Background:Hepatitis C virus (HCV) infection can now be cured with well-tolerated direct-acting antiviral (DAA) therapy. However, a potential barrier to HCV elimination is the emergence of resistance-associated substitutions (RASs) that reduce the efficacy of antiviral drugs, but real-world studies assessing the clinical impact of RASs are limited. Here, an analysis of the impact of RASs on retreatment outcomes for different salvage regimens in patients nationally who failed first-line DAA therapy is reported.Methods:We collected data from 363 Australian patients who failed first-line DAA therapy, including: age, sex, fibrosis stage, HCV genotype, NS3/NS5A/NS5B RASs, details of failed first-line regimen, subsequent salvage regimens, and treatment outcome.Results:Of 240 patients who were initially retreated as per protocol, 210 (87.5%) achieved sustained virologic response (SVR) and 30 (12.5%) relapsed or did not respond. The SVR rate for salvage regimens that included sofosbuvir/velpatasvir/voxilaprevir was 94.3% (n = 140), sofosbuvir/velpatasvir 75.0% (n = 52), elbasvir/grazoprevir 81.6% (n = 38), and glecaprevir/pibrentasvir 84.6% (n = 13). NS5A RASs were present in 71.0% (n = 210) of patients who achieved SVR and in 66.7% (n = 30) of patients who subsequently relapsed. NS3 RASs were detected in 20 patients (20%) in the SVR group and 1 patient in the relapse group. NS5B RASs were observed in only 3 patients. Cirrhosis was a predictor of relapse after retreatment, as was previous treatment with sofosbuvir/velpatasvir.Conclusions:In our cohort, the SVR rate for sofosbuvir/velpatasvir/voxilaprevir was higher than with other salvage regimens. The presence of NS5A, NS5B, or NS3 RASs did not appear to negatively influence retreatment outcomes.

Background & aims: To describe the process of credentialing and implementing dietitian insertion of nasogastric tubes (NGTs) in a regional setting in Australia, and report on patient outcomes, timeliness and safety of insertion, and staff acceptance. Methods: An observational, mixed-methods study of service and patient outcomes was undertaken during the 2 years (2018-2020) following the implementation of dietitian credentialling for the insertion and management of NGTs. Data relating to the insertion of NGTs by credentialled dietitians were collected prospectively. A staff survey was circulated during and after the data collection period. Data has been reported descriptively. Results: The model of care was successfully implemented with two dietitians credentialed to insert NGTs. There were 38 unique occasions of NGT insertions for 31 individual patients. Eighty-seven percent (n = 33) of cases were inpatients. NGT insertion was successfully performed by the dietitian 82% of the time (n = 31). No medical complications relating to NGT insertion were reported following a dietitian inserted NGT, with the exception of one incidence of mild epistaxis. The average insertion time was 25.5 min (14.1), the average number of insertion attempts by a dietitian was 1.7 (1.27) and on one occasion more than one x-ray was required. Conclusion: This study supports the recommendations of Dietitians Australia that this model of care is viable as an extended scope of practice model of care for dietetic departments across Australia. This evaluation adds to the evidence base for extended scope of practice and informs future directions for the service and training of dietitians. Crown Copyright (c) 2023 Published by Elsevier Ltd on behalf of European Society for Clinical Nutrition and Metabolism. All rights reserved.

INTRODUCTION:Aboriginal and Torres Strait Islander Australians living in remote locations suffer disproportionately from chronic hepatitis B (CHB). Defining the temporospatial epidemiology of the disease-and assessing the ability of local clinicians to deliver optimal care-is crucial to improving patient outcomes in these settings.METHODS:The demographic, laboratory and radiology findings in all patients diagnosed with CHB after 1990, and presently residing in remote Far North Queensland (FNQ), tropical Australia, were correlated with their management and clinical course.RESULTS:Of the 602 patients, 514 (85%) identified as Aboriginal and Torres Strait Islander Australians, 417 (69%) of whom had Torres Strait Islander heritage. Among the 514 Aboriginal and Torres Strait Islander Australians, there were only 61 (12%) born after universal postnatal vaccination was introduced in 1985. Community CHB prevalence varied significantly across the region from 7/1707 (0.4%) in western Cape York to 55/806 (6.8%) in the Eastern Torres Strait Islands. Although 240/602 (40%) are engaged in care, with 65 (27%) meeting criteria for antiviral therapy, only 43 (66%) were receiving this treatment. Among 537 with complete data, 32 (6%) were cirrhotic, of whom 15 (47%) were engaged in care and 10 (33%) were receiving antiviral therapy. Only 64/251 (26%) in whom national guidelines would recommend hepatocellular carcinoma (HCC) surveillance are receiving screening, however, only 20 patients have been diagnosed with HCC since 1999.CONCLUSION:Vaccination has had a dramatic effect on CHB prevalence in FNQ in only a generation. However, although engagement in care is the highest in Australia, this is not translating into initiation of antiviral therapy in all those that should be receiving it, increasing their risk of developing cirrhosis and HCC. New strategies are necessary to improve the care of Indigenous Australians living with CHB to reduce the morbidity and mortality of this preventable disease.

