Idiopathic giant-cell granulomatous hypophysitis mimicking acute meningitis

A 32-year-old woman presented with severe headache, photophobia, fever, nausea, vomiting, and worsening vision. She had also noted several months of amenorrhea. She was febrile to 38.9 degrees C. Laboratory evaluation revealed a markedly elevated erythrocyte sedimentation rate. Lumbar puncture revealed a cerebrospinal fluid lymphocytic pleocytosis and an elevated protein level. Endocrine studies revealed evidence of panhypopituitarism without diabetes insipidus. A magnetic resonance imaging study showed a 2-cm pituitary mass with optic chiasmal compression. The patient had a trans-sphenoidal resection of the mass. Pathology revealed multinucleated giant cells in necrotic debris, but no evidence of pituitary tumor. Studies looking for evidence of systemic granulomatous disease were negative. The patient was considered to have idiopathic giant-cell granulomatous hypophysitis. After surgery, the patient's vision improved and hormone replacement therapy was initiated. This case illustrates that idiopathic giant-cell granulomatous hypophysitis should be considered in the differential diagnosis of a patient presenting with a pituitary mass, hypopituitarism, and meningitis-like symptoms.

Gamma-aminobutyric acid (GABA) A and B receptors mediate the stimulatory effects of GABA on the human sperm acrosome reaction: interaction with progesterone

OBJECTIVE

To evaluate which gamma-aminobutyric acid (GABA) receptor mediates the stimulatory effects of this neurotransmitter on the human sperm acrosome reaction, and to examine the interaction of progesterone, a physiologic inducer of the acrosome reaction, with the GABA(A) receptor.

DESIGN

Prospective study.

SETTING

A university clinic of andrology.

PATIENT(S)

Men with normal sperm analysis parameters.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The acrosome reaction of motile spermatozoa.

RESULT(S)

The acrosome reaction was stimulated by GABA in a dose-dependent manner. This effect was inhibited completely by bicuculline, a GABA(A) receptor antagonist, and only partially by saclofen, a GABA(B) receptor antagonist. Accordingly, muscimol, a GABA(A) receptor agonist, stimulated the acrosome reaction to the same extent as GABA, whereas baclofen, a GABA(B) receptor agonist, was less effective. Preincubation with progesterone followed by the addition of GABA resulted in a significant increase in the percentage of acrosome-reacted spermatozoa compared with progesterone alone. However, this increase was less than a simple addition of effects, suggesting that GABA and progesterone act through the same receptor and/or use the same mechanism of action. To test this hypothesis, the ability of progesterone to induce acrosome reaction was tested in the presence of bicuculline, which suppressed the stimulatory effects of progesterone. Given that the GABA(A) receptor is linked to the chloride channel, we tested whether picrotoxin, a blocker of this channel, could modulate the effects of progesterone or GABA. Picrotoxin completely suppressed the acrosome reaction induced by progesterone and only partially suppressed that caused by GABA.

CONCLUSION(S)

gamma-Aminobutyric acid stimulated the acrosome reaction in human spermatozoa, acting mainly through the GABA(A) receptor and to a lesser extent through the GABA(B) receptor. Progesterone interacted with the GABA(A) receptor to induce the acrosome reaction, and the functional integrity of the chloride channel was vital for this effect.

Providing birthing services in rural health networks: coping with change in New York State

Making prenatal and birthing services accessible in rural communities no longer able to support a local full-service hospital and the introduction of managed care cost control has led to consideration of alternative models. One such model, the freestanding birth center located in an isolated rural community, challenges the guidelines of several state and professional organizations directed at assuring adequate emergency response, including cesarean sections. An extensive review of freestanding birth centers and their effect on birth outcomes revealed little outcomes data about birth centers distant from full-service hospitals. Most states have modeled their birth center regulations on recommendations from the National Association of Childbearing Centers, but others, such as New York, have more rigidly defined transport parameters that exclude many rural locations. A consensus panel convened by the New York State Rural Health Council concluded that demonstrations projects featuring a rural birthing center farther than 20 minutes from a full-service hospital and operated within a networked rural health system should be developed. Consumers would need to be fully informed about the implications of their choice of birth services and all qualified providers, including midwives, should be included in a team approach to care giving.

Use of a mini-grant program to stimulate generalist training at the University of Massachusetts Medical Center

The authors describe and evaluate an annual competitive "mini-grant" program, funded by The Robert Wood Johnson Foundation's Generalist Physician Initiative established at the University of Massachusetts Medical School as a strategy to stimulate greater faculty involvement in the development of innovative, generalist-oriented projects. The mini-grant program stimulated proposals from across the academic community. The average award was small (mean = $7,039) but at times the awards led to results exceeding the scope of the original funding. In several cases, mini-grant support provided seed funding for faculty to undertake pilot projects to test new initiatives that would otherwise not have been developed. Some projects led to further ideas or to collaborations between generalists and basic scientists or specialists. More than half of funded projects were eventually institutionalized, and nearly 20% led to formal presentations at national meetings. Two problems are identified: (1) there were fewer proposals generated by specialist faculty and fewer collaborative proposals from generalists and specialists than anticipated, and (2) no funded proposals were generated by community-based faculty who were predominantly clinicians, such as preceptors. Despite these problems, and in light of available solutions, the authors conclude that an institutional mini-grant program can provide an ongoing, flexible mechanism to support a shift in institutional culture toward an enhanced status for generalism.

