- Email: [email protected]
Plasma-cortisol levels and the frequency of bleeding in haemophilia
351
Clinica C~imica Acta, 53 (1974) 351-354 0 Elsevier Scientific Publishing Company, Amsterdam - Printed in The Netherlands
CCA 6413
PLASMA-CORTISOL HAEMOPHILIA
S.G. RAINSFORDa,
LEVELS
AND THE FREQUENCY
OF BLEEDING
IN
DOROTHY RICI-IARDSONb and C. STUART SHAWb
a Lord Mayor Treloar College, Froyle, Alton, Hants and ’ North Hampshire Group Hospitals, Hants (United Kingdom) (Received February 14,1974)
Summary The plasma-cortisol levels in 15 boys suffering from classical haemophilia were followed throughout one academic year, namely three terms. The bleeding frequency and the plasma-cortisol levels showed no seasonal variation. There was no evidence to suggest that the plasma-cortisol levels significantly affected the frequency of haemorrhagic episodes.
Introduction Giordano and Radivoyevitch [l] , after studying the plasma-cortisol levels of 15 boys suffering from haemophilia over a period of one year, suggested that there was some correlation between adreno-cortical activity and bleeding episodes. They found that the plasma-cortisol levels were lowest in late winter and early spring when most of the clinical problems in their cases occurred. Furthermore, in a study by Bennett and Ingram [Z] it was found that in children a dose of 1 mg t.d.s. of prednisolone significantly reduced the number of bleeding episodes. In a study of 40 adolescent boys suffering from classical haemophilia over a period of two academic years, Rainsford and Hall [3] found no significant variation in the frequency of bleeding episodes between one term and another, or from year to year. It has, however, been possible to follow the pl~ma-~ortisol levels of 15 of these boys throughout one academic year (254 days). Methods Blood samples were collected into lithium heparin tubes (Stayne Laboratories, Ltd) at between 09.00 and 09.30 h. The red cells were immediately centrifuged out and the plasma harvested and stored at -20’ until the plasmacortisol could be assayed.
352
Since these boys were treated with transfusions of factor VIII concentrate each time they suffered a bleed, care was taken that no sample of blood was collected for plasma-cortisol assay until at least 1 week had elapsed after any transfusion. The plasma-cortisol was assayed by the method of ~attingly [4] for free ll-hydroxycorticoids. The original method was modified by washing the solvent extract with 0.1 M sodium hydroxide, followed by a water wash. Associated investigations included those defining the patients’ haemophilic status. These were factor VIII assay (two-stage technique of Biggs et al. [ 51) and kaolin-cephalin clotting time (K.C.C.T.) (Denson and Biggs [6]) with the modification that the actual clotting time was measured with a Fibrometer (Becton and Dickinson). The results of these tests are given in Table I, but the K.C.C.T. results are expressed as a ratio, i.e. patient plasma clotting timefnormal plasma clotting time. Clinical severity The data with regard to clinical severity are expressed in terms of the number of bleeding episodes per 100 days. This method makes it possible to allow for the difference in the number of days between each term. All these boys were under close supervision during 254 days of the academic year, while they were in residence at the Lord Mayor Treloar College, and every bleeding episode was recorded. Over the period under review, there were in all 40 boys suffering from classical haemophilia in residence at the college. The annual mean frequency of bleeding for the whole group for the period was 7.25 per boy per 100 days with a mean term range of 7.0-7.5 (see Rainsford