPRM) www.fda.gov). menses may occur before the planned pertaining to the presence of hormone At present, as communicated directly collection vials are finished. Be aware ingredients in cosmetic products, to us by FDA personnel, it is illegal to which was published in the Federal that 8-9 vials are generallt sufficient list any hormones on the label of any Register on September 9, 1993 to provide an accurate picture of cosmetic, and it is also illegal for any (58 FR 47611). At that time, the the hormonal changes during that product actually to contain hormones. FDA proposed to allow up to 0.5% Compliance with these directives and particular cycle. Collection of any pregnenolone acetate and 5 mg/oz any potential harm from the addition of extra vials from the next cycle provides progesterone in cosmetic products. hormones to cosmetics remains for the no meaningful information about the Furthermore, 58 FR 47611 prohibited FDA Office of Compliance to determine. cycle under study and introduces spurious information to our computers, resulting in skewed graphing of that

DIAGNOS -TECHS™ CATALOG cycle’s estradiol and progesterone, as well as erroneous calculations for the

Non-Invasive Testing information provided on page two of Hormone Dynamics, Gastrointestinal Problems Announcing the

and Bone Density of the report. Once menses arrives, ™ New Diagnos-Techs resist the temptation to fill the unused Catalog! vial(s); do NOT submit them, lest they contribute to an inaccurate picture of your patient’s cycle. In addition, iagnos-Techs™ is excited to provide a new catalog for all clients. Colorful, should a patient have a bleeding Dcompact and easy to read, this new catalog will serve as a handy resource episode or “menses” midway through with detailed information about test panels, ordering, shipping, contact information, a collection (before 8-9 vials have and so much more. Please expect your copy of the catalog included with your been filled), discard the collection and next test kit order. If you do not receive a copy, please contact Technical perform a new collection with the next Customer Service at 800-878-3787 to request a copy. The catalog is also true menses. available to view online at www.diagnostechs.com/catalog.

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LABORATORY Salivary IgA Green Topped Added to the Food Intolerance Collection ADVISO Panel™ (FIP™). Tube Confusion GI Panel The Food Intolerance Panel™ from First collect the 1st B stool collection Diagnos-Techs™ measures salivary Confusion apparently has arisen over vial; collect the 2nd B vial and A vial secretory immunoglobulin A (SIgA) antibodies to casein (milk), soy, albumin some green-topped just prior to shipping. (egg), and gliadin (gluten). Unlike the collection tubes. Diagnos-Techs™ The kit for the GI Panel™ from other immunoglobulins, which are uses two green-topped collectors: Diagnos-Techs™ contains two types primarily in the blood compartment, IgA a green-topped saliva vial (labeled of vials for stool collection: one “A” antibodies are derived from the intestinal “F/L”), and a green-topped urine vial and two “B” vials. The B vials food antigens/IgA defense mechanisms of collector (labeled “U”). The “U” contain a preservative and are used the gut. The mucosa of the gastrointestinal container is wider than the standard for the microscopic ova and parasites tract is the major source of IgA in the saliva vial and is used for collecting an (O&P) exams, as well as the various body, and the strength of the IgA antibody aliquot of urine to measure D-pyrilinks tests run on desiccated stool. They response is related to the amount of in the Bone Health Panel™ (BHP™). have a greater stability. The A vial IgA present in the system. Depleted IgA This is the only urine assay offered containing sterile saline is used for levels will be reflected as low IgA by Diagnos-Techs™. The “F/L” green- the stool cultures (bacterial and antibody titers for the measured antigens. topped vial contains a preservative fungal). Unfortunately, it has a lesser In order to place the food sensitivity and is used for collecting saliva for stability (non-refrigerated) of 4-5 days. antibodies in the proper perspective, the expanded part of all the hormone Consequently, patients doing these consider ordering a total salivary IgA tests (i.e., to allow measurement of tests should be advised to fill the B (SIgA) level as well as the four food IgA the pituitary hormones FSH and LH). vials first, and then the A vial just antibodies (using the Flexi-Matrix™ Recently, the lab has received urine prior to shipping. kit). This datum can help obviate false samples in the “F/L” vial, and NOT for negative value interpretations. the bone density testing. Please advise your patients that simply because an “F/L” vial might be included in the kit TECHNICAL CUSTOMER SERVICE (Flexi-Matrix™ or standard panel), it Did you know that every day to testing, what kinds of treatment would should be used only if expanded (FSH Diagnos-Techs™ receives be appropriate for medical conditions, and LH) results are desired. For all many calls from patients who and general interpretation of test results. other hormone tests, the “H” vial (blue have medical-related questions? These types of questions are best topped) suffices. The wider green- Examples of such questions include answered by a healthcare practitioner topped “U” container is the only one whether to discontinue medications prior who knows the medical background used for urine and is only used of his or her individual patient. We when a Bone Health Panel™ (BHP™)

