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Chronic hepatitis B prevalence is low in most Australian populations, with universal infant HBV vaccination introduced in 2000. Migrants from high prevalence countries are at risk of acquisition before arrival and non-immune adults are potentially at risk through skin penetrating procedures and sexual contact, particularly during international travel. The risk profile of young adult students, many from high prevalence countries, is inadequately understood. A cross-sectional online survey conducted among university students collected data on demographic, vaccination and travel characteristics and blood samples were tested for hepatitis B surface antibody (HBsAb) and hepatitis B core antibody (HBcAb). Analyses identified factors associated with HBsAb seroprevalence and self-reported vaccination. The serosurvey was completed by 804 students born between 1988 and 1993, with 613/804 (76.2%, 95% CI 73.2-79.1) self-reporting prior HBV vaccination. Overall, 526/804 (65.4%, 95% CI 62.0%-68.6%) students were seropositive to HBsAb, including 438/613 (71.5%, 95% CI 67.8-74.9) students self-reporting a prior HBV vaccine and 88/191 (46.1%, 95% CI 39.2-53.2) students self-reporting no prior HBV vaccine. Overall, 8/804 (1.0%, 95% CI 0.5%-2.0%) students were HBcAb positive, of whom 1/804 (0.1%, 95% CI 0.02%-0.7%) was currently infectious. The prevalence of chronic HBV infection was low. However, more than one in four students were susceptible to HBV and over-estimated their immunity. Future vaccination efforts should focus on domestic students born before the introduction of the infant program and all international students. Screening and vaccination of students, including through campus-based health services, are an opportunity to catch-up young adults prior to undertaking at-risk activities, including international travel.

The Environmental Determinants of Islet Auto- immunity (ENDIA) project is Australia's largest study into the causes of Type-1 Diabetes (T1D). The ENDIA study is supported by a Cloud-based software platform including a clinical registry comprising extensive longitudinal information on families at risk of having a child that might go on to develop T1D. This registry includes both demographic and clinical information on families and children as well as the environmental factors that might influence the onset of T1D. A multitude of samples are obtained through the study and used to support a diverse portfolio of bioinformatics data analytics. The quality of the data in the registry is essential to the overall success of the project. This paper presents a Cloud-based log-analytics platform that supports the detailed analysis of patterns of usage of the registry by the clinical centres and collaborators involved. We explore the impact that the usage patterns have on the overall data quality. We also consider ways of improving data quality by mothers entering their own data through targeted mobile applications that have been developed for dietary data collection.

Treatment of Alzheimer's disease (AD) is significantly hampered by the lack of easily accessible biomarkers that can detect disease presence and predict disease risk reliably. Fluid biomarkers of AD currently provide indications of disease stage; however, they are not robust predictors of disease progression or treatment response, and most are measured in cerebrospinal fluid, which limits their applicability. With these aspects in mind, the aim of this article is to underscore the concerted efforts of the Blood-Based Biomarker Interest Group, an international working group of experts in the field. The points addressed include: (1) the major challenges in the development of blood-based biomarkers of AD, including patient heterogeneity, inclusion of the "right" control population, and the blood–brain barrier; (2) the need for a clear definition of the purpose of the individual markers (e.g., prognostic, diagnostic, or monitoring therapeutic efficacy); (3) a critical evaluation of the ongoing biomarker approaches; and (4) highlighting the need for standardization of preanalytical variables and analytical methodologies used by the field.

