Review of the Lyon Consensus, the process for reviewing and editing an impedance/pH study and walks through an impedance/pH study from start to finish.
Yeah, yeah. Mm. Yeah. Mhm. Yeah, mm. Welcome everyone. The respect. Healthcare is excited to present the final topic in our webinar series, reflux studies from start to finish. I'm General Schmidt, the marketing director here at diversity of health care and I'll be your host today. Today's topic is exploring impedance and ph studies. Our speaker for the series of Jason baker. Jason is the co motility director and director of clinical research at atrium health in charlotte north Carolina. He frequently present that national and international annual scientific meetings and is an elected council member for the american Euro gastroenterology and motility society. This webinar is being recorded so your microphones have been needed. Please send questions any time to the question box on your go to webinar panel. We'll do our best to answer all of them at the conclusion of the presentation and for those individuals that did not get their question addressed, we will respond once webinars over. I'll now turn it over to Jason. All right, thank you very much. Welcome all. On the second part of this webinar series, we're going to do a little bit of didactic. Then look at a study and show you some details of how to go through a study as in a rigorous method. So basically, the title of this one is the leon consensus in the process for reviewing an impedance ph study. Yeah. So the objectives are reviewed. The little consensus and this is the modern diagnosis of of gastric reflux disease. Um it's really important to start using these consensus is inside your lab or motility room just to stay current with the contemporary thought of from worldwide experts on an agreement of different type things from from the sofa geometry and erectile manama tree and reflux testing for good. We're going to describe the process for reviewing and editing impedance ph study. There's there's a method to go through this. You want to kind of create a standard method as you go through, especially as you hire new staff or staff moves on, then we're going to review a study, I mean penis ph study throughout the whole process of the next current slides. So the leo consensus, you know, they they basically, worldwide experts came up to agreement what was conclusive for evidence for re pathological reflux all the way down to evidence against reflex. Um You know, there's an endoscopy base about esophagitis, um, hissed a pathology and different things, Mickelson impedance. Um but really looking basically over here at ph and ph and ph testing The two main markers for evidence for reflexes, acid exposure time or a et greater than six And then a borderline is at 4-6%, but you need to have reflex episodes between 40 and 80. Then uh some additional evidence for reflux is the symptom association of probability, the symptom index, but more importantly the reflux episodes greater than 80, there's the national baseline impedance is gives you some adjunct evidence and then these post wall wave also is adjunct. But really the main to you want to keep an eye on, is this acid exposure time greater than 6% than anything below 4% in episodes less than 40. Is this considered non pathological reflexes? Common occurrence Then also within you know, hrm this high resolution of south of geometry, there's some other adjunct evidence from uh ineffective esophageal motility, hiatus, hernia and then a low E. G. J. So kind of final tape this uh from Gerbino types, you don't want to spend so much time here but I just want to point out a different thing. So when you guys, when you start your own lab or you're working your lab, you want to have a kind of a criteria what you're gonna when you're looking at people off medication, acid reduction medication to people who are on acid reflux medication. This kind of gives you a nice algorithm straight down. But if you're doing impedance ph testing should be done on on PPE primarily most of the time. Um different type things. If there's abnormal reflux burn, that's greater than 6%. This is processed persistent. A bigger display P. P. I. R. Off P. P. I. If you say you have normal reflex burdens, they basically lower than 4%. But you have a positive association between when they demarcated when they experienced a symptom and reflex occurred. This is reflects hypersensitivity. You have normal reflex burden again less than 4%, but a negative symptom association. This basically gets down to this functional uh functional symptoms. But they all this kind of overlaps with gastric reflux disease. So this is a nice little um flow chart to figure out when you're testing offer on um when different types of things occur with your ph test, where they may fall in this algorithm. So again, the two primary metrics for to Leon Consensus is acid exposure time again. Big thing remember is normal is less than four abnormal, is greater than 6%. Number of reflux episodes Again normal, less than 40 abnormal, greater than 80. So these are the two you're kind of on a key and ion. Because remember from our previous webinar that the damn easter score, which is, you know, legendary. It's an almost every ph report generally was was only studied on people from uh sample people off P. P. I. Or as a reduction medication. So you can still kind of um I say reported. But if they're on PP. I. These are really the two primary markers you want to look at. And even I would even argue, even if you're OFF PPE this are really two main markers you want to look at when you're deciding someone really feel pathological reflex or non pathological reflux. So an impedance reflects. So basically this is the identifies reflex based on the direction of the bullets. Which way is it going? Is it going, is it going from distal to proximal or approximately distal throughout the esophagus? It impedance reflex basically from distal to approximately the esophagus. So it was moving in a retrograde motion. So it has to bypass at least two of the bottom four impedance chance so has to surpass both of. So has it goes across one and this doesn't really fit the definition of impedance reflex. Has to go above two at least two as this movement is retrograde. For me. The