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OBJECTIVE: Identifying the responsible pathogen is required in order to select optimum antimicrobial therapy for infected wounds, but the best techniques to use remain the subject of debate. Our aim was to assess the evidence on the value of wound swabs compared with biopsies. METHOD: We conducted a systematic literature review with the terms 'wound infection', 'wound swab', 'wound swab technique', 'wound biopsy', 'wound culture', 'wound swab comparison', 'Levine swab technique', 'microbiological technique', 'specimen handling', 'bacterial load', 'perioperative care', 'swab', and 'culture'. We examined yields in identifying relevant pathogens, summarised salient features of qualifying studies, and defined knowledge gaps and endpoints that future studies should address. RESULTS: Studies have been inconsistent, lacking specificity regarding wound types, clinical features, and sampling methods. We found moderate quality evidence that punch biopsies provide qualitative and quantitative information about the bacterial load and tissue reaction with nearly 100% sensitivity, 90% specificity and 95% accuracy for predicting wound closure. Biopsies are relatively invasive, costly, require skilled operators, and potentially exacerbate infection. Needle aspiration samples a limited portion and may enter uninfected tissue and extend infection. Wound swabs are minimally invasive, easier to perform and widely employed in clinical practice, but techniques vary. In comparative studies, the Levine technique was superior to the Z-swab techniques, and biopsies were more sensitive for antibiotic-resistant wounds than Levine or Levine-like swabs, suggesting that swabs may be useful for initial wound monitoring, but biopsies are preferred when antibiotic resistance is suspected. CONCLUSION: The Levine swab is superior to the Z-swab technique and may be useful for initial wound monitoring, but quantitative biopsies are preferred for evaluation of antibiotic-resistant wounds and to monitor the response to treatment. There is limited evidence on the role of wound swabs for detecting wound colonisation versus infection and the impact of culture-guided therapy on such clinical outcomes as eradication of infection and accelerated healing. Future studies should specify patient populations, wound types, sampling protocols, and outcomes based on culture yield and treatment results, using rigorous statistical methodology.

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PURPOSE: To compare 2.0 mg ranibizumab (RBZ) injections with 0.5 mg RBZ for eyes with center-involved diabetic macular edema (DME) and a central subfield thickness (CFT) of ≥250 µm on time-domain optical coherence tomography.DesignRandomized, controlled, multicenter clinical trial. METHODS: Eligible eyes were randomized in a 1:1 ratio to 0.5 mg (n=77) or 2.0 mg (n=75) RBZ. Study eyes received 6-monthly injections.Main outcome measuresThe primary outcome measure was the mean change in best corrected visual acuity (BCVA) at month 6. Secondary outcomes included the incidence and severity of systemic and ocular adverse events and the mean change in CFT from baseline. RESULTS: In all, 152 eyes (152 patients) were randomized in the study. At month 6, the mean improvement from baseline BCVA was +9.43 letters in the 0.5 mg RBZ group and +7.01 letters in the 2.0 mg RBZ group (P=0.161). At month 6, one death occurred in the 0.5 mg RBZ group and three deaths in the 2.0 mg RBZ group, all due to myocardial infarction in subjects with a prior history of heart disease. Mean CFT was reduced by 168.58 µm in the 0.5 mg RBZ group and by 159.70 µm in the 2.0 mg RBZ group (P=0.708). CONCLUSIONS: There was no statistically significant difference in the mean number of letters gained between the 0.5 and 2.0 mg RBZ groups through month 6. In this DME study population, high-dose RBZ does not appear to provide additional benefit over 0.5 mg RBZ.

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There are four themes in this teaching exercise for Professor McCance. The first challenge was to explain how a premature infant with Bartter's syndrome could survive despite having such a severe degree of renal salt wasting. Second, the medical team wanted to know why there was such a dramatic decrease in the natriuresis in response to therapy, despite the presence of a permanent molecular defect that affected the loop of Henle. Third, Professor McCance was asked why this patient seemed to have a second rare disease, AQP2 deficiency type of nephrogenic diabetes insipidus. The fourth challenge was to develop a diagnostic test to help the parents of this baby titrate the dose of indomethacin to ensure an effective dose while minimizing the likelihood of developing nephrotoxicity. The missing links in this interesting story emerge during a discussion between the medical team and its mentor.

