SPRUCE - EXHIBIT 2003
`Neurocrine Biosciences, Inc. v. Spruce Biosciences, Inc.
`PGR2022-00025
`
`

`

`'°
`response to venouscatheterization. °:
`As part of ongoing research into
`psychological determinants of endocrine
`response, we were interested in how in-
`dividuals differ
`in their
`response to
`venous catheterization. With the use of a
`special nonthrombogenic catheter and
`portable pump,it is now possible to con-
`tinuously collect blood for at
`least 24
`hours in individuals who are free to move
`about and engage in their routine ac-
`tivities. Thus, with the use of
`this
`catheter and pump,it is possible to study
`how individuals may differ in their en-
`docrine
`responses
`to
`a
`variety
`of
`psychological stimuli,
`including work,
`anticipationoftests, interviews, etc,
`In order to determine the possible in-
`fluence of catheterization itself, how long
`such a response maylast, and whetheror
`not
`it
`is present during a second
`catheterization experience, the following
`study was undertaken.
`
`METHODS
`
`Subjects Studied
`Twenty-nine men, aged 18 to 38, were
`studied, Fourteen of these individuals
`were staff and laboratory personnel, and
`15 were student volunteers who were paid
`for their participation. A brief medical
`history was taken to exclude any in-
`dividuals with concurrent
`illness, and
`none of the subjects had any obvious
`signs or symptomsof any chronicillness,
`Eighteen of the 29 subjects had a
`second catheterization experience. The
`18 included all individuals who showed a
`response on the first occasion, plus
`several who failed to have increased
`secretion of either hormone during the
`first catheterization. Nine subjects had
`their first and second catheterization ex-
`perience in the morning, and five sub-
`jects had both catheterizations in the af-
`
`March, 1975
`
`ROSE and HURST
`
`ternoon; while four subjects had an
`initial catheterization in the afternoon,
`but had the repeat catheterization in the
`morning. After catheterization, all sub-
`jects
`remained near
`the
`laboratory,
`usually sitting and reading or walking
`short distances on thefloor.
`
`Procedure
`
`The skin was wiped with iodine,
`followed by alcohol, and a catheter was
`implaced in the antecubital vein. About
`half of the subjects had an intravenous
`catheter implaced with a stylus that was
`removedfor collection of blood. The other
`subjects had a special nonthrombogenic
`catheter implaced, which was attached
`to the Sigmamotor pump, with continu-
`ous’ collection of blood.
`'':
`|? © Five
`milliliter samples were collected every
`20 minutes, either by removal of blood
`at the 20-minute time or continuously for
`20 minutes to permit determination of
`the integrated concentration. All sub-
`jects were studied for a minimum of an
`hour and 20 minutes. Approximately one
`half of
`the individuals had samples
`drawn for a longer period of time, ie.,
`threeto five hours.
`The 15 student volunteers also filled
`out two questionnaires designed to assess
`whether reported psychological responses
`paralleled the endocrine response to
`catheterization. They were given the 20-
`item short form of the Taylor Manifest
`Anxiety Scale prior
`to the first
`catheterization experience. They were
`also given a seven-item questionnaire to
`fill out after their first catheterization ex-
`perience, We chose to administer this
`questionnaire after the first catheteriza-
`tion experience because essentially it
`queried the subjects on a numberofatti-
`tudes and possible responses to with-
`drawal of blood, such as fainting and
`lightheadedness, and we did not wish to
`“instruct” them as to possible symptoms
`
`Journal of Human Stress
`
`23
`
`

