Continuing medical education: a new vision of the professional development of physicians.

The authors describe their vision of what continuing medical education (CME) should become in the changing health care environment. They first discuss six types of literature (e.g., concerning learning and adult development principles, problem-based/practice-based learning, and other topics) that contribute to ways of thinking about and understanding CME. They then state their view that the Association of American Medical Colleges (AAMC) has made a commitment to helping CME be more effective in the professional development of physicians. In presenting their new vision of CME, the authors describe their interpretation of the nature and values of CME (e.g., optimal CME is highly self-directed; the selection and design of the most relevant CME is based on data from each physician's responsibilities and performance; etc.). They then present seven action steps, suggestions to begin them, and the institutions and organizations they believe should carry them out, and recommend that the AAMC play a major role in supporting activities to carry out these steps. (For example, one action step is the generation and application of new knowledge about how and why physicians learn, select best practices, and change their behaviors). Six core competencies for CME educators are defined. The authors conclude by stating that collaboration among the appropriate academic groups, professional associations, and health care institutions, with leadership from the AAMC, is essential to create the best learning systems for the professional development of physicians.

Beta-adrenergic regulation of H+ secretion by cultured outer medullary collecting duct cells.

The effects of the beta-adrenergic agonist isoproterenol (Iso) on cells of the inner stripe portion of the rabbit outer medullary collecting duct (OMCDi) grown in primary culture were examined using whole cell patch-clamp techniques and measurements of intracellular pH (pHi) and Ca2+. Iso (10(-6) M) increased the cellular Cl- conductance, and this effect was mimicked by treatment of the cells with dibutyryladenosine 3',5'-cyclic monophosphate (cAMP, 10(-5) M) or protein kinase A (PKA, 0.4 U/ml). Iso did not alter the baseline pHi, but it did increase the activity of both the Cl-/HCO3- antiporter and the H(+)-adenosinetriphosphatase (H(+)-ATPase). The increase in Cl-/HCO3- antiporter rate was mimicked by dibutyryl-cAMP plus 3-isobutyl-1-methylxanthine (cAMP + IBMX, 10(-4) M + 10(-5) M). However, the Iso-induced stimulation of the H(+)-ATPase activity was not mimicked by cAMP + IBMX. Measurements of intracellular Ca2+ showed that Iso also increased intracellular Ca2+ levels. This response was not dependent on extracellular Ca2+, nor did cAMP + IBMX appreciably alter intracellular Ca2+. Consequently, we postulate that beta-adrenergic agonists are potential stimulators of OMCDi H+ secretion. These agonists stimulate cellular HCO3- efflux through a signal transduction pathway involving cAMP and PKA. However, a different signal transduction pathway appears to mediate the stimulation of cellular H+ efflux. This second pathway may involve an elevation of intracellular Ca2+.

Electrophysiological properties of cultured outer medullary collecting duct cells.

Whole cell patch-clamp techniques were used to characterize the electrophysiological properties of cells from the inner stripe portion of the rabbit outer medullary collecting duct (OMCDi) grown in primary culture. With pipette and bathing solutions mimicking intracellular and extracellular fluid, the resting membrane voltage was -30 to -40 mV. The whole cell conductance exhibited slight outward rectification, and at the resting membrane voltage the cell conductance averaged 2.58 +/- 0.49 nS (n = 17). The major conductive ion species was Cl-. The Cl- conductance was also found to have a significant permeability to HCO3- and was inhibited by the Cl(-)-channel blockers diphenylamine carboxylic acid and 4,4'-diisothiocyanostilbene-2,2'-disulfonic acid. A small K+ conductance was also present, but no Na+ conductance was detected. Current generated by the H(+)-adenosinetriphosphatase (H(+)-ATPase) was quantitated. This current was dependent on the presence of ATP in the pipette. Dicyclohexylcarbodiimide, N-ethylmaleimide, and bafilomycin A1, inhibitors of the vacuolar H(+)-ATPase, also reduced this outward current in an ATP-dependent manner. The inhibitor-sensitive component of the outward current, a measure of the current generated by the H(+)-ATPase, was in the range of 35-100 pA/cell.

Characterization of acid-base transporters in cultured outer medullary collecting duct cells.