& R A L E S encourage practitioners to stress to their C E A or DPD test is ordered. I R I N C L H C

TM patients that they need to contact them DiagnosTechs directly regarding these matters. We do L A Y THE LEADING LAB IN SALIVA TESTING SINCE 1989 B R O R A T O have doctors on staff who are able to Did you know?: Issue #10 Chronobiology Letter is answer medical questions, but they are published quarterly by Diagnos-Techs™ Laboratory, Inc. in Kent, WA, USA as an only able to speak directly to a licensed Diagnos-Techs™ educational resource for our health care healthcare provider. A healthcare clients. The content in this newsletter is for makes return informational purposes only and is not to be provider can always arrange to have a construed as medical advice. three way consultation between him or shipping convenient Diagnos-Techs™, Inc. herself, our doctor in Medical Support, and easy! Log on to 19110 66th Avenue S. and the patient. Free consultations are Building G www.diagnostechs.com/ Kent, WA 98032 USA available between 7:30am and 5:00pm Pacific Time. WebReturns to learn more.  Printed on recycled paper.

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Billing Client Services Contact Us Courtesy Service Tips for Success How to Reach Us from our team of n Have your account number or Business Hours Insurance Specialists accession number ready before 7:30am–5:00pm Our dedicated team of Insurance you call. Pacific Standard Time (PST) Specialists is trained to assist you n Sign up to access results online. Monday through Friday, with insurance-related questions. Call Customer Service for except major holidays We avoid payment processing password, 1-800-878-3787. Corporate Address challenges by helping you and n We must have at least two forms 19110 66th Avenue S., Building G your patients navigate the maze of of written patient ID: name Kent, WA 98032 USA test codes and fees. and date of birth on all vials and Customer Service As a courtesy, we will submit order forms to process samples. p 800-878-3787 f 425-656-2871 claims to most insurance n Patients should not contact the p 425-251-0596 companies at our clients’ and lab with test related questions. Accounting patients’ requests. In addition, Please advise patients to consult f 425-264-0612 we are able to bill insurance with you if they have any questions email [email protected] carriers for all referring doctors, pertaining to collection. Medical Shipping nurse practitioners and registered Support is available for provider nurses. We are able to advise you questions about results or p 800-878-3787 f 253-398-2449 on which services are billable. treatment suggestions at Technical Services Although we are a non-contracted 1-800-878-3787. p 800-878-3787 f 425-251-0637 provider with all insurance n Review patient medication list. Lab Address companies (with the exception of This will help your patients to Medicare), most insurance carriers Sample Processing understand what to avoid before 6620 S. 192nd Place, Building J-106 offer coverage on our services taking our tests. We do not discuss Kent, WA 98032 USA and are billable. Depending on a medications directly with patients. patient’s benefit plan, insurance companies usually cover our tests n Tips for saliva production. Please visit us online at at the maximum allowable rates so In order to produce enough www.diagnostechs.com there are no out-of-pocket expenses. saliva, suggest to your patients to www.facebook.com/diagnostechs Patient Insurance Disclaimer chew dental grade paraffin wax. Diagnos-Techs™, Inc. is a non-contracted provider with all insurance companies. Please verify your out-of-network benefits (including out-of-network deductibles and co-insurances) by contacting your insurance carrier. Diagnos-Techs™, Inc. will Shipping bill your insurance at the retail price per line item. If deductibles and/or co-insurances are applied, Diagnos-Techs™, Inc. is obligated by law in the Free UPS Return Shipping State of Washington to collect. on returned domestic test kits STORAGE & MAILING INSTRUCTIONS FOR ALL SPECIMENS HIPAA Compliance n International Ship samples on the same day as last sample collection (preferred). Courier Shipping n If not possible, refrigerate samples and ship within 3 days. The Health Insurance Portability and Diagnos-Techs™, Inc. Accountability Act of 1996 (HIPAA) requires No ice bags are required during shipping. Sample Processing n us to protect and maintain the privacy of our Write the patient’s name and address on the outside of the box. 6620 S. 192nd Pl., #J-106 patients’ identifiable health information. The n Include all samples, test form and, if applicable, a check or a copy of the Kent, WA 98032 standards are meant to improve the efficiency front and back of insurance card together inside the supplied box. Please p 425-251-0596 and effectiveness of the nation's health care be sure to seal the box with clear tape OR the UPS shipping label (US only). system. We are committed to implementing • US Domestic: Deliver completed test kit box to any UPS location. www.UPS.com/dropoff appropriate administrative, technical and Return shipping to Diagnos-Techs™ is PRE-PAID. Kits will arrive within three business days of shipment. physical safeguards to protect the privacy of Protected Health Information. For more •  International: Delivery charges apply. Visit our website for access to discounted return information, go to www.diagnostechs.com shipping via UPS. Deliveries can also be made Monday through Friday via a private and click About Us/Notice of HIPAA courier of your choice. International deliveries should be addressed to the physical Privacy Practices. address only, as noted above and to the right. Do not address to the PO Box.