The neuroactive steroid allopregnanolone suppresses hypothalamic gonadotropin-releasing hormone release through a mechanism mediated by the gamma-aminobutyric acidA receptor

The central nervous system (CNS) is able to synthesize and/or metabolize steroid hormones. These neuroactive steroids are capable of modulating several brain functions and, among these, they seem to regulate the hypothalamic-pituitary-gonadal (HPG) axis. Indeed, recent observations have shown that 5 alpha-pregnane-3 alpha-ol-20-one (allopregnanolone), one of the most abundant naturally occurring neuroactive steroids, suppresses ovulation and sexual behaviour when administered within the CNS. The present study was undertaken to evaluate the effects of allopregnanolone and its inactive stereoisomer, 5 alpha-pregnane-3 beta-ol-20-one, upon the release of gonadotropin-releasing hormone (GnRH) from individually-incubated hemihypothalami. Allopregnanolone suppressed GnRH release in a concentration-dependent manner with maximal activity in the nanomolar range, a range at which this neurosteroid is capable of playing a biological action. The specificity of allopregnanolone suppression of GnRH release was provided by the lack of effect of its known inactive stereoisomer. To evaluate the involvement of gamma-aminobutyric acidA (GABAA) receptor, we examined the effects of two neurosteroids with GABA-antagonistic properties, pregnanolone sulfate (PREG-S) and dehydroepiandrosterone sulfate (DHEAS), and of bicuculline, a selective antagonist of the GABA binding site on the GABAA receptor, on allopregnanolone (10 nM)-suppressed GnRH release. Both PREG-S and bicuculline overcame the inhibitory effects of allopregnanolone on GnRH release, whereas DHEAS did not. To substantiate the involvement of the GABAA receptor further, we tested the effects of muscimol, a selective agonist for this receptor, which suppressed GnRH release. In conclusion, allopregnanolone suppressed hypothalamic GnRH release in vitro and this effect appeared to be mediated by an interaction with the GABAA receptor. We speculate that the inhibitory effect of allopregnanolone on the HPG axis may also be caused by its ability to suppress hypothalamic GnRH release.

Correlation between intracellular cAMP content, kinematic parameters and hyperactivation of human spermatozoa after incubation with pentoxifylline

Various compounds have been used in the attempt to improve sperm motility, including pentoxifylline (PF), a methylxanthine derivative. It has been postulated that PF, being a phosphodiesterase inhibitor, increases sperm kinematic parameters and the number of spermatozoa exhibiting hyperactivated motility by raising the intracellular content of cAMP, a molecule involved in the generation of sperm energy. However, it has not been clarified whether the biological effects of PF on sperm motility correlate with its ability to increase intracellular cAMP levels. To examine this relationship, the kinematic parameters, hyperactivation, and intracellular cAMP content were evaluated in motile spermatozoa, obtained by discontinuous Percoll gradient and swim-up from 21 normozoospermic semen samples, incubated without and with PF for 0, 1, 2, and 4 h. PF increased beat cross frequency after 1 and 2 h of incubation, curvilinear velocity and lateral head displacement (ALH) after 4 h, and hyperactivation after 1, 2, and 4 h, and decreased linearity (LIN) after 1 h of incubation. The intracellular cAMP content of spermatozoa incubated with PF increased at all time-points examined. Both intracellular cAMP content and increase in hyperactivation in response to PF decreased with the length of incubation. In the absence of PF, cAMP content was unchanged and was correlated significantly only with ALH and the percentage of spermatozoa with hyperactivated motility. Following incubation with PF, cAMP content correlated with hyperactivation and all sperm kinematic parameters, with the exception of LIN and straightness. These findings suggest that the beneficial effects of PF on sperm kinematic parameters and hyperactivation are related to its ability to increase intracellular cAMP content.

An analysis of vacancy rates, turnover, and wages among nursing occupations in New York state hospitals, nursing homes, and diagnostic and treatment facilities

This study investigates the balance between the supply and demand for nurses and nurse assistive personnel in New York state. Data collected in 1992 and 1993 from three surveys of hospitals, nursing homes, and diagnostic and treatment facilities are combined, reported, and analyzed. Although there were regional differences, the mean non-New York City vacancy rate was 4% for registered nurses and 5% for licensed practical nurses. The 6-month mean turnover rate for registered nurses was 8%; however, licensed practical nurses, nurse technicians, and nurse attendants had mean turnover rates of 16% and over. Turnover rates were lowest in hospitals. Nurse anesthetists earned the highest salary, a mean of about $61,000 per year. Salaries for nurse anesthetists and other nurses varied substantially by region.

[Fibrinogen, a cardiovascular risk factor]

Fibrinogen level is an independent predisposing factor for coronary heart disease and has a prognostic significance comparable with that of cigarette smoking, serum cholesterol level and hypertension. In our study fibrinogen levels were measured in 45 patients with cardiovascular disease of which 25 (55%) had a high fibrinogen level and in 45 persons healty, of which only 3 (6.6%) increased fibrinogen. The impact of fibrinogen level on the risk of cardiovascular disease was more consistent in men of all ages considered. The authors note that the independent contribution of fibrinogen to the cardiovascular risk may reflect hypercoagulability, hyperviscosity and increased platelet aggregation. Therefore they consider, the dosing of fibrinogen level important in the research of cardiovascular risk factors.

[Right atrial myxoma: echocardiographic diagnosis and review of the literature. Description of a clinical case]

Two-dimensional echocardiography is the method of first choice for diagnosing right atrial myxoma. A case of right atrial myxoma, documented by two-dimensional echocardiography, is here presented. Two-dimensional echocardiography allows accurate assessment of, tumor size, site of attachment, mobility and consistency. This non-invasive technique has replaced angiocardiography in the routine preoperative evaluation of these cases. The myxomatous nature of the mass was confirmed at surgery.