second thing you need to do, it needs the impedance baseline member. If it's, if it's reflux eight or anything with an eye on it that you're going to see the conventional way decrease or dip down, it has to decrease greater than 50% of the south of geo impedance baseline So more so it has to go at least 50 below the south video appearance baseline. There's different compositions of the bolas that may be moving in director greater integrate for mission. So steps to edit in this study. The first thing always you just want to do a study overview, want to trust your eyes, you want to see what you're saying. It's like a qualitative view of it. Uh this looks normal, This doesn't look normal, that type of thing. The next thing. You're going to go through the study and put some, you know, their symptoms in there, The diary thing. So basically back from Webinar one, we talked about the importance of really doing a good educational Proctor ship on the diary regards if they're writing it down or hit the buttons because you're going to be in putting these things or at least adjudicating them. And then the next step you're going to auto scan. It's like the artificial intelligence. We're kind of review the study for all the reflux events and that that type of formation. Then you're going to do a study over study view and then you're gonna go piece by piece through each one of the symptoms you say yea or nay, that you agree with what the auto scan populated for you. Um, So the first thing study just evaluate the whole study. Again. There's a qualitative, you you look at it, see what looks normal, what doesn't look normal then. Um at that point during the study overview you're gonna if you're gonna maybe exclude some because it's just artifact. You know, you've got the impedance floating values are greater than 10,000 or or zero. The ph is bouncing from all over what looks so a lot of times when you uh end a study by not stopping the recording, you end up just pulling the catheter out that whole area from that point on. You may have to you're going to have to exclude from evaluation or analysis. You're gonna edit the diary entries. It's really important to make sure that there's duplicates and uh everything is filled in with a beginning and time that needs that. You're going to delete duplicate instrument and annotations. So anything that happens within two minutes, say heartburn at uh 1300 a heartburn at 13 01 You wanna gonna delete those annotations because it all falls within that two minute window, that the software is going to see anything within two minutes of that annotation demarcated by the patient. So annotation types their symptoms where symptoms have no duration, It's just the one point in time, like at 1314 115 22 whatever. Maybe nails have a beginning and an end. So sometimes on the diary sheets that comes back with no end time, um, you're gonna make sure you get an end time for the patients. Um, These are generally sometimes they You get a good sense that the eight within 15 minutes or a half hour meals will be automatically excluded from analysis um, during this thing and then reflex symptoms during these meals are also um, not measured for evaluation because often our american meals and most meals around the country around the world are acidic base, so we don't want to include those during the analysis. If you are doing pediatrics and they're on a continuous feed, you're going to have to include the meal, um, on they're not, you'll have zero, almost no time for a value for analysis. So most of time the pediatric world will understand that. So you definitely want to mark that on the report itself or at least let's let the physicians know that this was done on continuous feed. Recumbent physicians need a beginning and an end time and the reflux reflux events are both evaluated in the supine or recumbent position and the upright position. So you'll get percentages on both, Which is really important because a lot of times people will complain about, you know, bad taste in their mouth, burning chess, especially when they're sleeping. You want to see what the percentage of acid exposure time occurs in that recumbent position. So the download page after you insert the sim card in the sim card reader that's connected to a computer, which it activates in the software. You open the software, you're gonna see this, you're gonna put in the probe depth of where you place the catheter. Um So again, the gold standard of placing a mps ph catheter is through Asafa geometry. First, you're going to measure approximately L. S. Border or at least a soft geometry has been done within a year without any surgical evaluation. Uh So you're measured approximately S. Border and then place it accordingly to the correct catheter you're using. And this one right here, 44 which is probably the most standard use and most recognized use commonly used, uh that's going to be placed five centimetres north of approximately S border. And then um then you're gonna select download. But if you don't have access to the South of Demonology, there's other means. There's the there's the airflow center locator, there's a struggle formula, but the gold standard has been set more at using sapphire geometry prior to um ph testing. Yeah, So study overview. This is basically what you see after the, after the studies uh downloaded, you're gonna see all, you're going to see this type of thing occur. And these top channels are basically the impedance channels. These two right here are the ph two ph channels and you're just kind of eyeball, you're looking from left to right, looking what, what looks maybe not normal, what looks abnormal, What may be excluded. You need to be excluded that type of thing. A lot of times you're looking at the penis channel being really boxy. It's kind of up here in the 10,000 range. You get the ph fascinating from zero all the way to 10 and that's a good sign that you're going to need to exclude that for artifacts. Diary adjustments. You know, orientations can be done through this thing called the diary editor on the software. But you're gonna see all the events that basically this person, either, uh, this person hit on the button or you're going to actually type in, you'll see all the events that are occurring here, all the symptoms, they have