Applying adaptive management and lessons learned from national assessments to address logistical challenges in the National Wetland Condition Assessment

The National Wetland Condition Assessment (NWCA) is one of a series of probability-based National Aquatic Resource Surveys (NARS) conducted by the U.S. Environmental Protection Agency (USEPA) to provide a comprehensive assessment of the condition of the Nation's waters. Randomized design and standardized training and protocols allow USEPA to analyze data that are nationally consistent and regionally relevant. Each NARS assessment was preceded by careful consideration of key logistical elements that included pre-survey planning, training, sampling logistics, and laboratory analysis. Numerous state, tribal, and contractor crews were supported across the country for each assessment; sampling and sample analyses were tracked from initiation; laboratory analyses were completed at USEPA, state, regional, and contract laboratories; and the data analyses and reporting were completed by USEPA-led workgroups, states, and contractors. The complexity and difficulty of each step offered unique challenges and provided lessons learned for each of the NARS assessments. Major logistical elements for implementing large scale assessments that are constrained by sampling period and number and duration of visits are covered in this paper. These elements include sample transport, equipment and supplies, sampling and sample tracking, information management regional technical expertise, and a sound field training program. This paper describes how lessons from previous assessments were applied to the NWCA and how new challenges faced in the NWCA were addressed and carried forward into future surveys.

Complications of office based arthroscopy of the knee

OBJECTIVE

To analyze the complication rates associated with office based arthroscopy in 2 community based rheumatology practices.

METHODS

A retrospective analysis of 335 office based arthroscopy performed on 306 patients over a 35 mo period. All patients met specific clinical criteria to qualify for office based arthroscopy. Patients were followed postarthroscopy for a minimum of 12 weeks to assess the rates and types of complications.

RESULTS

Of the 335 office based arthroscopies, 131 were diagnostic only, while 204 procedures were diagnostic and therapeutic. A total of 280 interventions were performed. Both major and minor complications were seen. The complication rates for major and minor events were 1.2 and 12.8%, respectively. There was no mortality or longterm morbidity.

CONCLUSION

Office based arthroscopy in patients with rheumatic diseases has a safety profile that compares favorably with arthroscopy performed in an ambulatory surgical center or operating room setting.

Laboratory variables of bladder autoaugmentation in an animal model

OBJECTIVES

Evaluations of the functional, radiologic, and pathologic outcomes of autoaugmentation by two surgical techniques (vesicomyectomy versus vesicomyotomy) were compared. Autoaugmentation or vesicomyotomy is being increasingly considered as a simplified method of bladder augmentation in the hypertonic decreased-capacity bladder.

METHODS

In a series of 35 laboratory sessions, creation of an animal model approximating the small-capacity hypertonic bladder was achieved. Sixteen vesicomyotomies and 16 vesicomyectomies were performed on the 32 stabilized one-third reduced bladders. Three stabilized one-third reduced bladders were used as controls.

RESULTS

Radiologic studies show a large diverticulum. A 17.2% net increase in surface area was achieved, compared with the reduced bladder, at the time of pathologic examination. Functional capacity was increased by 43.5% on urodynamic studies, and leak point pressure was decreased by 48.1%. Histologic and morphometric examinations of the autoaugmentation area showed a few muscle fibers with serosal deposition of collagen. There was less muscle ingrowth at the periphery of the autoaugmentation site utilizing vesicomyectomy.

CONCLUSIONS

There was no statistical difference between vesicomyotomy and vesicomyectomy with respect to radiologic, pathologic, or urodynamic outcome.

