Plasma cortisol is often decreased in patients treated in an intensive care unit.

OBJECTIVE: To investigate the prevalence of adrenal hypofunction, as assessed by plasma cortisol (p-cortisol) and its relationship to clinical events. DESIGN: Prospective, consecutive. SETTING: General intensive care unit in a university hospital. PATIENTS: Fifty-five patients (34 men and 21 women) were studied (surgery 40 patients, hemodialysis 5, ventilator treatment 45, sepsis 21). METHODS: Morning basal levels of p-cortisol were determined. Previous reports define adrenal insufficiency to be present if p-cortisol under stressful conditions is lower than either 400 or 500 nmol/l. The tetracosactoid test (250 microg Synacthen) was performed in 16 patients and urinary 24-h excretion of cortisol in 24 (none on corticosteroid treatment). RESULTS: Median p-cortisol was 550 nmol/l (range 20-1764). In 36% of patients p-cortisol was lower than 400 nmol/l and in 47% lower than 500 nmol/l. There was a significantly increased probability (P < 0.05) of p-cortisol being below 400 nmol/l in patients admitted due to trauma or cerebral disorder and in patients on ventilator therapy or on mannitol. Thirty minutes after tetracosactoid administration p-cortisol response was lower than 200 nmol/l in 56% of the patients. CONCLUSIONS: Several patients had low p-cortisol and attenuated responses to tetracosactoid, indicative of adrenal insufficiency. There seem to be certain risk factors for adrenal hypofunction which may justify more frequent use of physiological doses of corticosteroid in selected patients.

Coordinated expression of tissue-type plasminogen activator and plasminogen activator inhibitor type 1 during corpus luteum formation and luteolysis in the adult pseudopregnant rat.

Proteolytic activity generated by the plasminogen activator (PA) system is associated with many biological processes. Using an adult pseudopregnant rat model, we have studied how two components of the PA system, tissue-type plasminogen activator (tPA) and plasminogen activator inhibitor type 1 (PAI-1), are expressed temporally and spatially during different developmental stages of the corpus luteum (CL). Northern blot analysis, in situ hybridization, in situ zymography, and fibrin overlay were used to analyze the expression and distribution of tPA and PAI-1 messenger RNA (mRNA) as well as PA activity in CL of different ages. We demonstrated that during the luteinization period (approximately days 1-2), tPA mRNA was highly and evenly expressed in newly formed CL, whereas PAI-1 mRNA was mainly detected in the central part of the same CL. In accordance with these findings, proteolytic activity generated by tPA was detected in the outer region of newly formed CL by in situ zymography. During the luteotropic period (approximately days 3-10), tPA mRNA expression was very low. PAI-1 mRNA expression was also low, but increased on day 10. As expected, proteolytic activity was very low during this period. During functional luteolysis (days 13-14) and subsequent structural luteolysis, tPA mRNA was elevated. PAI-1 mRNA was also expressed during this period. Moreover, the net PA activity, as determined by fibrin overlay, was relatively high during this period. Our studies indicate that tPA and PAI-1 are coordinately expressed in the CL, resulting in increased proteolytic activities during the luteinization and luteolytic periods. PA-mediated proteolysis may, therefore, play a role in both CL formation and luteolysis in rats.

Life histories of single parents and illegitimate infants in nineteenth-century Sweden.

"This essay presents tentative findings for the Sundsvall area of Sweden, which is being studied in a recent project on the decline of infant and childhood mortality in the Nordic countries. The focus is on the complete reproductive histories of single mothers and the life expectancies among infants born to women who at least once in their reproductive life history experienced the birth of an illegitimate child. In Sundsvall, industrialization only temporarily affected the illegitimacy ratio, but its effect was obvious even in agrarian parishes. The number of illegitimate children per woman remained relatively stable over time, with the exception of the town of Sundsvall. It was more common in the urban environment to give birth to several illegitimate children. Mortality was also higher among these infants, but the negative effects can be seen equally among both legitimate and illegitimate children."

Castration plus oestrogen treatment induces but castration alone suppresses epithelial cell apoptosis in an androgen-sensitive rat prostatic adenocarcinoma.