Cells from the inner stripe of the rabbit outer medullary collecting duct (OMCDi) were grown in primary culture, and their acid-base transport properties were characterized using intracellular pH (pHi) measurements with the fluorescent probe 2',7'-bis(carboxyethyl)-5(6)-carboxyfluorescein (BCECF). Basal pHi in HCO(3-)-buffered solutions was 7.28 +/- 0.04 (n = 20). The presence of a Cl-/HCO(3-)-antiporter was demonstrated by reversible alkalinization on bath Cl- removal. The mean alkalinization seen on Cl- removal was 0.16 +/- 0.02 pH units (n = 20) and was inhibited 92% by 10(-4) M 4,4'-diisothiocyanostilbene-2,2'-disulfonic acid. Studies were also performed to determine the presence of an Na+/H+ antiporter and an H(+)-adenosinetriphosphatase (H(+)-ATPase). After an NH4Cl acid load the cells exhibited both Na(+)-dependent and Na(+)-independent pHi recovery mechanisms. The Na(+)-dependent mechanism was inhibited by amiloride. The Na(+)-independent mechanism was completely inhibited by 10(-3) M N-ethylmaleimide or 2.5 x 10(-9) M bafilomycin A1, but was not significantly altered by removal of bathing solution K+. Thus, the Na(+)-dependent recovery mechanism exhibited characteristics of an Na+/H+ antiporter, whereas the Na(+)-independent recovery mechanism was consistent with the presence of an H(+)-ATPase.

Cellular mechanisms of Cl- transport in outer medullary collecting duct.

The OMCDi secretes Cl- when perfused and bathed with symmetrical solutions. The route for this transepithelial Cl- movement appears to be the paracellular pathway, and the driving force is the lumen positive voltage generated by the process of electrogenic H+ secretion. Currently, there is no evidence to support the existence of a significant transcellular route for transepithelial Cl- movement. Although the primary function of the OMCDi is related to urine acidification, Cl- plays an important role in this process. The basolateral membrane of the OMCDi cell contains a band-3 related Cl-/HCO3- antiporter and a Cl- conductance. The Cl-/HCO3- antiporter serves as the primary route for the efflux of HCO3- generated during the process of H+ secretion. The Cl- conductance allows Cl- brought into the cell by the antiporter to recycle across this membrane. This conductance also serves to maintain cell charge balance. Accordingly, for each equivalent of H+ leaving the cell across the apical membrane, a Cl- equivalent exits the cell across the basolateral membrane. Based on whole-cell patch-clamp studies, this Cl- conductance is blocked by the Cl- channel blocker DPC. This conductance may also have a finite permeability to HCO3-, and thus could serve as a secondary route for cellular HCO3- efflux. Lastly, the conductance is activated by the beta-adrenergic agonist isoproterenol.

Duramycin enhances chloride secretion in airway epithelium.

The effect of duramycin, a polypeptide antibiotic, on Cl- transport in canine tracheal epithelium mounted in Ussing chambers was studied. Over a narrow concentration range, duramycin increased short-circuit current (Isc) and net Cl- secretion and had no effect on mannitol flux when added to the mucosal bathing solution. The maximum increase in Isc was observed at a duramycin concentration of 2 X 10(-6) M and was associated with an increase in both unidirectional Cl- fluxes. Higher duramycin concentrations produced a decrease in Isc. Submucosal addition of duramycin had no effect on Isc except at high concentrations. Pretreatment of tissues with mucosal amiloride (10(-4) M) to reduce basal Na+ transport had no effect on the subsequent response to duamycin. In other tissues pretreated with 10(-3) M dibutyryl adenosine 3',5'-cyclic monophosphate (cAMP), duramycin produced a further increase in Isc and net Cl- secretion similar to its effect in nonpretreated tissues. In all instances the increase in Isc was entirely accounted for by an increase in net Cl- secretion. We conclude that duramycin increases Isc and Cl- secretion in airway epithelium. Although the mechanism of activation is not known, these data demonstrate that duramycin increases Cl- secretion by a pathway other than cAMP. An understanding of the mechanism of action of duramycin may further our understanding of Cl- secretion regulation in airway epithelium.

Electrophysiology of collecting duct H+ secretion: effect of inhibitors.