`

`ENDOCRINE RESPONSES TO CATHETERIZATION
`
`prior to the actual catheterization ex-
`perience.
`
`Endocrine Assays
`Both cortisol and growth hormone
`were determined by radioimmunoassay.
`Cortisol was stripped from the cor-
`ticosteroid-binding globulin (CBG) by
`adding 40 microliters of plasma to a
`methanol-borate buffer and heating for
`30 minutes at 60° centigrade.
`'* Fifty
`microliters of this mixture were then
`removed and transferred to assay tubes
`for binding. No further chromatography
`or separation of cortisol was performed,
`as
`the
`antibody
`provides
`adequate
`specificity, 'S A 1:2500 dilution of the an-
`tibody (made to cortisol hemisuccinate-
`BSA conjugate) was added to the tubes
`and incubated for three hours at room
`temperature, Separation of bound and
`free cortisol] from the antibody was ac-
`complished by adding 250 microliters of
`saturated ammonium sulphate solution
`and centrifuging at 3,000 rpm for 10
`minutes. A 400 microliter aliquot was
`remoyed from each tubetoa scintillation
`vial, 10 milliliter scintillation solution
`added, and counted to 2 percentstatis-
`tics. The standard curve is made up in
`triplicate with values corresponding from
`one to 50 nanograms per 100 milliliters
`with a sensitivity equivalent to detecting
`one nanogram per 100 milliliters,
`Nonspecific binding for standard tubes
`ranged from 4 to 6 percent and for the
`samples 9 to 12 percent. The nonspecific
`binding value was used to correct
`the
`counts in calculating the sample values
`from the standard curve.
`All samples were run in duplicate. The
`intra-assay variability was calculated by
`determining the coefficient of variation
`for 100 duplicate values.¢ This coeffi-
`cient of variation for duplicates for 100
`
`samples equaled 1.02 percent. Interassay
`variability was determined by running
`three pools of control values over many
`months. The
`average
`coefficient of
`variation for these three different pools,
`calculated
`over
`30
`separate
`deter-
`minations, equaled 6.7 percent.
`Human growth hormone was deter-
`mined
`by double-antibody
`radioim-
`munoassay. Samples were determined in
`duplicate,
`using
`200 microliters
`of
`plasma in each determination. Purified
`growth hormone standard was provided
`by Dr. A. E. Wilhelmi from the National
`Pituitary Agency in the National Insti-
`tute of Arthritis and Metabolic Diseases
`(NIAMD) [Lot #1652C]. The '*5 I
`iodi-
`nated growth hormone was purchased
`from Abbott and antisera that was used
`was produced in rabbits and usedatfinal
`dilution of 1:600,000(v:v).
`The assay was carried out at room tem-
`perature for 24 hours, with each tube
`containing 200 microliters of the sample
`plasma, 10,000-14,000 DPM of '?* I
`-
`HGH, 50 microliters of growth hormone
`antibody, diluted with normal rabbit sera
`—- human serum albumin — PBS buffer.
`Separation of bound from free HGH was
`accomplished by addition of a 1:20 dilu-
`tion of goat anti-rabbit gamma globulin
`and incubation for 20 hours at room
`temperature. At this concentration,
`the
`percent binding equaled 58.5 + 2.7 per-
`cent (n = 30).
`;
`Standards were made up in triplicate,
`with eight values ranging from 0 to 32
`
`cv. =
`
`E g x 100 }
`
`\
`
`2n
`
`=oe ;ouol
`
`= difference between duplicates
`average of duplicates
`= numberofduplicate pairs
`
`24
`
`Journal of HumanStress
`
`March, 1975
`
`

`

`blank
`in
`per milliliter
`nanograms
`plasma, which was assayed to contain
`<0.25 nanograms permilliliter.
`Sensitivity of the assay varied between
`0.25 and 0.5 nanograms per milliliter,
`and the contribution from nonspecific
`binding averaged between 3 and 5 per-
`cent
`and was corrected for
`in
`all
`calculations.
`The intra-assay variation of 100 sam-
`ples in duplicate yielded a coefficient of
`variation of 1,54 percent. The interassay
`variation reflecting three controls added
`to each run yielded an average coefficient
`of variation of 10.7 percent for 30 dif-
`ferent runs.
`
`RESULTS
`
`Cortisol
`
`Since all catheterizations were not
`started at exactly the same time, we
`grouped both the cortisol and growth
`hormoneresults in terms of absolute time
`
`ROSE and HURST
`
`(i.e., all values collected from 0900 to
`0920, etc.) and compared these values
`with those obtained by grouping in terms
`of sample sequence number(i.e., first,
`second, third). At this stage of analysis,
`morning and afternoon values were not
`combined and were analyzed separately.
`No significant differences were ob-
`served between absolute time groups and
`the sequenced groupsfor either hormone
`in the morningor afternoon, This finding
`allowed us to compare data in terms of
`the sequence of samples. Lack of any dif-
`ference between time and sequence
`grouping relates to the fact that both in
`the morning and afternoon, start of
`catheterization did not differ from one
`subject to another by more than one or
`two hours
`of absolute
`clock
`time.
`Therefore, all results that are reported,
`unless stated otherwise, are based on
`sample sequence.
`Figure I presents the plasma cortisol
`
`1ST CATHETERIZATION EXPERIENCE
`
`
`
`Cortisol»g/100mi.
`
`24
`
`dB AM. {n=12)
`
`A PM. (n=17)}
`
`Sample
`
`Fig. 1.
`
`Plasma cortisol response of all subjects during the first venous catheterization. Twelve subjects
`were studied in the morning, and 17 subjects were studied in the afternoon.
`
`March, 1975
`
`Journal of Human Stress
`
`25
`
`