The positive effect of castration in prostatic cancer patients is considered to be related to the induction of apoptosis in androgen-dependent tumour cells. However, castration apparently does not induce apoptosis in the highly differentiated, androgen-sensitive Dunning R3327PAP rat prostatic adenocarcinoma. To elucidate potential mechanisms of apoptotic induction in this tumour model, rats with subcutaneously implanted tumours were treated with vehicle (I), castration+vehicle (C) or castration + 50 micrograms of oestradiol benzoate per day s.c. (C + E2). The effects on tumours were examined by morphometry, in situ end labelling (ISEL) of apoptotic cells and immunohistochemically with monoclonal antibodies to proliferating cell nuclear antigen (PCNA) at different time points up to 168 h after castration. Castration inhibited tumour growth and decreased the epithelial cell apoptotic rate (from 12 h) and epithelial cell proliferation rate (from 72 h) compared with that in the I group. Tumour volume, volume densities of epithelium and stroma and stroma cell proliferation rate remained constant in the C group during the study period. C + E2 treatment resulted in increases in cell proliferation in the stroma (from 12 h) and in the volume density of stroma (from 24 h) compared with that in the C and I groups. The number of apoptotic epithelial cells was increased (from 24 h), and this was followed by decreases in the volume density of epithelium (from 24 h), the epithelial cell proliferation rate (from 72 h) and the total tumour volume (from 72 h). We conclude that in the Dunning R3327PAP tumour model C + E2 treatment is more effective than castration alone. C+E2 treatment, in contrast to C, is able to induce tumour cell death and to decrease total tumour volume. The mechanism behind this effect is unknown, but it could be related to stimulatory effects of E2 in the tumour stroma.

Castration induces apoptosis in the ventral prostate but not in an androgen-sensitive prostatic adenocarcinoma in the rat.

Apoptosis in the androgen-sensitive Dunning R3327 PAP prostatic adenocarcinoma was studied during the post castration period of 14 days and compared with the ventral prostate. The mRNA expression of testosterone repressed prostatic message-2 and tissue-type plasminogen activator in the Dunning tumor and in the ventral prostate was analyzed by Northern blot experiments and immunohistochemical procedures. The degree of endonuclease-degraded genomic DNA was examined by gel electrophoresis. Apoptotic tumor epithelial cells were identified with in situ end labeling. Epithelial cells incorporating bromodeoxyuridine (BrdUrd) after castration in the ventral prostate and the Dunning tumors were localized with immunostaining. Androgen ablation resulted in an induction of testosterone repressed prostatic message-2 and tissue-type plasminogen activator transcripts in the normal prostate with a peak at approximately 2 to 5 days post castration. These transcript levels in the Dunning prostatic tumors did not show any induction during the same period. Immunohistochemical staining for sulfated glycoprotein-2 and tissue-type plasminogen activator confirmed this difference between the tumor tissue and the ventral prostate at the transcriptional level. The determination of DNA integrity showed similar results in that the degree of DNA fragmentation in the tumor was much lower than the initial and marked degradation of DNA in the ventral prostate. The number of in situ end-labeled epithelial tumor cells were not increased by castration. BrdUrd immunodetection showed that castration induced an initial increase in the number of BrdUrd-positive epithelial cells in the ventral prostate. In the tumors, castration resulted in a decrease in BrdUrd-positive epithelial cells. It was concluded that in the androgen-sensitive prostatic Dunning R3327 PAP adenocarcinoma, the biochemical cascade leading to apoptosis is not activated by androgen withdrawal, as in the ventral prostate.

Adoption of a demographic database for family studies of hereditary palmoplantar keratoderma type Gamborg Nielsen.

In the northernmost county of Sweden (Norrbotten) two different clinical and genetic types of hereditary palmoplantar keratoderma have been reported: a common autosomal dominant form, corresponding to the descriptions performed by Unna and Thost, and an obviously autosomal recessive form, which clinically differed from other diffuse palmoplantar keratodermas, named the Gamborg Nielsen type. For further family studies and to support its probably recessive inheritance a demographic mapping of four families with this rare keratinization disorder was performed. It could be shown that these families belonged to the same family at different levels of generations; however, a common ancestor, who connected these families was not found. Marital distance of heterozygotes and birth places of probands were limited to an area, which is generally known to harbour different inherited disorders. According to a map of the origin of family members, it was shown that the major part originated from the same area and that the integration of family members had occurred in the same places. It was concluded that adoption of a demographic database for family studies in genetic research may contribute valuable information about family relations.

