Background. Proton pump inhibitors (PPIs) are widely used for the long-term management of gastroesophageal reflux disease (GERD). However, concerns about the cost and/or inconvenience of continuous maintenance PPI treatment have led to the evaluation of various alternative approaches. Aim. To assess the effectiveness of on-demand PPI therapy in the maintenance treatment of nonerosive reflux disease (NERD) or mild erosive esophagitis (EE). Methods. We searched MEDLINE, EMBASE, Web of Science, and Cochrane Library from inception until October 2, 2017, for randomized controlled trials (RCTs) comparing on-demand PPI versus placebo or daily PPI in the management of NERD or mild EE (Savary-Miller grade 1). Discontinuation of therapy during the trial was used as a surrogate for patient dissatisfaction and failure of symptomatic control. We calculated pooled odds ratios (OR) to evaluate the efficacy of on-demand PPI treatment. Separate analyses were conducted for studies comparing on-demand PPI with daily PPI and with placebo. Subgroup analysis was done based on NERD studies alone and on studies of both NERD and mild EE. These were analyzed using a random effects model. Results. We included 10 RCTs with 4574 patients. On-demand PPI was superior to daily PPI (pooled OR = 0.50; 95% confidence interval (CI) = 0.35, 0.72). On subgroup analysis in NERD patients only, pooled OR was 0.44 (0.29, 0.66). In studies including patients with NERD and mild EE, pooled OR was 0.76 (0.36, 1.60). For studies comparing on-demand PPI with placebo, pooled OR was 0.21 (0.15, 0.29); subgroup analyses of studies evaluating NERD only and studies conducted in NERD and mild EE showed similar results (pooled OR was 0.22 (0.13, 0.36) and 0.18 (0.11, 0.31), resp.). Conclusions. On-demand PPI treatment is effective for many patients with NERD or mild EE. Although not FDA-approved, it may be adequate for those patients whose symptoms are controlled to their satisfaction.

Background: Despite optimal medical therapy, a significant proportion of patients' blood pressure remains uncontrolled. Catheter‐based renal denervation (RDN) has been proposed as a potential intervention for uncontrolled hypertension. We conducted an updated meta‐analysis to assess the efficacy and safety of RDN in patients with uncontrolled hypertension, with emphasis on the differential effect of RDN in patients on and off antihypertensive medications. Methods and Results: Online databases were searched to identify randomized clinical trials comparing efficacy and safety of RDN versus control in patients with uncontrolled hypertension. Subgroup analyses were conducted for sham‐controlled trials and studies that used RDN devices that have gained or are currently seeking US Food and Drug Administration approval. Fifteen trials with 2581 patients (RDN, 1723; sham, 858) were included. In patients off antihypertensive medications undergoing RDN, a significant reduction in 24‐hour ambulatory (−3.70 [95% CI, −5.41 to −2.00] mm Hg), office (−4.76 [95% CI, −7.57 to −1.94] mm Hg), and home (−3.28 [95% CI, −5.96 to −0.61] mm Hg) systolic blood pressures was noted. In patients on antihypertensive medications, a significant reduction was observed in 24‐hour ambulatory (−2.23 [95% CI, −3.56 to −0.90] mm Hg), office (−6.39 [95% CI, −11.49 to −1.30]), home (−6.08 [95% CI, −11.54 to −0.61] mm Hg), daytime (−2.62 [95% CI, −4.14 to −1.11]), and nighttime (−2.70 [95% CI, −5.13 to −0.27]) systolic blood pressures, as well as 24‐hour ambulatory (−1.16 [95% CI, −1.96 to −0.35]), office (−3.17 [95% CI, −5.54 to −0.80]), and daytime (−1.47 [95% CI, −2.50 to −0.27]) diastolic blood pressures. Conclusions: RDN significantly lowers blood pressure in patients with uncontrolled hypertension, in patients off and on antihypertensive medications, with a favorable safety profile. The efficacy of RDN was consistent in sham‐controlled trials and contemporary trials using US Food and Drug Administration–approved devices.

Acute purulent bacterial pericarditis is of rare occurrence in this modern antibiotic era. Primary involvement of the pericardium without evidence of underlying infection elsewhere is even rarer. It is a rapidly progressive infection with high mortality. We present an extremely rare case of acute purulent bacterial pericarditis in an immunocompetent adult patient with no underlying chronic medical conditions. A 33-year-old previously healthy white man presented with the complaints of chest pain and dyspnea. He was diagnosed as having acute pericarditis and was discharged home on indomethacin. Over a period of 2 weeks, his symptoms worsened gradually and he was readmitted to our hospital. He was found to have large pericardial effusion with cardiac tamponade. An urgent pericardiocentesis was done with drainage of 550 ml of purulent material. Cultures grew Streptococcus intermedius confirming the diagnosis of acute purulent bacterial pericarditis. No other focus of infection was identified on imaging workup suggesting primary infection of the pericardium. His clinical course was complicated by development of constrictive pericarditis for which he underwent surgical pericardiectomy. He received a total of 7 weeks of intravenously administered antibiotics with complete clinical recovery. Acute purulent bacterial pericarditis, although rare, should always be kept in mind as a possible cause of pericarditis. Early recognition and prompt intervention are important for a successful outcome.