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Ben Halima H, Zine N, Bausells J, Jaffrezic-Renault N, Errachid A. A Novel Cortisol Immunosensor Based on a Hafnium Oxide/Silicon Structure for Heart Failure Diagnosis. MICROMACHINES 2022; 13:2235. [PMID: 36557534 PMCID: PMC9786208 DOI: 10.3390/mi13122235] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 06/12/2023]
Abstract
Assessing cortisol levels in human bodies has become essential to diagnose heart failure (HF). In this work, we propose a salivary cortisol detection strategy as part of an easily integrable lab-on-a-chip for detection of HF biomarkers. Our developed capacitive immunosensor based on hafnium oxide (HfO2)/silicon structure showed good linearity between increasing cortisol concentration and the charge-transfer resistance/capacitance. Moreover, the developed biosensor was demonstrated to be highly selective toward cortisol compared to other HF biomarkers such as tumor necrosis factor (TNF-α) and N-terminal pro-brain natriuretic peptide (NT-proBNP). The precision of our developed biosensor was evaluated, and the difference between the determined cortisol concentration in saliva and its expected one is <18%.
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Affiliation(s)
- Hamdi Ben Halima
- Institut de Sciences Analytiques (ISA)-UMR 5280, Université Claude Bernard Lyon 1, 5 rue de la Doua, 69100 Lyon, France
| | - Nadia Zine
- Institut de Sciences Analytiques (ISA)-UMR 5280, Université Claude Bernard Lyon 1, 5 rue de la Doua, 69100 Lyon, France
| | - Joan Bausells
- Institute of Microelectronics of Barcelona (IMB-CNM, CSIC), Campus UAB, Bellaterra, 08193 Barcelona, Spain
| | - Nicole Jaffrezic-Renault
- Institut de Sciences Analytiques (ISA)-UMR 5280, Université Claude Bernard Lyon 1, 5 rue de la Doua, 69100 Lyon, France
| | - Abdelhamid Errachid
- Institut de Sciences Analytiques (ISA)-UMR 5280, Université Claude Bernard Lyon 1, 5 rue de la Doua, 69100 Lyon, France
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2
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Xu B, Jia P, Cai J, Gu L, Yan H, Zhao H, Qin S. Simultaneous quantitative analysis of seven steroid hormones in human saliva: A novel method based on O-ethylhydroxylamine hydrochloride as derivatization reagent. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2022; 36:e9242. [PMID: 34913217 DOI: 10.1002/rcm.9242] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/12/2021] [Accepted: 12/13/2021] [Indexed: 06/14/2023]
Abstract
RATIONALE Saliva has been widely accepted as a more convenient alternative to serum or plasma in the field of clinical diagnosis. However, the detection of trace components in saliva has been a bottleneck problem. The aim of this work was to develop a highly sensitive and reliable method for simultaneously determining the trace steroid hormones including some with poor ionization efficiency in human saliva by liquid chromatography/tandem mass spectrometry (LC/MS). METHODS Saliva was deproteinated by acetonitrile containing mixed isotope internal standards and extracted with methyl tert-butyl ether. The extraction solution was dried under a stream of nitrogen and the residue was derivatized using 50 mM O-ethylhydroxylamine hydrochloride in 80% methanol/water solution (v/v). The processed sample was determined by LC/MS in multiple reaction monitoring (MRM) mode. RESULTS The method was successfully established for the simultaneous quantification of seven steroid hormones in human saliva and showed excellent specificity and sensitivity. The limits of quantification (LOQs) of all steroid hormones were below 5 pg/mL, in particular, the LOQ of progesterone was as low as 0.15 pg/mL. The linear correlation coefficients (r) were greater than 0.9990 in the range of 2-200 pg/mL for T, DHEA, A4, P4, P5, and 17OHP4 and in the range of 5-500 pg/mL for 17OHP5. The intra-day and inter-day variability ranged from 1.86% to 7.83% and 1.95% to 10.4%, respectively. The recovery of the method ranged from 86.9% to 111.1% for all steroid hormones using three spiked concentrations. CONCLUSIONS A novel LC/MS/MS method was developed for the simultaneous quantification of seven kinds of trace steroid hormones in human saliva. The results of the methodological study showed that the method exhibited excellent sensitivity and reliability for the evaluation of free steroid hormones in the human body. It is believed that this method could provide useful information of steroid hormone metabolism for auxiliary diagnosis of some endocrine disorders.