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Mixed venous oxy-hemoglobin saturation (MVO2) is a physiological variable with several features that might be desirable as a control parameter for rate adaptive pacing. Despite these desirable characteristics, the long-term reliability of the MVO2 sensor in vivo is uncertain. We, therefore, designed a study to prospectively evaluate the long-term performance of a permanently implanted MVO2 saturation sensor in patients requiring VVIR pacing. Under an FDA approved feasibility study, eight patients were implanted with a VVIR pulse generator and a right ventricular pacing lead incorporating an MVO2 sensor. In order to accurately assess long-term stability of the sensor, patients underwent submaximal treadmill exercise using the Chronotropic Assessment Exercise Protocol (CAEP) at 2 weeks, 6 weeks, and 3, 6, 9, 12, 18, and 24 months following pacemaker implantation. Paired maximal exercise testing using the CAEP was also performed with the pacing system programmed to the VVI and VVIR modes in randomized sequence with measurement of expired gas exchange after 6 weeks and 12 months of follow-up. During maximal treadmill exercise the peak exercise heart rate (132 +/- 9 vs 71.5 +/- 5 beats/min, P < 0.00001) and maximal rate of oxygen consumption (1,704 +/- 633 vs 1382 +/- 407 mL/min, P = 0.01) were significantly greater in the VVIR than in the VVI pacing mode. Similarly, the duration of exercise was greater in the VVIR than the VVI pacing mode (8.9 +/- 3.6 min vs 7.6 +/- 3.7 min, P = 0.04). The resting MVO2 and the MVO2 at peak exercise were similar in the VVI and VVIR pacing modes (P = NS). However, the MVO2 at each comparable treadmill exercise stage was significantly higher in the VVIR mode than in the VVI mode (CAEP stage 1 (P = 0.005), stage 2 (P = 0.04), stage 3 (P = 0.008), and stage 4 (P = 0.04). The correlation between MVO2 and oxygen consumption (VO2) was excellent (r = -0.93). Telemetry of the reflectance of red and infrared light and MVO2 in the right ventricle during identical exercise workloads revealed no significant change over the first 12 months of follow-up (ANOVA, P = NS). The chronotropic response to exercise remained proportional to VO2 in all patients over the first 12 months of follow-up. The time course of change in MVO2 during maximal exercise was significantly faster than for VO2. At the 18- and 24-month follow-up exercise tests, a significant deterioration of the sensor signal with attenuation of chronotropic response was noted for 4 of the 8 subjects with replacement of the pacing system required in one patient because of lack of appropriate rate modulation. Rate modulated VVIR pacing controlled by right ventricular MVO2 provides a chronotropic response that is highly correlated with VO2. This parameter responds rapidly to changes in workload with kinetics that are more rapid than those of VO2. Appropriate rate modulation provides a higher MVO2 at identical workloads than does VVI pacing. Although the MVO2 sensor remains stable and accurate over the first year following implantation, significant deterioration of the signal occurs by 18-24 months in many patients.

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Azathioprine is administered to treat increasing numbers of disorders over a wide range of organ systems. The potential for the drug to cause widespread organ dysfunction is not fully appreciated. In fact, azathioprine can cause multisystem organ dysfunction involving the kidneys, liver, and cardiovascular system. The discovery of global cardiac dysfunction as one component of this complication may indicate a mechanism of hypotension. Clinicians must be aware of the potential for azathioprine to cause such toxicities to facilitate appropriate patient management.

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We report the case of a patient with visual loss and cystoid macular edema that was associated with the topical use of echothiophate iodide. After cessation of the drops, the cystoid macular edema nearly disappeared, and vision returned to normal.

