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Our purpose, by modification of standard bedside tilt–testing, was to search for lesser known but important initial orthostatic hypotension (IOH), occurring transiently within the first 30 seconds of standing, heretofore only detectable with sophisticated continuous photoplethysmographic monitoring systems, not readily available in most medical facilities. In screened outpatients over 60 years of age, supine blood pressure (BP) parameters were recorded. To achieve readiness for immediate BP after standing, the cuff was re–inflated prior to standing, rather than after. Immediate, 1–, and 3–minute standing BPs were recorded. One hundred fifteen patients were studied (mean age, 71.1 years; 50.5% male). Eighteen (15.6%) had OH, of whom 14 (12.1%) had classical OH, and four (3.5%) had IOH. Early standing BP detection time was 20.1 ± 5.3 seconds. Immediate transient physiologic systolic BP decline was detected in non–OH (−8.8 ± 9.9 mm Hg; P < .0001). In contrast to classical OH (with lesser but persistent orthostatic BP decrements), IOH patients had immediate mean orthostatic systolic/diastolic BP change of −32.8 (±13.8) mm Hg/−14.0 (±8.5) mm Hg (P < .02), with recovery back to baseline by 1 minute. Two of the four IOH patients had pre–syncopal symptoms. For the first time, using standard inflation–deflation BP equipment, immediate transient standing physiologic BP decrement and IOH were demonstrated. This preliminary study confirms proof of principle that manual BP cuff inflation prior to standing may be useful and practical in diagnosing IOH, and may stimulate direct comparative studies with continuous monitoring systems.

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Regardless of PPI dosage or concomitant diuretics prescribed, magnesium levels were unaffected. Routine screening of serum magnesium in PPI patients appears unnecessary.

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The bile-acid breath test, fecal analysis of labeled bile acids, and Schilling test were used to study bile-acid and vitamin B12 metabolism in 31 patients with ileal Crohn's disease. Results of the bile-acid breath test were positive for 42% of the patients; Schilling test, 42%; fecal analysis of bile-acid labels, 19%. Combination of the tests increased the percentage of positive cases to 65. About 50% of the patients who had positive breath tests had evidence of normal bile-acid absorption, indicating increased bile-acid deconjugation by small-intestinal bacteria. The other 50% had evidence of various degrees of bile-acid malabsorption. Disease activity did not correlate with results of any test. Extent of ileal involvement correlated with results of the bile-acid tests, but not with those of the Schilling test. The study demonstrates that there is a wide spectrum of disturbances of bile-acid and vitamin B12 metabolism in ileitis, and that the tests should be useful in the diagnostic evaluation of patients with proven or questionable Crohn's disease who have diarrhea and malabsorptive abnormalities that could be related to disturbances of bile-acid and vitamin B12 metabolism.

Background Eosinophilic esophagitis, once considered a rare disorder, has been increasingly recognized as a leading cause of dysphagia and food impaction in children and adults over the last few decades. It predominantly occurs in young men with a history of atopy. Dysphagia and food impaction are the most common presentations. However, rarely, spontaneous perforation (Boerhaave’s syndrome) may occur in association with eosinophilic esophagitis. Case presentation A 40-year-old white woman with known history of eosinophilic esophagitis, who was non-compliant with treatment, presented with chest pain and developed acute spontaneous transmural esophageal perforation while eating a snack. Surgical repair was required. Conclusion In a relatively young patient who presents with spontaneous esophageal perforation, eosinophilic esophagitis should always be ruled out as subsequent treatment may prevent recurrent perforation.