Rapid diagnosis of congenital adrenal hyperplasia by high performance liquid chromatography

New RIA Kit for the Determination of Progesterone in Cows' Milk

A new, single-step, specific, simple, economical, and ready to use RIA test for the determination of progesterone in cow's milk was developed. Tubes coated with the specific polyclonal anti-progesterone antibody and progesterone-CMO-125I-histamine as the tracer were used. Progesterone in buffer and fat-free cow's milk, without progesterone were the matrix for the standard curve preparation. Fifty microL of milk and 500 microL of tracer were incubated in the tube for 2 h at room temperature, decanted, and coated. Assay range was 0-270 nmol of progesterone x 1(-1); sensitivity, <1 nmol x 1(-1); recovery, 94-104%; precision as CV%, 2.44-6%.

Failure of cortisone acetate therapy in 21-hydroxylase deficiency in early infancy

BACKGROUND

Pediatric endocrinologists initially treat congenital adrenal hyperplasia with either cortisone acetate (CA) or hydrocortisone (HC). Despite high doses of CA, we noted that 17-hydroxyprogesterone (17-OHP) and corticotropin were not fully suppressed in serum from neonates with 21-hydroxylase deficiency (21-OHD) until they were 40- to 80-days-old. In contrast, serum concentrations of 17-OHP were suppressed immediately by oral treatment with HC.

METHODS

We sought to understand the reason for this discrepancy. Serum cortisol (F), cortisone (E), and 17-OHP were measured by radioimmunoassay or high-performance liquid chromatography in seven neonates with 21-OHD and in 118 normal subjects. From the time of diagnosis, CA was administered to four of the neonates with 21-OHD, while HC was given to the other three.

RESULTS

In normal subjects serum E concentrations were greater than F during the first 2 months after birth, whereas F concentrations exceeded E after 2 months of age. Although infants receiving CA initially were given a high dose, serum F concentrations were extremely low, while 17-OHP concentrations were high until about 2 months of age. Then serum F exceeded E, and 17-OHP became fully suppressed even though infants received only a moderate dose of CA. In contrast, HC administration successfully normalized serum 17-OHP in the neonatal period. With temporary switching of neonates from HC to CA, serum F concentrations immediately decreased and 17-OHP concentrations increased.

CONCLUSION

Conversion of E to F may be limited during early infancy, adversely affecting treatment with CA. Cortisone acetate may be inappropriate as a glucocorticoid replacement during early infancy in patients with 21-OHD.

Morning and afternoon serum levels of cortisone and cortisol in asthmatic patients

While the diurnal change of serum cortisol in asthmatics has been suggested to influence the occurrence of attacks, this relation remains controversial. Serum concentrations of cortisol, cortisone, and cortisol precursors were measured in the morning and in the afternoon in asthmatic patients by reversed-phase high-performance liquid chromatography. Cortisol and cortisone were detected but their precursors were not. In remission or during attacks, the serum cortisone level in the morning was significantly lower than that in the afternoon, and the serum cortisol level in the morning did not significantly exceed that in the afternoon, which differs from the normal diurnal patterns. In patients with severe asthma in remission, the diurnal pattern of serum cortisone and cortisol was opposite to that seen in normal controls. During the attack, the serum cortisol level showed a lesser increase in the afternoon than in the morning. In patients with persistent asthmatic attacks, the serum cortisone level in the afternoon showed a significant increase as compared with that in remission while their serum cortisol level in the afternoon was equal to that in remission. The diurnal pattern and the duration of asthmatic attacks might be taken into consideration for steroid treatment of asthma.

Influence of spironolactone on neonatal screening for congenital adrenal hyperplasia

AIM

To determine if the diuretic spironolactone cross reacts with 17alpha-hydroxyprogesterone (17OHP) in an enzyme linked immunosorbent assay (ELISA) kit used for the mass screening of congenital adrenal hyperplasia.

