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Introduction: Pregnant women with chronic hepatitis B (CHB) are at risk of transmitting virus in the perinatal period and may experience post-partum hepatic flares. There are accepted guidelines to manage immune prophylaxis (IPT) in the newborn, but these do not extend to testing response to immunization and there are few recommendations to guide monitoring of the mother postpartum. Our aim was to assess the post-partum care provided to CHB mothers and their babies born at a single Australian center. Method(s): 82 CHB women who delivered live infants at Monash Health between 2008 and 2013 participated in a telephone interview. Demographic and HBV specific data were extracted from medical records. The endpoints assessed were rates of specialist referral for antenatal and post partum surveillance of CHB, completion of infant vaccination and follow up serologic testing. Multivariate logistic regression analysis was utilized to identify the predictors for engagement with specialist care, administration of IPT, completion of the HBV vaccination schedule and serological testing of the baby. Result(s): 17.14% of CHB mothers were newly diagnosed on routine antenatal screening. 62.5% of women were referred for specialist antenatal management of CHB. HBe antigen status was documented in 22% of women. Viral load was tested in 34% of women in the third trimester, 39% of whom had HBV viral load >=7 log10 IU/ml. 4 patients with high viral load were not offered antiviral therapy, 2 were treated with short term tenofovir and 1 refused treatment. 20.59% of CHB mothers did not receive post-partum specialist care and 7.35% failed to attend a scheduled appointment. 89% of babies completed all 4 HBV vaccinations in the first 6 months of life. The rate of serologic testing by 1 year of age was 15.8% for HBsAb and 19.5% for HBsAg. There was no statistically significant association between administration of IPT, completion of the vaccination schedule and serologic testing of the baby with

Introduction: An estimated 160,000 individuals in Australia have chronic hepatitis B (CHB). The chronicity of this disease and in many cases indefinite monitoring and treatment require adherence to management protocols. Disease specific knowledge, health perception and expectations are important factors to consider in the education and management of CHB patients. Our aim was to identify the level of disease specific knowledge in CHB patients newly referred to a tertiary hospital outpatient clinic. Method(s): We conducted a qualitative study that included 6 participants with CHB. These participants were enrolled prior to their first appointment with a Hepatologist at Monash Health between January 2014 and May 2014. Participants were invited to respond anonymously to a questionnaire that included questions on transmission, treatment and complications of CHB, perception and attitude towards CHB and preferred methods of knowledge acquisition. The questionnaire also extracted demographic data. Four weeks after the first consultation, the same questionnaire was administered to measure longitudinal changes in knowledge of CHB. Result(s): The study included 6 males with CHB who were naive to anti viral treatment. All participants were fluent in English and the mean age was 46 +/- 9.1 years. 60% of participants were permanent residents and 50% had completed tertiary education. The mean age of HBV diagnosis was 38.2 +/- 5.2 years. The longitudinal change in knowledge improved in questions examining modes of transmission and antiviral treatment. There was no significant change in knowledge in the domains of disease prevention or long-term complications. Only 40% of participants were aware of HBV vaccination and believed treatment was only warranted in the setting of symptoms. There were also no longitudinal changes in perception and health expectations. Conclusion(s): Our study has identified important shortfalls in disease specific knowledge including the natural history of C