Segments of the outer medullary collecting duct were isolated from the inner stripe of the rabbit kidney (OMCDi), perfused in vitro, and impaled across their basolateral membranes with voltage-recording microelectrodes. The disulfonic stilbene 4-acetamido-4'-isothiocyanostilbene-2,2'-disulfonic acid (SITS) (10(-4) M) and the carbonic anhydrase inhibitor acetazolamide (10(-4) M) depolarized the lumen-positive transepithelial voltage (VT) toward 0 mV when added to the bath solution. Concurrently, the basolateral membrane voltage (Vbl) hyperpolarized. The hyperpolarization of Vbl, which averaged 19.3 +/- 2.9 mV (n = 11) for SITS and 22.7 +/- 3.5 mV (n = 11) for acetazolamide, was not due to an alteration in the ionic selectivity of the basolateral membrane, which was highly Cl- selective. The hyperpolarization of Vbl could best be explained by a decrease in the intracellular [Cl-], and the associated shift in the emf for Cl- (ECl) across the basolateral membrane. The decrease in intracellular [Cl-] could be attributed to inhibition of a Cl-HCO3 antiporter in the basolateral membrane. SITS appeared to inhibit this antiporter directly, whereas the effect of acetazolamide was indirect, probably secondary to a decrease in the intracellular [HCO3-]. Finally, both SITS and acetazolamide induced or unmasked an electroneutral K+-coupled transport system in the basolateral membrane.

Morphological heterogeneity of the rabbit collecting duct.

The localization of carbonic anhydrase by histochemistry, of Na-K-ATPase by immunocytochemistry and of rod-shaped intramembranous particles by freeze-fracture electron microscopy, was determined in the collecting duct of rabbits. In the cortical collecting duct (CCD), rod-shaped particles, which are abundant in intercalated cells were observed in both the apical and basolateral membrane of all intercalated cells examined. In the outer stripe of the outer medullary collecting duct (OMCDo) a high density of rod-shaped particles was found only in the apical membrane of intercalated cells. All cells of the inner stripe of the outer medullary collecting duct (OMCDi) had rod-shaped particles in the apical membrane but not in the basolateral membrane. As the collecting duct entered the inner medulla the density of rod-shaped particles decreased until they were virtually absent in the terminal segment. Na-K-ATPase, localized to the basolateral membrane, was more abundant in principal cells than in intercalated cells in the CCD. In the OMCDo, staining was equal in principal and intercalated cells. All cells of the OMCDi and the inner medullary collecting duct (IMCD) stained for Na-K-ATPase. Carbonic anhydrase in the CCD was localized to the cell membranes and cytoplasm of intercalated cells. Principal cells did not stain for carbonic anhydrase. A similar pattern was seen in the OMCDo. In the outer region of the OMCDi most cells did not stain for carbonic anhydrase, whereas in the inner region the apical and lateral membranes of all cells stained for carbonic anhydrase. Weak cytoplasmic staining was occasionally seen. A similar pattern was seen in the initial half of the IMCD, while the terminal half of the IMCD did not stain. In this study, the localization of enzymes and rod-shaped intramembranous particles associated with Na+, K+, and H+ transport shows both segmental and cellular heterogeneity, and correlates with the known transport properties of tubule segments. The distribution of these enzymes and rod-shaped intramembranous particles is different in rabbits and rats, and may explain some of the functional differences between homologous segments in these species.

Electrophysiological identification of principal and intercalated cells in the rabbit outer medullary collecting duct.

Intracellular microelectrode techniques were used together with inhibitors of Na+ transport (amiloride) and H+ transport (acetazolamide and SITS) to identify principal cells and intercalated cells in the outer stripe of the rabbit outer medullary collecting duct. The principal cell (n = 9) had a basolateral membrane voltage (Vbl) of -64.7 +/- 3.2 mV, a fractional resistance of the apical membrane (fRa = Ra/Ra + Rbl) of 0.82 +/- 0.02, and a K+-selective basolateral membrane. Luminal amiloride hyperpolarized Vbl by 10.3 +/- 2.1 mV and increased fRa to near unity (n = 7). Bath acetazolamide and SITS were without effect on these parameters. The intercalated cell (n = 5) had a Vbl of -25.0 +/- 3.2 mV, a fRa of 0.99 +/- 0.01, and a Cl(-)-selective basolateral membrane. Bath acetazolamide or SITS hyperpolarized Vbl by 26.4 +/- 8.2 mV. Luminal amiloride did not alter Vbl of this cell. The differential effects of the inhibitors also indicate that the principal and intercalated cells are probably not directly coupled electrically.

Electroneutral H+ secretion in distal tubule of Amphiuma.