INTRODUCTION: Idiopathic functional esophagogastric junction outflow obstruction (EGJOO), also called variant of achalasia or achalasia in evolution, is a newly defined abnormal esophageal pressure topographic pattern, characterized by an elevated median integrated relaxation pressure (IRP) with intact peristalsis. The clinical significance of this disorder is still unclear. The aim of this study was to evaluate and find any disparities in the presenting symptoms, diagnostic evaluation, and treatment strategy of EGJOO patients at two hospitals. METHODS: This is a four-year follow up case series of EGJOO between 2016 and 2020, at King Faisal Specialist Hospital (KFSH) & Research Centre, Riyadh, Saudi Arabia, and Cairns Hospital (CH), Cairns, Australia. The presenting symptoms were graded according to Eckardt achalasia score. The diagnosis of EGJOO was based on high IRP of more than 15 mmHg with intact peristalsis based on Chicago classification (version 3.0), acquired by MonoScan (Medtronic Inc. Minnesota, USA). The mean Lower Esophageal Sphincter (LES) Basal Pressure, Integrated Relaxation Pressure (IRP), Distal Contractile Integral (DCI), Distal Latency (DL) and Multiple Rapid Swallows (MRS) were recorded. Dysphagia patients with mechanical obstruction were excluded by endoscopy, barium swallow, CT scan or EUS. Depending on the age, comorbid conditions and severity of symptoms; patients were given conservative treatment, botox injection or achalasia balloon dilatation. RESULTS: 37 patients were included in this study (11 from CH and 26 from KFSH). 72.4% were females (M:F = 8:29) and average age was 60.1 years. Mean Eckardt Score was 4.0 (CH 7.8 and KFSH 2.4). MRS showed LES obstruction in 54.5% patients at CH while only 30.8% at KFSH. The basic high-resolution manometry data were not statistically significant between the two hospitals (Table 1). 26 patients received conservative treatment (KFSH 20, CH 6), 7 received botox injection (KFSH 2, CH 5) and 1 received achalasia balloon dilatation (KFSH 0, CH 1).Table 1CONCLUSION: EGJOO was mainly observed in older females. There were no statistically significant differences between the manometric data of the two hospitals. Majority of the patients in CH had high Eckardt score and showed partial LES obstruction during MRS challenge. Botox injection was the main therapeutic option in CH while conservative treatment was mainly practiced at KFSH.

INTRODUCTION: Benign esophageal strictures (BES) are mostly caused by gastroesophageal reflux disease (GERD). Although their incidence is declining with the increasing use of proton pump inhibitors (PPIs), the overall incidence of BES has not changed due to higher reported cases of eosinophilic esophagitis (EOE). The aim of this study is to determine the prevalence, common causes, and management approach of BES in a community-based hospital. METHODS: A retrospective chart review was done for all patients referred to Cairns Hospital endoscopy unit over a period of five years between 2015- and 2020. The data was obtained from an endoscopy-based program “ProvationMD,” by searching 2 keywords “esophagus” and “stricture.” 181 patients with BES were identified. Patient’s demographic data including age, gender, ethnicity, etiology, symptoms, EGD (esophagogastroduodenoscopy) findings, histopathology, and treatment plan were entered into an excel spreadsheet. Malignant strictures were excluded from the study. RESULTS: The prevalence of BES in our cohort was 1.62% (181 cases out of total 11152 EGDs). Mean age was 61(±15) years and 81% of BES patients were above 50, out of which the majority were males (M:F = 68:32). 17 patients (9%) were people with indigenous background. The most common cause of BES was GERD seen in 83 patients (46%), followed by esophageal stricture of unknown etiology in 25 patients (14%) in which the biopsy was inconclusive. The other causes of BES are as shown in Table 1. Esophageal biopsies were not taken in 8 patients (4%) with esophageal strictures, so the etiology was not established. 79 patients (43%) required intervention on their first elective or emergency visit. The most preferred method of dilatation in their first visit was TTS (through the scope) balloon, used in 56 (39%) patients, followed by Savary-Gilliard dilators in 19 (13%) of cases. In 3 (2%) of cases, the endoscope was used as a dilator. Out of 181 patients, 44 patients (24%) required a single dilatation and 75 patients (41%) required multiple dilatations.Table 1.: Causes of Benign Esophageal StrictureCONCLUSION: The prevalence of BES is significantly higher in our cohort than is reported in the literature. GERD was the commonest cause followed by stricture of unknown etiology and EOE. Two-third of the patients with BES required esophageal dilatation. TTS balloon was the most preferred method of dilatation used in the first visit.

Direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) has excellent cure rates and minimal side effects. Despite the high burden of disease, strategies to ultimately eradicate HCV are being developed. However, the delivery of care in regional settings is challenging and the efficacy of decentralised models of care is incompletely defined.A prospective cohort study of patients whose treatment was initiated or supervised by Cairns Hospital, a tertiary hospital which provides services to a culturally diverse population across a 380,748 km2 area in regional Australia. Patients' demographics, clinical features, DAA regimens and outcomes were recorded and correlated with their ensuing clinical course.Over 22 months, 734 patients were prescribed DAA therapy for HCV. No patients were prescribed interferon. Sofosbuvir/ledipasvir (n=371, 50.5%) and sofosbuvir/daclatasvir (n=287, 39.1%) were the most commonly prescribed regimens. No patients ceased treatment due to adverse effects. There were 612/734 (83.4%) patients with complete results, with 575 (94%) cured. At the end of the study period, there were 50 (6.8%) patients lost to follow-up and 72 (9.8%) awaiting SVR12 testing. The presence of cirrhosis (n=147/612, 24.1%) did not impact significantly on SVR12 rates, this being achieved in 136/147 (92.5%) cirrhotic patients versus 440/465 (94.6%) in non-cirrhotic patients (p=0.34). Treatment-experienced patients (95/612, 18.3%) were more likely to be non-responders than treatment-naïve patients (10/95 (10.5%) versus 26/517 (5%), p=0.04). Strategies to facilitate treatment included a dedicated clinical nurse consultant, education to primary health care providers, specialist outreach clinics to regional communities and shared care with general practitioners. SVR12 rates were similar amongst gastroenterologists (283/306, 92.5%), general practitioners (152/161, 94.4%), sexual health physicians (104/106, 98.1%) and other prescribers (37/39, 94.9%).This study confirms that decentralised, multidisciplinary models of care can provide HCV treatment in regional and remote settings with excellent outcomes.

BACKGROUND & AIMS:Incidence and mortality of hepatocellular carcinoma (HCC) is increasing globally, but varies between countries and regions. To target scarce resources to most need, clinical services must be informed by regional epidemiology. Using population-based data, we sought to document the incidence and mortality of HCC in Queensland, Australia, a state occupying a vast land area with diverse at-risk subpopulations.METHODS:Using population-based data from 1996 to 2011, the age-standardised incidence rate (ASR), annual percentage change (APC) and survival of HCC in Queensland were assessed with negative binomial regression, Kaplan-Meier and Cox survival analysis. Spatial patterns of HCC incidence and survival and relevant predictors were mapped.RESULTS:Thousand six hundred and twenty HCCs were diagnosed during this study period, with an overall ASR of 2.00-cases/1000 population. ASR increased by 3.5% per year, (95% CI: 2.1 to 5.0), P < 0.001) among males to 5.6/100,000 in 2011 and a non-significant increase of 2.6% per year, (95% CI = -0.7 to 6.0), P = 0.111) among females to 1.6/100,000 in 2011. Higher incidence was associated with male gender, older age, major city residence and proportionally higher area Indigenous population. Thousand and two hundred and eighty-seven patients died. Median survival was approximately 10 months. Five-year survival improved from 18% in 1996-2000 to 24% in 2006-2011 (P < 0.001). Poorer survival was associated with older age, less recent period of diagnosis, lower hepatitis B prevalence in country of origin and greater area-level social disadvantage.CONCLUSIONS:Over this study period, HCC incidence increased significantly. HCC survival improved but remains poor. Social determinants are critical to HCC epidemiology.