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The effect of grip on ulnar variance was evaluated in 66 symptom-free wrists of 53 volunteers. Zero-rotation posteroanterior x-ray films were taken of each wrist before and after exertion of a grip force measured with a Jamar dynamometer. The volunteers were randomly divided into two groups. Group I subjects (35 wrists) were asked to exert a constant grip force of 11.3 kg. Group II subjects (31 wrists) were asked to exert a maximum grip effort, which resulted in a mean grip force of 30 kg (range, 22.8 kg to 53.6 kg). Group I demonstrated a mean increase in ulnar variance of 1.27 mm and group II showed a mean increase of 1.95 mm. The minimum increase in ulnar variance observed was 0.25 mm. The changes observed were statistically significant. The results confirm that a relative increase in ulnar variance occurs with grip. There may be an etiologic role for daily activities that involve repetitive grip and forearm rotation in development of the ulnar impaction syndrome.

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Syphilis serologic testing is felt to be extremely reliable. A case of syphilitic neuroretinitis is reported where serologic testing was negative due to human immunodeficiency virus infection. A prompt response to high-dose intravenous penicillin was achieved.

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We sent questionnaires to 424 retina specialists in order to compile information on the use of fluorescein angiography in pregnant women. Four-hundred and three specialists responded. Of these, 313 (78%) had never performed fluorescein angiography on a pregnant woman. Ninety specialists (22%) had performed at least one fluorescein angiogram on a pregnant woman; detailed information was obtained on 105 patients. Authors of previous reports that included fluorescein angiography during pregnancy provided information on an additional 11 patients. Substantiated side effects were nausea and/or vomiting in seven patients. Anomalies at birth, an undescended testicle and syndactyly, were reported in two children. There was one stillbirth with pathologic findings classic for toxemia and one fetal death not related in time to fluorescein angiography. One therapeutic abortion was performed for complications in toxemia. One spontaneous abortion occurred 3 days after fluorescein angiography in a patient who was four weeks pregnant. Eight children born to toxemic mothers had low birth weights. Based on our data, we conclude that fluorescein angiography does not offer a high rate of birth anomalies or complications during pregnancy.

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We sent 424 retina specialists questionnaires on fluorescein angiography performed on pregnant women; 399 specialists responded. Of these, 309 (77%) had never performed fluorescein angiography on a pregnant woman. Ninety specialists (23%) had performed at least one fluorescein angiogram on a pregnant woman; detailed information was obtained on 105 patients. Authors of previous reports that included fluorescein angiography during pregnancy provided information about an additional 11 patients. Substantiated side effects were nausea or vomiting in seven patients. Anomalies at birth, an undescended testicle and syndactyly, were reported in two children. There was one stillbirth with pathologic findings classic for toxemia, and one fetal death occurred several months after fluorescein angiography. One therapeutic abortion was performed for complications in toxemia. One spontaneous abortion occurred three days after fluorescein angiography in a patient who was four weeks pregnant. Eight children born to toxemic mothers had low birth weights. We conclude that fluorescein angiography does not cause a high rate of birth anomalies or complications during pregnancy.

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This photo essay shows the retinal findings in a patient with presumed syphilitic disc edema and periphlebitis. Resolution of these findings after treatment with penicillin is documented by improvement in visual acuity from 20/50 to 20/25 in the right eye and from 20/200 to 2/20 in the left eye. Photographic documentation of the resolution of retinal findings, including disc edema and periphlebitis, is presented.

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We reviewed ten patients who had posterior segment complications of acquired syphilis. Five of these patients had a neovascular membrane of the choroid associated with secondary or tertiary syphilis. Vision was stabilized after laser photocoagulation in one patient who had a choroidal neovascular membrane. Five additional patients had ocular manifestations including uveitis, optic neuritis, neuroretinitis, chorioretinitis, retinal hemorrhages, arterial and venous occlusion, vasculitis, and retinitis. Treatment of chorioretinal complications of syphilis with intravenous penicillin, if initiated early in the course of the disease, may result in excellent visual recovery.

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