A short-term study of nitrofurantoin prophylaxis in children managed with clean intermittent catheterization

OBJECTIVE

Because there is no evidence for the effectiveness of antibiotic prophylaxis in children with neurogenic bladder, the value of once-daily nitrofurantoin macrocrystals was assessed in a selected population with neurogenic bladder due to meningomyelocele. METHODS AND TRIAL POPULATION: Children with significant urinary tract abnormalities other than neurogenic bladder were excluded. A urinary tract "infection" was defined as > or = 10(8) colony forming units of bacteria/L of urine together with pyuria of > or = 50 x 10(6) leukocytes/L, and/or symptoms consistent with an urinary tract infection. Fifty-six children participated in a 24-week double-blinded, placebo-controlled cross-over study. The infection status was assessed at two weekly intervals or if relevant clinical manifestations occurred.

RESULTS

For the whole trial the average percentage of "infections" per urine sample for each patient was reduced from 39% on placebo to 19% on single daily dose prophylaxis (P < .0003). For the first 12 weeks of the trial corresponding figures were 45% on placebo and 22% on prophylaxis (P < .0018). There was evidence for a marked carryover protective effect of nitrofurantoin into the placebo arm of the trial.

CONCLUSION

Nitrofurantoin is an effective prophylactic agent during a 3-month period. Long-term studies are needed to confirm the reasonable expectation of a beneficial effect on urinary tract damage.

A randomized, controlled trial of arthroscopic surgery versus closed-needle joint lavage for patients with osteoarthritis of the knee

OBJECTIVE

To compare arthroscopic surgery and closed-needle joint lavage for patients with non-end-stage osteoarthritis (OA) of the knee under controlled, experimental conditions.

METHODS

Thirty-two subjects who met specific clinical, radiologic, medical, and rehabilitation criteria were randomized to receive arthroscopic surgery (n = 18) or joint lavage (n = 14). Outcome measures evaluated at baseline and at 3 and 12 months of followup included 3 standard clinical parameters, self-reported pain and functional status (by the Arthritis Impact Measurement Scales), 50-foot walk time, 2 global scales, and direct and indirect medical costs.

RESULTS

At 3 months of followup, there were no significant between-group differences in pain, self-reported and observed functional status, and patient and "blinded" physician global assessments. The arthroscopic procedure cost $3,840 more than did closed-needle joint lavage. After 1 year, there were no between-group differences in medication costs, utilization of medical services, or indirect costs related to employment or use of household help. After 1 year, 44% of subjects who underwent arthroscopy reported improvement and 58% of subjects who underwent joint lavage improved. Patients with tears of the anterior two-thirds of the medial meniscus or any lateral meniscus tear had a higher probability of improvement (by "blinded" physician assessment) after arthroscopic surgery (0.63) than did patients with other intraarticular pathology (0.20).

CONCLUSION

The search for and removal of soft tissue abnormalities via arthroscopic surgery does not appear justified for all patients with non-end-stage OA of the knee who fail to respond to conservative therapy, but it may be beneficial for certain subgroups.

Tidal irrigation versus conservative medical management in patients with osteoarthritis of the knee: a prospective randomized study. Tidal Irrigation Cooperating Group

To determine the efficacy of tidal knee irrigation for knee pain due to osteoarthritis (OA), we conducted a randomized, single blind, 14-week prospective trial comparing medical management with tidal knee irrigation in 77 patients with non-end stage OA of the knee and unilateral pain refractory to standard medical treatment. Fifty-seven patients completed the study. Statistically significant differences (p less than 0.05) favoring tidal knee irrigation over medical management were pain after 50' walk, pain after 4-stair climb, most intense pain in previous day, frequency of knee stiffness with inactivity, days of morning knee stiffness in previous week, physician assessment of knee tenderness and overall assessments of therapy effectiveness by both patient and physician. Tidal knee irrigation results in more favorable improvement of pain due to OA than can be accomplished with traditional medical management.

Arthroscopy in the diagnosis and therapy of arthritis

The future of arthroscopy as an intervention in the management of patients with arthritis will depend largely on developments in technology and wider use of the procedure. With the capability of performing office arthroscopy, large-scale clinical studies will help improve both the diagnosis and management of rheumatoid arthritis and osteoarthritis.