the meal and the recumbent position. So say, you want to add something, you know, symptoms can be added only at the start time, remember. So for example, if it's abdominal pain, you're only going to have these boxes that populate is either day one or day two. For example, if you started to test eight o'clock in the morning to be at day one, but say they have the symptom at three o'clock the next morning, This would be day two. Then you're just going to input the start time, whatever that may be and it will be a military time. Then you select that. Then after you're done doing all these clicked on and they'll populate back into that diary editor. The difference is with me all you're gonna need as you see down here on the bottom, you need to know the start time and the end time. So be careful when people eat late at night, maybe like a 11 49. This one they get done in a day to be day two, it's a uh, 1215. This would be 0015. So this would have to be a two. So just keep an eye on as the day shift from one to to make sure sure you're not just putting these incorrectly. But the start day in the end it the recumbent position is the exact same thing. So remember you need to start time and finish time. Remember as a transition from day one day two that you put the correct end day. So editing, you say someone said, oh I on the paper or paper thing I hit the button or you haven't do both in the heartburn. It was really a belt or anything like that. You can you can edit these as you go so they get the correct symptoms, especially when you're these. That will be used to assess the symptom association probability and the symptom index. But you can re label stuff. But the key thing is after you do all this, remember to hit save. So it populates correctly in the diary editor. So re labelling is another thing, You know, you want to relabel these three to belch or whatever. Maybe you can re label it. And again, the big thing is after you hit. Okay, that kind of populates into this in just a diary editor that now they got the correct symptoms, especially if the symptom association or symptom index ends up being positive. The big thing is duplicates. Remember the key is that two minute window, so symptoms there identify um within that same two minutes of the primary one will just need to be delayed because of duplicate. So if you look at this this this image right here, you've got heartburn occurring someone, the demarcated day one At 1527. Um So and and uh so 33 27 in the afternoon. And then they had another heartburn. They either hit the button and wrote down at 15 28. So this is within this two minute window from the first one. So this is a duplicate similar to throat clearing here. You got the day one at 1900 or seven o'clock. Then another symptoms at 1901 So again within that two minutes. So we can we can identify where there's duplicates and it would delete them from from the analysis. Yeah. So this is what I was talking about artifact. When you're just doing that qualitative view of uh of the study beforehand, you're kind of looking what looks normal abnormal. If you see the left hand side here, you see the impedance channels all roughly. Somewhere around that 21,500 mark Kind of, you know, undulating um systematically throughout. But then you see this blocks right here. Or the impedance chances all riding that 10,000 line, you see the ph dramatically drops down the zero. This is an eyeball thing where I'm going to need to exclude this from evaluation and be. And then before I do the auto scan, so It basically does not analyze a ph of zero and impedance above 10 when they're looking for events. And that's what it would look like. Kind of this great out bar type thing looks like a great zebra throughout. And this is what you know that the software, basically the auto scan will bypass this. Like it never doesn't even exist. So, auto scan is like as an artificial intelligence, it does a few really four main things that creates these three resting pressures to quantify. May nocturnal baseline impedance or mm. B. I. Is what we talked about the last webinar basically how much resistance in this retrograde formation directionality is occurring. Why someone is sleeping. That's the gist of what that measurements doing. Uh Second thing identifies reflux, utilizing an impedance and creates a measurement. So basically it's identifying what they think it's a reflex event is occurring and creates a measurement box. It qualifies the ph of bullets. Is that acid base is a non acid base? It's all based on the Demarcation line of 4.0 it creates a separate ph measurement for any ph measurement where the ph is below four. Again that's acidic for at least five seconds. It occurs for one second or two seconds. It doesn't really count it but hasn't at least be five seconds or longer. So there's that mm. B. I. Again, many nocturnal baseline impedance as you see this as a in the sleeping um recumbent position. And and you see want rescue measurement. One rescue measurement. To rescue measurement three. You want to kind of keep. You may have to make some final justice making sure there they're pretty much there's not a lot of artifact moving through here. You want to kind of keep in somewhat of a quiescent space but you can adjust these to move it over a little bit to your right, a little bit to your left. If you have a lot of artifact in there. The key is that this is an adjunct measurement metric valuing for reflex activity is not a primary metric. So This is something if you're like in that in that uh you know 4.4.01-5.99. This is an adjunct evidence of why someone may be experiencing that overlap of that GERD that you may want to use inside the evaluation. So in the impedance measurement here, as you see, we're gonna look for directionality down here. Remember what we're looking at is we're going to look a little bit more further as we look at the study. But this is a P. H. Channel which is in the in the gastric character. This is a P. H channel that's in the five centimetres north of the L. A. S. And as you can see the reflex event and this directionality is going step this way, step this way, step this way and you can see the angle as it's going in, especially the entry point of the reflux as it bypasses these channels right here. And it shows you the