This study examines the cellular mechanisms of acid secretion by the in vitro perfused late distal tubule of Amphiuma kidney. Acidification of tubule fluid occurred against an electrochemical gradient of 16 mV; thus H+ secretion was active. Amiloride (1 mM) or a reduction of sodium in the perfusion fluid (from 83.7 to 7.7 mM) partially reduced acidification. Amiloride, in the presence of low sodium, completely inhibited acidification. Furthermore, acetazolamide and ouabain in the bath solution (0.1 mM) also inhibited acidification. Conductive properties of the epithelium and of individual cell membranes were determined by means of cable analysis of the tubule and intracellular voltage recordings. The transepithelial voltage and resistance averaged -0.4 +/- 0.4 mV, lumen negative, and 7,147 +/- 845 omega X cm, respectively. Two functionally different cell types were identified by intracellular microelectrodes. Type I cells had a basolateral membrane voltage (Vbl) of -67.7 mV. As determined by ion substitution experiments, the basolateral membrane was conductive to K+ and Cl-. This cell also had a 4-acetamido-4'-isothiocyanostilbene-2-2'-disulfonic acid (SITS)-sensitive Na+-dependent HCO3- exit pathway in the basolateral membrane. Type II cells had a Vbl of -76.1 mV (P less than 0.05 vs. type I) and the basolateral membrane was conductive to K+ and Cl- but not to HCO3-. HCO3- movement across the basolateral membrane in this cell may occur by electroneutral Cl- -HCO3- exchange. The apical cell membrane of both cell types did not contain measurable ionic conductances, as evidenced by a high value of apical membrane fractional resistance (0.98 +/- 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Conductive properties of the rabbit outer medullary collecting duct: outer stripe.

Segments of the outer medullary collecting duct were dissected from the outer stripe of the rabbit kidney (OMCDo) and perfused in vitro. The conductive properties of the tubule epithelium and individual cell membranes were determined by means of cable analysis and intracellular voltage-recording microelectrodes. The transepithelial voltage (VT) and resistance (RT) averaged -10.7 +/- 2.5 mV, lumen negative, and 28.5 +/- 2.9 k omega X cm (n = 27), respectively. Two cell types could be defined by their electrophysiological properties. One cell type (n = 7) had a mean basolateral membrane voltage (Vbl) of -30.1 +/- 2.4 mV, a fractional resistance of the apical membrane (fRa = Ra/Ra + Rbl) near unity (0.99 +/- 0.01), and a predominantly Cl(-)-selective basolateral cell membrane. The second cell type (n = 27) had a mean Vbl of -63.7 +/- 2.7 mV, a fRa of 0.81 +/- 0.02, and a predominantly K+-selective basolateral cell membrane. The present study focused on defining the conductive properties of this latter cell type. Amiloride (10(-5) M) and BaCl2 (2 mM) were used as probes of apical cell membrane Na+ and K+ conductive pathways, respectively. Amiloride increased fRa from 0.80 +/- 0.02 to 0.98 +/- 0.01 (n = 12), whereas BaCl2 increased fRa from 0.77 +/- 0.03 to 0.82 +/- 0.03 (n = 9). The conductive properties of the basolateral cell membrane were assessed by ion substitutions of the bath solution. A 10-fold increase in the bath [K+] depolarized Vbl by 34.9 +/- 1.9 mV (n = 16) in less than 1 s, indicating that this membrane was predominantly K+ selective.(ABSTRACT TRUNCATED AT 250 WORDS)

Conductive properties of the rabbit outer medullary collecting duct: inner stripe.

Segments of outer medullary collecting duct were dissected from the inner stripe of the rabbit kidney (OMCDi) and perfused in vitro. The conductive properties of the tubule epithelium and individual cell membranes were determined by means of cable analysis and intracellular voltage-recording microelectrodes. In 35 tubules the transepithelial voltage (VT) and resistance (RT) averaged 17.2 +/- 1.4 mV, lumen positive, and 58.6 +/- 5.3 k omega X cm, respectively. The basolateral membrane voltage, (Vbl) was -29.2 +/- 2.1 mV (n = 23). The apical cell membrane did not contain appreciable ion conductances, as evidenced by the high values of apical cell membrane fractional resistance (fRa = Ra/Ra + Rb), which approached unity (0.99 +/- 0.01; n = 23). Moreover, addition of amiloride or BaCl2 to the tubule lumen was without effect on the electrical characteristics of the cell, as was a twofold reduction in luminal [Cl-]. The conductive properties of the basolateral cell membrane were assessed with bath ion substitutions. A twofold reduction in bath [Cl-] depolarized Vbl by 14.7 +/- 0.4 mV (theoretical, 17 mV), while a 10-fold increase in bath [K+] resulted in only a 0.9 +/- 0.4 mV depolarization (theoretical, 61 mV). Substituting bath Na+ with tetramethylammonium (from 150 to 75 mM) was without effect. Reducing bath [HCO-3] from 25 to 5 mM (constant PCO2) resulted in a steady-state depolarization of Vbl of 8.4 +/- 0.4 mV that could not be attributed to conductive HCO-3 movement. Thus, the basolateral cell membrane is predominantly Cl- selective.(ABSTRACT TRUNCATED AT 250 WORDS)

Mineralocorticoid regulation of sodium and potassium transport by the cortical collecting duct.