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DiagnosTechsTM L A Y THE LEADING LAB IN SALIVA TESTING SINCE 1989 B R O R A T O 19110 66th Avenue South, Building G Kent, Washington 98032 USA www.diagnostechs.com

National Health Observances NOVEMBER 2011 American Diabetes Month Lung Cancer Awareness Month Healthy Skin Month Prematurity Awareness Month 14-20 Get Smart About Antibiotics Week 17 Prematurity Awareness Day 18 Great American Smokeout 19 Survivors of Suicide Day 20-26 Gastroesophageal Reflux Disease Awareness Week DECEMBER 2011 1 World AIDS Day 4-10 Handwashing Awareness Week JANUARY 2012 Cervical Health Awareness Month Birth Defects Prevention Month Glaucoma Awareness Month Radon Action Month Thyroid Awareness Month

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s ™ u l s e Flexi-Matrix Customized Test Panels t ™ o n m p a Flexi-Matrix i z e d “Build Your Own Panel” Flexi-Matrix™ test kits allow you to order individualized test combinations, with the exception of BHP™, FHP™, • Insulin x2 • Gluten Ab eFHP™, PeriM™ and ePeriM™ panels. When combining panels, be sure to include the individual tests listed • Chymotrypsin under each of the panels. Flexi-Matrix™ customized test kits may be the most economical way of customize • Tape Worm test panels and profiles to meet your clinical needs, possibly saving you 20-70% off individual test fees, and are • Round Worm required for testing by the laboratory. • Estriol n Choose 3 or more individual tests from the list shown on pages 4-6 of the Test and Fee Schedule. • Progesterone • FSH (Excludes DPD Bone Marker Test and CS3 Swab Culture for Yeast.) • Androstenedione n Be sure to read detailed instructions and fill out the requisition form included in each collection kit. • Estrone n You will always receive the lower price when your customized panel is identical to a standard panel. ASI GI-02 ePostM eMHP Adrenal Stress Expanded Gastrointestinal Expanded Post Expanded Male Index™ Health Panel™ Menopausal Hormone Panel™ • Cortisol x4 • Stool Culture for Yeast • Giardia Antigen Hormone Panel™ • DHEA + DHEA(S) • DHEA + DHEA(S) • Chymotrypsin • Intestinal Lysozyme • DHEA + DHEA(S) • Androstenedione • Insulin x2 • Ova and Parasites • Cryptosporidium Antigen • Testosterone • Testosterone • 17-OH Progesterone • Occult Blood • Alpha Anti-Chymotrypsin • Estrone • Dihydrotestosterone • Gluten Ab • Bacterial Stool Pathogens • Amoeba Histolytica Ab • Estradiol • Estrone • Total Secretory IgA • Fecal pH • Gluten Intolerance Test • Estriol • Progesterone • Clostridium Difficile Antigens • H. Pylori Ab • Progesterone • LH • Total Intestinal SIgA • Round Worm • LH • FSH • Tape Worm • Tissue Worm • FSH

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