Prerandomization: an alternative to classic randomization. The effects on recruitment in a controlled trial of arthroscopy for osteoarthrosis of the knee

Possibly the greatest threat to the success of a randomized clinical trial is the inability to recruit an adequate number of subjects. Concern that the randomized clinical trial will adversely affect the physician-patient relationship is the most common reason for physicians' reluctance to enroll patients in such trials. We report a modification of a prerandomized design, first described by Zelen, which was implemented in a randomized clinical trial of arthroscopy for patients who had osteoarthrosis of the knee. The method was associated with a sixfold increase in the rate of accrual of patients as compared with the use of a classic randomization trial. We propose the design as a potential solution to the problem of recruitment of subjects, particularly for clinical studies.

Augmentation ileocystoplasty in children with myelodysplasia

Over the past 8 years 20 children suffering from myelodysplasia were selected to undergo augmentation ileocystoplasty for urinary incontinence refractory to treatment by clean, intermittent catheterization and anticholinergic agents, or as part of urinary undiversion. The children ranged in age from 5 to 17 years, and the follow-up ranged from 6 months to 7 years. Three children underwent undiversion, two had vesicostomy closure and six had bladder outlet repair at the time of augmentation. In one patient, surgery was technically impossible. Postoperatively 16 children were fully continent on clean, intermittent catheterization and anticholinergic medication. Three boys failed to achieve satisfactory continence. Delayed perforation, a potentially serious complication, occurred in two patients several months postoperatively.

Salmonella lipopolysaccharide in synovial cells from patients with reactive arthritis

Synovial cells from nine patients with reactive arthritis following Salmonella enteritidis or Salmonella typhimurium infection were examined for salmonella antigens. Extensive bacterial cultures of the synovial fluid were negative. Eight synovial-fluid cell samples stained positively on immunofluorescence with rabbit antisera against heat-killed S enteritidis or S typhimurium or with monoclonal antibodies specific for the causative salmonella lipopolysaccharide (LPS). Synovial tissue from the ninth patient stained positively in the avidin-biotin-peroxidase complex method with the monoclonal antibody. Control samples (synovial-fluid cells from thirteen patients with other rheumatic diseases and synovial tissue from two) were negative. Synovial cells from eight patients and five controls were studied by western blotting with the same monoclonal antibodies. Four of the eight patients but no controls had blots indicating salmonella LPS in the synovial cells. The presence of bacterial LPS in the joint is a common and pathogenetically important feature of reactive arthritis.

Undiversion in patients with meningomyelocele

Since 1981, 12 patients with neurogenic bladder due to meningomyelocele who had had previous ileal conduit urinary diversions underwent assessment for undiversion. Two important criteria for undiversion were motivation and a reconstructable bladder. Four patients either did not fulfil these criteria or refused surgery. Eight patients (six females and two males) underwent undiversions. Uretero-ureteral anastomosis was achieved in 13 ureters and ureteroneocystostomy in 2; transureteroureterostomy was necessary in 1 ureter. Augmentation cystoplasty and vesicourethropexy were important in establishing continence postoperatively; these procedures were not performed in two patients whose undiversion failed early in the series. The evolution of an investigation protocol, surgical technique and final approach to this complex problem are discussed.

Bladder-outlet reconstruction in neurogenic bladder due to myelomeningocele

In a subgroup of children with myelomeningocele, urinary incontinence cannot be managed by clean intermittent catheterization and anticholinergic medication. The authors report on 24 such children who required bladder-outlet reconstruction. Twelve boys underwent the Young-Dees/Leadbetter procedure, 8 girls underwent the Burch procedure and the remaining 4 had a combination of the two. Augmentation cystoplasty was also carried out in seven girls and one boy. Results were most favourable in the girls, with improvement in 92%, in contrast to the boys in whom only 58% were improved. Artificial sphincter placement may be a more beneficial alternative for boys.