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Affiliation(s)
- Bin Xu
- Excellent Technology Co., Ltd, Suzhou, China
| | - Pengfei Jia
- Excellent Technology Co., Ltd, Suzhou, China
| | - Jun Cai
- Excellent Technology Co., Ltd, Suzhou, China
| | - Lidong Gu
- Excellent Technology Co., Ltd, Suzhou, China
| | - Huaxiao Yan
- Department of Bioengineering, College of Chemical and Biological Engineering, Shandong Innovation Center for Non-grain Ethanol Biorefinery Technology, Shandong University of Science and Technology, Qingdao, China
| | - Hui Zhao
- Department of Bioengineering, College of Chemical and Biological Engineering, Shandong Innovation Center for Non-grain Ethanol Biorefinery Technology, Shandong University of Science and Technology, Qingdao, China
| | - Song Qin
- Department of Bioengineering, College of Chemical and Biological Engineering, Shandong Innovation Center for Non-grain Ethanol Biorefinery Technology, Shandong University of Science and Technology, Qingdao, China
- Key Laboratory of Coastal Biology and Bioresource Utilization, Yantai Institute of Coastal Zone Research, Chinese Academy of Sciences, Yantai, China
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3
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Ponzetto F, Settanni F, Parasiliti-Caprino M, Rumbolo F, Nonnato A, Ricciardo M, Amante E, Priolo G, Vitali S, Anfossi L, Arvat E, Ghigo E, Giordano R, Mengozzi G. Reference ranges of late-night salivary cortisol and cortisone measured by LC-MS/MS and accuracy for the diagnosis of Cushing's syndrome. J Endocrinol Invest 2020; 43:1797-1806. [PMID: 32772255 DOI: 10.1007/s40618-020-01388-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/02/2020] [Indexed: 01/09/2023]
Abstract
PURPOSE International guidelines recommend salivary cortisol for the diagnosis of Cushing's syndrome. Despite mass spectrometry-based assays are considered the analytical gold-standard, there is still the need to define reference intervals and diagnostic accuracy of such methodology. METHODS 100 healthy volunteers and 50 consecutive patients were enrolled to compare LC-MS/MS and electrochemiluminescence assay for the determination of late-night salivary cortisol and cortisone. Moreover, we aimed to determine reference intervals of salivary steroids in a population of healthy individuals and diagnostic accuracy in patients with suspected hypercortisolism and in a population including also healthy individuals. RESULTS Method comparison highlighted a positive bias (51.8%) of immunoassay over LC-MS/MS. Reference intervals of salivary cortisol (0.17-0.97 µg/L), cortisone (0.84-4.85 µg/L) and ratio (0.08-0.30) were obtained. The most accurate thresholds of salivary cortisol for the diagnosis of hypercortisolism were 1.15 µg/L in the population with suspected hypercortisolism (AUC 1) and 1.30 µg/L in the population including also healthy individuals (AUC 1). Cut-off values of salivary cortisone (7.23 µg/L; Se 92.9%, Sp 97.2%, AUC 0.960 and Se 92.9%, Sp 99.1%, AUC 0.985 in suspected hypercortisolism and in overall population, respectively) and cortisol-to-cortisone ratio (0.20; Se 85.7%, Sp 80.6%, AUC 0.820 and Se 85.7%, Sp 85.5%, AUC 0.855 in suspected hypercortisolism and in overall population, respectively) were accurate and similar in both populations. CONCLUSION LC-MS/MS is the most accurate analytical platform for measuring salivary steroids. Obtained reference intervals are coherent with previously published data and diagnostic accuracy for diagnosis of overt hypercortisolism proved highly satisfactory.
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Affiliation(s)
- F Ponzetto
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - F Settanni
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
| | - M Parasiliti-Caprino
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy.
| | - F Rumbolo
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
| | - A Nonnato
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
| | - M Ricciardo
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
| | - E Amante
- Department of Chemistry, University of Turin, Turin, Italy
| | - G Priolo
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
| | - S Vitali
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
| | - L Anfossi
- Department of Chemistry, University of Turin, Turin, Italy
| | - E Arvat
- Oncologic Endocrinology, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - E Ghigo
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - R Giordano
- Department of Biological and Clinical Sciences, University of Turin, Turin, Italy
| | - G Mengozzi
- Clinical Biochemistry Laboratory, City of Health and Science University Hospital, Turin, Italy
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Zheng J, Huang S, Tong Y, Wei S, Chen G, Huang S, Ouyang G. In-situ layer-by-layer synthesized TpPa-1 COF solid-phase microextraction fiber for detecting sex hormones in serum. Anal Chim Acta 2020; 1137:28-36. [PMID: 33153606 DOI: 10.1016/j.aca.2020.08.047] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 01/18/2023]
Abstract
The secretion disorder of sex hormones is the source that leads to the occurrence of many diseases such as polycystic ovarian syndrome (PCOS), hyperandrogenism and so on. There exist physiological changes in human body when slight fluctuations in concentrations of sex hormones happen. Therefore, it's of great significance for accurate detection of sex hormones in human body. In this work, TpPa-1 COF solid-phase microextraction (SPME) fiber was prepared using high-efficient in-situ synthesis strategy and coupled with HPLC-MS/MS to detect three sex hormones, including Progesterone (P), testosterone (T) and dehydroepiandrosterone (DHEA) in human serum. The thickness of the coating reached 7 μm within 2 h. Under the optimal conditions, the established method presented low limit of detections (LODs, ≤ 0.75 ng/mL), wide linear ranges (0.100-100 ng mL-1) and good reproducibility, and three sex hormones (T, P, DHEA) were successfully detected and quantified in human serum. In conclusion, the established SPME method presented high-efficient fiber preparation and good analytical performances of sex hormone detection, therefore was in great potential for application in clinical.