Introduction: The natural history of chronic hepatitis B (CHB) warrants life-long surveillance for complications such as hepatocellular carcinoma (HCC). CHB patients lost to follow up from liver clinics have been poorly characterized and their disease outcomes are unknown. Our aim was to audit the retention rates of CHB patients within a high caseload Australian liver clinic and to identify the barriers to clinic attendance. Method(s): Demographic and disease characteristics of 761 CHB patients referred to the Monash Health liver clinic from 2000 to 2013 were extracted from medical records. Patients identified as lost to follow-up had documented absence of clinical contact for >=9 months. Patients were excluded if transferred to other centers for care. These patients were invited to participate in a survey to assess perceptions of CHB, expectations about disease management, and reasons for non-attendance. Patients lost to follow-up were compared to a cohort of CHB patients who remained in the clinic. Result(s): 499 CHB patients were still attending (SA) and 262 CHB patients were lost to follow-up (LTF) as of the study censure date the 1st of April 2014. Mean age, fibrosis staging with liver biopsy or fibroscan, blood testing and ultrasound for HCC surveillance and antiviral treatment rates were significantly higher in the SA group compared to the LTF group (p < 0.001). 82 CHB patients participated in a qualitative survey. The LTF surveyed group (n = 42) were younger (mean age 38.5 +/- 8.8 years vs. 49.6 +/- 14.3 years, p < 0.001), more likely to be single (26% vs. 7.7%, p = 0.015), and less likely to have been commenced on antiviral therapy (22.92% vs. 78.26%, p < 0.001) compared to the surveyed SA group (n = 40). 64.3% of LTF patients expected antiviral therapy as part of their attendance at the clinic. 42.6% of LTF patients had received no medical care for CHB for a mean of 39.4 +/- 32.3 months, 52.4% had no liver ultrasound or blood tests in the past 12 months. 1

Background and Aims: CXCL-8 is a pro-inflammatory chemokine that induces neutrophil chemotaxis. Low serum CXCL-8 levels correlate with virological response to IFNalfa in HCV patients. We examined the correlation of CXCL-8 and other markers with HBeAg seroconversion and ALT flares in CHB patients treated with IFNalfa. Method(s): Treatment naive CHB patients received either Peg-IFN alone or Peg-IFN and Tenofovir for 48 weeks. Plasma was collected prior to, during and post treatment. CXCL-8, CXCL-10, MCP-1, MIG and IP-10 were measured with cytometric bead array. HBV load, quantitative HBeAg and HBsAg were measured at 9 time points. Result(s): 17 HBeAg positive patients were recruited and 119 longitudinal plasma specimens collected. Serial ALT levels correlated with IL-10 (Spearman's rank correlation coefficient (rho) = 0.399, p < 0.001), MIG (rho = 0.492, p < 0.001) and IP-10 (rho = 0.534, p < 0.001). HBeAg seroconversion occurred in 31.3% of patients (no difference between treatment groups). Serum CXCL-8 >10,000 fg/ml at baseline predicted failure to achieve HBeAg seroconversion (PPV: 100%, NPV: 45%). 50% experienced a post-treatment ALT flare (median 87 days, IQR: 64-150 days post treatment). CXCL-8 >10,000 fg/ml one week post IFNalfa completion predicted a HBV flare within 6 months (PPV: 83%, NPV: 60%). Among patients who flared, an increase in CXCL-8 was detected 4-12 weeks before an ALT rise. Other markers rose in tandem with ALT but did not herald the occurrence of flares. Conclusion(s): CXCL-8 is a potential biomarker for predicting pre and post treatment response to IFNalfa therapy in CHB. CXCL-8 may affect the virological response to IFN-alfa therapy and requires further investigation.