The spiral ganglion of the newborn baby

Four temporal bones of human newborns were studied with light and electron microscopy. In contrast to the adult human spiral ganglion as described by Kimura and coworkers, that of the newborn baby shows no myelination, either of the large ganglion cells or of the small. Whereas in adults the small ganglion cells contain neurofilaments or neurotubules, newborns have no cytoplasmic criteria by which to differentiate large and small neurons. Except for the small neurons, unmyelinated nerve fibers end on the surface of the ganglion cell or they penetrate into the cytoplasm. They form synaptic contacts. It is assumed that they belong to the efferent intraganglionic spiral bundle.

Squamous cell carcinoma of the vulva and Fanconi anemia

Malignant neoplasia frequently occurs with Fanconi anemia. Generally this represents hematologic disease; however, solid tumors may also appear. The woman described here developed squamous cell carcinoma of the vulva at age 28, and is the third such case in a patient with Fanconi anemia that has been reported. It is a diagnosis to be considered for the young patient with this type of carcinoma. Increased chromosomal breakage in this syndrome may be important in the pathogenesis of these neoplastic changes.

Cellular immune deficiency with autoimmune hemolytic anemia in purine nucleoside phosphorylase deficiency

Immunologic and metabolic abnormalities were studied in a five year old boy with 0.07 per cent of normal erythrocyte purine nucleoside phosphorylase activity. The clinical course is characterized by severe autoimmune hemolytic anemia, a transient neurologic disorder with tremor and ataxia, and minor infectious illnesses. There is severe lymphopenia with decreased absolute numbers of T and B lymphocytes. Mitogen-stimulated blastogenesis is reduced, but response to allogeneic lymphocytes is normal. A monoclonal IgG protein is present. There is hypouricemia, elevated plasma inosine level, hypouricosuria and an increase in the urinary concentration of inosine and guanosine. The pattern of heterozygote distribution in the patient's family is compatible with an autosomal recessive trait in which heterozygotes are identifiable. In addition, the unusual laboratory and clinical manifestations of this patient illustrate the heterogeneity of the clinical syndrome associated with purine nucleoside phosphorylase deficiency.

Role of perilymph in the early stage of serous otitis

After injection of an electron-dense tracer into the cerebrospinal fluid (CSF) the particles can be seen within the lymphatic spaces of the middle ear mucosa after a few minutes. They find their way via the well known communication routes from CSF to the perilymphatic spaces of the inner ear. From there they enter through open fluid spaces into the fibrocytic network of the round window membrane which stands in open relationship to the extracellular fluid spaces of the middle ear mucosa. They were drained to the regional lymph nodes by lymphatic vessels. When inducing a serous otitis by experimental obstruction of the Eustachian tube it could be demonstrated that the fluid within the middle ear cavity is partly coming from the CSF and perilymph. Later the healing process of the middle ear epithelium was studied after the onset of serous otitis with and without artificial ventilation of the middle ear.

Fine structure of a murine mammary carcinoma cell line

A fine structural study was made of cells from the epithelioid MCF-8/5-2A cell line derived from a MuMTV-free D2 transplantable hyperplastic outgrowth. Electron microscopy shows the cells to be truly epithelial with many cell-to-cell junctions and microvilli. The cells are similar in many respects to normal mouse mammary gland and some of the conventional mammary tumor derived cell lines. This study supports previous observations of the absence of MuMTV in MCF-8 within the limits of morphological detection, and demonstrates the presence of numerous virus particles within, or budding into, cisternae of the endoplasmic reticulum and nuclear envelope. These intracisternal A particles have not been previously described in such abundance in mammary tumor tissue culture cells.

Hypoxanthine phosphoribosyltransferase deficiency: association of reduced catalytic activity with reduced levels of immunologically detectable enzyme protein

In the present study hemolysates from fourteen patients with a genetically determined deficiency of hypoxanthine phosphoribosyltransferase (EC 2.4.2.8; IMP:pyrophosphate phosphoribosyltransferase) activity were examined immunologically for the presence of material that crossreacts with the normal enzyme. A quantitative assay for crossreacting material in enzyme-deficient hemolysates was based on the inhibition of the immunoprecipitation of the normal enzyme. As little as 3% of normal crossreacting material could be detected. One patient in this series was found to have a normal amount of crossreacting material, whereas the remainder had no detectable crossreacting protein. The lack of detectable crossreacting material in these patients raises the possibility that a defect in synthesis or degradation of enzyme protein may be present in many patients deficient in hypoxanthine phosphoribosyltransferase.