and Hall [ 31). Using these data the 15 boys in this investigation can be divided into three categories of clinical severity (see Table I), as follows. Group 1. Those whose mean frequency of bleeding exceeded the mean figure of 7.25 per 100 days. Group 11. Those in whom the frequency of bleeding was less than the mean, but more than half the mean annual rate. Group III. Those in whom the frequency was less than half the mean annual rate. Results The individual results of these ~vestigations are shown in Table I, but because of the very great difference in the frequency of bleeding among the three different groups of clinical severity, an analysis of the figures for each group is shown separately as well as for all three groups combined. First it will be noted that the mean annual cortisol level for each of these groups ranged from only 14.3 to 16.8 pg/lOO ml. The lowest figure recorded for plasmacortisol level was 7.5 pg/lOO ml of plasma and the highest figure 27 E.rg/lOO ml. The normal range for this method is 6-26 ~g/lOO ml at about 09.00 h. It would therefore appear that all the plasma-cortisol levels recorded were within the range of normal. The arithmetic mean found by Mattingly for this method was 14.2 pg/lOO ml for the ‘normal’ patients. The mean plasma-cortisol level for our whole group over the three terms ranged from 15.1 &g/100 ml to 16.1
Factor
Mean
Range
Combined
Total
-
-
9.5-22.6
15.3
18.5 12.4 11.0 24.0 16.5 [email protected]
2.52 2.05 1.55 2.00 -
16 22 25 40 Mean Range
III
1.1-21.3
6.4
2.1 2.1 2.4 1.1 1.9 1.1-2.4
5.4 4.3 4.3 3.5 4.5 5.4 7.G 6.5 5.2 3.5-7.6
7.5-27.0
16.1
14.5 27.0 14.7 15.8 18.0 14.5-27.0
16.2 7.5 11‘9 13.5 18.5 19.8 24.0 19.9 16.4 7.5-24.0
0.0-17.0
5.0
1.4 2.8 0.0 1.4 1.4 0.0-2.8
4.3 5.7 4.3 4.3 4.3 4.3 4.3 7.1 4.3 4.3-7.1
5.7 8.6 17.0 10.4 5.7-17.0
8.8-24.9
15.1
17.1 15.4 12.5 19.2 16.0 12.5-19.2
16.0 10.8 17.4 8.8 13.7 16.2 20.5 13.5 14.6 8.8-20.5
9.7 10.7 24.9 15.1 9.7-24.9
14.2 12.0 21.3 15.8 12.0-21.3
3.5
9.5 11.3 17.8 12.9 9.5-17.8
Plasmacortisol wiz/lOO~)
PlasmaBleeds per cortisol lOOdays @g/l00 ml)
Bleedsper lOOdays
Plasmacortisol Ow100mI)
17.5 17.8 14.9 9.6-17.8
Summerterm (92 days)
Springterm (70 days)
Autumnterm (92 days)
15.3 11.0 13.4 12.1 12.0 12.9 22.6 19.7 14.9 11.0-22.6
2 11 24 27 36 41 43 44 Mean Range
II
2.80 2.44 2.60 -
K.C.C.T. ratio
1.86 1.70 2.68 2.97 2.70 3.10 3.18 2.68 -
VIII%
4 5 10 Mean Range
CaseNo.
I
severity groupno.
(JilliCat
RESULTSOFTESTSCARRIEDOUTON15BOYSSUFFERINGFROMHAEMOPHILIA
TABLE1
1.1-17.6
6.0
6.6 2.2 2.2 0.0 2.7 0.0-6.6
8.8 5.5 5.5 7.7 6.6 3.3 3.3 1.1 5.2 1.1-8.8
9.6-22.3
15.3
16.7 18.2 12.7 19.7 16.8 11.0-27.0
15.8 9.7 14.2 11.4 14.7 16.3 22.3 17.6 16.3 7.5-24.0
0.8-18.6
5.8
3.3 2.7 1.5 0.8 2.0 0.0-6.6
6.2 5.2 4.7 5.1 5.1 4.3 5.1 4.9 4.9 1.1-8.8
10.3 9.8 18.6 12.9 5.7-21.3
PlasmaBleeds per cortisol lOOdays tl.tg/lOOml)
11.0 9.6 13.2 8.8 17.6 20.0 12.5 14.3 8.8-17.6 9.5-24.9
lOOdays
Bleeds per
Annualmean
@g/l00 ml, a difference between the three terms of only 1 pg. Nevertheless, it will be seen that the highest figure, namely 16.1 pg, was during the spring term and this coincided with the lowest figure for haemorrhagic episodes. The fre quency of bleeding each term however, only showed a range of 5.0-6.4 per 100 days. The lowest rate was during the spring term and the highest during the autumn term; the mean annual rate being 5.8 bleeds per 100 days. The mean plasma-cortisol level and mean bleeding frequency were approximately the same for both the autumn and summer terms. Discussion All three groups showed a slightly lower incidence of haemorrhagic episodes during the spring term and this coincided with the highest mean cortisol level for any three terms in