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Fits Toyota, Case, Caterpillar and International Harvester. The pitch of the hat and crash voices is adjustable and automatable. There are 56 locations for saving user patterns. Be our guest! You’ll need the Arduino IDE to edit, compile and upload the firmware. For more detailed instructions, see this guide. Keep in mind that the Bravo has even less space for samples than the Bleep Drum, so keep those samples short! T oggle between Edit Mode and Trigger Mode modes with Shift L. The button assignment is as follows: The pitch of the sound corresponds to the vertical position of the button with the lowest pitch assigned to Button 4 and the highest pitch assigned to Button 32. Sets the level of XOR distortion. Sets the MIDI channel on which pattern change messages are sent. Setting “0” stops trigger messages from being sent. While the sequencer is running MIDI clock is transmitted at 24 ppq (pulses per quarter), allowing other devices to be synced to the Bravo. The current bpm will be displayed. (When displaying numeric values, values over 99 are indicated with the LED for Shift L lit. Values over 199 are indicated with the LEDs for both Shift L and Step 25 lit. ). Press and hold Shift R to make it come to its senses. If a pattern is stored in a location its LED will be lit. Cue a pattern to play next by pressing its button. The currently playing pattern will be indicated by with slow blink. The pattern cued to play next is indicated with a fast blink. If the location is not currently occupied, the pattern will be stored immediately. Once step 1 or 17 is reached (pattern recall is quantized to the closest bar), the location will start to slow-blink to indicated that it is currently playing. If the location is already in use (ie.Press the location again to overwrite the pattern stored there with the current pattern. Press any other button to cancel the save request. It will fast blink to show it’s waiting for confirmation. {-Variable.fc_1_url-

Press the location again (no shift) to confirm, or anything else to cancel. When F1 is released, the playback position will jump to the true step. In Live Mode, the drum sounds are playable from the front panel buttons. Malaysia Find articles by Yeong Yeh Lee Author information Article notes Copyright and License information Disclaimer 1 Section of Gastroenterology, De La Salle Health Sciences Institute, Dasma-rinas City, Cavite. Philippines 2 School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kota Bahru, Kelantan. This article has been cited by other articles in PMC. Abstract Gastroesophageal reflux disease (GERD) is a disease predominantly seen in the West but there is a rising trend in Asia. Ambulatory 24-hour catheter-based pH monitoring has been the de facto gold standard test for GERD that correlates symptoms with acid reflux episodes. However, drawbacks such as patients’ discomfort, and catheter displacement render the test as cumbersome and error-prone. The Bravo pH wireless system is designed to be user-friendly and has an added advantage of prolonged pH monitoring. The system is comparable to the catheter-based pH monitoring system in terms of diagnostic yield and symptom-reflux association. Indications include evaluation of patients with refractory GERD symptoms and prior to anti-reflux surgery. Bravo utilizes a wireless pH-sensing capsule with a complete prepackaged system, and a data processing software. The capsule may be positioned indirectly using endoscopic or manometric landmarks or under direct endoscopic guidance. Optimal threshold cut-off values are yet to be standardized but based on available studies, for the Asian population, it may be recommended for total time pH Keywords: Asia, Esophageal pH monitoring, Gastroesophageal reflux disease Introduction Gastroesophageal reflux disease (GERD) is on the increase in Asia with prevalence ranging from 5 up to 18. http://careerhack.net/wp-content/plugins/formcraft/file-upload/server/content/files/162854eff3a669---bushnell-78-8890-manual.pdf