depth of these channels. It's three centimeters approximately S 579 15 in 17th. So you can see how far it's actually getting up that it also allows you to assess if this is acid base or not. Ask to base. Remember, it has to be greater than five seconds for this to demarcate a reflux, um an acid reflux about. So ph measurement, this is event is greater than five seconds. It has been this retrograde formation, basically going from the stomach emanating into the esophagus um has greater than five seconds because it's going to, the software is going to measure this an amount of seconds. So it has to be greater than five seconds. And over here on the left, it will tell you how many seconds this event uh this acid reflux event occurred. So how long was it inside the esophagus where it was acidic? Then in a non acid reflex. And on this is basically when you get this retrograde took the formation as you see, it's moving its way from distal to proximal but its quality. But the ph this is the key one. Looking at this one right here, you have to be careful. Everybody may not be using the same catheter. So you want to know the configuration of your catheter because it will, especially when you start to analyze these or at least edit pre edited them. You need to know what your catheter formation is uh looks like to understand where the ph sensor is located within the body. But as you see, this did not drop below this demarcation line at four point oh for greater than five seconds or at all. And so it's considered non acid. You're gonna get a report. It's gonna be several pages long. It's going to give you all the demographics that we put in last week as we taught how to to uh upload someone's uh get someone uh since card ready. That's going to give you the acid exposure time overall. It's gonna give you a recumbent, it's gonna give you in the upright position. I'm gonna give you symptoms, how many symptoms, how many reflex events? The symptom association, the symptom index, measurements, percentages them FBI. And it's gonna give you the strip of down here, of the ph itself. So you can actually have that as a nice report. May be populated in your EMR system. Again. Going back to the one of the very first slides that we just talked about. It's all about kind of if you're using the Liam Consensus, the two main markers is the acid exposure time. Again, anything less than four is not considered gastric reflux disease. six or higher is considered a gastric reflux disease. And then um the symptoms going lower than 40 greater than 80. And then the symptom metrics, remember symptom index is 50 greater than 50%. And the symptom association probability that's that. Cross tabulation um four by four cross tabulation of greater than 95% is considered a positive for that symptom association. Often again, you talked about, the last one is you're going to use a. S. A. P. But adjudicated with S. I. The strength and your rigor of these uh statistical markers. It's a little bit of an overview. What we're gonna do is a quick reference. This is a nice slide to have is basically just kind of walks you step by step through and you're going to open up the seaview program. You're gonna open up the patient management, you're gonna select the patient, you're gonna review. You might have a lot on your on your board, on the left hand side, but you want to make sure you select the correct patient, click on review study briefly. Look at the entire study to assess for gastric acid suppression. If applicable meal recumbent ties the presence of the symptoms. You're going to exclude any artifact or loss of signal if applicable. You want to decrease that from uh analysis. You're gonna look at the diary closely at it relabel, delete duplicate symptoms. Then you're going to perform the auto scan. Then you're going to zoom into the data for a closer view. You can change the homes. I would say I would stay with this, the automated one that popped software populates. But you may sometimes, especially different patient populations, um uh lung transplant people come to my mind uh those people that own maybe the way for maybe really lower. So you have to kind of um Change the scale on the home side. But I would say if you can stick with what the software popular, it's gonna be, that's gonna be good for at least 90 of the people that you may have to make some adjustments to that. Um, in in that a scale system. So the next thing we're gonna do is I'm gonna tag from symptoms, the symptoms and there's a move feature will show you that here in a few minutes. Um, and, and then we're gonna look at there's a five minute window before each a symptom and we're gonna basically assesses if the auto scan got it correctly began retrograde bullish movement as that. That was not measured by odyssey auto scan. We can create a reflex measurement if needed and a ph measurement. We're gonna show you how to do that by um on the software here in a second. Andrew Gables, movement has to swallow activity which is coming from the proximity to the distant location which may have been mistakenly measured. You can right click and delete that. Then we're going to create the report. All right. So we're gonna move on to does that have any questions before we move on to the strip? The ph strip itself? Yes. Jason. Are there men be values for pediatrics? There is not not that I've been aware of. I think there's been about there's only been several studies and it's been done in um the adult world. I think there's more studies coming out relative in the near future. But I think they're all done in adults. Which is that's a very interesting question because um it would be interesting for some of the study that to understand especially the younger kids that may be failing to thrive or thrive and re flexing in the night time. That's a good question. But not as I know. How do you know if the probe was placed correctly in a study? Mhm. Yeah, a couple, a couple of things. So when you're placing the peach cath, well let's say, we'll say you did a stop the geometry before. So you know where the approximately exporters will say it's 40. So, you know, you need to place it and you have a catheter 44. I mean, it's the one that's gonna be in the gastric 15 centimetres north of the approximately S. Border. So, you know, you're