groups II and III but not in group I, the most severely affected group in which the lowest plasma-eortisol level recorded was during the spring term. The data were therefore submitted for statistical analysis and the following conclusions were drawn. The bleeds per 100 days in the three different seasons were highly correlated with each C&herand the three sets of plasma-cortisol data were also highly correlated with each other. However, for all three seasons, the bleeds per 100 days had very low correlations with the pl~ma-~ortisol levels. An analysis of the bleeds per 100 days showed no significant variation between seasons and a similar result was obtained for the plasma-cortisol. We would therefore not regard the three sets of data as coming from different populations, and so we considered it next as one sample for the same population. We again found a very low correlation between bleeds per 100 days and the plasma-cortisol. We could find no evidence at all to show that the ~I~ma-~ort~oI levels s~~ifi&~~ly affect the bleeds per 100 days. A&no wledgemen ts Thank are due to Lesley Rushton, Assistant Statistician, Wessex Regional Hospital Board, for the statistical analysis of the data and Angela Hall, Research Assistant in Haemophilia, Treloar Haemophilia Centre, for the haematological and coagulation tests. These jnvestigations could not have been carried out without supper-t from the National Fund for Research into Crippling Diseases and the Lord Mayor Treloar Trust. References 1 2 3 4 5 cj
N.D. Giordano and M, Radivoyevitch, Lmcet, i (1970) 249 LE. Bennett and G.I,C, Ingram, Lane&, i f1967) 967 S.G. Rainsford and A, Hall, 3% 3. Haematol., 24 (1973) 539 D. M&tingly, J. Clin. Pathol., 15
Haemostasis and Thmm-
Clinica C~imica Acta, 53 (1974) 351-354 0 Elsevier Scientific Publishing Company, Amsterdam - Printed in The Netherlands
CCA 6413
PLASMA-CORTISOL HAEMOPHILIA
S.G. RAINSFORDa,
LEVELS
AND THE FREQUENCY
OF BLEEDING
IN
DOROTHY RICI-IARDSONb and C. STUART SHAWb
a Lord Mayor Treloar College, Froyle, Alton, Hants and ’ North Hampshire Group Hospitals, Hants (United Kingdom) (Received February 14,1974)
Summary The plasma-cortisol levels in 15 boys suffering from classical haemophilia were followed throughout one academic year, namely three terms. The bleeding frequency and the plasma-cortisol levels showed no seasonal variation. There was no evidence to suggest that the plasma-cortisol levels significantly affected the frequency of haemorrhagic episodes.
Introduction Giordano and Radivoyevitch [l] , after studying the plasma-cortisol levels of 15 boys suffering from haemophilia over a period of one year, suggested that there was some correlation between adreno-cortical activity and bleeding episodes. They found that the plasma-cortisol levels were lowest in late winter and early spring when most of the clinical problems in their cases occurred. Furthermore, in a study by Bennett and Ingram [Z] it was found that in children a dose of 1 mg t.d.s. of prednisolone significantly reduced the number of bleeding episodes. In a study of 40 adolescent boys suffering from classical haemophilia over a period of two academic years, Rainsford and Hall [3] found no significant variation in the frequency of bleeding episodes between one term and another, or from year to year. It has, however, been possible to follow the pl~ma-~ortisol levels of 15 of these boys throughout one academic year (254 days). Methods Blood samples were collected into lithium heparin tubes (Stayne Laboratories, Ltd) at between 09.00 and 09.30 h. The red cells were immediately centrifuged out and the plasma harvested and stored at -20’ until the plasmacortisol could be assayed.