1 Heartburn and regurgitation are typical symptoms of GERD, but are unreliable in terms of distinguishing GERD from functional gastrointestinal (GI) diseases particularly among Asians. 2, 3 In addition, the presence of reflux symptoms lack direct correlations with increased esophageal acid exposure, as well as endoscopically proven esophagitis. 2, 3 In a symptomatic Asian patient with normal endoscopic findings, the diagnosis of GERD would often rely on documented high esophageal acid exposure. Ambulatory 24-hour pH monitoring, first introduced in 1974, was developed to detect abnormal levels of acid reflux in the lower esophagus. 4, 5 Conventional pH monitoring requires a nasopharyngeal catheter with pH electrode placed 5 cm above the lower esophageal sphincter to document distal esophageal acid exposure and correlate this with reflux symptoms. 5 Although highly sensitive and specific, several pitfalls with this procedure have been cited. Drawbacks include patient discomfort due to nasal and pharyngeal irritation from the pH catheter. Oftentimes, patients limit their daily physical activities and alter their diets, which may underestimate the amount of actual reflux episodes. Methodological difficulties such as incorrect placement and catheter migration have been observed which may affect test accuracy thus leading to erroneous results. 3, 4, 6 A wireless pH capsule was designed and developed in 2003 to overcome these limitations. 7, 8 The Bravo pH wireless capsule system (Given Imaging; Medtronic Inc, Shoreview, MN, USA) is a device that is temporarily implanted in the distal esophageal mucosa to avoid the inconvenience of wearing a nasopharyngeal electrode. 5, 9 The diagnostic yield of Bravo system was comparable to the catheter-based system as seen in studies performed in both the Caucasians and Asian populations. 4, 5 Symptom association with reflux episodes is likewise similar between the wireless and conventional pH monitoring systems. https://localhost/travestismexico/paneldecontrol/files/black20u002620decker20gizmo20gm20020manual.pdf

9 More importantly, the Bravo capsule was observed to be significantly better than the conventional system in terms of tolerability with minor impact on diet and daily activities. 10, 11 Test Equipment The Bravo pH monitoring system utilizes a wireless pH-sensing capsule. Prepackaged system consists of (1) Bravo pH capsule with delivery system, (2) pH receiver kit, (3) buffer solution, (4) vacuum pump with suction tubes; and (5) manufacturer-provided software. Prior to usage, the Bravo pH capsule is activated by a magnetic switch and requires pH calibration. The capsule is submerged in a buffer solution of pH 7.01 for at least 10 minutes, at room temperature, calibrated, rinsed, and then recalibrated in the second buffer solution of pH 1.07. The receiver hardware is also checked to confirm proper data transmission. 14 The carrier frequency of the pH signal is in the 433-MHz band. 12 Digital data transmission occurs every 12 seconds with 2 pH data-points obtained every 6 seconds. 12, 15 The average battery-life of a Bravo capsule may be up to 14 days. 16 Test Procedure Prior to the test, medications such as proton pump inhibitors (PPIs) and H2-blockers should be discontinued for 14 days and at least 3 days respectively. 5, 10 Antacids should be stopped 24 hours before the study. 17 Patients are instructed to fast for 6 hours prior to the procedure. Upper endoscopy is usually performed to guide placement of the capsule either through conventional or direct guidance. After activation and calibration, connect the vacuum tubing to the Bravo delivery device and perform vacuum pump check to verify gauge reaches 700 mmHg. The Bravo capsule can be inserted through the nostril or mouth while the patient is in a left lateral de-cubitus position. Oral insertion is preferred compared to transnasal insertion due to difficulty in passing the delivery system through the angles of the nasopharynx. 15 With conventional endoscopic guidance, the gastroesophageal junction (GEJ) is identified, followed by removal of endoscope and then the capsule is placed 6 cm proximal to the GEJ. 12, 14 This position is derived from observation that the high pressure zone of lower esophageal sphincter (LES) is typically 1 to 1.5 cm proximal to the GEJ. With direct endoscopic guidance, the endoscope is left in place within the esophagus while the Bravo delivery system is being deployed and capsule placed under direct view of the endoscope. 18 Direct-guidance has been shown to be equally effective as conventional-guidance with the added advantage of avoiding a second endoscopy to confirm the placement. More recently, manometry-guided placement has been shown to be equally suitable. 19 With manometry guidance, the Bravo capsule is positioned at 5 cm above the proximal border of the LES if delivered transnasally. 