This document discusses esophageal pH monitoring and combined multichannel intraluminal impedance-pH (MII-pH) monitoring. It provides details on:
1) The standard location of the pH electrode 5 cm above the lower esophageal sphincter and reasons for this location.
2) Classification of reflux into acid, weakly acidic, and weakly alkaline types based on pH levels, as detected by MII-pH but not standard pH monitoring.
3) Advantages of MII-pH monitoring include detection of non-acid and proximal reflux, in addition to acid reflux detected by pH monitoring. MII-pH provides more detailed analysis of reflux composition and events.
Constipation due to difficulty in passing stools once it has reached rectum as a result of Rectorectal Intussusception (Internal Rectal Prolapse) or Rectocele.
Gastroesophageal Reflux Disease (GERD) is a common disorder that has undergone many paradigm changes in the last 15 years. We discuss the current paradigms in the pathophysiology, diagnosis and management of GERD.
Colon cancer is the second leading cause of cancer in the United States. Having a colonoscopy is essential to screen for colon cancer. Learn how to prepare your bowels for a colonoscopy or colon surgery.
Constipation due to difficulty in passing stools once it has reached rectum as a result of Rectorectal Intussusception (Internal Rectal Prolapse) or Rectocele.
Gastroesophageal Reflux Disease (GERD) is a common disorder that has undergone many paradigm changes in the last 15 years. We discuss the current paradigms in the pathophysiology, diagnosis and management of GERD.
Colon cancer is the second leading cause of cancer in the United States. Having a colonoscopy is essential to screen for colon cancer. Learn how to prepare your bowels for a colonoscopy or colon surgery.
Gastroesophageal reflux disease (GERD) is defined as the failure of the antireflux barrier, allowing abnormal reflux of gastric contents into the esophagus. It is a condition which develops when the reflux of stomach contents causes troublesome symptoms and complications.
Gastroesophageal reflux disease in children.Indian Society of Pediatric Gast...Vijitha A S
Gastroesophageal reflux disease in children.Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition (ISPGHAN) 2022 update
DR VIJITHA A S
GERD is the commonest GI problem afflicting the mankind. The cause is lax LES which is just opposite to Achalasia cadia. That is why GERD is also known as Chalasia cardia.
Peptest - Pepsin detection in digestive and respiratory fluidsPeptest
What is Peptest™
Peptest is a new, accurate, painless and inexpensive saliva test that tells you conclusively if you have reflux. Peptest can be ordered by both doctors and patients direct.
Your body produces Pepsin in the stomach to break down protein. If Pepsin is found outside of the stomach you are suffering from Reflux.
We take samples of your saliva and test them in our laboratory for Pepsin.
If Pepsin is present the concentration in your sample is measured to show the severity of Reflux and give a benchmark to assess the success or failure of any treatment. Retesting can be used at any future treatment point.
Similar to Combined esophageal pH-Multiple Intraluminal Impedence (20)
Description of various ultrasound features of benign and suspicious thyroid nodules with multiple ultrasound systems for risk stratification of malignancy.
Description of different ultrasound features of carpal tunnel syndrome before and after carpal tunnel release including Doppler imaging and elastography
Doppler ultrasound of visceral arteriesSamir Haffar
Doppler ultrasound of different diseases of visceral arteries including arterial stenosis and occlusion, arterial aneurysm, artrial pseudoaneurysm, arterio-venous fistula, artrial dissection, and abdominal vascular compression syndromes
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
3. Why 5 cm above LES?
• Has been standard for many years
• Chosen to avoid catheter migration into stomach
• Moving by a 1 cm or two would not change results
• Moving it 10 cm above LES miss a number of patients
who are identified by the more distal location
4. Location of LES
• Manometric localization Reference method
• pH step-up method Sudden rise to pH > 4
• LES locator Prior to pH
• Fluoroscopic techniques Not accurate
• Endoscoic technique Not accurate
5. Why pH < 4?
• Defined early in development of the technology
• Its choice was based on:
- Marked difference from normal esophageal pH of 7
- Pepsinogen converted to pepsin at pH 4
- pH < 4 was one that tends to produce symptoms
• Some believe that drops in pH that do not reach level
of 4.0 still may represent reflux that these events
should also be used in calculations of indices
6. Composite scoring systems
Johnson & DeMeester is the most commonly used
Percentage of total time pH < 4
Percentage of upright time pH < 4
Percentage of supine time pH < 4
Number of reflux episodes
Number of reflux episodes >5 min
Longest reflux episode
DeMeester score
Normal < 14,72
7. Normal values of DeMeester’s score
50 healthy volunteers
DeMeester TR et al. Ann Surg 1976 ; 184 :459 – 470.
