BACKGROUND:Gastric reflux is one of the most important causes of the referral of patients to the internal clinic, which in some cases causes problems for patients due to resistance to common treatments. Therefore, timely diagnosis and treatment of this group of patients are very important.AIM:The purpose of the present study was to determine the off-proton pump inhibitor (off-PPI) 24 h pH-impedance analyses in patients with refractory gastroesophageal reflux disease (GERD) attending to Taleghani Hospital since 2009 to 2017.METHODS:In this observational descriptive-comparative off-PPI study, 572 patients with refractory GERD who were referred to Taleghani Hospital in Tehran from 2009 to 2017 were selected, and the results of 24 h pH Impedance analysis were then assessed.RESULTS:The results of 24h pH-impedance indicated that 7% of cases belonged to Pure Acid Reflux followed by weakly Acid (1%), non-acid (0.3%), mixed & gas (5.2%), functional (58.4%) and oesophagal hypersensitivity (28%). Furthermore, weakly acid plus acid was also found to be 8% and Weakly Acid + Acid + Non-Acid were determined as 8.3%.CONCLUSIONS:Our findings suggested that nearly more than half of the patients with refractory GERD would have a functional disorder in the 24h pH-impedance analysis.

Introduction: Infective endocarditis is a serious disease with high morbidity and mortality, especially when associated with renal failure. Anemia is a common finding in chronic kidney disease. Here, we present a case of renal failure and severe anemia with a complicated mechanical heart valve infection with a Delayed diagnosis. Case Presentation: A 68-year-old male patient with a history of chronic kidney disease and metallic aortic valve surgery presented with fever, severe anemia, and about 10-kg weight loss that eventually revealed infective endocarditis in echocardiography with significant valvular leakage, pseudoaneurysm of mitral-aortic intervalvular fibrosa and a fistula to left ventricular outflow tract and sinus Valsalva of the aorta. Conclusions: This case report indicates that anemia, renal failure, and fever of unknown origin can be one of the diagnostic signs of endocarditis. It is important to consider infectious endocarditis in high-risk patients because late diagnosis greatly increases mortality, serious complications, and morbidity.