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Affiliation(s)
- Jiating Zheng
- KLGHEI of Environment and Energy Chemistry, School of Chemistry, Sun Yat- Sen University, Guangzhou, Guangdong, 510275, China
| | - Shuyao Huang
- KLGHEI of Environment and Energy Chemistry, School of Chemistry, Sun Yat- Sen University, Guangzhou, Guangdong, 510275, China
| | - Yuanjun Tong
- KLGHEI of Environment and Energy Chemistry, School of Chemistry, Sun Yat- Sen University, Guangzhou, Guangdong, 510275, China
| | - Songbo Wei
- KLGHEI of Environment and Energy Chemistry, School of Chemistry, Sun Yat- Sen University, Guangzhou, Guangdong, 510275, China
| | - Guosheng Chen
- KLGHEI of Environment and Energy Chemistry, School of Chemistry, Sun Yat- Sen University, Guangzhou, Guangdong, 510275, China
| | - Siming Huang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics, Sun Yat- Sen Memorial Hospital, Guangzhou, Guangdong, 510120, China
| | - Gangfeng Ouyang
- KLGHEI of Environment and Energy Chemistry, School of Chemistry, Sun Yat- Sen University, Guangzhou, Guangdong, 510275, China; Guangdong Provincial Key Laboratory of Emergency Test for Dangerous Chemicals, Guangdong Institute of Analysis (China National Analytical Center Guangzhou), Guangzhou, 510070, China.
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Chao CS, Shi RZ, Kumar RB, Aye T. Salivary cortisol levels by tandem mass spectrometry during high dose ACTH stimulation test for adrenal insufficiency in children. Endocrine 2020; 67:190-197. [PMID: 31535345 DOI: 10.1007/s12020-019-02084-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 09/06/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Serum cortisol measurements after ACTH stimulation are currently used to evaluate for adrenal insufficiency in children. We aim to determine if salivary cortisol measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) can confirm or replace serum cortisol during high dose ACTH stimulation test to improve test compliance and interpretation. We also aim to gain preliminary understanding of normal ranges of salivary cortisol in normal children at am, bedtime, and midnight. METHODS Children aged 6-17 years meeting study criteria and tested for adrenal insufficiency were recruited to concomitantly collect saliva and serum samples during high dose ACTH stimulation test. Normal children aged 3-18 years were recruited to collect morning, bedtime, and midnight saliva samples. Salivary cortisol was measured using LC-MS/MS while serum cortisol was determined by an immunoassay. RESULTS Salivary cortisol in normal children were higher at am and lower at bedtime and midnight (p value <0.0002 and <0.007, respectively). The midnight and bedtime levels were not sufficiently different (p value 0.36). Salivary cortisol during ACTH stimulation test positively and closely correlated with serum cortisol with 100% specificity and sensitivity when 18 µg/dL for serum and 500 ng/dL for salivary cortisol were used as cutoff values respectively for adrenal sufficiency. CONCLUSIONS Measurement of salivary cortisol by LC-MS/MS is less invasive, more convenient and better time controlled in busy pediatric clinic, therefore is better suited for young children to be used during high dose ACTH stimulation test to evaluate for adrenal insufficiency and to assist interpretation of test results by serum cortisol.
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Affiliation(s)
- Christina S Chao
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Palo Alto, CA, USA
- Pediatric Endocrinology, Kaiser Permanente Roseville Medical Center, Roseville, CA, USA
| | - Run-Zhang Shi
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Rajiv B Kumar
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tandy Aye
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Palo Alto, CA, USA
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Study of temporal variability of salivary cortisol and cortisone by LC-MS/MS using a new atmospheric pressure ionization source. Sci Rep 2019; 9:19313. [PMID: 31848390 PMCID: PMC6917784 DOI: 10.1038/s41598-019-55571-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 11/30/2019] [Indexed: 12/17/2022] Open
Abstract
There is a growing interest concerning the relevance of salivary cortisone levels in stress-related research. However, studies investigating morning patterns and day-to-day variability of cortisone versus cortisol levels are lacking. Cortisol and cortisone analysis by liquid chromatography-tandem mass spectroscopy (LC-MS/MS) has been widely used for routine laboratory measurements in the last years. The aim of this study was to develop an ultra-performance LC-MS/MS method for the simultaneous quantification of salivary cortisol and cortisone levels for assessing the temporal variability of these hormones. Saliva samples were collected from 18 healthy volunteers at 0, 15, and 30 min after awakening on each day for 1 week and analysed with the newly developed method. We used a novel atmospheric pressure ionization source, which resulted in high sensitivity and specificity for both cortisol and cortisone as well as higher peak values and signal-to-noise ratio as compared with the electrospray ionization source. Cortisone showed similar morning patterns as cortisol: a 25% and 49% increase in levels at 15 and 30 min after awakening, respectively. Most cortisone indices showed somewhat lower day-to-day variability and were less affected by state-related covariates. We recommend further exploration of the potential of salivary cortisone as a biomarker in stress-related research.