4, 9, 10 Alternatively, the Bravo capsule is better delivered orally because of tolerability, and by using a correction factor of 4 cm for the difference between oral and nasal intubation. A retrospective study suggests that manometry placement may be better since endoscopic placement resulted in higher acid exposure on day one and the cost might be higher. 19 Furthermore, capsule misplacement with endoscopy is common especially more proximal displacement, however, misplacement is not necessarily associated with poor pH results. 20 Once it is in the correct position, the vacuum pump is used to apply suction to the wall of the capsule. A vacuum pressure of more than 510 mmHg for 15 to 30 seconds is required for successful deployment, although 700 mmHg is usually recommended by the manufacturer. 8, 9, 11, 12 The activation button is pressed to deploy a spring-loaded, stainless-steel pin to attach the capsule to the mucosa.Open in a separate window Figure 2 Steps in placement of the Bravo capsule. (A) Position Bravo pH capsule. (B) Apply suction to catheter until 700 mmHg is reached for 60 seconds. (C) Depress plunger to advance pin. (D) Release capsule by rotating the plunger clockwise. (E) Begin pH recording. Patients are instructed to keep a daily diary to log their symptoms, meals, and sleep. Esophageal acid exposures for the first day, second day and combined 48 hours are calculated separately. 10 In patients who underwent endoscopic guidance under sedation, it has been proposed that to eliminate the effects of sedatives on the LES, the first 6 hours of pH data should be excluded in the analysis of results. 10 There is day-to-day variability in acid exposure and therefore an extended recording beyond 24 hours may be preferable. 10 Ang et al 5 compared Bravo pH monitoring with that of conventional pH catheter but the mean acid exposure time was not significantly different. However, the Bravo capsule seemed to have recorded fewer reflux episodes, a finding similar to a previous study by Varannes et al. 9 Acid exposure values were found to be 1.2 greater with the catheter system compared to the Bravo system. 5, 9 Extended monitoring becomes of value in this case and Ang et al 5 noted a 61 positive diagnostic yield with an incremental diagnostic yield of 30 seen at 48-hour period. Moreover, monitoring can be extended up to 96 hours to increase the chance of detecting reflux events and to establish symptom association. 5 Therefore, it can be used to evaluate medications responses or to document acid reflux in patients with refractory symptoms despite therapy. 15 To assess the temporal relationship between acid refluxes and symptoms, the patient’s symptom index score (SI), symptom sensitivity index (SSI) and symptom association probability (SAP) are utilized. SI, first described by Wiener et al 19 in 1988, is defined as the number of times reflux symptoms occured when pH was 95. 6, 13 Results An abnormal composite pH score is the most accurate method to identify presence of GERD. 21 However, optimal threshold cut-off values are yet to be standardized.More studies are needed from Asia to confirm and to compare the findings with those from the West. Based on the above observations, for now in Asia, the recommended normal values for total percentage of time pH 7 that is 22 that is Indications In 2005, the United States Food and Drug Administration approved the use of Bravo pH monitoring system for the evaluation of patients with GERD. The American Gastroenterology Association also approved the use of Bravo capsule for documenting adequacy of PPI therapy in Barrett’s esophagus and to evaluate atypical symptoms unresponsive to PPI therapy. 15 Table 2 summarizes the clinical uses of the capsule monitoring system. Table 2 Indications for Esophageal pH Testing Using the Bravo Capsule System (Adapted from Lacy et al, 3 Ang et al, 5 and Pandolfino and Kwiatek 15 ) Many gastroenterologists in Asia often face the dilemma in choosing the appropriate pH diagnostic tools. In the ideal situation where cost is not an issue, we would recommend Bravo capsule for its better tolerability, and for its ability to evaluate the efficacy on-PPI. If cost is an issue then pH probe is recommended for exclusion of GERD off-PPI. For non-acidic reflux detection, the pH-impedance probe is clearly superior over both pH alone and Bravo capsule. Besides, the pH-impedance probe can be performed both off- and on-PPI, and the study duration for pH-impedance can be potentially extended beyond 24 hours. However, besides cost, tolerability is an issue with the pH-impedance probe. Relative contraindications to the use of Bravo capsule include pregnant patients, history of underlying bleeding diathesis, the presence of esophageal strictures, varices, diverticula and severe esophagitis with intestinal metaplasia. 