going to eventually place it at 35. Um if they're off, acid suppression medication will say they're off it when you place the Catheter. I I've always thought that you tried to move the catheter down to about 60 cm on all people that and then you definitely should be in the gastric region on all individuals. And then you'll see on the data recorder itself, the ph recording. And if it's below four, you know, you're in you're in the gastric or stomach area and as you do to pull through back to move it from 60 to 35, the catheters placed correctly. If there On acid suppression medication, it gets a little bit trickier because generally you won't see that drop below 4.0, and then a couple of things you need to keep your eye on is when I'm placing the catheter and getting a lot of retro action at the nose. Especially people that have hernias is a big thing. Carassava, hernias, all this type of stuff. Outflow obstruction. That's another reason why it's good to do. And Asafa geometry before because you know what uh what they're swallowing mechanism actually um is uh they're swallowing mechanism actually is but if you're getting a lot of retro reflection at the nose as you advance your probably curling in the stomach and not getting through that E. G. J. Um freely. So then there's some techniques where you can you know you want to move it back out. You know around that 25 cm you may have to reposition the patient for a little bit further back. Maybe Lean them on their left side. Some deep breath, take a little bit slower, sometimes bigger gulps of water, warm cups of water. But um it gets a little bit more challenging when they're on as the suppression medication. Because you don't get the flash of ph to let you know exactly that you're in the gastric region. But that's a good reason, I think. A good question, but it comes a little bit more with experience as you're placing these. Because the challenge of the catheter is smaller than south of geometry catheter, which is a benefit. But the negative that is that has less integrity. So you can kind of curl much easier for an impudent study on PPE is still appropriate to still qualify the PPE response, for example. Excellent gastric control. Good gastric control. Fair and poor. That's a good question. We do that. Um at both places, I've been over the last 20 years. We do that. Um it probably holds a little bit less weight and rigor, but we do we do uh illustrate or uh populate that metric, but it does hold a little bit less rigor. All right, we have one more question. Do use a one channel ph probe in any of your cases. I'm sorry. You know, a long channel ph cancer. Is that a question? A one A single channel ph probe in any reclusive. Yeah. So, we do that. Um Often we do that when people are off OFF PPE we'll do the one channel and do the dual channel when they're on PP. Um But it's I would say at each individual lab. It's it's probably individualist. But that's our practice here. One if they're off and if they're on we do both. Um But I think it's a little bit more individualized and that type of thing. But um we do both commonly that way. And then um generally and pediatric rule all the all the all the impedance we've I've ever done where um the ph sensors were inside the esophagus. But I would say going back to the placement question, do you want to disclaim that our practice was? If if it's a pediatric, we always we used a struggle formula or to Cincinnati chart to get a good range where rivers eventually going to place the catheter at three centuries north of approximately. Yes, but we also verified that with a chest x ray immediately after placing the ph catheter. All right, good questions. Um So I want to we're gonna move on to a study itself. So, um so this is what would happen when you um the overview after you download the study, go to patient management. Um Let me show you. Let me close this then. Um then we can go from the from this step forward um looking at the from patient management on. But this is this would be the process as your So this is the face pages, see and you've got on your left hand side, you know, download a study that's where you would click to download the study if you have the importer exporter. But these are the two main ones right here, we're gonna patient management. So say we downloaded the sims card already. Now we have your basically your menu bar down on your left hand side. And then we're going to look at um this one right here, say this is the person we're looking at right here, it tells you it's an impedance members. E equals the impedance. And if it's a single ph sensor to ph sensors. And so we're gonna select this person has all the information that we pre populated the day before that were required, especially the asterix marks right here, then we're going to click review studying that was and then that window won't pop up. That was something I was playing around with earlier. But it will say this will be the process right here. You'll see loading study Then this all comes about. So this is the entire strip. You notice the entire strip because it says 24 hours and eight minutes. So, you know, this is a complete stripped is how long the study was taken. And we're just gonna come walk through a few different things. Or you're gonna look at your eyeballs throughout here and generally before auto scan, you wouldn't see these yellow things. These are what the auto scan kind of created. But you just want to look through here, make sure that there's no member of the homes going up to 10,000 or the ph floating around zero. Um So we don't need to basically exclude anything, but we'll show you how to do that regardless. And then over here, we know this what type of catheter design right here is because we got we have ph two and ph one and ph to it shows you it's 10 centimeters below the approximately s then um the ph one is five centimeters north of approximately S so this one is in the sausages, esophagus, this one is in the gastric region, then you've got the impedance channels as it works its way up from approximately S. You have 3579 15, 17 centimeters respectively. So as you're going through here is a couple of different things. You got the time bar right here. This is the the the hue right here, this is we can the data view gives us some other