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Trends in Analysis of Cortisol and Its Derivatives. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1140:649-664. [DOI: 10.1007/978-3-030-15950-4_39] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
PURPOSE OF REVIEW A resurgence of interest in salivary biomarkers has generated evidence for their value in assessing adrenal function. The advantages of salivary measurements include only free hormone is detected, samples can be collected during normal daily routines and stress-induced cortisol release is less likely to occur than during venepuncture. We review the use of salivary biomarkers to diagnose and monitor patients for conditions of cortisol excess and deficiency and discuss the value of measuring salivary cortisone versus salivary cortisol. RECENT FINDINGS Developments in laboratory techniques have enabled the measurement of salivary hormones with a high level of sensitivity and specificity. In states of altered cortisol binding, salivary biomarkers are more accurate measures of adrenal reserve than serum cortisol. Salivary cortisone is a superior marker of serum cortisol compared with salivary cortisol, specifically when serum cortisol is low and during hydrocortisone therapy when contamination of saliva may result in misleading salivary cortisol concentrations. SUMMARY Salivary cortisol and cortisone can be used to assess cortisol excess, deficiency and hydrocortisone replacement, with salivary cortisone having the advantage of detection when serum cortisol levels are low and there is no interference from oral hydrocortisone.
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Affiliation(s)
- Joanne Blair
- aAlder Hey Children's Hospital, Liverpool bUniversity Hospital South Manchester cManchester Healthcare Academy, Manchester dThe University of Sheffield, Sheffield, UK
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Mezzullo M, Fanelli F, Fazzini A, Gambineri A, Vicennati V, Di Dalmazi G, Pelusi C, Mazza R, Pagotto U, Pasquali R. Validation of an LC-MS/MS salivary assay for glucocorticoid status assessment: Evaluation of the diurnal fluctuation of cortisol and cortisone and of their association within and between serum and saliva. J Steroid Biochem Mol Biol 2016; 163:103-12. [PMID: 27108942 DOI: 10.1016/j.jsbmb.2016.04.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 03/21/2016] [Accepted: 04/20/2016] [Indexed: 01/06/2023]
Abstract
Salivary steroid testing represents a valuable source of biological information; however, the proper measurement of low salivary levels is challenging for direct immunoassays, lacking adequate sensitivity and specificity and causing poor inter-laboratory reproducibility. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) has overcome previous analytical limits, often providing results deviating from previous knowledge. Nowadays, LC-MS/MS is being introduced in clinical laboratories for salivary cortisol testing; however, so far only a few studies have reported thorough biological validation based on LC-MS/MS data. In this study, we provide a thorough analytical, pre-analytical and biological validation of an LC-MS/MS method for the measurement of salivary cortisol (F) and of its inactive metabolite cortisone (E). Analytes were extracted from 50μl of saliva, were then separated in 7.5min LC-gradient and detected by negative electrospray ionization-multiple reaction monitoring. The reliability of a widely diffused collection device, Salivette(®), was assessed and the overall procedure was validated. The diurnal cortisol and cortisone fluctuation in saliva and serum was described by a four paired collection protocol (8 am, 12 am, 4 pm and 8 pm) in 19 healthy subjects. The assay allowed the quantitation of F and E down to 39.1 and 78.1pg/ml, with an imprecision range of 5.5-9.5%, 3.9-14.1% and 2.6-14.4%, and an accuracy range of 105.5-113.1%, 88.5-98.7% and 90.7-96.7% for both analytes at low, medium and high levels, respectively. Salivette(®) provided comparable results and better precision (CV<1.0%) as referred to direct spitting (CV<13.0%). A parallel diurnal rhythm in saliva and serum was observed for cortisol and cortisone, with values lowering from the morning to the evening time points (P<0.0001). While salivary E linearly correlated to total serum F (R(2)=0.854, P<0.001), salivary F showed an exponential relationship (R(2)=0.903, P<0.001) with serum F reflecting the free circulating fraction. A non linear association between E and F was observed in saliva (R(2)=0.941, p<0.001) consistent with the type II 11β-HSD activity. We concluded that our LC-MS/MS method allowed a sensitive evaluation of salivary levels of cortisol and cortisone. The simultaneous determination of both hormones in saliva allowed the differential estimation of the active and of the total glucocorticoid exposure over the daytime. The assay could provide further insight into the comprehension of normal and dysfunctional glucocorticoid circadian rhythm.
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Affiliation(s)
- Marco Mezzullo
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Flaminia Fanelli
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Alessia Fazzini
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Alessandra Gambineri
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Valentina Vicennati
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Guido Di Dalmazi
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Carlotta Pelusi
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Roberta Mazza
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Uberto Pagotto
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - Renato Pasquali
- Endocrinology Unit, Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research (C.R.B.A.), S. Orsola-Malpighi Hospital, Alma Mater University of Bologna, Bologna, Italy.
