24 Versus 48-hour bravo pH monitoring.

BACKGROUND: Historical ambulatory pH monitoring systems for the evaluation of gastroesophageal reflux disease have been catheter based and uncomfortable for patients, commonly limiting both their diet and activities. Catheter-based studies have also been reported to underestimate the amount of reflux a patient may have in a normal, routine day. Compared with conventional catheter-based pH monitoring systems, wireless (Bravo) pH monitoring is better tolerated by patients and allows for an increased duration of pH recording. Currently, there is lack of data regarding the optimal duration of wireless studies and concern that day 1 results are not typical of a patient's routine lifestyle, given the effects of sedation. Few studies have evaluated the merits of 24 versus 48-hour wireless pH monitoring. AIMS: The aims of this study were (1) to identify differences in reflux parameters between 24 versus 48-hour testing as measured by wireless pH monitoring and (2) to assess the effect of 48-hour studies on the number of reflux episodes and symptom correlation as compared with 24-hour studies. METHODS: A retrospective chart review of 124 consecutive patients who underwent 48-hour wireless esophageal pH monitoring studies was prepared. All patients underwent esophagogastroduodenoscopy using intravenous conscious sedation before wireless capsule placement. Acid reflux variables (including total reflux time, number of reflux episodes, and total percent time of pH<4) and symptom-association probability (SAP) scores were compared for day 1 versus day 2 versus total. RESULTS: Forty-eight-hour SAP scores were significantly higher when compared with the first 24 hours for all reported primary symptoms. SAP scores were calculated at 24 and 48 hours, respectively for heartburn (56 vs. 65, P<0.0001), regurgitation (65 vs. 80, P<0.0001), chest pain (59 vs. 78, P=0.0009), and cough (55 vs. 64, P=0.0027). In addition, the percentage of SAP scores >95 was significantly higher for both heartburn and regurgitation (34% vs. 48%, P=0.003 and 38% vs. 62%, P=0.005). As expected, 48-hour testing also captured a significantly higher number of reflux episodes as compared with day 1 results alone (97 vs. 47, P<0.0001). There were no statistical differences noted between the 2 days for total percent time of pH <4. CONCLUSIONS: Forty-eight-hour wireless (Bravo) pH monitoring strengthens symptom correlation as compared with 24-hour results alone and yields a greater percentage of SAP scores >95 for typical symptoms of gastroesophageal reflux disease. Prolonged recording of patient symptoms and/or sedation effects may account for the better symptom correlation. Although there were no statistical differences seen in this study between 24 and 48-hour studies for total percent time pH <4, 48-hour studies captured significantly more reflux episodes as compared with 24 hours of monitoring alone. These results suggest that patients undergoing wireless pH monitoring should have 48-hour studies performed as a standard of practice.

Prospective evaluation of acute graft-versus-host disease.

BACKGROUND: Graft-versus-host disease (GVHD) is a common complication of allogeneic bone marrow transplantation. Severe GVHD carries significant morbidity and mortality and remains one of the leading causes of treatment failure. Unfortunately, intestinal GVHD may present with a variety of non-specific symptoms and diagnosis based on clinical presentation is often inaccurate; biopsy is therefore needed for definitive diagnosis. At present, the optimal endoscopic approach to the diagnosis of gastrointestinal GVHD remains uncertain. AIMS: The primary aims of our study were: (1) to evaluate the yield of upper versus lower endoscopy, and (2) to determine which anatomic regions were most likely to provide a histologic diagnosis. METHODS: We conducted a prospective study of 27 consecutive patients who had undergone stem cell transplantation within the past 100 days and were referred to the Yale Gastrointestinal Procedure center between August 2002 and February 2006 for the evaluation of suspected acute GVHD. All patients underwent standardized endoscopic evaluation of the upper and lower gastrointestinal tract with biopsies. The diagnostic yield of upper versus lower endoscopy was compared in all patients. RESULTS: GVHD was identified in 18 of the 27 patients (67%). Of those with GVHD, 15 patients (83%) had diffuse intestinal involvement. Six of 10 patients (60%) with an endoscopically normal EGD had GVHD on biopsies of the upper gastrointestinal tract. Six of 13 (46%) patients with an endoscopically normal appearing colonoscopy had GVHD on colonic biopsies. Two of 18 (11%) patients had isolated GVHD of the upper intestinal tract and 1 (6%) had isolated colonic GVHD. Rectal biopsy alone identified 89% (16 of 18) of GVHD cases and all 16 cases of GVHD with colonic involvement. A diagnosis of GVHD was not altered by the additional performance of biopsy of the proximal colon or terminal ileum. CONCLUSIONS: In the present study, the majority of cases of acute GVHD demonstrate diffuse upper and lower gastrointestinal involvement with rectal, sigmoid, gastric and duodenal biopsies having similarly diagnostic yield. Based on our findings, we recommend starting with flexible sigmoidoscopy with rectal biopsy alone in patients who are poor candidates to undergo full colonoscopy with sedation or in those in whom GVHD is strongly suspected based on clinical findings. However, more extensive evaluations may be necessary to rule out infection and should be considered in those with no contraindications to sedation and in whom other differential diagnoses are also being considered.