5, 12 Likewise, patients with previous upper GI surgery, history of Zollinger-Ellison syndrome, active malignancy or Crohn’s disease are not recommended for this procedure. 5 Other contraindications include presence of a pacemaker or defibrillator which may interfere with signal transmission. 12, 13 Other Clinical Utility In the pathophysiology of GERD, many patients develop reflux symptoms in the post-prandial state but this is a paradox since meals buffer the stomach acid. 16 An area of the proximal stomach distal to the squamocolumnar junction (SCJ) eludes the buffering effect of meals, the so-called “acid pocket,” and studies have found an association between acid pocket and GERD. In this regard, measuring intragastric pH in this acid pocket using the Bravo wireless capsule system may be useful. Pandolfino et al 17 demonstrated that concurrent measurement of esophageal pH (6 cm proximal to the SCJ) and gastric pH (1.5 to 2 cm distal to SCJ) using 2 Bravo capsules was feasible and reliable. 16 Study results showed that the median pH of the cardia were significantly lower than the median esophageal pH during reflux events, which is compatible with an acid pocket. 17 Another study done by Ono et al 16 showed that the Bravo capsule, attached with multiple hemoclips at the greater curvature of the gastric body, can monitor treatment responses while on histamine receptor blockers. In the evaluation of patients with non-cardiac chest pain (NCCP), pH monitoring may also be advantageous especially when they are unresponsive to a therapeutic trial of PPI. In cases where capsule failed to detach within 5 days as confirmed from radiological identification, endoscopic retrieval may be warranted. 21 Removal is performed by applying gentle pressures to the capsule using the tip of an endoscope to dislodge the capsule followed by its retrieval. 13 Limitations The cost is an important consideration especially in the Asian developing countries. Furthermore, a higher rate of technical failures among inexperienced operators and associated chest pain symptom needing removal are other limitations to consider. Conclusion The Bravo pH monitoring system is a safe and well-tolerated alternative to the catheter-based pH monitoring. It is patient-friendly with the ability for prolonged pH recording. The Bravo capsule is recommended in the evaluation of patients with refractory GERD, prior to antireflux surgery, and monitoring of patient responses during therapy. Optimal threshold values have yet to be standardized particularly in Asia and prospective studies are still required to formulate appropriate interpretation guidelines. Acknowlegements Reckitt-Benckiser has provided funding for research in relation to this article. Footnotes Financial support: This study was supported by Reckitt-Benckiser. Conflicts of interest: None. Author contributions: Yeong Yeh Lee and Rona Marie A Lawenko provided the idea, performed studies, and written the manuscript. References 1. Jung HK. Epidemiology of gastroesophageal reflux disease in Asia: a systematic review. Bravo catheter-free pH monitoring: normal values, concordance, optimal diagnostic thresholds, and accuracy. The Bravo pH capsule system. Wireless esophageal pH monitoring: establishing values in a multiracial cohort of asymptomatic Asian subjects. Ayazi S, Hagen JA, Zehetnes J, et al. Day-to-day discrepancy in Bravo pH monitoring is related to the degree of deterioration of the lower esophageal sphincter and severity of reflux disease. Chotiprashidi P, Liu J, Carpente S, et al. ASGE Technology Status Evaluation Report: wireless esophageal pH monitoring system. Bredenoord AJ, Weunsten NL, Smout AJ. Pandolfino JE, Schreiner MA, Lee TJ, Zhang Q, Boniquit C, Kahrilas PJ. Comparison of the Bravo wireless and digitrapper catheter-based pH monitoring systems for measuring esophageal acid exposure. Pandolfino JE, Kwiatek MA. Use and utility of the Bravo pH capsule. Ono S, Kato M, Ono P, Asaka M. New method for long-term monitoring of intragastric pH. Pandolfino JE, Schreiner MA, Zhang Q, Kahrilas PJ.