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Hawley JM, Keevil BG. Endogenous glucocorticoid analysis by liquid chromatography-tandem mass spectrometry in routine clinical laboratories. J Steroid Biochem Mol Biol 2016; 162:27-40. [PMID: 27208627 DOI: 10.1016/j.jsbmb.2016.05.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 05/11/2016] [Accepted: 05/12/2016] [Indexed: 02/07/2023]
Abstract
Liquid chromatography-tandem mass spectrometry (LC-MS/MS) is a powerful analytical technique that offers exceptional selectivity and sensitivity. Used optimally, LC-MS/MS provides accurate and precise results for a wide range of analytes at concentrations that are difficult to quantitate with other methodologies. Its implementation into routine clinical biochemistry laboratories has revolutionised our ability to analyse small molecules such as glucocorticoids. Whereas immunoassays can suffer from matrix effects and cross-reactivity due to interactions with structural analogues, the selectivity offered by LC-MS/MS has largely overcome these limitations. As many clinical guidelines are now beginning to acknowledge the importance of the methodology used to provide results, the advantages associated with LC-MS/MS are gaining wider recognition. With their integral role in both the diagnosis and management of hypo- and hyperadrenal disorders, coupled with their widespread pharmacological use, the accurate measurement of glucocorticoids is fundamental to effective patient care. Here, we provide an up-to-date review of the LC-MS/MS techniques used to successfully measure endogenous glucocorticoids, particular reference is made to serum, urine and salivary cortisol.
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Affiliation(s)
| | - Brian G Keevil
- University Hospital South Manchester, Manchester, UK; Manchester Healthcare Academy, Manchester, UK
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11
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Crişan LG, Vulturar R, Miclea M, Miu AC. Reactivity to Social Stress in Subclinical Social Anxiety: Emotional Experience, Cognitive Appraisals, Behavior, and Physiology. Front Psychiatry 2016; 7:5. [PMID: 26858658 PMCID: PMC4728202 DOI: 10.3389/fpsyt.2016.00005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 01/11/2016] [Indexed: 11/17/2022] Open
Abstract
Recent research indicates that subclinical social anxiety is associated with dysfunctions at multiple psychological and biological levels, in a manner that seems reminiscent of social anxiety disorder (SAD). This study aimed to describe multidimensional responses to laboratory-induced social stress in an analog sample selected for social anxiety symptoms. State anxiety, cognitive biases related to negative social evaluation, speech anxiety behaviors, and cortisol reactivity were assessed in the Trier Social Stress Test (TSST). Results showed that social anxiety symptoms were associated with increased state anxiety, biased appraisals related to the probability and cost of negative social evaluations, behavioral changes in facial expression that were consistent with speech anxiety, and lower cortisol reactivity. In addition, multiple interrelations between responses in the TSST were found, with positive associations between subjective experience, cognitive appraisals, and observable behavior, as well as negative associations between each of the former two types of response and cortisol reactivity. These results show that in response to social stressors, subclinical social anxiety is associated with significant changes in emotional experience, cognitive appraisals, behaviors, and physiology that could parallel those previously found in SAD samples.
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Affiliation(s)
- Liviu G Crişan
- Department of Psychology, Babeş-Bolyai University , Cluj-Napoca , Romania
| | - Romana Vulturar
- Department of Cell and Molecular Biology, "Iuliu Haţieganu" University of Medicine and Pharmacy , Cluj-Napoca , Romania
| | - Mircea Miclea
- Department of Psychology, Babeş-Bolyai University , Cluj-Napoca , Romania
| | - Andrei C Miu
- Department of Psychology, Babeş-Bolyai University , Cluj-Napoca , Romania
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Vänskä M, Punamäki RL, Lindblom J, Tolvanen A, Flykt M, Unkila-Kallio L, Tulppala M, Tiitinen A. Timing of Early Maternal Mental Health and Child Cortisol Regulation. INFANT AND CHILD DEVELOPMENT 2015. [DOI: 10.1002/icd.1948] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Mervi Vänskä
- Psychology/School of Social Sciences and Humanities; University of Tampere; Tampere Finland
| | - Raija-Leena Punamäki
- Psychology/School of Social Sciences and Humanities; University of Tampere; Tampere Finland
| | - Jallu Lindblom
- Psychology/School of Social Sciences and Humanities; University of Tampere; Tampere Finland
| | - Asko Tolvanen
- Department of Psychology; University of Jyvaskyla; Jyvaskyla Finland
| | - Marjo Flykt
- Psychology/School of Social Sciences and Humanities; University of Tampere; Tampere Finland
| | - Leila Unkila-Kallio
- Department of Obstetrics and Gynaecology; Helsinki University Central Hospital; Helsinki Finland
- Department of Obstetrics and Gynaecology; University of Helsinki; Helsinki Finland
| | - Maija Tulppala
- Department of Obstetrics and Gynaecology; University of Helsinki; Helsinki Finland
| | - Aila Tiitinen
- Department of Obstetrics and Gynaecology; Helsinki University Central Hospital; Helsinki Finland
- Department of Obstetrics and Gynaecology; University of Helsinki; Helsinki Finland
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13
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Salivary cortisol and cortisone by LC–MS/MS: validation, reference intervals and diagnostic accuracy in Cushing's syndrome. Clin Chim Acta 2015; 451:247-51. [DOI: 10.1016/j.cca.2015.10.004] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 09/08/2015] [Accepted: 10/05/2015] [Indexed: 01/17/2023]
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14
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Nunes LAS, Mussavira S, Bindhu OS. Clinical and diagnostic utility of saliva as a non-invasive diagnostic fluid:
a systematic review. Biochem Med (Zagreb) 2015; 25:177-92. [PMID: 26110030 PMCID: PMC4470107 DOI: 10.11613/bm.2015.018] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 05/14/2015] [Indexed: 12/17/2022] Open
Abstract
This systematic review presents the latest trends in salivary research and its applications in health and disease. Among the large number of analytes present in saliva, many are affected by diverse physiological and pathological conditions. Further, the non-invasive, easy and cost-effective collection methods prompt an interest in evaluating its diagnostic or prognostic utility. Accumulating data over the past two decades indicates towards the possible utility of saliva to monitor overall health, diagnose and treat various oral or systemic disorders and drug monitoring. Advances in saliva based systems biology has also contributed towards identification of several biomarkers, development of diverse salivary diagnostic kits and other sensitive analytical techniques. However, its utilization should be carefully evaluated in relation to standardization of pre-analytical and analytical variables, such as collection and storage methods, analyte circadian variation, sample recovery, prevention of sample contamination and analytical procedures. In spite of all these challenges, there is an escalating evolution of knowledge with the use of this biological matrix.