8. Normal 24 hours esophageal pH monitoring
Composite DeMeester score: 8.4
DeMeester normal < 14.72 (95th percentile)
Bremner CG et al. Esophageal disease & testing. Taylor & Francis Group, 2005.
9. Qualitative analysis
Symptom–reflux correlation
• Symptom index: Positive if ≥ 50%
• Symptom sensitivity index: Positive if > 10 %
• Symptom association probability Positive if > 95%
Determine relationship between heartburn episodes & acid
reflux events, regardless if pH test is normal or abnormal
12. Symptom Association Probability Calculation
Positive if 95%
• Divides tracing into 2-min segments & looks at
whether a symptom & acid are present during each 2
minute segment
• The analysis uses contingency table analysis of 4
possible outcomes for each segment:
acid + symptom +
acid + symptom –
acid – symptom +
acid – symptom –
13. Overall amount of acid exposure & number of
reflux episodes are the focus of many studies
using ambulatory pH testing
Relationship between symptoms & esophageal
acid is equally (or perhaps more) important
14. 24 hours pH monitoring & medications
• PPI should be stopped for 5 – 7 days
• Other medications should be stopped for 1 – 3 days
• Patient must not use antacids or other OTC
medications for duration of the study
15. 24 hour pH esophageal monitoring
On & off therapy
• Off therapy
Uncertainty about diagnosis of reflux
Mildest grades of esophagitis: redness - friability
Very short segments of BE
• On therapy
Patient who has failed a therapeutic trial
Patient has known reflux or highly likely to have reflux
pH probe in esophagus & another in stomach (NAB)
16. Percentage of total time pH < 4
Normal values
• Off therapy
5 cm above LES
20 cm above LES 1 %
Periods of meals or acidic beverages excluded
• On therapy
5 cm above LES
20 cm above LES ?
* Based on 95% CI obtained in healthy subjects treated with omeprazole 40 mg qd
Kuo B et al. Am J Gastroenterol 1996 ; 91 : 1532 – 8.
4 – 5.5 %
1.6 – 4 %*
18. Principle of “MII”
• 2 steel rings separated by isolator
• Alternating-current generator to apply electrical PD
• Circuit closed through electrical charges (ions)
contained in structures surrounding the catheter
Gastrointest Endoscopy Clin N Am 2005 ; 15 : 257 – 264.
19. Impedance scale
Refluxate: High conductivity & low impedance
Air: Low conductivity & high impedance
Bremner CG et al. Esophageal disease & testing.
Taylor & Francis Group, New York, 1st edition, 2005.
20. Advantages of MII
• Content of refluxate Liquid – Gas – Mixed
• Direction of bolus Anterograde – retrograde
• Height of refluxate
• pH characteristics Acid
(combined MII-pH) Weekly acid
Weekly alkaline
Acid re-reflux
21. Liquid bolus
Gastrointest Endoscopy Clin N Am 2005 ; 15 : 257 – 264.
1) Initial drop Liquid enters impedance-measuring segment
2) Rise Bolus cleared from this segment
3) Overshoot Decreased luminal cross-section during contraction
4) Return to baseline
22. Air bolus
(Belch, Air swallow)
1) Rapid rise Presence of air bolus inside esophagus
2) Rapid decrease Air bolus clears from this segment
Gastrointest Endoscopy Clin N Am 2005 ; 15 : 257 - 264.
23. Mixed air – liquid Bolus
1) Rapid Rise Air in front of the bolus
2) Rapid drop Liquid component of mixed bolus
3) Rise Liquid being cleared from this segment
4) Return to baseline
Gastrointest Endoscopy Clin N Am 2005 ; 15 : 257 – 264.
24. Antegrade bolus movement (MII)
Observed during swallowing
Progression of impedance from proximal to distal
Gastrointest Endoscopy Clin N Am 2005 ; 15 : 257 – 264.
25. Retrograde bolus movement (MII)
Observed in reflux
Progression of impedance from distal to proximal
Gastrointest Endoscopy Clin N Am 2005 ; 15 : 257 – 264.
26. Combined MII
• MII used clinically only in combination
– With esophageal manometry (MII-EM)
– With pH (MII-pH)
• MII not considered as replacement for manometry &
pH techniques but as complementary procedure that
expands diagnostic potential of esophageal function
testing & reflux monitoring
27. Combined MII-pH probe
• Impedance orifices
3, 5, 7, 9, 15, & 17 cm from the tip
• pH orifice
5 cm from the tip
• MII-pH probe = pH probe
Do not change patient comfort
Bremner CG et al. Esophageal disease & testing.