METHODS

Concentrations of 17OHP on a blood filter paper disc were measured using an ELISA kit (kit C-7: ENZAPLATE N-17alpha -OHP-7; Chiron, Tokyo, Japan). The cross reactivity of spironolactone and its metabolites with 17OHP was determined. The concentrations of spironolactone and its metabolites in blood were measured using HPLC (high performance liquid chromatography).

RESULTS

Spironolactone cross reacted with 17OHP using kit C-7 (0.01%), by increasing 17OHP concentration in a dose dependent manner. The blood concentration of spironolactone and its metabolites was nearly 900 ng/ml, high enough to show an additive effect on the 17OHP concentration. About 12% of the false positive cases screened using the kit were due to the administration of spironolactone.

CONCLUSIONS

Spironolactone interferes with 17OHP concentrations, leading to false positive test results for CAH.

Immature adrenal steroidogenesis in preterm infants

Screening for congenital adrenal hyperplasia is associated with a high rate of false positive results in preterm infants. Some RIA studies have detected elevated levels of 17 alpha-hydroxy-progesterone in severely ill preterm infants. However, because the antisera used with RIAs have a high degree of cross-reactivity, RIA results may not be reliable. Adrenal steroidogenesis was evaluated in 33 preterm infants born at less than 32 weeks' gestation using reversed-phase high performance liquid chromatography. 17 alpha-hydroxyprogesterone, 11-deoxycortisol, and/or corticosterone were detectable temporarily at about 29 weeks of equivalent gestational age in 27 of 33 preterm infants. Levels of cortisol and cortisone were markedly decreased in 4 of 16 infants whose mothers had received steroids. These findings suggest that the activities of 21-hydroxylase, 11 beta-hydroxylase, and 18-hydroxylase are decreased at about 29 weeks of equivalent gestational age. Steroid levels should be carefully monitored in preterm infants with elevated intermediate steroids and preterm infants whose mothers receive steroids before delivery using reversed-phase high performance liquid chromatography.

Serum concentrations of cortisone and cortisol in premature infants

To determine the relationship between biological active cortisol and its inert metabolite cortisone accurately in premature infants, serum cortisone and cortisol concentrations were measured by reversed-phase high-performance liquid chromatography (HPLC) in a group of 232 premature infants and in a control group of 127 children and 88 adults. In the control group, serum cortisone concentrations were greater than serum cortisol levels during the first 2 months after birth; cortisol levels were higher than cortisone levels after 2 months of age. However, in premature infants, serum cortisone concentrations were greater than serum cortisol levels even after the first 2 months, and total concentrations of cortisone and cortisol were equal to those in controls. Results were then analyzed according to the equivalent gestational age of premature infants. Cortisone was predominant in premature infants older than 32 weeks of equivalent gestational age, but cortisol was higher than cortisone from equivalent gestational age 24 to 31 weeks. These findings suggest that the ability of premature infants to secrete glucocorticoids resembled that of normal controls. Also, the fetal zone of the cortex, which is associated with a predominance of cortisone, remained functional in premature infants for a longer time than in control infants. Our findings that in premature infants cortisone was predominant compared with cortisol and the sum of cortisone and cortisol was equal to that in the controls indicate that cortisone cannot be disregarded whenever the cortisol level is estimated, although cortisone itself is recognized to be biologically inactive. Simultaneous measurement of serum cortisone and cortisol concentrations is important when adrenocortical function is being determined, especially in premature infants.

Clinical significance of cortisone and cortisone/cortisol ratio in evaluating children with adrenal diseases

Cortisone is derived from the peripheral metabolism of cortisol and lacks biological activity. The rapid interconversion between cortisol and cortisone has been well established. The altered equilibrium between these steroids may regulate glucocorticoid activity in various tissues. We evaluated the serum levels of cortisol and cortisone, and the cortisone/cortisol ratio in ten children with adrenal diseases using reversed-phase high performance liquid chromatography. Children with hypoadrenalism exhibited a greater decrease in cortisol as compared with cortisone. Cortisone levels were higher than cortisol levels, and the cortisone/ cortisol ratio exceeded 1.0. Children with adrenal cancer exhibited normal or high values of cortisol, whereas cortisone levels were decreased and the cortisone/cortisol ratio was decreased to nearly zero. The ratio returned to normal after the excision of adrenal tumors. The simultaneous evaluation of cortisol, cortisone, and cortisone/cortisol ratio provides a clinical clue of adrenal diseases.