`

`ENDOCRINE RESPONSES TO CATHETERIZATION
`
`responses for the first catheterization ex-
`perience of morning and afternoon sam-
`ples. Twelve
`subjects
`underwent
`catheterization in the morning and 17 in
`the afternoon. There was no significant
`difference between these values. This
`suggested that
`the first catheterization
`experience tended to obliterate the nor-
`mal diurnal decrease in cortisol values
`observed in the afternoon.
`
`In an attempt to clarify the relation-
`ships between the various independent
`variables, a three-way analysis of variance
`for repeated measures was performed.
`The first four values were used (0, 20,
`40 and 60 minutes), as all subjects had this
`number of samples drawn. This analysis
`is given in Table 1. The table shows that
`there was a significant drop in cortisol
`from the first to the second venipuncture
`experience (F = 4.781, p<.05). One of
`the major sources of variance was the
`consistent decrease over time, whether the
`samples were drawn in the morning or
`afternoon. This is shown as ‘‘sample se-
`quence’
`in
`the table,
`F = 7.641,
`p< .001. This is consistent with the ex-
`pected decrease during the day due to
`general diurnal effects,
`To summarize, the results indicated a
`general
`response to catheterization in
`plasma cortisol
`levels
`that decreased
`during a second experience, a decrease in
`response over time within an experience
`that was consistent with diurnal rhythm,
`and a small difference between having
`the catheterization experience in the
`morning or afternoon. There was no in-
`teraction between these maineffects.
`
`Figure 2 presents the cortisol values for
`the morning and afternoon samples
`during the second catheterization ex-
`perience. During the second catheteriza-
`tion experience, the afternoon values are
`significantly lower
`than the morning
`cortisol values, and the expected diurnal
`difference becomes readily apparent. A
`two-way analysis of variance showed that
`the AM-PM diurnal difference for the
`second catheterization was highly signifi-
`cant over 12 sequential samples, F =
`9.766, p< .007. Cortisol showed a sig-
`nificant drop over time from sample to
`sample,
`in both groups (F = 1.877, p
`<.046).
`Figure 3 graphs the first and second
`catheterization experience, holding time
`of day constant. It is apparent from this
`that
`there was a significant difference
`Growth Hormone
`
`in the_firstthe samples during
`
`
`
`catheterization experience, as compared
`The growth hormone responses
`to
`to the second. However,
`it also was ap-
`catheterization were much more variable
`parent
`that by the second hour,
`the
`than those observed for cortisol. The
`values approached one another and then
`HGH valuesfor all 29 individuals for the
`the first catheterization experience values
`first hour (at 0, 20, 40 and 60 minutes)
`were no longer significantly higher than
`during thefirst catheterization are shown
`those of the second.
`in Figure 4.
`It
`is apparent
`that
`the
`distribution of values was logarithmic. In
`addition, over 50 percent of all values
`were =
`|
`nanogram per milliliter.
`(Although the sensitivity of the method
`was < 0.5 nanogram per milliliter, all
`values of | nanogram per milliliter or less
`were combined for graphic display.) Only
`25 percent of all values exceeded 5
`
`Only five individuals were studied
`when the first and the second cathe-
`terizations occurred,
`in the afternoon.
`Althoughthe values in the second experi-
`ence tended to be lower than those in
`the first, there was too muchvariability
`between subjects to yield any significant
`difference.
`
`26
`
`Journal of Human Stress
`
`March, 1975
`
`