Background and Aims: Cirrhotic ascites is associated with significant morbidity and reduced health-related quality of life. We evaluated whether adherence to quality indicators (QI) of care for ascites affected readmission rates and mortality. Method(s): 302 cirrhotic patients were admitted for new onset ascites between 2000 and 2012. Patient histories were interrogated for demographic and clinical data plus adherence to each of the eight Delphi panel-derived QIs for ascites management. The association between adherence to each QI and 30-day readmission and 90-day mortality were compared on multivariate Poisson and logistic regression analysis. Result(s): Median admission MELD score was 14 (IQR 11-19). 71% of patients were readmitted within 90 days and 41% within 30 days of index admission. The risk of 30-day cirrhosis related readmission reduced significantly if an abdominal paracentesis occurred within 30 days of ascites diagnosis (QI 1: Incidence Rate Ratio (IRR): 0.409, P = 0.004, 95% CI: 0.224-0.747) or during index hospitalization (QI 2: IRR: 0.567, P = 0.006, 95% CI: 0.379-0.850). Baseline serum bilirubin >25 mmol/L increased the risk of 30-day cirrhosis-related readmission (IRR: 1.508, P = 0.033, 95% CI 1.034-2.199). 18.5% of patients died within 90 days of index admission (median interval to death was 139 days; IQR: 37-562 days). Older age (OR: 1.03, P = 0.029) and MELD-Na (OR: 1.06, P = 0.05) independently predicted 90-day mortality. Discharge diuretic prescription (QI 8: OR: 0.28, P = 0.014) was independently associated with a 72% reduction in 90-day mortality. Conclusion(s): Early paracentesis in new onset cirrhotic ascites lowers 30-day readmission rates. Early initiation of diuretic therapy lowers 90-day mortality. Adherence to these QIs should be prioritized in the management of cirrhotic ascites.

Introduction: Chronic Hepatitis B Virus (HBV) affects 400 million people worldwide. It is estimated that 30% of chronically infected adults living in Australia may be unaware of their disease. Universal guidelines recommend opportunistic testing and immunization againstHBVin susceptible household and sexual contacts and first-degree relatives of index cases. Our aim was to identify the factors which influence screening and HBV immunization in relatives and household contacts of patients with chronic HBV. Method(s): Individuals identified as a first degree relative, household or sexual contact of a Chronic HBV patient attending the Monash Health liver clinic were invited to participate in an online survey which was translated into Vietnamese, Mandarin, Khmer, Dhari and Arabic. Screening and vaccination rates for HBV as well as the factors influencing uptake were captured and analyzed on multivariate logistic regression. Result(s): The baseline characteristics for the 24 respondents are summarized in Table 1. 71% self-reported a history of HBV vaccination, with 35% of these respondents completing the full course. Of those who had not been vaccinated, 28.6% did not believe there was a need to be vaccinated. The reported barriers to vaccination included perceived lack of access (43%), needle phobia (43%) and time constraints (17%). 11% of all participants reported there was a stigma attached to requesting or receiving HBV vaccination. There was a 91.7% rate of opportunistic testing for HBV. 16% had self-initiated serologic testing and 58% of testing was instigated by the GP. The primary reason for HBV screening in 68.4% of participants was knowing someone with CHB. There was no statistically significant association between a participant's age, gender, fluency in English years living in Australia and rates of screening and receiving HBV vaccination. There was also no correlation between vaccination status and testing for HBV (OR 2.4, p = 0.32). Conclusion(s): In relative

© 2014 IEEE. QoS-based service rating has made positive contributions to the area of service selection. Especially for Cloud service users, the right decision when choosing suitable Cloud services can help them improve user satisfaction and trading revenues. This work aims to address the issue of uncertainty in service requests, service descriptions, user and expert preferences, as well as evaluation criteria in a MCDM-based service selection procedure. A hybrid fuzzy framework for Cloud service selection is proposed, addressing the challenge using three approaches: a fuzzy-ontology-based approach for function matching and service filtering; a fuzzy AHP technique for informed criterion weighting; and, a fuzzy TOPSIS approach for service ranking.

© 2014 IEEE. With the advent of Cloud computing and subsequent big data, online decision makers usually find it difficult to make informed decisions because of the great amount of irrelevant, uncertain, or inaccurate information. In this paper, we explore the application of multicriteria decision-making (MCDM) techniques in the area of Cloud computing and big data, to find an efficient way of dealing with criteria relations and fuzzy knowledge based on a great deal of information. We propose a MCDM framework, which combines the ISM-based and ANP-based techniques, to model the interactive relations between evaluation criteria, and to handle data uncertainties. We present an application of Cloud service selection to prove the efficiency of the proposed framework, in which a user-oriented sigmoid utility function is designed to evaluate the performance of each criterion.