options we can look at as we're reviewing this. Um you just kind of hover over these shows you this is going to be the impedance contour. So you click on that, you got you've got to click off that you get this purple magenta hue here, you've got the next one. Is is this the ph contour you've got here is the impedance waveform, then right here is the ph waveform. So go back to the main strip. And then here is basically the options how you kind of migrate your through a traverse your way through this touch. You can move from measurement, from symptoms, um from moved from post meal, all the way throughout the test. Um Right here you're gonna but there's options, you know, we're going to look at a sink view here on a thing, then this is a diary editor. Um and then um then the report itself. All right, So as we work our way through this and we didn't we're going to go to the diary editor 1st Walk through something. So you've got all these diarrhea that it's in here. Let's say let's say we have to make some changes here. It's just let's say we have to let's just add so we have heartburn at 1527. So let's just add um heartburn. Tell you someone said Oh I forgot to write down, tell you that I had heartburn at 15 28. And then this hit add okay if you want to add that here and it's going to calculate because we already hit auto scan. But going to calculate this All right, we're gonna get done. So now we have again, remember 1527 and 1528? Remember the within two minutes it's gonna it's only going to uh analyze the primary marker. So we're gonna look for duplicates and it's basically highlighted. Found this one, it was within two minutes of the primary one. So then we're just gonna hit delete then we're going to say yes. So it takes that out and recalculate everything all over again. So this is a way that you can you can add different things throughout um throughout your test that may have been missed. You want you can add like end of meal times. They say person forgot to add um the end of their meal uh time or recumbent time. You can do it all through this diary editor over here on the right hand side. Throughout this test you're gonna you're gonna have different things. This is the ph met uh measurement metrics. If you pull these up kind of hovered over them, you can we can eventually pull these up as we walk through this thing. So we're going to go from, the first thing we're gonna do is this walk through each measurement that the auto scan populated. Yeah, I think we can make let's look at the window. It's a little smaller than 20 per say 10 minutes. All right. So we're looking at the measurement. So we see we see here that it has a member and we have an entry and an exit and entry and exit entry and exit. As you can see the entries here that it goes systematically from the from the distal to proximal here. And we can turn on the purple color and you can see it a little bit better than your eyeballs. So we're looking through here and making sure and then over here on the right hand side, we see this as liquid. Remember liquid is what moves uh impedance and uh wait for him in a deep decrease things with more resistance a deep and has to go across two channels At least and hasn't had an entry and exit of 50 below the impedance baseline. The second thing we look at right here, remember this peach channels in the stomach is mostly acidic. This one's five centimetres north of the L. E. S. And as you see it drop below this um dr below the 44 point oh mark for for greater than that five seconds. So it's considered acidic. So then if you pull these metrics up as the data scan, this is pretty entire. Test for all the reflex, the resting in the distal body. Then you got the summary metrics so tenderly as I walk through this, I keep these down below this is see what is going through each one of these um events. So the talk go to the next one, will agree with that. We'll leave that one. The next one here, as you see here, the same type of thing you have the this is the ph sensor in the stomach, this one's in the esophagus and you see it It's moving in this retrograde formation across two channels lower than 50%. Then you got to see this red hue. So now this is indicating that it did extend for a greater amount of time. And And you click on that, it tells you exactly how long this is the ph of 56.5 seconds. So, and if you click back up here it shows you it's liquid and we agree that's acid. Let's say for example that um we didn't agree with this. So you say we this was mismarked, we didn't agree with this. How you get rid of these is if you just right click on the Z, then you just delete the measurement that it allows you to delete the measurement when you click that and it will calculate and we'll get rid of that measurement. So the first step, you know, you want to go through each one of these reflex events. Do you verify that that they are? What their um they meet all the criteria for reflex event or they don't meet all the criteria. Reflex fence 10. I tend to think that as time goes on that um when the impedance channels have lower OEMs, this the software has, you need to look at a little bit more clear. But when it's standardized home level, the software is very, very good at catching nearly all of these. The second thing we want to do is go by move from symptoms, symptoms. So again, here's here's the symptom of heartburn. Right here you see Marcus heartburn and over here you see all the lines which are demarcated. You have the meal, the recumbent heartburn, regurgitation, throat clearing. So you get heartburn here and then it's going to look at a five minute window back here and you see the gold box that kind of goes around this and it's looking for looking for reflux events that occur within this five minute window. This first symptom association and probability. So it's looking through this window to say yes, it occurred with the reflux event or did not curve with reflux. So you toggle through by just going, you're moving through here to the next event, heartburn. And it's looking back at this five minute window again as you see it's acid base and its liquid because it's going up in this formation. Then you keep going through all these but say you disagree again. Like this is that, I'm not sure if this is this was you can basically