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BACKGROUND Hepatitis E virus (HEV) infection is a cause of chronic hepatitis in immunosuppressed patients. Sustained virologic response rates to a 12-wk course of ribavirin therapy were reported to be > 70% in the West. This study describes the outcome of HEV treatment in a transplant center in Singapore. AIM To study the outcome of ribavirin treatment in a series of chronic HEV patients, and the cause of treatment failure. METHODS We studied all of the transplant recipients who were diagnosed with HEV infection between 2012 to 2015. The outcome of therapy and virologic relapse are monitored for three years after the end of therapy. RESULTS Ten transplant recipients (4 liver, 5 kidney, and 1 bone marrow transplantation) with positive HEV RNA were studied. Nine patients received at least 12 wk of ribavirin therapy, and the remaining patient resolved after reducing immunosuppression therapy. Two subjects had prolonged viremia that lasted more than one year, despite continuous ribavirin therapy. Four ribavirin-treated patients (44.4%) had HEV RNA relapse after achieving a virologic response by the end of treatment. The overall failure rate is 66.7%. Being a kidney transplant recipient is the strongest risk factor for not achieving an initial sustained virologic response (0/5 treated, Chi-Square test, P < 0.05). The most common side effect of ribavirin is anemia (100%) (haemoglobin reduction of 3-6.2 g/dL). Seven patients required either a blood transfusion or erythropoietin therapy. CONCLUSION The sustained virologic response rate of 12-wk ribavirin therapy for HEV infection in this Asian series was lower than expected. Kidney transplant recipients had a higher rate of treatment failure due to higher immunosuppression requirements and adverse effects.

Entecavir switch is one of the treatment options for lamivudine-resistant hepatitis B (HBV) patients in Asia. This study examined the outcome of patients with different baseline resistance genotypes in a cohort study. In this study, 14 patients with chronic HBV were treated with entecavir 1 mg/day for 5 years. Enrolment criteria include: documented lamivudine resistant mutations, treatment with adefovir 10 mg/day for at least 24 weeks, and Child-Pugh score <7. Most had previous failed adefovir therapy and compensated cirrhosis of the liver. Clinical outcomes, liver biochemistries, and HBV DNA were monitored regularly. Patients with virologic breakthrough were rescued with add-on adefovir. At the end of the treatment period, the mean HBV DNA fell from 5.92 × 10(6) (baseline) to 3.67 × 10(1)  IU/ml. The presence of a HBV polymerase rtM204V mutation at the baseline was found to be the major risk factor for adverse outcomes. Compared to the patients with the rtM204I mutant, patients with the rtM204V mutant had increased risk of virologic breakthrough (80% vs. 0%, P = 0.010) requiring add-on adefovir, slower virologic responses (log rank test, P = 0.0011), failure to reach undetectable HBV DNA levels (60% vs. 0%, P = 0.045), and higher risk of entecavir-resistance (60% vs. 0%, P = 0.045). All the patients with rtM204I and rtA181 mutants had undetectable HBV DNA from 18th month. In summary, lamivudine-resistant HBV patients with the rtM204V mutation have the highest risk of developing entecavir resistance, and entecavir monotherapy should be avoided. Those with the rtM204I and rtA181V mutations may have lower risks, but regular surveillance for viral breakthrough is required.

Decompensated chronic hepatitis B cirrhotics may suffer early mortality despite antiviral treatment, and therefore should be considered for early liver transplantation.

Sedation by non-anaesthesiologists in gastrointestinal endoscopyLETTER TO THE EDITOR Dear Editor, We read with interest the paper by Ang et al. 1 on Singapore guidelines in the use of sedation by nonanaesthesiologists during gastrointestinal endoscopy in the hospital setting. We are especially intrigued by Statement 6, stating that propofol sedation for endoscopy can be safely and effectively administered by trained non-anaesthesiologists. The sentence from the discussion that resonated most with us was this: "The critical issue for endoscopic procedures is not the administration of propofol by an anaesthesiologist versus an endoscopist, but rather the monitoring of the patient to detect complications, the ability of the physician to recognise and manage the complications, and the availability of resources to manage these complications."We note the high-quality evidence from their GRADE methodology for this statement and agree with their recommendations. Reflecting on these statements has convinced us to evaluate how we train our gastroenterology endoscopy trainees regarding sedation principles, and we are certain that training is crucial if we are to effect this change throughout the nation in allowing endoscopists to administer propofol.Why is it important that endoscopists are trained in using propofol? Propofol sedation is efficacious and has advantages in terms of recovery profile, especially in common populations we see (e.g. cirrhotic patients). Therefore we need to have the flexibility of knowing how to use all the options available for sedation. 2 We understand that this topic may be controversial as the European National Societies of Anaesthesia issued a consensus statement that non-anaesthesiologists should not administer propofol. 3 However, dedicated anaesthesia providers for all types of endoscopies may not be a prudent use of resources. In a cost-effectiveness model, Hassan et al. 4 showed that endoscopist-directed propofol sedation was more cost-effective than anaesthesiologist-administered propofol sedation, and this is especially important in settings with large numbers of low-risk patients and limited anaesthesiology services. Multiple large studies 5,6 have also shown that non-anaesthesiologist-administered propofol (NAAP) was just as safe compared to it being given by our anaesthesiology colleagues.Statement 16 from the same paper by Ang et al. 1 states that non-anaesthesiologists using propofol for sedation should have additional training with respect to propofol,