Background and Purpose —Five pretreatment variables ( P 300 mg/dL), predicted symptomatic intracerebral hemorrhage (ICH) in the National Institute of Neurological Disorders and Stroke rtPA trial. We retrospectively studied stroke patients treated Methods —Baseline characteristics, including 5 prespecified variables (age, baseline glucose, smoking status, National Institutes of Health Stroke Scale [NIHSS] score, and CT changes [>33% middle cerebral artery territory hypodensity]), were reviewed in 138 consecutive patients. Variables were evaluated by logistic regression as predictors of all hemorrhage (including hemorrhagic transformation) and symptomatic hemorrhage on follow-up CT scan. Variables significant at P Results —Symptomatic hemorrhage rate was 9% (13 of 138). Any hemorrhage rate was 30% (42 of 138). Baseline serum glucose (5.5-mmol/L increments) was the only independent predictor of both symptomatic hemorrhage [OR, 2.26 (CI, 1.05 to 4.83), P =0.03] and all hemorrhage [OR, 2.26 (CI, 1.07 to 4.69), P =0.04]. Serum glucose >11.1 mmol/L was associated with a 25% symptomatic hemorrhage rate. Baseline NIHSS (5-point increments) was an independent predictor of all hemorrhage only [OR, 12.42 (CI, 1.64 to 94.3), P =0.01]. Univariate analysis demonstrated a trend for nonsmoking as a predictor of all hemorrhage [OR, 0.45 (CI, 0.19 to 1.08), P =0.07]. Diabetes was also an independent predictor of ICH when substituted for glucose in repeat analysis. Conclusions —Serum glucose and diabetes were predictors of ICH in rtPA-treated patients. This novel association requires confirmation in a larger cohort.

Background There is an increasing trend to treating proximal vessel occlusions with intravenous–inter-arterial (IV-IA) thrombolysis. The best dose of IV tissue plasminogen activator (tPA) remains undetermined. We compared the combination of full-dose IV recombinant tissue plasminogen activator (rtPA) and IA thrombolytic therapy to IA therapy. Methods Between 2002 and 2009, we reviewed our computed tomographic angiography database for patients who received full-dose intravenous rtPA and endovascular therapy or endovascular therapy alone for acute ischaemic stroke treatment. Details of demographics, risk factors, endovascular procedure, and symptomatic intracranial haemorrhage were noted. Modified Rankin Scale ≤2 at three-months was used as good outcome. Recanalization was defined as Thrombolysis in Myocardial Ischaemia 2–3 flow on angiography. Results Among 157 patients, 104 patients received IV-IA treatment and 53 patients underwent direct IA therapy. There was a higher recanalization rate with IV-IA therapy compared with IA alone (71% vs. 60%, P < 0·21) which was driven by early recanalization after IV rtPA. Mortality and independent outcome were comparable between the two groups. Symptomatic intracranial haemorrhage occurred in 8% of patients (12% in the IA group, 7% in the IV-IA group) but was more frequent as the intensity of intervention increased from device alone to thrombolytic drug alone to device plus thrombolytic drug(s). Recanalization was a strong predictor of reduced mortality risk ratio (RR) 0·48 confidence interval95 0·27–0·84) and favourable outcome (RR 2·14 confidence interval95 1·3–3·5). Conclusions Combined IV-IA therapy with full-dose intravenous rtPA was safe and results in good recanalization rates without excess symptomatic intracranial haemorrhage. Testing of full-dose IV tPA followed by endovascular treatment in the IMS3 trial is justified.

Tumor-to-tumor metastasis (TTM) is a relatively rare but well-documented phenomenon. The authors report a unique case of esophageal carcinoma metastatic to an intracranial paraganglioma. A sellar and suprasellar tumor was found using MR imaging in an 81-year-old man who presented with a 3-week history of progressive headache and blurred vision. A subtotal excision of the tumor was achieved. Histopathological examination of the tumor disclosed a neoplasm with two distinct components: one showing the classic Zellballen pattern of a paraganglioma, the other exhibiting malignant features leading to the diagnosis of a poorly differentiated carcinoma metastatic to a sellar/suprasellar paraganglioma. The primary esophageal carcinoma was not uncovered until 2 months later, after the patient presented with upper gastrointestinal bleeding. The patient died 4 months after initial presentation. This case expands the spectrum of TTM, and emphasizes the importance of TTM in the practice of pathology.

We report chronic histopathological features in thrombi mechanically retrieved from five acute ischemic stroke patients with a median age of 68 years and a median pretreatment National Institutes of Health Stroke Scale score of 13. Early endothelialization occurred over and within the thrombus, and calcifications were seen, in addition to the usual acute laminar fibrin, intervening red blood cells, and neutrophils. The effectiveness of tissue plasminogen activator in clot dissolution might be affected by these features, if extensive. Thrombus composition could critically determine the success of chemical thrombolysis. Our results should stimulate the development of imaging modalities to determine thrombus composition.

