Aberrant regeneration in an international registry of patients with 3rd-nerve palsy.

BACKGROUND/AIMS: To describe the patterns of pre-operative aberrant regeneration and motility outcomes reported in an international registry of patients with 3rd-nerve palsy treated with nasal transposition of the split lateral rectus muscle (NTSLR). METHODS: This cross-sectional study used data from an international, multicentre registry of patients with 3rd-nerve palsy treated with NTSLR. Patients with aberrant regeneration were identified, and patterns of innervation described. Demographics and postoperative success defined as horizontal alignment ≤15 PD were compared based on the presence, and type, of aberrant regeneration using Wilcoxon rank sum and Fisher's exact tests. RESULTS: Aberrant regeneration was reported in 16% (21/129) of patients. Age at diagnosis, sex, and aetiology of palsy were not significantly associated with aberrant regeneration. Abnormal movements were triggered by adduction in 52% (11/21), infraduction in 23% (5/21), and supraduction in 23% (5/21) of cases. Presentation patterns involved rectus muscle innervation in 29% (6/21) and levator muscle innervation in 71% (15/21) of cases. Although patients with aberrant regeneration had similar probability of success in comparison to those without following NTLSR (76% vs. 69%, p = 0.5), those with abnormal innervation of a rectus muscle had a lower success rate than those with abnormal innervation of the levator palpebrae superioris muscle (17% vs. 93%; p = 0.002). CONCLUSION: Successful treatment of a 3rd nerve palsy with NTSLR was not influenced by aberrant regeneration involving the levator muscle. Alternative surgical interventions should be considered when aberrant regeneration alters rectus muscle function given its adverse impact on motor outcomes with NTSLR.

Worldwide outcomes of nasal transposition of the split lateral rectus muscle for strabismus associated with 3rd-nerve palsy.

BACKGROUND/AIMS: To determine success rate and complications associated with nasal transposition of the split lateral rectus muscle (NTSLR) for treating strabismus from 3rd-nerve palsy. METHODS: An international, multicentre, registry of patients with unilateral 3rd-nerve palsy treated with NTSLR was created. Patients with concurrent surgery on the contralateral eye were excluded. Primary outcome was horizontal alignment within 15 prism dioptres (PD) of orthotropia. Incidence of technical difficulties and vision-threatening complications by 6 months post-procedure were reported. RESULTS: Ninety-eight patients met inclusion criteria. Median age was 33.5 years (IQR 10.75-46). Aetiologies included congenital (31%), neoplastic (16%) and traumatic (15%). Twenty-five per cent of patients had prior ipsilateral strabismus surgery. Median exotropia decreased from 70PD preoperatively (IQR 50-90) to 1PD postoperatively (IQR 0-15.5), with a success rate of 69%. Performing concurrent superior oblique muscle tenotomy (SOT) was independently associated with success (p=0.001). Technical challenges occurred in 30% of cases, independently associated with a history of ipsilateral strabismus surgery (p=0.01). Eleven per cent of patients had vision-threatening complications, independently associated with more posterior placement of the split lateral rectus (LR) muscle (p<0.001), and most commonly transient serous choroidal effusion. Surgical placement of the split LR muscle within 4.25 mm of the medial rectus (MR) muscle insertion reduced this risk. CONCLUSION: NTSLR significantly improved primary position alignment altered by 3rd-nerve palsy. Concurrent SOT and placement of the split LR muscle ≤4.25 mm posterior to the MR muscle insertion optimised outcomes. NTSLR proved technically challenging when prior ipsilateral strabismus surgery had been performed.

Extraocular muscle ductions following nasal transposition of the split lateral rectus muscle.