Taylor & Francis Group, NY, 1st edition, 2005.
28. “Sleuth” monitor – Sandhill
“Sleuth” monitor attached to the catheter
& worn around a belt during the recording period
29. GERD classification by combined MII-pH
Acid reflux
Reflux with drop of pH from above 4.0 to below 4.0
Superimposed acid reflux (Acid re-reflux)
Acid reflux occurs while pH < 4.0
Weakly acidic reflux
Reflux results in esophageal pH between 4.0 & 7.0
Weakly alkaline reflux
Reflux with nadir esophageal pH does not drop < 7.0
Sifrim D et al. Gut 2004 ; 53 ; 1024 – 1031.
31. GERD classification by combined MII-pH
Acid reflux
Reflux with drop of pH from above 4.0 to below 4.0
Superimposed acid reflux (Acid re-reflux)
Acid reflux occurs while pH < 4.0
Weakly acidic reflux
Reflux results in esophageal pH between 4.0 & 7.0
Weakly alkaline reflux
Reflux with nadir esophageal pH does not drop < 7.0
Sifrim D et al. Gut 2004 ; 53 ; 1024 – 1031.
33. GERD classification by combined MII-pH
Acid reflux
Reflux with drop of pH from above 4.0 to below 4.0
Superimposed acid reflux (Acid re-reflux)
Acid reflux occurs while pH < 4.0
Weakly acidic reflux
Reflux results in esophageal pH between 4.0 & 7.0
Weakly alkaline reflux
Reflux with nadir esophageal pH does not drop < 7.0
Sifrim D et al. Gut 2004 ; 53 ; 1024 – 1031.
34. Weakly acidic reflux (MII-pH)
Gastrointest Endoscopy Clin N Am 2005 ; 15 : 361 – 371.
35. GERD classification by combined MII-pH
Acid reflux
Reflux with drop of pH from above 4.0 to below 4.0
Superimposed acid reflux (Acid re-reflux)
Acid reflux occurs while pH < 4.0
Weakly acidic reflux
Reflux results in esophageal pH between 4.0 & 7.0
Weakly alkaline reflux
Reflux with nadir esophageal pH does not drop < 7.0
Sifrim D et al. Gut 2004 ; 53 ; 1024 – 1031.
37. Recommendations for MII-pH monitoring
• Endoscopy-negative patients with heartburn or
regurgitation despite PPI & performed on PPI therapy
• Utility of impedance in refractory reflux patients with
chest pain or extraesophageal symptoms unproven
• Current interpretation relies on SI, SSI or SAP
• Therapeutic implications of abnormal test unproven
ACG Practice Guidelines: Esophageal reflux testing.
Am J Gastroenterol 2007 ; 102 : 668 – 685.
38. Advantages of 3 major types of pH testing
pH Tubeless Combined
MII-pH
Comfort _ + _
Monitoring > 24 h _ + _
Nonacid reflux _ _ +
Normal values + _ _
Proximal reflux + ? +
Gastric monitoring + ? +
Intragastric pH Monitoring:The evidence supporting the clinical significance and applicability of gastric pH monitoring is insufficient to recommend its routine use inclinical practice.Proximal pH Recording:available evidence does not support the routine use of proximal pH monitoring in clinical practice.
Relatively new technique developed in early 1990s at Helmholtz Institute in Aachen (Germany)Silny* provided first description of this technique that assesses intraluminal bolus movement by measuring changes in conductivity of intraluminal content
A recent, multicenter study examined the impedance characteristics of 60 healthy subjects during 24-h ambulatory monitoring. Based on impedance values 5 cm above the LES, the median number of total reflux episodes per 24 h was 30, the majority of which occurred in the upright position.Approximately two-thirds of the episodes were acid and another third weakly acidic reflux. Weakly alkaline reflux was distinctly uncommon in this healthy cohort. Similar frequencies were recently reported from a multicenter European study. References:Shay S, Tutuian R, Sifrim D, et al. Twenty-four hour ambulatory simultaneous impedance and pH monitoring: A multicenter report of normal values from 60 healthy volunteers. Am J Gastroenterol 2004;99:1037–43.Zerbib F, Bruley des Barannes S, Roman S, et al. 24 hour ambulatory esophageal multichannel intraluminal impedance-pH in healthy European subjects. Gastroenterology 2005;128:A396.