QoS-based service rating has made positive contributions to the area of service selection. Especially for Cloud service users, the right decision when choosing suitable Cloud services can help them improve user satisfaction and trading revenues. This work aims to address the issue of uncertainty in service requests, service descriptions, user and expert preferences, as well as evaluation criteria in a MCDM-based service selection procedure. A hybrid fuzzy framework for Cloud service selection is proposed, addressing the challenge using three approaches: a fuzzy-ontology-based approach for function matching and service filtering; a fuzzy AHP technique for informed criterion weighting; and, a fuzzy TOPSIS approach for service ranking.

With the advent of Cloud computing and subsequent big data, online decision makers usually find it difficult to make informed decisions because of the great amount of irrelevant, uncertain, or inaccurate information. In this paper, we explore the application of multicriteria decision-making (MCDM) techniques in the area of Cloud computing and big data, to find an efficient way of dealing with criteria relations and fuzzy knowledge based on a great deal of information. We propose a MCDM framework, which combines the ISM-based and ANP-based techniques, to model the interactive relations between evaluation criteria, and to handle data uncertainties. We present an application of Cloud service selection to prove the efficiency of the proposed framework, in which a user-oriented sigmoid utility function is designed to evaluate the performance of each criterion.

Introduction: The bone disease associated with chronic liver disease is common and poorly characterised in patients with chronic viral hepatitis. Tenofovir is recommended as first line therapy for chronic hepatitis B (CHB); however, an association with increased bone loss and kidney toxicity in HIV lead us to investigate bone mineral density (BMD) and renal tubular function in hepatitis B patients. Method(s): We conducted a cross-sectional single-centre study of CHB patients treated with tenofovir compared to untreated CHB patients. BMD was measured by dual-energy X-ray absorptiometry (DXA) at the hip and lumbar spine and expressed as a Z score (age and gender adjusted). Testosterone, oestradiol, calcium, phosphate, PTH, 25(OH)VitD and biochemical markers of bone turnover (C-telopeptide of type I collagen (CTX), N-terminal propeptide of type I collagen (P1NP)) were measured. Urine testing for phosphate, amino acid, B2-microglobulin and glucose excretion was performed. Mann Whitney U was used to compare baseline characteristics and multivariate logistic regression to adjust for cirrhosis status, age, gender and weight. Result(s): 10 untreated CHB controls and 22 patients treated with tenofovir (mean treatment duration 2.6 +/- 1.4 years) were enrolled. The mean age was 44.1 +/- 8.7 and 52% were female (11.8% post-menopausal) and 48% were male (6.2% hypogonadal). Cirrhosis was present in 16% (5 patients on tenofovir; no patients in the control group). BMD at the lumbar spine as measured by Z score was lower in the tenofovir treated group compared to controls in the univariate analysis (-1.14 +/- 1.18 vs -0.2 +/- 1.3, P = 0.02) and remained significant in the multivariate analysis (P = 0.03) after adjusting for cirrhosis, age, gender and weight. There was no significant difference in serum calcium, phosphate, P1NP, CTX, 25(OH)VitD between the tenofovir and control group. Increased duration of tenofovir use was correlated with increased urinary excretion of phosphate (r