OBJECTIVE: To quantify changes in ductions following nasal transposition of the split lateral rectus muscle (NTSLR) for treating third nerve palsy. DESIGN: Retrospective cohort study. PARTICIPANTS: A single eye from each patient with third nerve palsy treated with NTSLR with ocular motility measurements. METHODS: Observation of changes in pre- and postoperative ductions. Outcome measures including patient demographic and surgical factors associated with the ability to adduct beyond the midline after NTSLR were evaluated using multivariable logistic regression. RESULTS: A total of 116 patients met the inclusion criteria for this study. The NTSLR significantly decreased abduction (median of 0 limitation [interquartile range (IQR), 0-0] prior to surgery to -4 [IQR, -4 to -3] after NTSLR; p < 0.001), with a corresponding improvement in adduction (median, -5 [IQR, -5 to -4] prior to surgery to -4 [IQR, -4 to -3] after NTSLR; p < 0.001). There was no change in median supraduction or infraduction after NTSLR (p > 0.05). The ability to adduct beyond the midline after NTSLR was demonstrated in 42% of patients. Although not statistically significant, a trend toward a postoperative ability to adduct beyond the midline was seen in patients who had concurrent superior oblique muscle tenotomy (odds ratio [OR] = 5.08; 95% CI, 0.91-40.9) or who were designated with partial rather than complete third nerve palsy (OR = 2.29; 95% CI, 0.82-6.70). CONCLUSIONS: NTSLR improves the horizontal midline positioning of eyes with third nerve palsy. Most eyes lose the ability to abduct, but some regain a modest ability to adduct while vertical ductions remain unchanged.

Nasal Transposition of the Split Lateral Rectus Muscle for Strabismus Associated With Bilateral 3rd-Nerve Palsy.

PURPOSE: To determine the success rate and complications associated with nasal transposition of the split lateral rectus muscle (NTSLR) for treating bilateral 3rd-nerve palsy. DESIGN: Retrospective, interventional case series. METHODS: An international, multicenter registry was used for the study. The study population was all patients with bilateral 3rd-nerve palsy treated with NTSLR. Sensorimotor evaluations were conducted before and 6 months after unilateral or bilateral NTSLR. Outcome measures were postoperative horizontal alignment ≤15 prism diopters (PD), intraoperative technical difficulties, and vision-threatening complications. The association of patient demographics and surgical technique with each outcome was analyzed using multivariable logistic regression. RESULTS: A total of 34 patients were included, with a median age of 46 years (interquartile range [IQR] = 25-54 years) at surgery. The most common etiologies were ischemic (29%), neoplastic (15%), and congenital (12%). NTSLR performed unilaterally with alternative surgery on the opposite eye (65%) resulted in a median postoperative exotropia of 18 PD (IQR = 7-35 PD), and when performed bilaterally (35%) resulted in postoperative exotropia of 14 PD (IQR = 5-35 PD). Success was achieved in 50% of cases, intraoperative technical difficulties were reported in 18%, and vision-threatening complications occurred in 21%. Attachment of the lateral rectus muscle ≥10 mm posterior to the medial rectus insertion was associated with increased vision-threatening complications (odds ratio = 9.0; 95% CI = 1.3-99). CONCLUSIONS: NTSLR can address the large-angle exotropia associated with bilateral 3rd-nerve palsy. Surgeons should be aware that posterior placement of the lateral rectus muscle may increase the risk of vision-threatening complications, particularly serous choroidal effusion.

Isolated orbital amyloidosis causing internal and external ophthalmoplegia.

Amyloid is a protein precursor known to deposit in ocular tissue. Although its presentation is protean, it is rarely seen in the orbit. We report the case of an 85-year-old woman with primary orbital amyloidosis causing internal and external ophthalmoplegia. Strabismus surgery with muscle biopsy alleviated her symptoms and assisted with solving the diagnostic challenge.

Acquired reversible Brown syndrome caused by focal abscess of the superior oblique muscle.

A 16-year-old boy with a history of relapsed acute myeloid leukemia and a right lower lobe lung abscess confirmed to be Aspergillus presented for a baseline eye examination prior to consideration of bone marrow transplantation. He noted double vision in up-and-left gaze, and his examination was consistent with an acquired right-sided Brown syndrome. Magnetic resonance imaging revealed a 4 mm rim-enhancing inflammatory focus in the right superior oblique muscle. His Brown syndrome resolved after treatment with systemic antimicrobials.

Tear osmolarity and subjective dry eye symptoms in migraine sufferers.