Collection of clinical information can be a fraught and intimidating process in hospital environments, especially for children with neurological conditions. Gaming and mobile technology offer many potential advantages for data collection where clinically important data can be collected as a side effect of playing games. Niemann-Pick Disease (NPD) is one example of a condition where gaming technology has the potential to greatly help patients and doctors alike. NPD is a severe, often fatal neurological condition where extensive physiological and cognitive information needs to be collected by doctors, typically in hospital environments. To help healthcare providers collect far richer information on NPD patients and reduce the burden/stress of patients and their families alike, a suite of targeted mobile games was developed to capture specific clinical information on NPD patients. These were evaluated with NPD patients and the feedback received was used to tailor the games accordingly. Personalised clinical information obtained through game playing was recorded, analysed and visualised through a flexible and extensible Cloud-based solution including capabilities for tracking patients longitudinally. This work has been directly aligned with the International Niemann-Pick Disease Registry. We suggest that this approach offers the potential for improved processes for data collection and importantly, a less stressful and more cost effective approach for collecting clinical information from and for patients.

OBJECTIVE Hyperperfusion syndrome is a rare and potentially devastating complication of carotid endarterectomy or carotid artery angioplasty and stenting. With the advent of new imaging techniques, we reviewed our experience with this phenomenon. METHODS This report is a retrospective review of 129 consecutive cases of carotid endarterectomy performed between June 1, 2000, and May 31, 2002, and 44 consecutive cases of carotid artery angioplasty and stenting performed between January 1, 1997, and May 31, 2002. We specifically searched for examples of patients who developed postprocedural nonthrombotic neurological deficits that typified the hyperperfusion syndrome. RESULTS Seven cases of hyperperfusion syndrome occurred, four after endarterectomy (3.1% of carotid endarterectomy cases) and three after stenting (6.8% of stenting cases). The cases of hyperperfusion were classified as presenting with 1) acute focal edema (two cases with stroke-like presentation, attributable to edema immediately after revascularization), 2) acute hemorrhage (two cases of intracerebral hemorrhage immediately after stenting and one case immediately after endarterectomy), or 3) delayed classic presentation (two cases with seizures, focal motor weakness, and/or late intracerebral hemorrhage at least 24 hours after endarterectomy). CONCLUSION Hyperperfusion syndrome may be more common and more variable in clinical presentation than previously appreciated.

Background: Fine needle aspiration is an accurate technique to diagnose metastatic melanoma. Few reports exist in the literature describing its usefulness in many patients with melanoma confirmed by open biopsy. Objective: The purpose of this study was to determine the utility and predictive value of fine needle aspiration in patients with malignant melanoma who presented with lesions suspected to be metastatic. Methods: We retrospectively reviewed 99 cases of fine needle aspiration and the corresponding histologic findings obtained by open biopsy in 82 patients. Results: Of the 99 cases, 86 were positive for melanoma, 12 were negative, and one was indeterminate. The positive predictive value of fine needle aspiration was 99%. One patient had a false-positive diagnosis. Conclusion: Fine needle aspiration is a rapid, accurate, and minimally invasive procedure that is useful in the diagnosis of metastatic melanoma. Patients with a positive aspirate of palpable regional nodes can proceed directly to surgery, bypassing the need for an open biopsy. (J Am Acad Dermatol 2000;42:735-40.)

This chapter focuses on the group differences between disorders and highlights the role of structural and functional imaging in non-Alzheimer dementias. Modern imaging techniques have allowed for structural and functional analysis of patients with frontotemporal dementia-behavioral variant (bv-FTD). In searching for an imaging biomarker for FTD or frontotemporal lobar degeneration (FTLD), functional brain imaging studies, including both single-photon emission computed tomography (SPECT) and positron emission tomography (PET), represented a significant step forward in the clinical diagnosis of bv-FTD. FDG-PET studies in semantic dementia (SD) patients have shown dysfunction in the bilateral temporal regions and medial orbitofrontal regions. Volumetric magnetic resonance imaging (MRI) studies in individual patients with progressive non-fluent aphasia (PNFA) have shown minimal atrophy, left perisylvian atrophy, or left-hemispheric atrophy. The first antemortem diagnostic tests for Creutzfeldt-Jakob disease (CJD) came from cerebrospinal fluid analysis and elecroencephalography (EEG).