A 56-year old man presented with a 2-week history of intermittent right upper quadrant and central abdominal pain. He also reported night sweats, fever, vomiting and diarrhoea. The past medical history included asthma, ischaemic heart disease, hypertension and gastro-oesophageal reflux disease. Aspirin was the only regular medication. Physical examination revealed a fever of 38.7degreeC and positive Murphy's sign. Laboratory studies revealed a peripheral eosinophilia of 12.70 x 109/L (RR: 0.0-0.5 x 109/L) and erythrocyte sedimentation rate (ESR) of 37 (RR: 0-15 mm/hr). Lipase was 91 U/L (RR: <60 U/L). Atypical p-ANCA was positive. Urinary sediment was bland with normal red cell morphology. A cholecystectomy was performed. The gallbladder histopathology demonstrated a medium vessel eosinophilic necrotising vasculitis. Contrastenhanced computed tomography of the abdomen showed multiple liver lesions and celiac axis lymphadenopathy.The pancreatic head was enlarged measuring 75 mm x 65 mm as well as duodenal wall thickening. A small bowel biopsy obtained during oesophagogastroduodenoscopy revealed eosinophilic duodenitis. A bone marrow aspirate excluded a primary haematological malignancy but revealed a high eosinophil count of 8.0% (1.1-5.3%). This patient was diagnosed with Churg-Strauss syndrome (CSS) according to the Lanham diagnostic criteria. Our case is noteworthy as the CSS predominantly affected the foregut with involvement of the duodenum, pancreas, liver and gall bladder.A complete clinical, biochemical and radiological remission was achieved with oral corticosteroids (1 mg/kg), which was weaned over 6 weeks.The patient remains in remission after 3 years of follow-up. Whilst this case masqueraded as metastatic malignancy, a high index of clinical suspicion was raised by the presence of a peripheral eosinophilia and the past history of asthma, which prompted further investigations. Issues of Interest in the Case * Eosinophilic infiltration of the gastrointesti

Background/Aims: Hepatitis B virus (HBV) is a global health concern with 450 million chronically infected worldwide. Due to migration from endemic countries, CHB significantly contributes to chronic liver disease in Australia. Transition from primary to tertiary care for the management of CHB is poorly characterised. The aim of this study is to evaluate risk factors impacting access to tertiary care for CHB patients. Method(s): 204 new CHB patients were referred to Liver Clinics at Monash Health between January 2010 and 2012. Our retrospective study systematically reviewed the General Practitioner (GP) referral regarding the patient's ethnicity and stage of CHB. Patient histories were interrogated extracting clinical characteristics and virological data. Engagement with the Liver Clinics was quantified according to time from referral to first clinic appointment, non-attendance, loss to follow-up and this was correlated with ethnicity, gender, age, CHB phase, presence of advanced disease and geographical distance between patient's residence and clinics. Result(s): Of the 204 patients referred, 62% attended the clinics. The mean waiting time from the date of the referral to first attendance was 403 +/- 289 days. Of those who had one or more clinic engagements, 47% were lost to follow up through non-attendance as of the 1st January 2013. Ten patients were classified as cirrhotic in the GP referral, 9 attended clinic, the waiting time to the first attendance was 349 +/- 364 days vs.408 +/- 289 in the noncirrhotic population (p-value: 0.6). The immunological phase of CHB was characterised in 60% of the patients in the referral with 9.3% in immune clearance phase and 1% in immune escape phase. Top 5 ethnicities were Cambodian 24%, Vietnamese 24%, Mainland Chinese 18%, Afghani 7% and Sudanese 5%. Multivariate logistic regression analysis found no association between age, gender and geographical distance from clinic with rates of attendance, loss to follow up and clinic wai

Background and aims: The MELDNa was developed to improve the prognostic value of the MELD score in predicting mortality for patients with cirrhosis. The utility of MELDNa to predict other clinical outcomes in patients with cirrhosis and an initial presentation of decompensation with ascites has not been assessed. Our study evaluated the prognostic value of MELDNa as a predictor of health care utilization and overall mortality among such patients. Method(s): A retrospective cohort study was performed in patients with cirrhosis and new onset ascites admitted to a large tertiary hospital between January 2002 and January 2012. Patient histories were interrogated for demographic and clinical data including serum sodium, MELD, aetiology of cirrhosis, readmission, frequency of hospitalization and mortality. The predictive factors for re-admission, frequency of hospitalization and overall mortality were analyzed and compared using logistic regression. Result(s): We identified 302 patients with cirrhosis and new onset ascites; of these 71% were re-admitted within 90 days of their index admission. The top 3 diagnoses for re-admission were recurrence of symptomatic ascites (42%), hepatic encephalopathy (15%) and variceal haemorrhage (10%). Multivariate logistic regression analysis (Table 1) showed that MELDNa was the only independent risk factor for re-admission (OR 3.806, CI 1.69-8.52, p = 0.006). Gender, serum sodium, MELD, aetiology of cirrhosis, living alone and prescription of diuretics or prophylactic antibiotics upon discharge from the index admission were not risk factors for re-admission. While a predictor of readmission, MELDNa failed to predict mortality (p = 0.950). Interestingly, younger age appeared to be a protective factor for re-admission. Conclusion(s): In patients with cirrhosis presenting with ascites as their initial episode of decompensation, MELDNa predicted re-admission but not long- term mortality, which may reflect effective therapy for ascites. (Tabl