Introduction Oxycodone is a widely-used semisynthetic opioid analgesic that has been used for over eighty years. Oxycodone is known to cause side effects such as nausea, pruritus, dizziness, constipation and somnolence. As far as we are aware cholestatic hepatitis as a result of oxycodone use has not been reported so far in the world literature. Case presentation A 34-year-old male presented with cholestatic jaundice and severe pruritus after receiving oxycodone for analgesia post-T11 vertebrectomy. Extensive laboratory investigations and imaging studies did not reveal any other obvious cause for his jaundice and a liver biopsy confirmed canalicular cholestatis suggestive of drug-induced hepatotoxicity. The patient's symptoms and transaminases normalised on withdrawal of oxycodone confirming that oxycodone was the probable cause of the patient's hepatotoxicity. Conclusion We conclude that cholestatic hepatitis is possibly a rare side effect of oxycodone use. Physicians should be aware of the possibility of this potentially serious picture of drug-induced hepatotoxicity.

Composites of recycled carbon fiber (CF) with up to 30 wt % loading with polyethylene (PE) were prepared via melt compounding. The morphology of the composites and the degree of dispersion of the CF in the PE matrix was examined using scanning electron microscopy, and revealed the CF to be highly dispersed at all loadings and strong interfacial adhesion to exist between the CF and PE. Raman and FTIR spectroscopy were used to characterize the surface chemistry and potential bonding sites of recycled CF. Both the Young's modulus and ultimate tensile stress increased with increasing CF loading, but the percentage stress at break was unchanged up to 5 wt % loading, then decreased with further successive addition of CF. The effect of CF on the elastic modulus of PE was examined using the Halpin-Tsai and modified Cox models, the former giving a better fit with the values determined experimentally. The electrical conductivity of the PE matrix was enhanced by about 11 orders of magnitude on addition of recycled CF with a percolation threshold of 7 and 15 wt % for 500-mu m and 3-mm thick samples. (c) 2007 Wiley Periodicals, Inc.

Purpose: A 40 year old Caucasian lady from a rural community near Cairns presented to our gastroenterology clinic for investigation of chronic diarrhoea since infancy. She passed at least 8 bulky stools per day and her bloating and flatulence had been worsening recently. Past medical history was otherwise unremarkable. She was on no medications. Physical examination was normal. Her family history was significant for a deceased brother who had diarrhoea since infancy that had also never been investigated. Her dietary history was notable for avoidance of sugary foods since early childhood. Results: Her faecal fat test was mildly raised. IgA deficiency was noted on blood tests 0.77 (1.24–4.16 g/L). HIV testing and her immunoglobulin subsets apart from IgA were normal. Coeliac serology was negative. She was started on a gluten challenge prior to endoscopy. Upper endoscopy and colonoscopy revealed no macroscopic lesions. Duodenal and colonic light microscopies were completely normal. Evaluation for disaccharidase deficiency revealed pandisaccharidase deficiency (see Table 1). She commenced a lactose free diet which resulted in partial alleviation of symptoms. Capsule endoscopy noted a number of small aphthous ulcers in the proximal and mid small intestine. Abdominal CT scan revealed only mild gas distension of small bowel loops. A repeat endoscopy 6 months later was normal with no abnormalities found on small intestinal light and electron microscopies. Testing of duodenal and jejunal disaccharidases reconfirmed pandisaccharidase deficiency. Conclusion: Special approval was obtained for sacrosidase enzyme replacement. She was commenced on sacrosidase with lactose dietary restriction. Her symptoms resolved within 10 days. This lady is thought to have a congenital sucrose isomaltase deficiency combined with an IgA and acquired lactase deficiency. She has consented for genetic analysis of her blood and intestinal tissue.Table: Results of disaccharidase testing

Infestations of parasitic monogenean trematodes (Lepidotrema bidyana and Gyrodactylus sp.) on freshwater silver perch (Bidyanus bidyanus Mitchell) in earthen ponds were treated with formalin (37% formaldehyde). Concentrations of 30 and 40 mg L-1 formalin were effective, but fish in ponds treated with 20 or 25 mg L-1 remained infested. At temperatures of 24.1-26.9 degrees C, concentrations of 30 or 40 mg L-1 formalin caused dissolved oxygen (DO) to decline from 10.1-11.9 to 3.0-3.3 and 1.2-1.7 mg L-1, respectively, within 36-42 h of treatment. In addition, pH declined from 7.2-8.4 to 6.3-6.7, within 36 h and turbidity decreased over 48 h. In the ponds where DO was 1.2-1.7 mg L-1, silver perch showed signs of severe stress, but continuous aeration (10 hp ha(-1)) for 3 days and inflow of well-oxygenated water for 6-8 h prevented mortalities. At temperatures of 13.2-15.7 degrees C, concentrations of 30 or 40 mg L-1 formalin caused DO to decline from 9.0-10.0 to 6.0-8.1 mg L-1 and pH from 7.0-7.3 to 5.9-6.6 within 72 h. Total ammonia-nitrogen increased over 72 h in ponds treated with 30 or 40 mg L-1 formalin. Fish became re-infested with L. bidyana in all ponds within 30 days of treatment. A concentration of 30 mg L-1 formalin is recommended as a treatment for monogeneans on silver perch in ponds, but aeration is necessary to maintain adequate water quality at higher temperatures.