Background In ischemic stroke, functional outcomes vary depending on site of intracranial occlusion. We tested the prognostic value of a semiquantitative computed tomography angiography-based clot burden score. Methods Clot burden score allots major anterior circulation arteries 10 points for presence of contrast opacification on computed tomography angiography. Two points each are subtracted for thrombus preventing contrast opacification in the proximal M1, distal M1 or supraclinoid internal carotid artery and one point each for M2 branches, A1 and infraclinoid internal carotid artery. We retrospectively studied patients with disabling neurological deficits (National Institute of Health Stroke Scale score ≥ 5) and computed tomography angiography within 24-hours from symptom onset. We analyzed percentages independent functional outcome (modified Rankin Scale score ≤ 2), final infarct Alberta Stroke Program Early Computed Tomography Score and parenchymal hematoma rates across categorized clot burden score groups and performed multivariable analysis. Results We identified 263 patients (median age 73-years, National Institute of Health Stroke Scale score 10, onset-to-computed tomography angiography time 165 min). Clot burden score < 10 was associated with reduced odds of independent functional outcome (odds ratio 0.09 for clot burden score ≤5; odds ratio 0.22 for clot burden score 6–7; odds ratio 0.48 for clot burden score 8–9; all versus clot burden score 10; P Conclusion The quantification of intracranial thrombus extent with the clot burden score predicts functional outcome, final infarct size and parenchymal hematoma risk acutely. The score needs external validation and could be useful for patient stratification in stroke trials.

✓ To the authors' knowledge, only 1 case of communicating hydrocephalus after endovascular coiling of unruptured brain aneurysms has been reported previously. Here, they report on 2 such cases of delayed communicating hydrocephalus after treatment with hydrogel-coated coils and offer the first histopathological evidence of foreign material, presumably related to the coils, as the cause of hydrocephalus.

Purpose To describe a canine embolic stroke model that is appropriate for endovascular procedure evaluations and develop local cerebral blood flow (CBF) maps to monitor the progression of stroke and thrombolysis. In the future, MR may displace X-ray imaging in some endovascular procedures, such as intraarterial (IA) thrombolysis for stroke therapy, due to increased monitoring capabilities. For MR to attain its full potential in endovascular therapy, the development of appropriate disease models and monitoring techniques is essential. Materials and Methods The canine stroke model uses an injection of autologous clot to produce ischemic and infarcted tissue and produces a range of stroke severities within the anterior cerebral circulation. Local CBF maps were formed by using the catheter that would be in place to deliver the thrombolytic agent for treatment to deliver the gadolinium-based contrast agent for perfusion imaging. Results After the injection of clot, changes on imaging were consistent with the progression of ischemic stroke. Local CBF maps showed perfusion changes with stroke progression and treatment. Conclusion We successfully demonstrate the progression of ischemic stroke in the canine to mimic the progression of human stroke. CBF maps to show local perfusion characteristics show great potential in the evaluation of stroke therapy. J. Magn. Reson. Imaging 2007. © 2007 Wiley-Liss, Inc.

Background— The Alberta Stroke Program Early CT Score (ASPECTS) has been used to quantify early ischemic changes on computed tomography (CT) brain scans of acute stroke patients. We sought to assess the reliability of the score when performed in real time as compared with an expert rating performed at a later time point. Methods— Two hundred fourteen patients presenting with acute ischemic stroke or transient ischemic attack were prospectively recruited if they had a brain CT scan performed within 12 hours of symptom onset. Each scan was read for ASPECTS prospectively by the treating physician and later by 1 expert reader. A weighted kappa statistic was used to determine the interobserver agreement. Results— The median baseline National Institutes of Health Stroke Scale score was 5 (range: 0 to 32) and the median time to CT scan was 152 minutes (range: 22 to 769). The interobserver agreement between ASPECTS performed in real time and expert ASPECTS was substantial (κ w =0.69). The mean difference between real-time ASPECTS and expert ASPECTS was 0 (SD: 1.1). Conclusions— ASPECTS is a reliable clinical scale for rating early ischemic changes on CT when performed in real time.