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Affiliation(s)
| | - Sayeeda Mussavira
- Department of Biochemistry, Centre for Post Graduate Studies, Jain University, Bangalore, India
| | - Omana Sukumaran Bindhu
- Department of Biochemistry, Centre for Post Graduate Studies, Jain University, Bangalore, India
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15
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Cărnuţă M, Crişan LG, Vulturar R, Opre A, Miu AC. Emotional non-acceptance links early life stress and blunted cortisol reactivity to social threat. Psychoneuroendocrinology 2015; 51:176-87. [PMID: 25462891 DOI: 10.1016/j.psyneuen.2014.09.026] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Revised: 08/14/2014] [Accepted: 09/24/2014] [Indexed: 11/17/2022]
Abstract
Early life stress (ELS) has been recently associated with blunted cortisol reactivity and emotion dysregulation, but no study until now examined whether these characteristics are related. The main goal of this study was to examine the potential mediator role of emotion dysregulation in the relation between ELS and cortisol reactivity to social threat. Only women who were free of psychiatric and endocrine disorders, had regular menstrual cycle and did not use oral contraceptives were selected for this study (N=62). After filling in ELS and multidimensional emotion dysregulation measures, participants underwent the Trier Social Stress Test during which cortisol and autonomic responses were assessed. Most participants (85.5%) reported one or more major stressful events (i.e., physical abuse, sexual abuse, major parental conflicts, death of a family or close friend, severe illness) experienced before age 17. ELS was negatively associated with cortisol reactivity and positively associated with skin conductance level (SCL) reactivity, but it did not influence heart rate and respiratory sinus arrhythmia. In addition, ELS was positively related to emotional non-acceptance (i.e., a tendency to develop secondary emotional responses to one's negative emotions), and the latter was negatively related to cortisol responses and positively related to SCL responses. Bootstrapping analyses indicated that emotional non-acceptance was a significant mediator in the relationships between ELS and both cortisol and SCL responses. Emotional non-acceptance is thus one of the psychological mechanisms underlying blunted cortisol and increased sympathetic reactivity in young healthy volunteers with a history of ELS.
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Affiliation(s)
- Mihai Cărnuţă
- Cognitive Neuroscience Laboratory, Department of Psychology, Babeş-Bolyai University, Cluj-Napoca, Romania
| | - Liviu G Crişan
- Cognitive Neuroscience Laboratory, Department of Psychology, Babeş-Bolyai University, Cluj-Napoca, Romania
| | - Romana Vulturar
- Department of Cell and Molecular Biology, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Adrian Opre
- Cognitive Neuroscience Laboratory, Department of Psychology, Babeş-Bolyai University, Cluj-Napoca, Romania
| | - Andrei C Miu
- Cognitive Neuroscience Laboratory, Department of Psychology, Babeş-Bolyai University, Cluj-Napoca, Romania.
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16
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Abstract
Cortisol is quantitatively the major glucocorticoid product of the adrenal cortex. The main reason to measure cortisol is to diagnose human diseases characterised by deficiency of adrenal steroid excretion in Addison's disease or overproduction in Cushing's syndrome (CS). In both cases a sensitive, accurate and reproducible assay of cortisol is required. Several methods have been described for the quantitative measurement of cortisol in both serum and urine. The most widely used methods in routine clinical laboratories are immunoassays (IA) and enzyme immunoassays (EIA), luminescence and fluorescence assays, which are available in numerous commercial kits and on automated platforms. However, there remains a number of problems in the so-called direct immunoassays if extraction and prepurification are not carried out before the assay. Recently, more specific chromatographic methods have been introduced, such as high pressure liquid chromatographic (HPLC) or liquid chromatography tandem mass spectrometric assays (LC-MS/MS). The high specificity especially of LC-MS/MS facilitates reliable measurement of cortisol both in plasma, urine and saliva samples.
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Affiliation(s)
- Ursula Turpeinen
- HUSLAB, Laboratory of Women's Clinic, Haartmaninkatu 2, 00290 Helsinki, Finland.