Background In comparison to the general population, Hepatitis C virus (HCV) infection is more prevalent in patients with chronic kidney disease (CKD). Furthermore, renal transplant candidates infected with HCV experience low rates of antiviral treatment and increased morbidity and mortality from accelerated liver disease post-transplantation. Reduced renal allograft survival in HCV positive recipients has been reported in observational studies with 5 years of follow-up. However, the rates of HCV treatment and the longer-term clinical outcomes beyond 5 years for renal transplant recipients in Australia remain poorly characterised. Aims To describe the baseline demographics, determinants of HCV seroclearance and graft survival in a single-centre Australian cohort of renal transplant recipients. Methods We conducted a retrospective analysis of patients with chronic HCV who underwent renal transplantation between 1974 and 2011 (n = 19) at Monash Medical Centre, Victoria. Patient histories were interrogated for staging and management of both chronic kidney disease (CKD) and HCV. The determinants of HCV seroclearance and graft loss were identified. Results For a summary of baseline patient characteristics please refer to Table 1. 19 patients received a total of 26 renal grafts over a mean observation period of 15.7 +/- 13 years (range 1 to 38 years). 22% of these patients have returned to dialysis. Of those referred for consideration of HCV assessment pre renal transplant, treatment was deferred in 84% due to either a low ALT, low viral load, low fibrosis scores or concerns regarding potential side effects. This is compared to a 50% rate of treatment deferral in normal HCV patients reviewed through our centre. Despite low rates (3/19) of pre transplant HCV treatment there were 2 patients who achieved a sustained virological response (SVR) with combination pegylated interferon and ribavirin. These patients had HCV Genotype 1 and Genotype 2 respectively with low fibrosis sc

Background Tenofovir (TDF) and Entecavir (ETV) are nucleos(t)ide (NUC) analogues which are potent inhibitors of hepatitis B virus. However, the long-term effect of TDF on renal function in CHB patients remains unclear. Aims To compare the incidence, severity and clinical significance of changes in renal function over 2 years amongst CHB patients treated with TDF 300 mg daily or ETV 0.5 mg or 1.0 mg daily versus an untreated cohort. Methods We retrospectively identified 124 patients treated with either ETV (n = 74) or TDF+/- LMV (n = 50) for a minimum of 2 years. 73 untreated CHB patients were used as controls. Renal function was assessed by estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease formula (MDRD) at baseline, 6, 12 and 24 months. Exclusion criteria included concomitant use of potential nephrotoxins, decompensated cirrhosis and previous NUC exposure apart from lamivudine if renal function was normal upon commencement of TDF. Baseline demographics, MELD score, presence of cirrhosis and risk factors for renal impairment were recorded. Outcomes assessed included kidney function (decline in eGFR >=40% and change in eGFR over time) and dose adjustment or cessation of either therapy. Analysis was performed using a mixed linear model to incorporate repeated measures. Results Baseline characteristics were closely matched between the three cohorts (p = NS). Older age (p = 0.0043) and cirrhosis (p < 0.0001) were more prevalent in the ETV group. The proportion of patients with >=40% reduction in eGFR from baseline was 3.92% in the TDF +/- LMV group vs. 2.7% in the ETV group (p = NS). In the univariate mixed linear model, compared to control subjects at baseline, eGFR at 2 years declined in the ETV group by -7.6 ml/min (95% CI -15.8-+0.6, p = 0.07) and -8.7 ml/ min (CI -18.3-+1.0, p = 0.08) in the TDF +/- LMV group while in the control it remained stable at +7.4 ml/min (CI 0.78 - 14.1, p = 0.03). After adjustment for age, gender