`

`2ND CATHETERIZATION EXPERIENCE
`
`ROSE and HURST
`
`aA
`
`O AM n=I13
`@ PM n-5
`
`20
`
`16
`
`
`
`Cortisolug/100ml. :PePytoeah eeoggttt44
`
`
`
`Fig.2. Plasmacortisol responses ofall individuals who had a second catheterization. Thirteen individuals
`had their second catheterization in the morning, while five had their second catheterization in the
`afternoon.
`
`Sample
`
`A.M.
`
`24
`
`n=9
`0 1ST Catheterization
`@ 2ND Catheterization n=?
`
`20
`
`16
`
`
`
`Cortisolpg/100ml.
`
` 0
`Sample # 1
`2
`3
`4
`5
`6
`7
`#68
`9
`10
`«6
`O12
`Minutes 9
`20
`40
`60
`80
`100
`120
`140
`160
`180
`200
`220
`
`Fig. 3. Plasma cortisol responses in the morning only, contrasting first and second catheterization. In-
`dividuals are their owncontrols in this figure. Note the significantly increased levels during thefirst
`hour ofcatheterization on the first experience.
`
`March, 1975
`
`Journal of Human Stress
`
`27
`
`

`

`ENDOCRINE RESPONSES TO CATHETERIZATION
`
`found in
`significant differences were
`nanograms per milliliter, but once over
`this amount, there was great variability,
`HGH for AM vs. PM levels orfor first vs.
`with one individual showing a very large
`second
`catheterization. However,
`the
`response, peaking at 68,4 nanograms per
`great variability of the HGH levels may
`have obscured a real drop in HGH
`milliliter during his first catheterization.
`response during the second catheteriza-
`An examination of
`the
`responses
`tion experience. The results given in
`during the first hour suggested that the
`HGHresponse might be more ofan all-
`Table 2 tended to support this sugges-
`tion. For the nine subjects who had both
`or-none mode of response compared to
`that observed for cortisol. That is, most
`their first and second catheterizations in
`of the time there appeared to belittle
`the AM, there were five who had one or
`more values during the first hour that
`HGH release, but if it was released, the
`were 25 nanogramsper milliliter during
`response was morelikely to reach a very
`high level. These changes also occurred
`this first experience. Only one of these
`quite rapidly, and among those
`in-
`saine nine individuals had a response
`dividuals who showed values in excess of
`during the second catheterization experi-
`5 nanograms per milliliter,
`there were
`ence. However, there was no significant
`large fluctuations from one 20-minute
`difference by t-test, either using the raw
`period to another.
`data or a log transformation of the data.
`values were
`When
`individual’s
`Howeyer, the trend for HGH to dropin
`averaged and examined in the way the
`the second catheterization experience
`
`cortisol no_wasclearly evident.results were studied,
`
`
`
`3-WAY ANOVAWITH 2 REPEATED MEASURES
`
`Table 1
`
`31.197
`
`SOURCE
`
`AM vs. PM
`Unit
`
`Ist vs, 2nd venipuncture
`AM/PM X Ist/2nd venipuncture
`Ist/2nd veni. x unit
`
`Sample sequence
`AM/PM X sample sequence
`Sample sequence X unit
`
`Ist/2nd veni. X sample seq.
`AM/PM X 1st/2nd veni. X sample seq.
`Ist/2nd veni. X sample seq. X unit
`
`TOTAL
`
`SUM OF
`SQUARES
`
`357.850
`1604.717
`
`282.926
`3.982
`710.147
`
`110.802
`10.173
`174.011
`
`16.256
`23.622
`168.395
`
`3462.880
`
`MEAN
`SQUARE
`
`357.850
`133.726
`
`282.926
`3.982
`59.179
`
`36.934
`3.331
`4.834
`
`5.419
`7.874
`4.678
`
`F-TEST SIGNIFICANCE
`
`2.676
`
`0.128
`
`4.781t
`0.067
`
`0.050
`over 0.500
`
`7.641**
`0,702
`
`under 0.001
`over 0.500
`
`1,158
`1.683
`
`0,340
`0.188
`
`28
`
`Journal of HumanStress
`
`March, 1975
`
`

