Interference with daily activities and major adverse events during esophageal pH monitoring with bravo wireless capsule versus conventional intranasal catheter: a systematic review of randomized controlled trials.

For three decades, ambulatory 24-hour intranasal pH monitoring has been the established gold standard for detecting acid reflux in patients with refractory gastroesophageal reflux disease. However, device-associated adverse events and unpleasant experiences, reported by patients during pH monitoring have led to the invention of more convenient pH monitors such as Bravo wireless capsule. To compare the interference with daily activities and major adverse events during pH monitoring with Bravo wireless capsule (Bravo) versus conventional intranasal catheter (catheter), PubMed, Cochrane Library, Clinical Trials.gov, and Google Scholar were searched up to March 20, 2015. Only randomized controlled trials in adult patients that compared the interference with routine daily activities and adverse events between Bravo and catheter pH monitors were included. After screening 574 articles, three unique studies with 167 patients met our inclusion criteria. The average age of patients enrolled in these studies was 51 years. Interference with normal daily activities was more in the catheter than Bravo group: 75 ± 5 versus 92 ± 2, P < 0.001 (Andrews et al, findings were reported as100 mm, mean visual analogue scale (VAS) ± standard error of the mean, 100 = completely normal); Wong et al. (mean ± standard error of the mean): 1.3 ± 0.2 versus 0.32 ± 0.1, P = 0.001 and Wenner et al. using 10 cm median VAS (Interquartile range),10 been the worst is 5.7 (2.3-8.0) compared to 0.7 (0.2-3.4), P < 0.0001, respectively. Overall adverse events were more in the catheter group than Bravo (39 ± 4 vs. 26 ± 4, P = 0.012 for Andrews et al. (100 been the worst) and 5.1 (2.0-6.6) vs. 2.1 (0.5-4.6), P < 0.001 for Wenner et al.). No overall adverse events recorded for Wong et al. Most patients in catheter group complained of nasal and throat symptoms. Significantly, runny nose in 24 out of 25 patients (96%) catheter versus 13 out of 25 (52%) Bravo, P = 0.001 and nose pain 15 out 25 (60%) versus 8 out of 25 patients (32%), P = 0.047, respectively for Wong et al. Andrews and Wenner et al also showed profound nasal discomforts in catheter group compared to Bravo (39 ± 3 vs. 10 ± 3, P < 0.001 and 6.5 (1.5-8.0) versus 0.2 (0.0-1.9), P < 0.0001, respectively. Throat symptoms reported in Wong et al. were mainly throat discomfort in catheter group 23 out of 25 patients (92%) versus Bravo 12 out of 25 (48%), P = 0.001 and throat pain catheter (12 out of 25 patients (48%) vs. Bravo 4 out of 25 (16%)), P = 0.032. This trend was also observed in Andrews et al. with profound throat discomfort in the catheter group 43 ± 4 compared to Bravo 19 ± 4, P < 0.001. Majority of the patients randomized to Bravo group reportedly perceived chest pain higher than those in catheter group; 9 out of 25 patients (36%) versus 2 out of 25 (8%), P = 0.037 in Wong et al. 29 ± 4 versus 14 ± 3, P = 0.001 for Andrews et al., 2.4 (0.3-5.9) versus 1.1 (0.3-2.9), P = 0.084 in Wenner et al. respectively (though not statistically significant). Bravo wireless capsule pH monitor interfered less with daily activities and adverse events were minimal compared to conventional intranasal catheter.

Geographical clustering of mortality from systemic sclerosis in the Southeastern United States, 1981-90.

OBJECTIVE: To determine whether elevated rates of mortality from systemic sclerosis (SSc) in the Southeastern United States result from local, multicounty clusters of the disease. METHODS: Detection of spatial clusters of SSc mortality by applying the method of Kulldorff and Nagarwalla to death certificate data from 955 counties in 12 southeastern states. RESULTS: From 1981 to 1990, significant excess mortality from SSc in the Southeastern US occurred among white males [standardized mortality ratio (SMR) = 1.2; p = 0.0004] and black males (SMR = 1.2; p = 0.04), but not among white females (SMR = 0.98; p = 0.55) or black females (SMR = 1.1; p = 0.06). When the cluster detection algorithm was applied to data for white males, 3 significant clusters were identified. The primary cluster (p = 0.001) was centered around Coffee, Tennessee. Two smaller clusters overlapped the primary cluster -- one centered at Calhoun, Alabama, (p = 0.008) and another centered at Chattooga, Georgia, (p = 0.04). Analysis of data for black males resulted in a single significant cluster (p = 0.02) centered at Northampton, North Carolina. When data for white or black females were analyzed, no clusters reached statistical significance. In combination, excess SSc mortality in the detected clusters accounted for 79.0 and 66.2%, respectively, of the excess deaths among white and black males across the whole Southeast. CONCLUSION: Elevation of SSc mortality rates in the Southeastern US results from local clusters of concentrated mortality. These clusters may be artifacts of regional variation in death certificate quality. If not, distinctive environmental factors in these areas may provide new insights into the etiology of SSc.

Shoulder girdle abscess due to Streptococcus agalactiae complicating esophageal dilation.

Bacteremia can result very unusually in significant complications after esophageal dilation. Procedure-related mucosal trauma may be a determinant, whereas pathogenic bacteria primarily originate from the patient's oropharyngeal flora. We describe an unusual case of Streptococcus agalactiae bacteremia and shoulder girdle abscess complicating esophageal bougienage. Consideration of specific risk factors and use of scrupulous procedural technique are warranted and will likely reduce pyogenic sequelae.