Silver perch fingerlings (range mean weights, 109.3–115.4 g) were stocked at densities of 12, 25, 50, 100 or 200 fish/m3 in cages (1 m3) in an aerated, 0.32-ha earthen pond, with four replicate cages for each density. Fish were fed a formulated diet containing 32% crude protein and 13 MJ/kg energy and cultured for 210 days. Water temperatures ranged from 20.6 to 29.8 °C. There was aggression between fish in cages stocked at 25 or 50 fish/m3 and survival (50% and 64.5%, respectively) was significantly lower (P<0.01) than at the other densities (87.5%, 98.5% and 97.4%). Stocking density did not affect final weight (454.6–471.1 g), specific growth rate (0.65–0.70%/day) or absolute growth rate (1.6–1.7 g/fish/day), but feed conversion ratios (FCR) of fish stocked at 25 or 50 fish/m3 (4.4 and 3.7) were significantly higher (P<0.01) than FCRs (range, 2.3–2.5) at other densities. Coefficients of variation in weight (CV) at 25 or 50 fish/m3 (24.4% and 28.3%) were significantly higher (P<0.01) than at other densities and the lowest CV of 16.1% was at 200 fish/m3. Production was significantly affected (P<0.01) by stocking density, with the highest mean rate of 88.5 kg/m3 in cages stocked with 200 fish/m3. One infestation of the ectoparasitic ciliate, Chilodonella hexasticha, and two infestations of the monogenean gill fluke, Lepidotrema bidyana, were each treated successfully with an application of 30 mg/l formalin. The high survival, relatively fast growth, low variation in weight and high production rates of silver perch stocked at 100 or 200 fish/m3 demonstrate that cages are a viable alternative to ponds for the commercial production of silver perch.

To develop a feeding strategy for the Australian freshwater fish silver perch (Bidyanus bidyanus Mitchell), a series of eight experiments was done in 1 m(3) cages in an aerated, earthen pond to determine the effects of feeding rate (% body weight) and feeding frequency (no. of feeds day(-1)) on the growth and feed conversion ratio (FCR) of fingerlings and larger fish under ambient water temperatures over the range 13.8-30.6 degrees C. Fish were fed extruded pellets of a silver perch diet containing 34% digestible protein and 14 MJ kg(-1) digestible energy. Commercial silver perch farmers were consulted about feeding practices for large fish (> 500 g) and at water temperatures below 12 degrees C, and winter feeding practices for other warmwater species were used to complete the strategy. In the feeding experiments, growth and FCR increased with increasing feeding rates to a level above which only FCR increased. Optimal feeding rates and frequencies were those which resulted in maximal growth, while minimizing effort (feeding frequency) and FCR. The highest feeding frequency required for maximal growth, including that of small fingerlings was twice (2 x) daily, and the optimal feeding rates varied with water temperature and size of fish. The optimal daily regimes were: small fingerlings (initial mean weight, 2.0 g) 7.5% 2 x at a mean temperature of 23.3 degrees C; fingerlings (14.9-27.7 g) 7.5% 2 x at 27.1 degrees C, 5.0% 2 x at 23.7 degrees C and 2.0% 1 x at 16.8 degrees C; and large silver perch (162.5-510.6 g) 0.5% 1 x daily or 1.0% on alternate days at 15.6 degrees C, 1.0% 1 x at 17.3 degrees C, 3.0% 2 x at 24.1 degrees C and 2.0% 2 x at 27.9 degrees C. It is suggested that regimes of 0.5% 1 x daily for fingerlings (< 50 g) and 0.5% 1 x on alternate days for larger fish are used at temperatures of 9-12 degrees C, and 0.5% 3 days week(-1) and 0.5% 1 day week(-1) for fingerlings and larger fish, respectively, at 6-9 degrees C. Feed inputs should not exceed 150 kg ha(-1) day(-1) in ponds less than 0.3 ha and 100 kg ha(-1) day(-1) in larger ponds. Our research has established a feeding strategy for silver perch based on restricted rations.