352
Since these boys were treated with transfusions of factor VIII concentrate each time they suffered a bleed, care was taken that no sample of blood was collected for plasma-cortisol assay until at least 1 week had elapsed after any transfusion. The plasma-cortisol was assayed by the method of ~attingly [4] for free ll-hydroxycorticoids. The original method was modified by washing the solvent extract with 0.1 M sodium hydroxide, followed by a water wash. Associated investigations included those defining the patients’ haemophilic status. These were factor VIII assay (two-stage technique of Biggs et al. [ 51) and kaolin-cephalin clotting time (K.C.C.T.) (Denson and Biggs [6]) with the modification that the actual clotting time was measured with a Fibrometer (Becton and Dickinson). The results of these tests are given in Table I, but the K.C.C.T. results are expressed as a ratio, i.e. patient plasma clotting timefnormal plasma clotting time. Clinical severity The data with regard to clinical severity are expressed in terms of the number of bleeding episodes per 100 days. This method makes it possible to allow for the difference in the number of days between each term. All these boys were under close supervision during 254 days of the academic year, while they were in residence at the Lord Mayor Treloar College, and every bleeding episode was recorded. Over the period under review, there were in all 40 boys suffering from classical haemophilia in residence at the college. The annual mean frequency of bleeding for the whole group for the period was 7.25 per boy per 100 days with a mean term range of 7.0-7.5 (see Rainsford and Hall [ 31). Using these data the 15 boys in this investigation can be divided into three categories of clinical severity (see Table I), as follows. Group 1. Those whose mean frequency of bleeding exceeded the mean figure of 7.25 per 100 days. Group 11. Those in whom the frequency of bleeding was less than the mean, but more than half the mean annual rate. Group III. Those in whom the frequency was less than half the mean annual rate. Results The individual results of these ~vestigations are shown in Table I, but because of the very great difference in the frequency of bleeding among the three different groups of clinical severity, an analysis of the figures for each group is shown separately as well as for all three groups combined. First it will be noted that the mean annual cortisol level for each of these groups ranged from only 14.3 to 16.8 pg/lOO ml. The lowest figure recorded for plasmacortisol level was 7.5 pg/lOO ml of plasma and the highest figure 27 E.rg/lOO ml. The normal range for this method is 6-26 ~g/lOO ml at about 09.00 h. It would therefore appear that all the plasma-cortisol levels recorded were within the range of normal. The arithmetic mean found by Mattingly for this method was 14.2 pg/lOO ml for the ‘normal’ patients. The mean plasma-cortisol level for our whole group over the three terms ranged from 15.1 &g/100 ml to 16.1
Factor
Mean
Range
Combined
Total
-
-
9.5-22.6
15.3
18.5 12.4 11.0 24.0 16.5 [email protected]
2.52 2.05 1.55 2.00 -
16 22 25 40 Mean Range
III
1.1-21.3
6.4
2.1 2.1 2.4 1.1 1.9 1.1-2.4
5.4 4.3 4.3 3.5 4.5 5.4 7.G 6.5 5.2 3.5-7.6
7.5-27.0
16.1
14.5 27.0 14.7 15.8 18.0 14.5-27.0
16.2 7.5 11‘9 13.5 18.5 19.8 24.0 19.9 16.4 7.5-24.0
0.0-17.0
5.0
1.4 2.8 0.0 1.4 1.4 0.0-2.8
4.3 5.7 4.3 4.3 4.3 4.3 4.3 7.1 4.3 4.3-7.1
5.7 8.6 17.0 10.4 5.7-17.0
8.8-24.9
15.1
17.1 15.4 12.5 19.2 16.0 12.5-19.2
16.0 10.8 17.4 8.8 13.7 16.2 20.5 13.5 14.6 8.8-20.5
9.7 10.7 24.9 15.1 9.7-24.9
14.2 12.0 21.3 15.8 12.0-21.3
3.5
9.5 11.3 17.8 12.9 9.5-17.8
Plasmacortisol wiz/lOO~)
PlasmaBleeds per cortisol lOOdays @g/l00 ml)
Bleedsper lOOdays
Plasmacortisol Ow100mI)
17.5 17.8 14.9 9.6-17.8
Summerterm (92 days)
Springterm (70 days)
Autumnterm (92 days)
15.3 11.0 13.4 12.1 12.0 12.9 22.6 19.7 14.9 11.0-22.6
2 11 24 27 36 41 43 44 Mean Range
II
2.80 2.44 2.60 -
K.C.C.T. ratio
1.86 1.70 2.68 2.97 2.70 3.10 3.18 2.68 -
VIII%
4 5 10 Mean Range
CaseNo.