OBJECTIVE: Previous studies have suggested an association between dry eye and migraine. In a busy ophthalmologist clinic, quick identification of dry eye in migraine sufferers may improve their quality of life. Tear osmolarity is an objective and reliable tool for diagnosing dry eye. It has not been investigated in any population with migraine. Using tear osmolarity and questionnaires, we aimed to explore the relationship between dry eye and clinical symptoms in patients with migraine. DESIGN: Prospective cross-sectional study. PARTICIPANTS: Thirty-four adults with migraine sequentially recruited from a single neurologist's practice. METHODS: Patients were assessed for subjective and objective signs of migraine and dry eye by using the Migraine Disability Assessment Score, the Ocular Surface Disease Index, and tear osmolarity (TearLab). Headache characteristics were compared by using χ2, Fisher's exact, and Mann-Whitney U tests. Osmolarity scores were compared with scores for headache features. RESULTS: Median age of patients was 38 years, and 76.5% were females. Severe migraine disability was reported in 75.6%, and 34.5% reported moderate to severe dry eye symptoms. Objectively, 49.5% had evidence of dry eye, significantly higher than the 20% recognized in the general population (p < 0.0001). Aura was found to occur more frequently with dry eye (43.8% vs 5.9%; p = 0.02). Those with daily headaches were also more likely to have higher tear osmolarity with marginal significance (median osmolarity 310 mOsm/L vs 299 mOsm/L; p = 0.08). CONCLUSIONS: Patients with migraine, especially those with aura, appear more likely to have dry eye, as indicated by tear osmolarity. Tear osmolarity may also be greater in those who suffer from daily headaches.

Effect of prolonged photoperiod on ocular tissues of domestic turkeys.

OBJECTIVE: The objective of this study is to investigate the structural and functional ocular changes that develop in turkeys exposed to a photoperiod of 23 h of light (23L) compared with a photoperiod of 14 h of light (14L). PROCEDURES: Ten-day-old Nicholas heavy strain poults were exposed to either a 14L or 23L photoperiod. Between 16 and 18 weeks of age, equal numbers of turkeys per treatment group underwent ophthalmic examination (biomicroscopy, indirect ophthalmoscopy) (n = 14), refractometry (n = 20), keratometry (n = 20), tonometry (n = 20), and full-field electroretinography (ERG) (n = 14). Postmortem analyses included orbital magnetic resonance imaging (MRI) (n = 10) and light microscopy (n = 24) at 18 weeks of age. RESULTS: Autorefraction revealed a median of -0.13 for sphere in both groups (P = 0.69), which is approximately emmetropia. The radius of curvature of the cornea was significantly higher (P = 0.0001) and the refractive power of the cornea was significantly lower (P = 0.0001) in the 23L group. The astigmatic power was significantly greater in the 23L group (P = 0.0001). Mean intraocular pressure did not differ between groups (P = 0.085). Turkeys from the 23L group had significantly larger globes in nasotemporal (P = 0.0007), dorsoventral (P = 0.015), and anterioposterior (P = 0.021) directions, and anterior chambers were more shallow (P = 0.0002). ERGs revealed the 23L group to have lower a- and b-wave amplitudes and significantly lower cone flicker amplitudes (P = 0.0008). Light microscopic examination revealed 23L turkeys to have significantly decreased numbers of nuclei in the outer nuclear layer (P = 0.0001) and inner nuclear layer (P = 0.0186), and decreased choroidal thickness (P = 0.0008). The prevalence of cataract in the 23L group was significantly higher (P = 0.001). CONCLUSIONS: Exposing turkeys to a prolonged photoperiod induces significant ocular disease.

Reliability and validity of a single item measure of quality of life scale for adult patients with cystic fibrosis.

BACKGROUND: It is important to monitor health related quality of life in order to determine the efficacy of interventions and physical functioning of patients with cystic fibrosis in their daily activities. There is no a single-item global quality of life scale for routine clinical practice for adult patients with cystic fibrosis. We assessed the reliability and validity of a single-item global quality of life scale and compared with the Cystic Fibrosis Quality of Life Questionnaire (CF-QOL) for adult patients with cystic fibrosis. METHOD: 121 (men = 66, women = 55) adult cystic fibrosis patients self-completed the CF-QOL, the Hospital Anxiety Depression Scale, and the single item global quality of life scale at the out patient clinic. 33 (17 women) completed the repeat questionnaires at home within two weeks. Socio-demographic characteristic and lung function data were extracted from the recent medical notes. RESULTS: Mean (SD) age was 29.6 (8.9) years and mean (SD) forced expiratory volume in 1 second was 2.20 (0.94) litres. The test-retest reproducibility using the intra-class correlation coefficient (ICC) for the CF-QOL was 0.83, 95% confidence interval 0.68 to 0.91. The single item global quality of life ICC score was 0.78, 95% confidence interval 0.59 to 0.88. Concurrent validity of the single-item global quality of life was examined in relation to all items of the CF-QOL, frequent episodes of readmission, anxiety and depression (all, p < 0.01) were moderately correlated. CONCLUSION: The study provides preliminary evidence that the single-item quality of life scale is acceptable, valid and repeatable for adult patients with cystic fibrosis. It is a promising tool that can be easily incorporated into a routine clinical practice to assess patients' quality of life.

