Differential effects of neuroexcitatory amino acids on corticotropin-releasing hormone-41 and vasopressin release from rat hypothalamic explants.

We have investigated the direct effects of different neuroexcitatory amino acids (EAA) on the secretion of CRH-41 and arginine vasopressin (AVP) from the rat hypothalamus maintained in vitro. CRH-41 and AVP released in the medium were assayed by RIA before and after incubation with N-methyl-D-aspartate (NMDA), N-methyl-D,L-aspartic acid, kainate (KA), and quisqualate in the concentration range 1 nM to 1 mM in either the absence or the presence of 1 mM Mg2+ in the medium. In the case of NMDA, the effect of the addition of glycine (1 and 10 microM) to the incubation medium was also studied. Finally, we investigated whether different periods of exposure (up to 100 min) of hypothalamic explants to NMDA and KA would affect CRH-41 release. While no EAA was able to induce CRH-41 release under any of the above conditions, 20-min incubations with NMDA in the dose range of 1 nM to 1 mM in the absence of added Mg2+ significantly stimulated AVP release in a dose-related fashion; the maximum effect occurred at a concentration of 1 mM [ratio of stimulated collection/basal collection: NMDA, 1.51 +/- 0.10, controls, 0.86 +/- 0.05 (mean +/- SEM); P < 0.001]. KA also showed a dose-related stimulatory effect in the dose range of 1 nM to 1 mM, with maximal AVP stimulation at 10 microM (KA, 1.91 +/- 0.28; controls, 0.90 +/- 0.03; P < 0.01). The effects of both NMDA and KA on AVP were completely reversed by the competitive antagonists D,L-2-amino-5-phosphonovaleric acid and 6-cyano-7-nitroquinoxaline-2,3 dione, respectively, at doses 10 times higher than those of the agonists. N-Methyl-D,L-aspartic acid stimulated AVP secretion only at a dose of 10 mM (P < 0.01), whereas quisqualate was ineffective at any concentration. The addition of 1 mM Mg2+ to the medium blocked the effect of NMDA, while attenuating AVP stimulation induced by KA. The stimulatory effect of KA on AVP was significantly reduced by D-L-2-amino-5-phosphonovaleric acid (P < 0.05), suggesting that KA may also act through NMDA receptors. Moreover, the presence of glycine in the incubation medium did not result in any effect of NMDA on CRH-41 secretion, nor did it appear to potentiate NMDA-induced AVP release.(ABSTRACT TRUNCATED AT 400 WORDS)     

Activating point mutations in cyclin-dependent kinase 4 are not seen in sporadic pituitary adenomas,insulinomas or Leydig cell tumours

Cell cycle dysregulation is one of the defining features of cancer. Cyclin-dependent kinase 4 (CDK4), together with its regulatory subunit cyclin D, governs cell cycle progression through the G1 phase. Cyclin-dependent kinase inhibitors, including p16(INK4A) (encoded by CDKN2A), in turn regulate CDK4. In particular, dysregulation of the p16/CDK4/cyclin D complex has been established in a variety of types of human tumours. Dominant activating mutations affecting codon 24 of the CDK4 gene (replacement of Arg24 by Cys or His) render CDK4 insensitive to p16(INK4) inhibition and are responsible for melanoma susceptibility in some kindreds. However, 'knock-in' mice homozygous for the CDK4(R24C) mutation were noted to develop multiple neoplasia, most commonly including endocrine tumours: pituitary adenomas, insulinomas and Leydig cell testicular tumours. We therefore speculated that sporadic human endocrine tumours might also harbour such mutations. The aim of the current study was to analyze the CDK4 gene for the two characterized activating mutations, R24C and R24H, in sporadic human pituitary adenomas, insulinomas and Leydig cell tumours. We used DNA extracted from 61 pituitary adenomas, and paired tumorous and neighboring normal genomic DNA extracted from 14 insulinoma and 6 Leydig cell tumour samples. Genomic DNA from patients with familial melanoma harbouring the R24C or the R24H mutations served as positive controls. All samples were subjected to PCR, mutation-specific restriction digests and/or sequencing. Both methodologies failed to detect mutations at these two sites in any of the sporadic endocrine tumours including pituitary adenomas, benign or malignant insulinomas or Leydig cell tumours, while the positive controls showed the expected heterozygote patterns. Protein expression of CDK4 was demonstrated by immunohistochemistry and Western blotting in pituitary and pancreatic samples. These data suggest that the changes in the regulatory 'hot-spot' on the CDK4 gene, causing various endocrine tumours in CDK4(R24C/R24C )mice, are not a major factor in sporadic pituitary, insulin beta-cell or Leydig cell tumorigenesis.     

Barriers and motivators to blood and cord blood donations in young African-American women

The primary aim of this study was to assess potential barriers and motivators to blood and cord blood donation among African-American women. A telephone survey of African-American women, ages 18-30 years, in the St. Louis metropolitan area was performed. The survey was administered by trained telemarketing personnel using a Computer-Assisted Direct Interview (CADI) system. One hundred sixty-two women were surveyed. Common barriers to blood donation were inconvenience of donor sites (19%), fear of needles (16%), and too much time required to donate (15%). Potential motivators were increasing awareness of need for blood (43%), increasing the number of convenient donor locations (19%), and encouragement by spiritual leaders to have blood drives at their church (17%). Lack of awareness was the only identified barrier to cord blood donation. Most women surveyed (88%) indicated that they definitely or probably would donate cord blood. Strategies to increase the proportion of African-American blood and cord blood donations may include educating potential donors about the process and benefits of donation to particular patient populations and engaging church leadership in supporting blood and cord blood donations.     