make fine adjustments to the window but you're gonna talk go through each one of these to figure out if it's uh associated with the reflux or not or needs to be adjudicated. So say for example on this one you want to make a note um You can you can write a note. Mhm. Yeah that's no tax. No but you can you can you can populate a note and write a note in here that a note tab will come up and you can write in um any any additional information that the position may. Um um I want to know about the study as your review in the study or something that may occur during the study at that particular time. So as you go through all these and then you get to the very end. The next thing we're gonna do is is populated report. And the report I haven't pulled up already right here. Is that this this nice formation of report comes up all this stuff that you've populated into the report their name, the data, data birth. All the other stuff that you may want the M. R. N. Um the probe that was used in that type of thing. The date of study you can have all these other things in there. It's really good to start putting you know if they have like um findings on endoscopy that may be relevant to reflex other findings symptoms. You know why they were coming in here um heartburn or that type of thing medications that may be relevant to um um gastric reflux disease. Then the first thing you find is acid exposure time. Remember going back to leon consensus is that the total acid exposure time? You see we have conventional and then you have legally own. Yeah, this is a member. This shows you the approximately S. one, so the total acid exposure time for this one is 4.4%. So again it's in that it's in that time frame where um you know, it's it's in that borderline type thing, it gives you the recumbent. But the good thing is you see the upright position is where it's primarily driving the acid exposure time. So they have much trouble when they're sleeping. Its primary in the upright position. And it shows you the acid exposure and the gas revolution, which mostly it was acidic. The next thing you see the domestic score. Again, if this person was done on PP. I. This has a little bit less rigor, but if they're done off PP. I. This has a little bit more rigor, gives you a normal range, so it's slightly above the normal range. The next is the number uh episodes reflects episode 70 so we're definitely above the normal range. The next thing we walk down is a symptom correlation to reflux. So we're seeing right here at S. I remember s eyes, anything about 50% is considered significant and S. A. P. Or association probability anything above 95% is considered significant. So here, but remember, It does not say 100%, but that's throat clearing. So there was only one, it didn't matter acid reflux, so it was significant. So when you're talking about S I remember the N. S. A. P. The denominator, or how many are in there do kind a lot to dictate what these percentages are. So, you know, even though they're high, I'd also taking account how many events that actually were associated with that to get to that percentage. The next thing we're going to look at the homes and this is a member. There's these 10 3 10 minute windows with inside um with inside the uh supine position or a recumbent position when they're sleeping. And we can let me talk about ready to go back to when they're in the supine position. I'll show you where these the software populate these for you and these boxes right here. So in the resting, so you see these are always trying to move it out just 15. So I can see a little bit before a little bit after you see all the impedance channels are quite quiet isn't throughout Um this 12th box. So this is a good one to look at. So they have three different one of these save time And Softwares like appears little slow right now but you can look at this but it's good to look at all three to make sure everything is basically in a quieter. You don't got a lot of up and down a lot of undulating thing. And if you do you can you can just make some fine adjustments Of the window itself but make sure it's in a 12th window. So you got the mmb I there's a normal value um um 2292. You see that? It was it was below that so it's a little bit abnormal but um not too much but that's something you want to keep an eye on for adjunct evidence for reflux as you start down gets a little bit more detailed of the level of the position, how long they were in operating recumbent in total analysis time um position. Then this is more of a table, basically a summary table of all this same thing is involved. Just makes it a little bit more um in a table form for you and this are this right here, a lot of them. The long episode, how long the longest episode of acid exposure time of 7.3 minutes in the upper 85 little bit of five minutes when they're sleeping. So um it's good information to have as you're trying to figure out if if the person is um has evidence for reflux. These are all the basically components of the day MR. Score. Let you know what the values are, how they got to that point. Um the number of Reflex episodes that were um demarcated by the within the studies of 70 60 when the upright timber in the recovery. So you see the report is very detailed as you go throughout throughout this whole process. And it gives you some similar percentages that we've seen upstairs. Then eventually the last few pages you get this ph strip and they're broken down two epochs of time. So you can see what is happening through different epochs of time. To get a quick qualitative view of the study itself as you're reviewing it. So that's a little that's an overview of the what we look at in the study, how to toggle your way through it. The key is the kind of creating a very systematic way of going through this again, I think doing a qualitative review excluding any artifact, making sure that diary is completely um and and and put it correctly with on the paper or through the diary editor itself. Beginning and end. Times when you need it decreased, duplicates. Change anything that you maybe add some notes if if needed. Hit auto scan and then toggle your way through um through each measurement as you go through it. Then look at it from the symptoms also. And then after that generate the report. I have