Variation in migraine prevalence by race

PURPOSE

Estimates of migraine prevalence from African and Asian populations are lower than those observed in European and North American populations. To determine if these international differences reflect differences in cultural, environmental, or genetic factors, we compared the prevalence of migraine among Caucasians, African Americans, and Asian Americans in the United States. If genetic factors predominate, racial differences should persist in the United States.

METHODS

In Baltimore County, Maryland, 12,328 individuals 18 to 65 years of age were selected by random-digit dialing and interviewed by telephone about their headaches. Migraine diagnoses were assigned using International Headache Society criteria.

RESULTS

In women, migraine prevalence was significantly higher in Caucasians (20.4%) than in African (16.2%) or Asian (9.2%) Americans. A similar pattern was observed among men (8.6%, 7.2%, and 4.2%). African Americans were less likely to report nausea or vomiting with their attacks, but more likely to report higher levels of headache pain. In contrast, African Americans tended to be less disabled by their attacks than Caucasians. There were no statistically significant differences in associated features between Asian American and Caucasian migraineurs.

CONCLUSIONS

In the United States, migraine prevalence is highest in Caucasians, followed by African Americans and Asian Americans. While differences in socioeconomic status, diet, and symptom reporting may contribute to differences in estimated prevalence, we suggest that race-related differences in genetic vulnerability to migraine are more likely to predominate as an explanatory factor.

High-performance liquid chromatographic analysis of corticosteroids

This review presents recent developments in high-performance liquid chromatographic (HPLC) analysis of corticosteroids for the determination of clinically important steroids in biological specimens. Various sample preparation techniques are described.

Long-term physical exercise retards trabecular bone loss in lumbar vertebrae of aging female mice

The present study examined the effect of long-term, moderate physical exercise on trabecular bone volume (TBV), calcium content, 3H-proline uptake, and the activities of alkaline and acid phosphatases in lumbar vertebrae of aging and senescent mice. It became apparent that if physical activity starts at an early stage of life, i.e., prior to middle age and is extended until old age, it exerts beneficial effects on trabecular bone mass and mineralization. Such a positive effect is not obtained if the training program is initiated after middle age. The training-induced reduction in bone loss was accompanied by a significant decrease in acid phosphatase activity whereas no changes took place with regard to the activity of alkaline phosphatase. Long-term physical exercise also enhanced the uptake of 3H-proline by lining cells along the bone trabecules. In spite of its moderate nature, the endured training program served as a stress factor for the involved animals, a fact that was manifested by an increase in the serum levels of corticosterone. Thus, it seems that whereas young animals respond favorably to such a stimulatory stress, older animals lose this ability of adaptation.

High-performance liquid chromatography of steroid hormones

Although a considerable amount of work has been carried out in the last ten years in developing methods for the separation of steroids by HPLC, it is still not widespread for the reasons discussed above. There is however no doubt that further developments in HPLC technology, in increasing sensitivity and/or specificity of detection systems, perhaps with microbore columns, may lead to an increase in the use of this powerful analytical procedure as an additional separation method to improve specificity of assay. Solution of the problem of simple interfacing of HPLC systems with mass spectrometers (discussed in another chapter by Games) should further increase the application of HPLC. HPLC is of particular value in providing a means of separating unstable compounds prior to assay by relatively nonspecific quantitation methods. Most steroids do not fall into this category, but the steroid vitamin D and its metabolites do and HPLC has proved in this area to be invaluable (see chapter by Jones & DeLuca). There are a multiplicity of different HPLC systems for the separation of steroids, varying in column type (and manufacturer), solvent composition and method of elution, temperature of elution, etc., and only a few attempts have been made to rationalise these data. It would therefore seem that a fruitful area of future study would be the investigation of computerised systems for the selection and optimisation of HPLC systems for particular steroid separations.