Background The management of baseline anticoagulants in patients with non-valvular AF undertaking an endoscopic procedure is a common clinical problem. There is a lack of evidence-based protocols to guide management of peri-endoscopic anticoagulation. The clinical and economic impact of incorporating CHA2DS2VASc - a new stroke risk stratification model - in this clinical context has yet to be elucidated. Aims The aim was to determine the 30-day incidence of bleeding and cerebrovascular accidents (CVA) in patients with non-valvular AF undergoing endoscopic procedures and to project the potential clinical impact of integrating CHA2DS2VASc into routine clinical practice. Methods We conducted a retrospective study of 113 patients with non-valvular AF who underwent 130 endoscopic procedures at Monash Medical Centre, Victoria between March 2011 to March 2012. All patients had one of the following procedures: Colonoscopy +/- polypectomy, Endoscopic retrograde cholangiopancreatography (ERCP) +/- sphincterotomy or an Endoscopic ultrasound (EUS) +/- fine needle aspiration (EUS). Baseline characteristics and 30-day complications were recorded. CHADS2 and CHA2DS2VASc scores were calculated for each patient. Results The 30 day bleeding rate was 6.2% with 5% requiring hospital admission. The mean CHADS score was 3 +/- 1 versus a mean CHA2DS2VASc of 4 +/- 1.4. Only 1 patient had a CVA (CHADS score 3) after warfarin was withheld for 6 days following ERCP and sphincterotomy without bridging anticoagulation. The low rate of CVA could be attributed to a 40% rate of bridging anticoagulation with clexane for patients on warfarin. 14% of patients during were reclassified to a higher stroke risk classification mandating warfarinastion which may increase the risk of post endoscopy bleeding. On projected analysis, the cost of providing bridging anticoagulation for these extra 14% patients is $13,500 through hospital in the home per year. A comparision of demographics and outcomes in each gr

Background Fanconi syndrome is a rare complication of long-term adefovir therapy for chronic hepatitis B virus (CHB). Aims We describe the first case series of two CHB patients diagnosed with avascular necrosis (AVN) in the setting of adefovir-induced Fanconi Syndrome. Methods The case records are as documented below: Results Case 1: A 52 year-old Asian male presented with decompensated cirrhosis from CHB eAntigen (eAg) positive disease. He was commenced on lamivudine (LMV) 100 mg daily in 2003. Adefovir was introduced following the development of LMV resistance. The dose was progressively increased to 20 mg daily to maintain viral suppression. The patient underwent bilateral total hip replacements in September 2011 to treat bilateral femoral head AVN and proximal femoral fractures. Biochemistry showed severe hypophosphataemia (PO4: 0.44 nmol/L RR: 0.80-1.50), vitamin D deficiency (19 nmol/L RR: 75-250) and de novo renal dysfunction with serum creatinine 160 mumol/L (RR: 55-105) and elevated ALP (546 U/L RR: 30-120). Further investigations revealed the full spectrum of Fanconi syndrome including: hypokalaemia, hypophosphataemia, non-anion gap metabolic acidosis and normoglycaemic glycosuria. Symptoms resolved two weeks after aggressive correction of vitamin D, calcium and phosphate. Adefovir and lamivudine combination therapy were ceased and the patient was switched to entecavir 1.0 mg daily. Case 2: A 64 year-old Asian female with eAg-negative CHB was treated with lamivudine 100 mg daily from 2001. Adefovir 20 mg daily was added in 2008 for a similar indication to Patient 1. In July 2010, the patient developed bilateral disabling knee pain associated with hypophosphataemia (0.51 nmol/L), increased ALP, elevated serum creatinine (101 mumol/L), hypouricaemia (111 U/L RR: 160-35), non-anion gap metabolic acidosis and hypokalaemia (2.6 mmol/L RR: 3.5-5.0). An MRI of the knees in July 2011 showed bilateral proximal insufficiency tibial fractures complicated by AVN. A DE