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17
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Abstract
Mass spectrometry methods have the potential to measure different hormones during the same analysis and have improved specificity and a wide analytical range compared with many immunoassay methods. Increasingly in clinical laboratories liquid chromatography-tandem mass spectrometry (LC-MS/MS) assays are replacing immunoassays for the routine measurement of testosterone, 17-hydroxyprogesterone, and other steroid hormones. Reference LC-MS/MS methods for steroid, thyroid, and peptide hormones are being used for assessment of the performance and calibration of commercial immunoassays. In this chapter, the general principles of tandem mass spectrometry and examples of hormone assays are described.
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Affiliation(s)
- Helen P Field
- Department of Specialist Laboratory Medicine, St. James's University Hospital, Leeds, UK
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18
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Kataoka H, Ehara K, Yasuhara R, Saito K. Simultaneous determination of testosterone, cortisol, and dehydroepiandrosterone in saliva by stable isotope dilution on-line in-tube solid-phase microextraction coupled with liquid chromatography–tandem mass spectrometry. Anal Bioanal Chem 2012; 405:331-40. [DOI: 10.1007/s00216-012-6479-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 09/30/2012] [Accepted: 10/02/2012] [Indexed: 11/25/2022]
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19
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Gassling V, Holterhus PM, Herbers D, Kulle A, Niederberger U, Hedderich J, Wiltfang J, Gerber WD. Stress-coping and cortisol analysis in patients with non-syndromic cleft lip and palate: an explorative study. PLoS One 2012; 7:e41015. [PMID: 22911731 PMCID: PMC3401206 DOI: 10.1371/journal.pone.0041015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 06/15/2012] [Indexed: 11/19/2022] Open
Abstract
Background Non-syndromic clefts of the orofacial region occur in approximately 1 per 500 to 2,500 live births, depending on geographical area and ethnicity. It can be supposed that the disruption of the normal facial structure and the long-standing pressure of treatment from birth to adulthood bring about a range of life stressors which may lead to a long-lasting impact on affected subjects throughout their lives. Therefore, the present study aimed to assess different aspects of psychosocial stress in affected individuals. Methods The study was divided into two parts: first, the Trier Social Stress Test which involves uncontrollability and high levels of social-evaluative stress under real conditions and second, the query of various aspects of coping with psychosocial stress. The test group consisted of 30 affected adult subjects, and an equally sized control group of unaffected volunteers. Cortisol dysregulation was determined by saliva samples before and after stress induction. Meanwhile, participants were asked to complete the SVF 120 stress-coping questionnaire. Results The analysis of saliva samples showed a similar baseline concentration as well as a similar increase in cortisol levels after stress induction for both groups. Subsequently, the decline in cortisol concentrations was significantly faster in the CLP group (course: p<0.001; groups: p = 0.102; interaction: p = 0.167). The evaluation of the stress-coping questionnaire revealed a significantly shorter rumination about a stressful event in individuals with CLP-related malformations (p = 0.03). Conclusion We conclude that adults with CLP have significantly better stress-coping strategies than their healthy peers. Trial Registration German Clinical Trials Organization DRKS00003466
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Affiliation(s)
- Volker Gassling
- Department of Oral and Maxillofacial Surgery, University Hospital of Schleswig-Holstein, Kiel, Germany.
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20
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Abstract
This short review summarizes the use of late-night salivary cortisol measurement in the diagnosis of Cushing's syndrome, in the evaluation of patients with adrenal incidentalomas, and in monitoring of post-operative patients, with a focus on the different assay methodologies currently in common use. The focus is on recent studies identified by literature searches using Ovid Medline and Google Scholar as well as analysis of several recent review articles on the topic. Measurement of late night salivary cortisol (LNSC) has an excellent sensitivity and specificity for the diagnosis of Cushing's syndrome regardless of the assay methodology used. Immunoassays have the advantage of simplicity, low cost, and small sample volume requirement, while liquid chromatography-tandem mass spectrometry has the advantage of a high specificity for cortisol and the ability to measure cortisone. The overnight dexamethasone suppression test appears to be superior to LNSC measurement in the evaluation of patients with adrenal incidentalomas. LNSC measurement is an excellent approach to monitor post-operative Cushing's disease patients for surgical failure or recurrence. Salivary cortisol is most useful as the initial test when Cushing's syndrome is suspected and for periodic patient monitoring after pituitary surgery for Cushing's disease.
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Affiliation(s)
- Hershel Raff
- Endocrine Research Laboratory, Endocrine-Diabetes Center, Aurora St. Luke's Medical Center, Milwaukee, WI 53215, USA.