Synthesis of 4-methoxy-2,3,5-trimethylpyridine: a specific building block for compounds with gastric-acid inhibiting activity.

A new synthesis of 4-methoxy-2,3,5-trimethylpyridine (2), an important building block for the preparation of gastric-acid inhibiting compounds, is described. Condensation of ethyl 3-amino-2-methyl-2-butenoate (3) and diethyl 2-methylmalonate (4) gives 4-hydroxy-3,5,6-trimethyl-2(1H)-pyridone 5. Reaction of 5 with phosphoryl chloride affords 2,4-dichloro-3,5,6-trimethylpyridine (9a), which, upon hydrogenolysis with palladium on charcoal, gives 2,3,5-trimethylpyridine (10). However, selective hydrogenolysis in acidic solution yields 4-chloro-2-3-5-trimethylpyridine (11). Substitution of the chlorine in 11 with methoxide ion gives 4-methoxy-2,3,5-trimethylpyridine (2), which can be oxidized to the corresponding N-oxide (13). This constitutes a new and efficient route to compound 2 in an overall yield of 43%.

Biological control of tissue plasminogen activator-mediated fibrinolysis.

Fibrinolysis, the body's ability to degrade fibrin, is an integrated part of hemostasis. Overactivity in the fibrinolytic system causes bleeding and underactivity causes thrombosis. Tissue plasminogen activator (tPA), plasminogen activator inhibitor type 1 (PAI-1), alpha 2-antiplasmin (alpha 2-AP) and plasminogen are definitely involved in fibrinolysis because: (1) these components can be assigned a fibrinolytic role in purified systems, i.e. in vitro, and (2) abnormal structural variants and abnormal levels of these components give rise to bleeding or to thrombosis. The biological control of tPA-mediated fibrinolysis is both cellular and humoral. The cellular regulation compasses synthesis of tPA and PAI-1 and release/uptake of these components. The humoral regulation involves: (1) the reaction between tPA and PAI-1; (2) the fibrin-stimulated plasminogen activation; (3) the reaction between plasmin and alpha 2-AP and (4) plasmin degradation of fibrin. The highly developed biological control of tPA-mediated fibrinolysis is indicative of its physiological importance.

The mechanism for inhibition of gastric (H+ + K+)-ATPase by omeprazole.

Omeprazole was found to inhibit the K+-stimulated ATPase activity of the gastric (H+ + K+)-ATPase in parallel with the K+-stimulated p-nitrophenylphosphatase activity and the phosphoenzyme formation. The degree of inhibition of ATPase activity was directly correlated to the amount inhibitor bound to the enzyme preparation down to about 15% of the control enzyme activity. The acid-decomposed form of omeprazole, i.e. the inhibitory form, was found to react with and bind to sulfhydryl groups within the (H+ + K+)-ATPase preparation with close to a 1:1 stoichiometry. beta-Mercaptoethanol, when added beforehand and in a 10-fold excess of omeprazole, completely prevented binding of the inhibitor and its inhibition of the enzyme. In the presence of beta-mercaptoethanol two different reaction products could be detected in addition to omeprazole; the reduced form of omeprazole (H 168/22), and a product formed between beta-mercaptoethanol and a decomposition product, generated from omeprazole. Under those conditions neither inhibition nor binding was obtained, indicating that none of these three compounds was the inhibitor. Rather, the compound generated from omeprazole and reacting rapidly with either beta-mercaptoethanol or the -SH groups of the enzyme was the likely inhibitor compound. In order to reverse already established inhibition higher concentrations of beta-mercaptoethanol were needed than for protection indicating two different reaction pathways for protection and reversal by beta-mercaptoethanol. The reversal reaction was explained by a two-step reaction; in the first step the bound inhibitor was exchanged for a beta-mercaptoethanol molecule resulting in formation of compound H 168/22 and a mixed disulfide between the enzyme and beta-mercaptoethanol. In the second step, attack of another beta-mercaptoethanol molecule results in liberation of active enzyme and generation of the disulfide form of beta-mercaptoethanol. This hypothesis was substantiated by the fact that when 1 mM beta-mercaptoethanol was added to inhibited enzyme the radiolabel was partially displaced, without any change in the concentration of modified -SH groups.