Discharge preparation: do healthcare professionals differ in their opinions?

Discharge preparation is a multiprofessional activity that is not always conducted efficiently. Perspectives of staff provide an insight into challenges and solutions for this organizational process. The study aimed to examine current discharge practice in one hospital and to compare perceptions of this activity between healthcare workers from different professions. A questionnaire was sent to 1344 staff in an English hospital. It consisted of items related to discharge, which were rated on a Likert scale, and included space for free text. Data were analyzed using descriptive and inferential statistics. The survey method has a number of limitations and conclusions must be considered with caution. A total of 455 usable questionnaires were returned from nurses/midwives, doctors and therapists/allied health professionals. Although respondents showed agreement on a number of areas, differences did arise, which could be linked, in part, to values and roles associated with specific healthcare disciplines. Tensions between professional groups were evident, especially between social workers, nurses and medics. Differences of opinion also appeared between practitioners, patients and carers. Different views among practitioners of discharge preparation could impede efficient joint working. Better understanding of the roles and expertise of team members might improve this process. Factors affecting discharge preparation need to be understood to reduce staff and consumer dissatisfaction and to avoid potential readmissions.

The Adaptive Aerosol Delivery system in a telehealth setting: patient acceptance, performance and feasibility.

BACKGROUND: The telehealth service is one of the fastest growing healthcare segments. It is increasingly utilizing computer technology and telecommunication equipment to either provide continuous vital sign monitoring or facilitate patient care at home, rather than relying solely on in-person care. METHODS: We conducted a 6-week open study in nineteen patients with cystic fibrosis enrolled from three centers, to investigate patient perception of a telehealth enabled nebulizer system (Prodose Adaptive Aerosol Delivery [AAD] System), which enabled the doorstep delivery of repeat medication. RESULTS: The results showed that patient confidence in the device and perception of ease of use was high with no significant change between the start and end of the trial. Views on the home delivery of medication were split between 'great' and 'inconvenient.' However, if the delivery system had been more flexible and delivered all the patients' drugs, the majority of patients would have had their medication delivered in this way. CONCLUSIONS: The trial showed that it was possible to build telehealth technology into an advanced nebulizer system, and that patient acceptance of the technology was unlikely to be a barrier to the adoption of such a telehealth system.

Clinical outcome for cystic fibrosis patients infected with transmissible pseudomonas aeruginosa: an 8-year prospective study.

BACKGROUND: Although there is now compelling evidence for cross-infection by strains of Pseudomonas aeruginosa at some specialist (cystic fibrosis [CF]) centers, the clinical impact of infection by transmissible strains is unclear. METHODS: In an 8-year prospective study, we compared the clinical outcome of two groups of patients with CF infected by transmissible (n = 28) and sporadic strains (n = 52) of P aeruginosa. RESULTS: There were no differences between the two groups in survival, annual changes in spirometry, or BMI. There were differences in requirements for IV antibiotic treatment (mean [SD]: 29.3 [21.9] days vs 53.1 [32.5] days) and hospitalization (median [range]: 11.6 [1.1, 49.3] days vs 23.3 [5.5, 103.6] days) between patients infected with sporadic and transmissible strains of P aeruginosa, respectively. CONCLUSIONS: We conclude that infection by transmissible P aeruginosa does not increase mortality but is associated with increased health-care and antibiotic use for patients with CF.

Systems and people under pressure: the discharge process in an acute hospital.

