Proton pump inhibitors and bleeding ulcers.

In this randomized controlled trial done at the National Cheng Kung University, Tainan, Taiwan, Cheng et al. aimed to establish the role of an increased and more aggressive dosage of esomeprazole in reducing peptic ulcer bleeding in high-risk patients. They aimed to evaluate whether a twice-daily oral dose of esomeprazole would be more effective than the present approach of a single-daily dose of 40 mg oral esomeprazole after the initial infusion in patients with high Rockall scores. They enrolled 293 patients with bleeding peptic ulcers who were managed with endoscopic means and esomeprazole infusion for 3 days following which, patients with a Rockall score >6 were randomized to receive either oral esomeprazole 40 mg twice daily (double-dose group; n=93) or once daily (standard-dose group; n=94). This therapy was continued for 11 days following which esomeprazole was continued in a once-daily dose for another 2 weeks till the 28-day study period. Among patients with high Rockall scores, the cumulative proportion of rebleeding-free patients was higher in the double-dose group as compared with the standard-dose group (p=0.02). The day 4 to 28 rebleeding in patients with a high Rockall score was significantly lower in the double-dose group compared with the standard-dose group (10.8% v. 28.7%, p=0.002). The proportion of patients free from rebleeding during days 4 to 28 among patients with a high Rockall score in the double-dose group remained lower than that of the group with a Rockall score <6 (p=0.03).

Role of ultrathin transnasal esophagogastroduodenoscopy: experience with 50 patients.

Conventional gastroscopes have a diameter of 8.8–12 mm; ultrathin endoscopes have an outer diameter of 5.3–5.9 mm. We share our experience with 50 patients who underwent transnasal esophagogastroduodenoscopy using an ultrathin endoscope. The indications included endoscopyassisted nasogastric tube placement in 25 patients, tight lesions not negotiable with conventional endoscope in 9, restricted mouth opening in 9, corrosive injury in 3, restricted cervical spine movement in 2 and altered sensorium following cerebrovascular accident in 2 patients. Transnasal esophageal intubation failed in 1 patient each with oropharyngeal malignancy and lipoma annularis coli. Wire-guided naso-jejunal tube placement was done in 2 patients and transnasal percutaneous endoscopic gastrostomy was done in 1 patient. Two patients developed self-limiting epistaxis. Ultrathin transnasal esophagogastroduodenoscope is a useful tool in endoscopy units, particularly those dealing with oncology patients. Inability to deliver endotherapy due to small diameter of the working channel is a limitation.

Treatment of chronic hepatitis B: will entecavir and telbivudine do the trick?

Rapid evolution and development in the treatment strategy of chronic hepatitis B (CHB) has taken place in the last decade. Six agents have been so far approved by the FDA for the management of HBV infection including two parenteral drugs (interferon alpha2b and pegylated interferon alpha-2a) and four oral nucleotide/nucleosides (lamivudine, adefovir dipivoxil, entecavir, and telbivudine). The two parenteral drugs have significant side effects and limited rates of HBeAg seroconversion. Lamivudine and Adefovir have been plagued by significant levels of drug resistance.The newer drugs entecavir and telbivudine have been in focus recently with claims of increased potency, with low side effects and lesser drug resistance. While these new drugs are definitely a welcome addition to the family of antiviral drugs against HBV, they are not necessarily a cure for all the evils of their predecessors.