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21
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The coming of age of liquid chromatography coupled to tandem mass spectrometry in the endocrinology laboratory. J Chromatogr B Analyt Technol Biomed Life Sci 2012; 883-884:50-8. [DOI: 10.1016/j.jchromb.2011.08.027] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 08/19/2011] [Indexed: 02/07/2023]
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van den Ouweland JMW, Kema IP. The role of liquid chromatography-tandem mass spectrometry in the clinical laboratory. J Chromatogr B Analyt Technol Biomed Life Sci 2011; 883-884:18-32. [PMID: 22197607 DOI: 10.1016/j.jchromb.2011.11.044] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 10/31/2011] [Accepted: 11/29/2011] [Indexed: 01/31/2023]
Abstract
Liquid chromatography coupled to mass spectrometry (LC-MS/MS) is increasingly used as a routine methodology in clinical laboratories for the analysis of low molecular weight molecules. The high specificity in combination with high sensitivity and multi-analyte potential makes it an attractive complementary method to traditional methodology used for routine applications. Its strength and weaknesses in this context will be discussed and examples of successful clinical applications will be given. For LC-MS/MS to truly fulfil its promise in clinical diagnosis, the prerequisite steps being sample pre-treatment, chromatographic separation and detection by selected reaction monitoring must become more integrated as they are in conventional clinical analysers. The availability of ready-to-use reagents kits, eliminating efforts needed for method development and extensive validation, are likely to contribute to a wider acceptance of LC-MS/MS in clinical laboratories. Growing applicability of LC-MS/MS in the clinical laboratory field is expected from quantitative protein analysis.
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Jensen MA, Hansen AM, Abrahamsson P, Nørgaard AW. Development and evaluation of a liquid chromatography tandem mass spectrometry method for simultaneous determination of salivary melatonin, cortisol and testosterone. J Chromatogr B Analyt Technol Biomed Life Sci 2011; 879:2527-32. [PMID: 21803007 DOI: 10.1016/j.jchromb.2011.07.005] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Revised: 06/14/2011] [Accepted: 07/07/2011] [Indexed: 01/30/2023]
Abstract
Circadian disruption can have several possible health consequences, but is not well studied. In order to measure circadian disruption, in relation to shift or night work, we developed a simple and sensitive method for the simultaneous determination of melatonin, cortisol and testosterone in human saliva. We used liquid-liquid extraction (LLE) followed by liquid chromatography coupled to electrospray tandem mass spectrometry (LC-ESI-MS/MS) recorded in positive ion mode. Saliva samples were collected by spitting directly into tubes and 250 μL were used for analysis. The limits of detection were 4.1 pmol/L, 0.27 nmol/L and 10.8 pmol/L for melatonin, cortisol, and testosterone, respectively. The developed method was sensitive enough to measure circadian rhythms of all 3 hormones in a pilot study among four healthy volunteers. It can therefor be used to study the impact of night work and working in artificial light on the workers circadian rhythms. To our knowledge this is the first LC-ESI-MS/MS method for simultaneous determination of salivary melatonin, cortisol and testosterone.
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Affiliation(s)
- Marie Aarrebo Jensen
- National Research Centre for the Working Environment, Lersø Parkallé 105, DK-2100 Copenhagen Ø, Denmark.
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24
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Kushnir MM, Rockwood AL, Roberts WL, Yue B, Bergquist J, Meikle AW. Liquid chromatography tandem mass spectrometry for analysis of steroids in clinical laboratories. Clin Biochem 2011; 44:77-88. [DOI: 10.1016/j.clinbiochem.2010.07.008] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 06/28/2010] [Accepted: 07/04/2010] [Indexed: 01/18/2023]
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25
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Plenis A, Konieczna L, Olędzka I, Kowalski P, Bączek T. Simultaneous determination of urinary cortisol, cortisone and corticosterone in parachutists, depressed patients and healthy controls in view of biomedical and pharmacokinetic studies. MOLECULAR BIOSYSTEMS 2011; 7:1487-500. [DOI: 10.1039/c0mb00313a] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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26
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Shackleton C. Clinical steroid mass spectrometry: a 45-year history culminating in HPLC-MS/MS becoming an essential tool for patient diagnosis. J Steroid Biochem Mol Biol 2010; 121:481-90. [PMID: 20188832 DOI: 10.1016/j.jsbmb.2010.02.017] [Citation(s) in RCA: 161] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 02/04/2010] [Accepted: 02/18/2010] [Indexed: 10/19/2022]
Abstract
Automated rapid HPLC tandem mass spectrometry has become the method of choice for clinical steroid analysis. It is replacing immunoassay techniques in most instances because it has high sensitivity, better reproducibility, greater specificity and can be used to analyze multiple steroids simultaneously. Modern multiplex instruments can analyze thousands of samples per month so even with high instrument costs the price of individual assays can be affordable. The mass spectrometry of steroids goes back decades; the first on-line chromatography/mass spectrometry methods for hormone analysis date to the 1960s. This paper reviews the evolution of mass spectrometric techniques applied to sterol and steroid measurement There have been three eras: (1) gas chromatography-mass spectrometry (GC/MS), (2) Fast Atom Bombardment (FAB) and (3) HPLC/MS. The first technique is only suitable for unconjugated steroids, the second for conjugated, and the third equally useful for free or conjugated. FAB transformed biological mass spectrometry in the 1980s but in the end was an interim technique; GC/MS retains unique qualities but is unsuited to commercial routine analysis, while LC-MS/MS is rightly stealing the show and has become the dominant method for steroid analysis in endocrinology.
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Affiliation(s)
- Cedric Shackleton
- Centre for Endocrinology, Diabetes and Metabolism (CEDAM), Institute of Biomedical Research, University of Birmingham, UK.
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