Introduction IgG4 related sclerosing cholangitis is a novel disease entitywhich, while often associated with autoimmune pancreatitis, can presentin isolation. We describe two patients diagnosed with IgG4 related sclerosingcholangitis with contrasting clinical presentations and treatmentcourse.Case 1: A 43 year-old man was referred in Dec 2010 with painlessobstructive jaundice. He reported a 9-month history of 20 kg loss ofweight, right upper quadrant pain, fevers and deranged liver function tests.The patient had left sided proptosis, bilateral submandibular and parotidgland enlargement. An abdominal CT demonstrated mass lesions of thekidneys, liver, pancreas and gall bladder. MRCP confirmed a common bileduct stricture measuring 15 mm in length. The serum IgG4 level wasmarkedly elevated at 17.6 g/L (normal range: 0.04-0.86 g/L). The patienthad a laparoscopic cholecystectomy for the purpose of histopathologicaldiagnosis. This demonstrated multiple pseudo tumours of the gall bladder,which stained 80% positive for IgG4. Treatment with oral corticosteroidresulted in clinical and radiological remission of the patient's pseudotumours, lymphadenopathy and biliary stricture. Disease remission hasbeen maintained with azathioprine for 6 months.Case 2: A 73 year-old man presented with a 4-month history of painlessobstructive jaundice and 12 kg loss of weight. CT cholangiogram demonstrateda 2 cm hilar mass associated with a CBD stricture suspicious fora cholangiocarcinoma of the porta hepatis. Cytology on EUS guided FNAshowed benign cells. The biliary stricture and presumed cholangiocarcinomawere treated by right hemi-hepatectomy and the bile duct reconstructedwith roux-en-y limb. Histopathology of the resected lesionshowed a 20 mm x 12 x 20 mm mass with a moderate infiltration oflympho-plasmacytic cells. IgG4 immunostain of the specimen showed thatthe majority of plasma cells were IgG4 positive. The patient has not beentreated with corticosteroids as there has been no evidence

A 40 year-old man presented to a General Surgeon with a 9 month history of dramatic weight loss, right upper quadrant pain and deranged liver function tests. His abdominal CT demonstrated multiple liver, pancreatic, gall bladder and bilateral renal lesions as well as diffuse intra-abdominal lymphadenopathy suspicious for malignant lymphoma. His past history included recurrent presentations to 3 different hospitals over a period of 3 years for recurrent pancreatitis, cholecystitis, biliary strictures and a left retro-orbital mass. The diagnosis of IgG4 related systemic disease (ISRD) was considered and his biochemistry demonstrated a markedly elevated serum IgG4 level. Furthermore, retrospective analysis of his previous lacrimal gland biopsies showed strongly positive tissue immunostaining for IgG4. The patient proceeded to have a laparascopic cholecystectomy which demonstrated multiple pseudotumours which also stained positive for IgG4. Clinical and radiological remission of the patient's lymphadenopathy and pseudotumours was achieved with corticosteroids and maintained with azathioprine. This case illustrates the natural history of progressive IRSD and its varied clinical presentations. Issues of Interest in the Case 1. IgG4 related systemic disease is an under recognized condition which often clinically, histologically and radiologically mimics as multicentric Castleman's syndrome or malignancy. 2. It is a novel disease entity with variable manifestations. 3. It is a condition which should be easily diagnosed with a serum IgG4 level and immunostain. 4. Early diagnosis and treatment is important, as the condition is highly steroid-responsive.

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