Eosinophilic myenteric ganglionitis: a case of intestinal pseudo-obstruction in a 93-year-old female.

Eosinophilic myenteric ganglionitis is a disorder characterized by infiltration of the Auerbach plexus by eosinophils. It can be associated with a bowel dysmotility and a few cases of intestinal pseudo-obstructive syndrome have been described in children. In this case report, we present an elderly 93-year-old woman who presented with episodes of functional bowel obstruction of unknown etiology. After several admissions for recurrent obstipation requiring fecal disimpaction, she had a Hartmann procedure performed with a resection of the sigmoid colon. The sigmoid colon was markedly dilated and the only significant finding on histology was infiltration of the Auerbach plexus by eosinophils. The mucosa and the muscular layers appeared unremarkable. Her symptoms resolved after the resection and the patient is currently well after 5 months. Recurrent gastrointestinal pseudo-obstruction can arise secondary to eosinophilic myenteric ganglionitis even in adults. Clinical improvement is likely if this disease entity is promptly recognized and treated.

Teaching the competencies: using objective structured clinical encounters for gastroenterology fellows.

BACKGROUND AIMS: Objective structured clinical encounters (OSCEs) are used widely to educate and assess the competence of medical students and residents; they generally are absent from fellowship training. The Accreditation Council for Graduate Education has cited OSCEs as a best practice for assessing the 6 core competencies. This article reports on the use of an OSCE to assess the competence of second-year gastroenterology fellows in the difficult-to-assess core competencies: interpersonal and communication skills and professionalism. METHODS: We developed a 4-station, faculty-observed OSCE with 4 standardized patients. Information gathering, relationship development, patient education, and counseling skills were assessed. Professionalism skills assessed included obtaining informed consent, delivering bad news, managing difficult situations, and showing interdisciplinary respect. In each station, faculty and standardized patients completed an 18- to 24-item checklist evaluating fellows' performance and provided feedback to the fellows. Nine fellows and 5 faculty from 4 gastroenterology training programs in NYC participated. RESULTS: Fellows and faculty generally highly rated the realism of the OSCE and favorably rated the OSCE for its difficulty and their overall experience. Across all cases, fellows were rated as receiving "well dones" for 56.4% of the communication items (SD, 18.3%) and for 79.1% of the professionalism items (SD, 16.4%). CONCLUSIONS: Integrating OSCEs into gastroenterology fellowship training may help enhance communication skills and prepare fellows for dealing with difficult clinical situations and provides mechanisms for constructive feedback. OSCEs developed collaboratively can assist in program self-evaluation and reduce costs by sharing resources, in addition to fulfilling Accreditation Council for Graduate Education mandates.

FK506 is neuroprotective in a model of antiretroviral toxic neuropathy.

Antiretroviral toxic neuropathy is the most common neurological complication of human immunodeficiency virus infection. This painful neuropathy not only affects the quality of life of human immunodeficiency virus-infected patients but also severely limits viral suppression strategies. We have developed an in vitro model of this toxic neuropathy to better understand the mechanism of neurotoxicity and to test potential neuroprotective compounds. We show that among the dideoxynucleosides, ddC appears to be the most neurotoxic, followed by ddI and then d4T. This reflects their potency in causing neuropathy. AZT, which does not cause a peripheral neuropathy in patients, does not cause significant neurotoxicity in our model. Furthermore, in this model, we show that the immunophilin ligand FK506 but not cyclosporin A prevents the development of neurotoxicity by ddC, as judged by amelioration of ddC-induced "neuritic pruning," neuronal mitochondrial depolarization, and neuronal necrotic death. This finding suggests a calcineurin-independent mechanism of neuroprotection. As calcineurin inhibition underlies the immunosuppressive properties of these clinically used immunophilin ligands, this holds promise for the neuroprotective efficacy of nonimmunosuppressive analogs of FK506 in the prevention or treatment of antiretroviral toxic neuropathy.