The goal of this retrospective study was to evaluate the performance of different diagnostic tests for Legionnaires' disease in a clinical setting where Legionella pneumophila PCR had been introduced. Electronic medical records at the Cleveland Clinic were searched for Legionella urinary antigen (UAG), culture, and PCR tests ordered from March 2010 through December 2013. For cases where two or more test methods were performed and at least one was positive, the medical record was reviewed for relevant clinical and epidemiologic factors. Excluding repeat testing on a given patient, 19,912 tests were ordered (12,569 UAG, 3,747 cultures, and 3,596 PCR) with 378 positive results. The positivity rate for each method was 0.4% for culture, 0.8% for PCR, and 2.7% for UAG. For 37 patients, at least two test methods were performed with at least one positive result: 10 (27%) cases were positive by all three methods, 16 (43%) were positive by two methods, and 11 (30%) were positive by one method only. For the 32 patients with medical records available, clinical presentation was consistent with proven or probable Legionella infection in 84% of the cases. For those cases, the sensitivities of culture, PCR, and UAG were 50%, 92%, and 96%, respectively. The specificities were 100% for culture and 99.9% for PCR and UAG. L egionnaires' disease is an atypical, respiratory illness associated with exposure to water colonized with Legionella species (1). In the United States, up to 18,000 hospitalizations occur each year for legionellosis, with the vast majority (70% to 92%) attributed to Legionella pneumophila serogroup 1 (Lp1) (2). This predominance of Lp1 disease is thought to be a reflection of virulence rather than environmental distribution (3-5). Besides Lp1, the strains most commonly associated with human disease are other L. pneumophila serogroups, Legionella micdadei, Legionella bozemanii, and Legionella longbeachae (2, 6). Risk factors for legionellosis include whirlpool spa exposure, recent overnight travel or plumbing repairs (two weeks prior to onset of symptoms), immunosuppression, alcoholism, diabetes, malignancy, hepatic or renal failure, chronic obstructive lung disease, smoking history, and patient age of Ͼ50 years (7). Patients with Legionnaires' disease often require intensive care unit (ICU) admission, have failed outpatient antimicrobial treatment, or may meet criteria for nosocomial pneumonia (8).The urinary antigen (UAG) test is commonly used to diagnose Legionnaires' disease because sputum production is limited and Legionella culture requires special techniques. The Lp1 antigen is typically detectable in urine beginning 2 to 3 days after the onset of clinical symptoms until 2 months after clearance of disease but may persist for a much longer period of time (2). The widespread availability of rapid, FDA-cleared, Lp1 UAG tests in the United States coincided with a 76% decrease in mortality rate (34% to 8%) from Legionnaires' disease during 1985 to 2009 (9, 10). However, it has been suggested that non-Lp1 Legio...

No abstract

Both cavernous angiomas and focal cortical dysplasia (FCD) are well recognized causes of pharmacoresistant epilepsy. Anecdotal cases of FCD adjacent to cavernous angiomas have been documented in the literature. This study systematically reviews a series of cavernous angiomas in epilepsy patients, looking for evidence of coexistent FCD. 146 patients were diagnosed with cavernous angiomas on resection specimens from January 1989 to May 2011; 18 cases also had epilepsy and had ample tissue excised to assess for FCD. FCD was classified according to criteria outlined by Palmini et al. [12]. Patients included 10 females (55.6%); the mean age of study patients was 38.5 years (range 21 - 51 years) at the time of resection. All patients had a history of epilepsy (median 11 years) prior to surgery. 17 cavernomas were located in the temporal lobe and 1 in the occipital lobe. Adjacent FCD was identified in 13 out of the 18 cases (72.2%): Type Ia (n = 8; 61.5%), Type Ib (n = 4; 30.8%), and Type IIa (n = 1; 7.7%). After resection, a majority of the patients experienced resolution of their epilepsy (n = 14; 77.8%). Of the 4 patients that did not experience seizure resolution, 2 had evidence of adjacent FCD (Type Ia = 1, Type Ib = 1) and 2 did not. FCD is frequently present in association with cavernous angiomas in patients with chronic epilepsy. The type of FCD seen adjacent to these lesions varies, but most are Palmini et al. Type I. Resection of the cavernous angiomas and adjacent FCD often results in a resolution of the epilepsy.

ObjectivesTo evaluate if cumulative prostate cancer length (CCL) on prostate needle biopsy divided by the number of biopsy cores (CCL/core) could improve prediction of insignificant cancer on radical prostatectomy (RP) in patients with prostate cancer eligible for active surveillance (AS). Patients and MethodsPatients diagnosed with prostate cancer on extended (≥10 cores) biopsy with an initial prostate-specific antigen (iPSA) level of <15 ng/mL, clinical stage (cT) ≤ 2a, and highest biopsy Gleason score 3 + 3 = 6 or 3 + 4 = 7 with <3 positive cores who underwent RP were included in the study. The CCL/core and presence of insignificant cancer (organ-confined, volume <0.5 mL, Gleason score at RP ≤6) were recorded. pT2 prostate cancer with RP Gleason score ≤3 + 4 = 7 and volume <0.5 mL were categorised as low-tumour-volume organ-confined disease (LV-OCD). ResultsIn all, 221 patients met the inclusion criteria: the mean age was 59 years and the median iPSA level was 4.5 ng/mL. The clinical stage was cT1 in 86% of patients; biopsy Gleason score was 3 + 3 = 6 in 67% (group 1) and 3 + 4 = 7 in 33% of patients (group 2). The maximum percentage of biopsy core involvement was <50 in 85%; the median CCL/core was 0.15 mm. Insignificant cancer was found in 27% and LV-OCD in 44% of patients. Group 2 was associated with higher number of positive cores, maximum percentage core involvement, total prostate cancer length, and CCL/core. Group 1 was more likely to have insignificant cancer (39%) or LV-OCD (54%) than group 2 (3% and 23%, respectively). Group 2 had significantly higher RP Gleason score and pathological stage. Univariate analysis of group 1 showed that the iPSA level, maximum percentage core involvement, prostate cancer length, and CCL/core were all significantly associated with insignificant cancer and LV-OCD. For group 2, the number of positive cores (1 vs 2) was also significantly associated with LV-OCD. On multivariate logistic regression analysis, maximum percentage core involvement of <50, and number of positive cores (1 vs 2) were independent predictors of insignificant cancer in group 1; biopsy Gleason score, maximum percentage core involvement of <50 and prostate cancer length of <3 mm or CCL/core of <0.2 mm were all independent predictors of LV-OCD in the whole population. The maximum percentage of core involvement of <50 and prostate cancer length of <3 mm or CCL/core of <0.2 mm were also independent predictors of LV-OCD in group 1 patients.