AIMS: To understand the perspective of hospital-based health professionals with regard to preparing patients for discharge from an acute hospital in England. BACKGROUND: The hospital experience in England over recent years is characterised by increasing admission rates and decreasing length of stay. Legislation and policy initiatives have also focussed upon the need to reduce delayed discharges. Discharge preparation is known to be a complex intervention with multiple obstacles within and outside of the hospital setting. DESIGN: Qualitative. METHODS: Posters were displayed within a hospital asking health professionals to take part in a focus group. Maximum variation, in terms of job titles, was sought for within the sample. Focus groups were held in December 2006. Six senior members of staff divided into pairs to run them. All groups were taped and transcribed verbatim and analysed using a framework approach. RESULTS: Three focus groups were conducted, which involved 11 nurses, 15 allied health professionals, five social workers and one doctor. Analysis identified the following themes and sub themes: 1 Conflicting pressures on staff: Keeping patients in hospital vs. getting them out; Striving for flexibility within a system; A paucity of intermediary provision. 2 Casualties arising from conflicting pressures: Professionals losing their sense of professionalism; Patients being 'systematised'. CONCLUSIONS: Pressures described during focus groups stemmed from five main sources: external targets placed upon the system, internal hospital inflexibility and poor communication, the dominance of the medical model of care, a desire to address the complex needs of individuals and a lack of community services. Staff felt themselves to be victims of these competing pressures and that many of the solutions were beyond their influence. Staff described the dehumanising effect of sometimes having to ignore patient concerns, wishes and choices. RELEVANCE TO CLINICAL PRACTICE: Understanding of the pressures surrounding discharge could inform relevant service improvements.

Living with cystic fibrosis-related diabetes or type 1 diabetes mellitus: a comparative study exploring health-related quality of life and patients' reported experiences of hypoglycaemia.

OBJECTIVES: To compare patients with type 1 diabetes mellitus (T1DM) or cystic fibrosis-related diabetes (CFRD) on frequency and severity of symptoms suggestive of hypoglycaemia and diabetes-specific health-related quality of life (HRQoL). METHODS: This was a cross-sectional comparison study. Participants with T1DM or CFRD completed a questionnaire that assessed symptoms suggestive of hypoglycaemia and diabetes-specific HRQoL, and recorded episodes of low blood sugars in a prospective diary. Comparisons of responses were conducted, and Pearson product correlations were determined between HRQoL scores and other continuous variables. HRQoL scores were compared between the groups after adjusting for confounding factors. RESULTS: Diabetes in cystic fibrosis (CF) patients had a less negative impact on HRQoL than in T1DM patients. Both groups experienced hypoglycaemia, but loss of consciousness or needing help was more common in T1DM patients. Symptoms suggestive of hypoglycaemia were less of a problem for CFRD patients in terms of severity, with T1DM patients having more neuroglycopenic symptoms. DISCUSSION: Although the same percentage of patients in both groups reported experiencing hypoglycaemia, severity (e.g. symptoms and loss of consciousness) was higher for those with T1DM. Symptoms of hypoglycaemia appear to have a significant impact on HRQoL, and could account for the worse HRQoL in T1DM patients.

Isolation, motivation and balance: living with type 1 or cystic fibrosis-related diabetes.

AIMS AND OBJECTIVES: To explore patients' responses to developing and managing cystic fibrosis-related diabetes and to contrast their views with those of individuals with type 1 diabetes mellitus. BACKGROUND: The incidence of diabetes among people with cystic fibrosis has increased with improvement in life expectancy. However, little is known about how patients respond to and manage cystic fibrosis-related diabetes, and how this compares with people living with type 1 diabetes mellitus. DESIGN: Qualitative research was undertaken in order to fully explore meanings and views. METHODS: Semi-structured telephone or face-to-face interviews were conducted with patients who had cystic fibrosis-related diabetes or type 1 diabetes mellitus, during which, they discussed diagnosis and management of diabetes. Framework analysis was employed to identify themes and to consider similarities and differences between the two groups. RESULTS: Eleven cystic fibrosis-related diabetes and 12 type 1 diabetes mellitus patients were interviewed in 2006. Patients with cystic fibrosis-related diabetes described their diabetes diagnosis as a progression of their primary illness, management of which was important owing to the benefits it brought to their cystic fibrosis. Those with type 1 diabetes mellitus were more likely to report feeling psychologically low because of diabetes and to list long-term complications as a key factor motivating self-management. Both groups struggled to balance the demands of diabetes with other life and health obligations, and experienced isolation because of diabetes. Conclusions. Variation in perceptions recalled during interviews stemmed from diabetes being part of an existing life-threatening chronic illness in people with cystic fibrosis-related diabetes. Similarities and differences in attitudes and management practices were found, with less urgency regarding glucose monitoring and fewer information resources available for those with cystic fibrosis-related diabetes. RELEVANCE TO CLINICAL PRACTICE: Both groups need support for optimal diabetes management and access to appropriate resources outside specialist clinics. Web-based technologies could prove useful for those with cystic fibrosis-related diabetes as face-to-face interaction may be prevented owing to the risk of cross-infection.