any questions. As he walked our way through that we have a few Jason. What does the Bayakoa score? And what is its usage? Yeah. The broncos score is generally more done in pediatrics. Um. Um World but I was most a lot of people do you still do? Mr but more for the pediatrics impedance testing with a patient with barrett's esophagus is difficult to analyze reflux episodes because of the low impedance throughout the test. Do you have any tips? Yeah that's a good question. Um You're gonna you're gonna, first thing you're gonna have to probably adjust the OEMs um To shorten the scale from like 00 to 10,000. Probably try to start 0 to 5000. Um You're gonna be you're gonna have to have a keen eye a little bit as you walk your way through the measurements because the homes tend to be um on the lower side you're gonna have to have a keen eye as you're going through that they look through that um that particular study. So that does take a little bit more time and you may end up deleting or adding some things as you go through it. But adjusting the OEMs would be the first step um going through that and then um having a systematic review how you do it and and really concentrate on looking at if those events meet the three criteria that demarcated reflux event. And do you have uh an example where you would delete a reflux event and how would you do that? Yeah, we can go back to here. All right. Good question. All right. Yeah, mm. All right. All right. Let's say this is a this is a reflex event. So um what we're gonna do is you're gonna on this bronze Z number whatever Z 12 affinity, left, right click. And you can deep pleat this measurement right here and it will delete data from the analysis. So you can do that with any any event. You can add and say for example that we were talking through the toggle through this and we wanted to add a measurement. We can add a measurement. Say right here we'll add it. Well is in the resting position. Is that the reflex are going to say we want to add a reflex, do that and say for example this this speak this peak right here was um greater than 55 seconds. We want to add a ph measurement. Can do one of these and we'll add that ph measurement as you see it demarcates it that color red hue under four but is less is basically quick quick reflex fence that didn't really count. But this is how you add and delete and say you want to delete that again. Right click and delete the measurement. All right. Um Sometimes our nurses program the recorder to include vomiting as a symptom. But doesn't that make the I. N. S. A. P. Positive automatically? Yeah. Exactly. Um I think vomiting as a symptom probably would stay away from that. I would probably have vomiting as more of a note because if you if someone vomits they're obviously going from a distal to proximal directionality which is going to be all acidic and S. I. And S. A. P. Will be 100% positive. So very few people would vomit something that's not a sick. So um I would put that more as a note and not a symptom. Um because it S. A. P. And S. I. For that or you can put it anyways and just not really um reported because that's that's more Of course it's going to be 100 or greater than 50%. So um either way you can you can you can demarcate as a symptom but just bypass that on the report when you're reporting it overall as your interpretation. But I would report that more as a note than a symptom a lot of times that you know you see that in pediatric world you know um uh you do a test because they're you know, they're failing to thrive or they're vomiting. Um We always stand and just demarcate that as a note more than a symptom. Good question in regard regarding MND. I. Um you said that it was measured in the fifth channel. Why not the six channel? Can you speak more about FBI and how it's measured? Yeah. Currently um it was Japan is its word that Dr Wally and his group kind of measured it at that point. Um But um in that channel it's more about how much you're gonna have to have some distance where it moves from your your emanates from your esophagus, your gastric into your esophagus. So um that is the reason is that at that location it kinda it's right around near the ph marker to so allows allows some evaluation at that point from the at the ph what's occurring at the ph level but it's more comes from the literature base than than just a random number. Mhm. One last question, Jason, is there a normal gastric percentage exposure time, especially for tests done on PP. Um say that one more time, you know, I missed a hair gastric disclosure time on P. P. I. Sure. Is there a normal gastric percentage exposure time especially for to have done on PP. Yeah. So gastric exposure time? Not necessarily that there's an on or off PP. I. Um some people use that to evaluate um in the past way, way back another time. A lifetime ago people would use it for just we call a ph flash type of thing. Um But to my recollection, there's no like normal value for that. But I mean that I could be I could be incorrect on that, but I'm not aware of a normal value for that. Okay. Yeah. One last one. Um, in your daily practice, what are the most important measures that you point out in the report for a ph impedance studying? Yeah. Really, for me it's for it's really three things. We look at asset total acid exposure time, the number of reflux episodes and symptom association, probability. Those are the three main ones. And the reason our that total asset exposure time is really how much asked. The percentage of time acid is spending time in the esophagus, the number of reflux episodes that are occurring that with an acid event. And then the symptoms association probabilities because of the statistical rigor of that with a disclaimer that depending on the number the denominator, how many are actually um uh annotated during the test, but those are the three the three key ones that we keep our eye on then. Probably in the fourth, A deep 4th 1 after that would be the day Mr. Score. Thank you, Jason. Well, this concludes our webinar exploring in patients, page studies. The recordings for the webinars in the series will be uploaded this week to diverse attack University for you and your colleagues to access in the future. Thanks for attending and good night. All right. Good night. Thank you.