Chronic high-dose mineralocorticoid hormone treatment of rabbits results in marked alterations of the structure and function of the cortical collecting duct. Most importantly, the reabsorption of Na+ and the secretion of K+ are increased. Intracellular microelectrode measurements provide evidence consistent with the idea that the increased transport of these ions is a result of changes in the membrane conductances and electrochemical driving forces for passive ion movement and of the activity of the Na+,K+-ATPase. Specifically, the Na+ and K+ conductances of the apical membrane are increased, and the cellular potential profile is altered to promote transcellular movement of K+ from the peritubular to the luminal fluid compartments. The associated increase in the activity of the Na+,K+-ATPase facilitates extrusion of Na+ from and accumulation of K+ into the cell. The resistance of both the apical and basolateral cell membranes are reduced with DOCA treatment, while the resistance of the paracellular pathway is increased. Consequently, the electrophysiological properties of the tubule epithelium reflect to a greater degree the properties of the transcellular pathway.

Patch clamp studies of apical membranes of renal cortical collecting ducts.

Patch clamp techniques were used in study of the apical membrane of isolated renal cortical collecting ducts. Whereas on-the-cell patches (reported previously) gave channel activity due primarily to K+, isolated inside-out patches of the same membranes bathed with 150 mM Na+, 5 mM K+, and 1 mM Ca2+ gave channel activity due primarily to Na+. Na+ channels could remain either open or closed for periods of milliseconds to minutes. Although unitary currents of tenths of a pA were observed routinely, patch activity could change spontaneously between quiescent and violent with 'apparent' unitary currents of several pA. It was not possible to rule out the idea that the complex activity of the patches was due to synchronous or near synchronous openings/closings of several channels of identical unitary current. The unpredictable spontaneous changes of patch activity make difficult the design of experiments to test for the influence of agents expected or suspected to alter channel behavior.

Cellular electrophysiology of potassium transport in the mammalian cortical collecting tubule.

Electrophysiological studies were carried out on single perfused cortical and medullary collecting ducts to define the potassium and sodium transport properties of their apical and basolateral cell membranes. In addition, the effects of chronic mineralocorticoid hormone treatment on the mechanism of transport of potassium ions were evaluated. Studies included the measurement of transepithelial and cell potentials, and the resistance of individual cell membranes. The apical cell membrane of principal cells of the cortical collecting duct is characterized by separate potassium and sodium conductances. The basolateral cell membrane has also a potassium conductance, whereas the intercellular shunt pathway is largely permeable to chloride ions. Stimulation of potassium secretion by mineralocorticoids is associated with the following events. Increased cell potassium uptake across the basolateral cell membrane due to stimulation of Na-K ATPase and a more favorable electrical driving force for passive entry, facilitated exit of potassium from the cell to the tubule lumen by a more favorable electrochemical gradient (apical cell membrane depolarization) and enhanced potassium secretion by in increase of the potassium conductance of the apical cell membrane. Some properties of single potassium channels in the apical membrane of rabbit cortical collecting tubules are also described.

Single-channel currents in renal tubules.

Patch-clamp techniques were used to study isolated renal cortical collecting ducts of rabbits. Gigaohm seals of the native apical membranes of the principal cells were obtained from tissues superfused with a Ringer solution. No enzymatic or other pretreatment of the tissues was required. The patches studied were primarily of the on-cell type, although excised patches could be obtained. Unitary currents in a range of tenths of picoamperes were observed at holding voltages between +/- 100 mV. Since the apparent reversal potential was at a holding voltage at or near 0 eatment of the tissues was required. The patches studied were primarily of the on-cell type, although excised patches could be obtained. Unitary currents in a range of tenths of picoamperes were observed at holding voltages between +/- 100 mV. Since the apparent reversal potential was at a holding voltage at or near 0 eatment of the tissues was required. The patches studied were primarily of the on-cell type, although excised patches could be obtained. Unitary currents in a range of tenths of picoamperes were observed at holding voltages between +/- 100 mV. Since the apparent reversal potential was at a holding voltage at or near 0 mV and since the current-voltage relationship was markedly nonlinear, the unitary currents are most likely due to K+ . Na+-channel current fluctuations, if present, could not be uniquely identified in the presence or absence of amiloride.