I
severity groupno.
(JilliCat
RESULTSOFTESTSCARRIEDOUTON15BOYSSUFFERINGFROMHAEMOPHILIA
TABLE1
1.1-17.6
6.0
6.6 2.2 2.2 0.0 2.7 0.0-6.6
8.8 5.5 5.5 7.7 6.6 3.3 3.3 1.1 5.2 1.1-8.8
9.6-22.3
15.3
16.7 18.2 12.7 19.7 16.8 11.0-27.0
15.8 9.7 14.2 11.4 14.7 16.3 22.3 17.6 16.3 7.5-24.0
0.8-18.6
5.8
3.3 2.7 1.5 0.8 2.0 0.0-6.6
6.2 5.2 4.7 5.1 5.1 4.3 5.1 4.9 4.9 1.1-8.8
10.3 9.8 18.6 12.9 5.7-21.3
PlasmaBleeds per cortisol lOOdays tl.tg/lOOml)
11.0 9.6 13.2 8.8 17.6 20.0 12.5 14.3 8.8-17.6 9.5-24.9
lOOdays
Bleeds per
Annualmean
@g/l00 ml, a difference between the three terms of only 1 pg. Nevertheless, it will be seen that the highest figure, namely 16.1 pg, was during the spring term and this coincided with the lowest figure for haemorrhagic episodes. The fre quency of bleeding each term however, only showed a range of 5.0-6.4 per 100 days. The lowest rate was during the spring term and the highest during the autumn term; the mean annual rate being 5.8 bleeds per 100 days. The mean plasma-cortisol level and mean bleeding frequency were approximately the same for both the autumn and summer terms. Discussion All three groups showed a slightly lower incidence of haemorrhagic episodes during the spring term and this coincided with the highest mean cortisol level for any three terms in groups II and III but not in group I, the most severely affected group in which the lowest plasma-eortisol level recorded was during the spring term. The data were therefore submitted for statistical analysis and the following conclusions were drawn. The bleeds per 100 days in the three different seasons were highly correlated with each C&herand the three sets of plasma-cortisol data were also highly correlated with each other. However, for all three seasons, the bleeds per 100 days had very low correlations with the pl~ma-~ortisol levels. An analysis of the bleeds per 100 days showed no significant variation between seasons and a similar result was obtained for the plasma-cortisol. We would therefore not regard the three sets of data as coming from different populations, and so we considered it next as one sample for the same population. We again found a very low correlation between bleeds per 100 days and the plasma-cortisol. We could find no evidence at all to show that the ~I~ma-~ort~oI levels s~~ifi&~~ly affect the bleeds per 100 days. A&no wledgemen ts Thank are due to Lesley Rushton, Assistant Statistician, Wessex Regional Hospital Board, for the statistical analysis of the data and Angela Hall, Research Assistant in Haemophilia, Treloar Haemophilia Centre, for the haematological and coagulation tests. These jnvestigations could not have been carried out without supper-t from the National Fund for Research into Crippling Diseases and the Lord Mayor Treloar Trust. References 1 2 3 4 5 cj
N.D. Giordano and M, Radivoyevitch, Lmcet, i (1970) 249 LE. Bennett and G.I,C, Ingram, Lane&, i f1967) 967 S.G. Rainsford and A, Hall, 3% 3. Haematol., 24 (1973) 539 D. M&tingly, J. Clin. Pathol., 15
Haemostasis and Thmm-