Growth retardation in the Lesch-Nyhan syndrome

The Lesch-Nyhan syndrome is an inherited neurologic disorder due to deficiency of hypoxanthine-guanine phosphoribosyl transferase and characterized clinically by self-mutilation, choreoathetosis, spasticity and mental retardation. This study demonstrates that these patients have significant growth retardation similar to that observed in other groups of patients with mental retardation. Endocrine studies indicate that this growth retardation cannot be attributed to pituitary or thyroid dysfunction. Serum somatomedin (sulphation factor) measurements were within the range of normal in 4 of the 5 patients studied. Therefore, the defect in growth and osseous maturation must be due to an abnormality in the end organ (cartilage).

Dietary-induced variation of hypoxanthine-guanine phosphoribosyl transferase activity in patients with the Lesch-Nyhan syndrome

We have studied three patients with the Lesch-Nyhan syndrome to assess the effect of dietary purines on erythrocyte hypoxanthine-guanine phosphoribosyltransferase (HGPRT) activity. During dietary purine restriction HGPRT activity rose in all three patients; resumption of normal dietary purine intake or the addition of adenine (10 mg/kg per day) to a purinefree diet resulted in a fall in HGPRT activity. These changes in enzyme activity appeared to be due to an activation or inactivation of the mutant enzyme without a change in the half-life or absolute amount of HGPRT enzyme protein.

Hypoxanthine-guanine phosphoribosyltransferase: characteristics of the mutant enzyme in erythrocytes from patients with the Lesch-Nyhan syndrome

The Lesch-Nyhan syndrome is characterized clinically by choreoathetosis, spasticity, selfmutilation, and mental and growth retardation. Biochemically, there is a striking reduction of hypoxanthine-guanine phosphoribosyltransferase (HGPRT) activity in affected individuals. We have examined erythrocytes from 14 patients with the Lesch-Nyhan syndrome for the presence of hypoxanthine-guanine phosphoribosyltransferase activity and enzyme protein. In contrast to the usual finding of no detectable hypoxanthine-guanine phosphoribosyltransferase activity, we have found low levels (0.002-0.79 nmoles/mg protein per hr) of hypoxanthine-guanine phosphoribosyltransferase activity in erythrocyte lysates from five of these patients. In three of the five patients, hypoxanthine-guanine phosphoribosyltransferase activity appeared to be substantially more labile in vivo than normal using erythrocytes which had been separated according to their density (age). Immunochemical studies using a monospecific antiserum prepared from a homogeneous preparation of normal human erythrocyte hypoxanthine-guanine phosphoribosyltransferase revealed immunoreactive protein (CRM) in hemolysate from all 14 patients with the Lesch-Nyhan syndrome. The immunoreactive protein from each patient gave a reaction of complete identity with normal erythrocyte hypoxanthine-guanine phosphoribosyltransferase and was present in quantities equal to those observed in normal erythrocytes. In addition, a constant amount of CRM was found in erythrocytes of increasing density (age) from patients with the Lesch-Nyhan syndrome despite the decreasing hypoxanthine-guanine phosphoribosyltransferase activity. These studies confirm previous data which indicate that the mutations leading to the Lesch-Nyhan syndrome are usually, if not always on the structural gene coding for hypoxanthine-guanine phosphoribosyltransferase. In addition, although the mutant proteins appear to be present in normal amounts, they are often very labile in vivo with respect to enzymatic activity. These observations suggest that therapy directed at stabilization or activation of enzyme activity in vivo may be of potential benefit.