The changing epidemiology of Burkholderia species infection at an adult cystic fibrosis centre.

BACKGROUND: This study reviews the impact of changing infection control practices at the Manchester Adult Cystic Fibrosis Centre (MACFC) upon the epidemiology of Burkholderia species infections. METHODS: We reviewed strain and genomovar typing of all available Burkholderia isolates at our centre between 1983-2006. RESULTS: The incidence/prevalence of infection with Burkholderia species between 1983-1990 was below 5%/9% each year. There was a rise in incidence/prevalence of Burkholderia species between 1991 and 1994 with a peak of 16.3%/31.2% in 1992. Following complete cohort segregation, the incidence has fallen to below 3% for all but one year and the prevalence has gradually reduced to 9.3% in 2005. Currently, there is an increase in the prevalence to 10.6% for the first time since 1994, predominantly due to patients with unique infections transferring into the unit from referring centres. The presence of unique strains now exceeds transmissible strains for the first time since 1991. CONCLUSIONS: Infection control measures including patient segregation have controlled spread of transmissible B. cenocepacia strains, but not the acquisition of unique strains. Unique strains of Burkholderia species now account for the majority of new infections at the Manchester Adult Cystic Fibrosis Centre.

Outcomes of community-based social service interventions in homebound elders.

OBJECTIVE: To document within-client change in function and quality of life over 6 months, and determine whether social service interventions, comorbidity, depressive symptoms, social support and stress are predictors of within-patient change. METHOD: Assess homebound elderly referred for social services on depressive symptoms measured by the Geriatric Depression Scale (GDS), comorbidity with the Charlson Index, and stress and support with the Duke instrument. Function was measured by the Functional Autonomy Scale (FAS), measuring Activities of Daily Living (ADL), Independent Activities of Daily Living (IADL), mobility, communication and mental function. The SF-36 measured quality of life. RESULTS: Among 56 new homebound clients with an average age of 82, 33% had depressive symptoms at baseline (>7 on the GDS). At baseline clients were at or below 25th percentile for five of eight domains of the SF-36, and mental and physical summary scores. Further at baseline, 90% had difficulties with mobility and IADLs; 61% had ADL limitations. At 6-month follow-up overall, 26% had depressive symptoms at follow-up. Greater comorbidity was associated with more depressive symptoms at both baseline and follow-up. By 6 months, 18% had deteriorated on the FAS, while 11% improved. More clients had changes in quality of life; regarding the physical component score, 13% had important deterioration, while 63% improved. Similarly, 33% declined on the mental component while 27% improved. CONCLUSION: Among newly homebound elders, those with significant depressive symptoms are more likely to experience deterioration in function and quality of life over 6 months. However, those with more support showed significant improvement in the SF-36 mental component scale at 6 months.

Recirculating immunomagnetic separation and optimal enrichment conditions for enhanced detection and recovery of low levels of Escherichia coli O157:H7 from fresh leafy produce and surface water.

The objective of this study was to develop a rapid, simple method for enhanced detection and isolation of low levels of Escherichia coli O157:H7 from leafy produce and surface water using recirculating immunomagnetic separation (RIMS) coupled with real-time PCR and a standard culture method. The optimal enrichment conditions for the method also were determined. Analysis of real-time PCR data (C(T) values) suggested that incubation of lettuce and spinach leaves rather than rinsates provides better enrichment of E. coli O157:H7. Enrichment of lettuce or spinach leaves at 42 degrees C for 5 h provided better detection than enrichment at 37 degrees C. Extended incubation of surface water for 20 h at 42 degrees C did not improve the detection. The optimized enrichment conditions were also employed with modified Moore swabs, which were used to sample flowing water sites. Positive isolation rates and real-time PCR results indicated an increased recovery of E. coli O157:H7 from all samples following the application of RIMS. Under these conditions, the method provided detection and/or isolation of E. coli O157:H7 at levels as low as 0.07 CFU/g of lettuce, 0.1 CFU/g of spinach, 6 CFU/100 ml of surface water, and 9 CFU per modified Moore swab. During a 6-month field study, modified Moore swabs yielded high isolation rates when deployed in natural watershed sites. The method used in this study was effective for monitoring E. coli O157:H7 in the farm environment, during postharvest processing, and in foodborne outbreak investigations.