A case history of training outside the hospital and its future.

Hospital-based medical residencies are slowly changing to include experience in ambulatory practices. This development is traced by the case example of the medical residency at the Massachusetts General Hospital which has always contained a component of ambulatory training. The history reveals that the institution's economy and work have determined the content and sequence of residency training, perhaps more than educational ideas on the proper training of the doctor. The early ambulatory experience (1900–1940) was prompted by the need to take care of a large number of outpatients, supported by the view of training for future private practice in the office. The residency became hospital-based (1940–1972) with the expansion of hospital beds, hospital insurance and of specialized jobs in academic medical centers. Residents were now required to care for more hospital patients, to manage the technology of acute care and to aid the growth of subspecialization. Although public interests today demand more ambulatory care, the future of expanded ambulatory training remains problematic, although a modern necessity if medicine is to redirect its attention to prevention and care outside the hospital. Expanded training outside the hospital depends on better financing of ambulatory services, the modernization of outpatient departments as group practices providing primary care, the development of teaching units and research in ambulatory practices, along with support for the idea of the generalist, which itself has had limited support by treatment and learning institutions.     

Right ventricular function in adults with pulmonary hypertension with and without atrial septal defect

Using equilibrium (gated) radionuclide ventriculography, right ventricular (RV) function was studied in 22 adults with pulmonary hypertension and in 16 patients without evidence of cardiac disease. To assess the effect of volume overload on RV performance in pulmonary hypertension, RV ejection fractions were compared in patients with and without left-to-right shunts due to atrial septal defect (ASD). In addition, the effect of ASD repair on RV function was examined. In 14 patients with pulmonary hypertension without RV volume overload (group I), the RV ejection fraction (0.35 ± 0.11, mean ± standard deviation [SD]) was significantly lower than in the normal group (0.47 ± 0.11, p < 0.01). In 8 patients with left-to-right shunts due to ASD (group II) and with RV systolic pressures similar to those in group I, the mean RV ejection fraction (0.53 ± 0.15) was normal and was significantly higher than in group I (p < 0.01). Right ventricular end-diastolic volumes, estimated from combined radionuclide and hemodynamic data, were higher (p < 0.01) in group II patients (171 ± 70 ml/m²) than in group I patients (70 ± 13 ml/m²). In 5 patients who underwent isolated shunt repair, mean RV ejection fraction decreased postoperatively from 0.57 ± 0.17 to 0.40 ± 0.12 (p < 0.05). It is concluded that (1) pulmonary hypertension frequently causes a decrease in RV systolic function due to abnormal afterload; (2) in patients with RV volume overload due to left-to-right shunt, systolic function, as measured by the ejection fraction, remains normal despite pulmonary hypertension, possibly through the Starling mechanism; and (3) RV systolic function often decreases after repair of an ASD.     

Monozygotic twins discordant for systemic lupus erythematosus.

A pair of monozygotic twins discordant for systemic lupus erythematosus(SLE) were studied and no differences noted in their immune respose to tetanus toxoid, keyhole lympet hemocyanin, DNCB, delayed sensitivity, or antibody titers to viruses. Both were noted to have biologically false positive serology at an early age, but only one twon developed SLE. The clinically unaffected twin underwent castration at an early age, suggesting that ovarian hormones may play an important role in the development of SLE.     

Predicting In-Hospital Mortality at Admission to the Medical Ward: A Big-Data Machine Learning Model

BackgroundGeneral medical wards admit high-risk patients. Artificial intelligence algorithms can use big data for developing models to assess patients’ risk stratification. The aim of this study was to develop a mortality prediction machine learning model using data available at the time of admission to the medical ward.MethodsWe included consecutive patients (ages 18-100) admitted to medical wards at a single medical center (January 1, 2013-December 31, 2018). We constructed a machine learning model using patient characteristics, comorbidities, laboratory tests, and patients’ emergency department (ED) management. The model was trained on data from the years 2013 to 2017 and validated on data from the year 2018. The area under the curve (AUC) for mortality prediction was used as an outcome metric. Youden index was used to find an optimal sensitivity-specificity cutoff point.ResultsOf the 118,262 patients admitted to the medical ward, 6311 died (5.3%). The single variables with the highest AUCs were medications administered in the ED (AUC = 0.74), ED diagnosis (AUC = 0.74), and albumin (AUC = 0.73). The machine learning model yielded an AUC of 0.924 (95% confidence interval [CI]: 0.917-0.930). For Youden index, a sensitivity of 0.88 (95% CI: 0.86-0.89) and specificity of 0.83 (95% CI: 0.83–0.83) were observed. This corresponds to a false-positive rate of 1:5.9 and negative predictive value of 0.99.ConclusionA machine learning model outperforms single variables predictions of in-hospital mortality at the time of admission to the medical ward. Such a decision support tool has the potential to augment clinical decision-making regarding level of care needed for admitted patients.