Structure activity relationships of substituted benzimidazoles.

The omeprazole molecule consists of three parts, a substituted pyridine ring, a substituted benzimidazole ring and CH2SO chain connecting the 2-positions of these ring systems. All three are essential for the antisecretory effect. In order to maintain a good effect the pyridine ring has to be substituted by alkyl or alkoxy groups, but not in the 6-position. The substituents in the benzimidazole ring are not that important, but substituents with strongly electron withdrawing groups such as NO2 or highly hydrophilic groups such as NHCOCH3 tend to give compounds with low antisecretory effects.

Evidence for acid-induced transformation of omeprazole into an active inhibitor of (H+ + K+)-ATPase within the parietal cell.

The chemical reactions of omeprazole, leading to inhibition of gastric acid secretion, were investigated. In acid buffer solutions, omeprazole was found to be labile, whereas at physiological pH it was stable (t1/2 greater than 17 h at pH 7.4). The stability of omeprazole was also studied in isolated, acid producing, gastric glands under conditions where acid formation was either stimulated or inhibited. The rate of transformation of omeprazole was high (t1/2 approximately 3 min) under stimulation. Inhibition of acid formation in the gland greatly retarded the decomposition of omeprazole (t1/2 approximately 73 min). The time-course for inhibition of acid formation by omeprazole was parallel to that for decomposition. The major product formed from omeprazole was the reduced form, H 168/22. The inhibitory action of omeprazole was shown to depend on acid-induced transformation, since no inhibition was obtained when omeprazole was incubated under neutral conditions, both in the isolated gastric mucosal- and the (H+ + K+)-ATPase preparations. Despite the fact that H 168/22 was the major product formed in the glandular preparation, it was found to be virtually inactive in both the glandular- and (H+ + K+)-ATPase preparations. Therefore, a model is proposed in which the inhibition of acid formation by omeprazole is mediated by a compound formed during the reduction of omeprazole to H 168/22 within the acid compartments of the parietal cell. Furthermore, mercaptanes, such as beta-mercaptoethanol, were found to prevent as well as reverse inhibition by omeprazole in both the glandular- and (H+ + K+)-ATPase preparations. This indicates that -SH groups are most likely involved in the chemical reactions leading to inhibition of acid secretion.

Differentiation among inhibitory actions of omeprazole, cimetidine, and SCN- on gastric acid secretion.

The action of the substituted benzimidazole omeprazole (H 168/68) was studied in three different in vitro preparations: the isolated guinea pig gastric mucosa, isolated intact and permeable rabbit gastric glands, and hog fundic microsomal membrane vesicles containing H+-K+-ATPase. The effects of omeprazole were compared with those of cimetidine and thiocyanate (SCN-). Under all the conditions studied, cimetidine only counteracted histamine-induced acid secretion, consonant with its H2-receptor antagonism. In contrast, omeprazole and SCN- were found not only to inhibit histamine-induced secretion but also basal acid formation and acid formation induced by dibutyryl cAMP and a high cell medium concentration of K+. Moreover, acid production induced by ATP in permeable gastric glands was antagonized by omeprazole and SCN-, whereas cimetidine was without effect. The interaction pattern of omeprazole and SCN- was differentiated by studies using the weak base antipyrine in the isolated mucosal preparation, where it was found that antipyrine could reverse the inhibition induced by SCN- but not that of omeprazole. Furthermore, omeprazole was found to inhibit the isolated H+-K+-ATPase, whereas cimetidine or SCN- was without effect. In the isolated mucosal preparation omeprazole caused an increase in K+ secretion rates in parallel with the inhibition of acid formation. This was in contrast to what was observed for cimetidine and SCN-, which exhibited no such increased K+ secretion. The results obtained from intact mucosa and isolated glands are in agreement with the ability of omeprazole to inhibit the isolated H+-K+-ATPase and thus provide evidence of a novel mechanism of action for this inhibitor.