`

`ROSE and HURST
`
`Table 2
`
`HGH RESPONSE(ng./ml.)
`
`FIRST CATHETERIZATION
`
`SAMPLE
`PERIOD
`
`1
`
`APPROXIMATE 0900
`TIME
`
`SUBJECT NO.
`
`2.41
`
`SECOND CATHETERIZATION
`
`SUBJECT NO.
`
`04
`
`09
`
`120612
`
`242
`05
`
`05
`
`05
`
`655
`313
`
`13
`
`02
`
`160616
`
`30
`
`21
`
`#17
`
`20
`
`O09
`
`#370
`
`26
`OF
`
`O05
`
`02
`
`#15
`
`#13
`
`30
`
`-— 0
`
`#1)
`
`==
`OS
`
`14
`
`O04
`
`#18
`
`«623
`
`43
`
`1.2
`
`ha
`O85
`
`7.2
`
`O03
`
`«15
`
`«80
`
`107
`
`3.78
`
`#174
`
`1.28
`
`1.69
`
`3.52
`
`i
`
`.
`
`‘
`i
`
`f
`
`s
`
`;
`
`\
`
`F
`
`‘
`
`;
`:
`
`:
`
`i
`
`‘
`
`.
`
`d
`
`:
`F
`
`z
`
`:
`
`‘
`
`:
`
`--
`
`12
`
`03
`05
`
`Os
`
`06
`
`16
`
`--
`
`#10
`
`O05
`05
`
`ht
`
`O02
`
`2.0
`
`Og
`
`1.0
`
`O05
`--
`
`WI
`
`O06
`
`24
`
`1901.8)
`
`(10.4
`
`0.94
`
`1.27
`
`March, 1975
`
`Journal of Human Stress
`
`29
`
`

`

`ENDOCRINE RESPONSES TO CATHETERIZATION
`
`ConcomitantCortisol
`and HGH Response
`
`Individuals who had one or more cor-
`tisol values >16.0 micrograms per 100
`milliliters during the first hour were
`defined as responders. This value was
`selected as a relative cutoffpoint in terms
`of the distribution of all cortisol values
`during the first vs. second experience.
`Duringthefirst experience, 35 percent of
`all cortisol values were > 16.0 micrograms
`per
`100 milliliters, while during the
`second catheterization, only 7.4 percent
`of all values were = 16.0 micrograms per
`100 milliliters. A similar shift
`in the
`cumulative distribution of HGH values
`from first to second experience was ob-
`served. During the first catheterization
`experience, 27,5 percent of all values
`were >S nanograms per milliliter, com-
`pared to 11.9 percent of all values 25
`nanogramsper milliliter during the first
`hour of the second catheterization ex-
`perience. These observations provide fur-
`ther evidence for the interpretation that
`HGHresponses tended to drop during
`the second catheterization,
`Using this classification of response,
`we examined the relationship between
`cortisol and growth hormone response.
`The relationship between cortisol and
`growth hormone during the first
`catheterization experience is shown in
`Table 3. This chi-square contingency
`table combines the first experience for
`both AM and PM subjects, which ts
`justified by the observation that
`there
`was no significant difference between
`these groups for either cortisol or growth
`hormoneduringthe first catheterization.
`It is apparent that there was a significant
`relationship between growth hormone
`and cortisol responses. Individuals who
`tended to have a response in one hor-
`mone had a response in the other; and
`those who failed to respond in one
`
`generally tended to have lower levels in
`the other. HGH responses tended to drop
`during the second catheterization.
`To further illustrate this relationship,
`Figures 6 and 7 present the cortisol and
`growth hormone responses of two indi-
`viduals during their first and second
`catheterization experiences.
`
`Psychological Data
`The 15 student volunteers were given
`two paper and pencil tests. The first test
`was a short form of the Taylor Manifest
`Anxiety Scale. It was given before the
`catheterization and contained 20 items,
`such as “] work under a good dealof ten-
`sion,”’ or “I feel anxiety about something
`or someone almostall the time,"’ or “‘I
`frequently find myself worrying about
`something.”” Scores on this test did not
`relate to either cortisol or growth hor-
`mone responses, as
`tested either by
`correlational statistics or by chi-square
`analysis. As the Taylor Manifest Anxiety
`Scale was essentially designed to test
`psychological trait, and not state,
`it
`is
`perhaps not surprising that this did not
`predict
`the
`endocrine
`response
`to
`catheterization.
`The students also were asked to fill out
`a simple seven-item questionnaire after
`their
`first catheterization experience.
`This
`questionnaire
`asked more
`specifically about
`their
`reactions
`to
`venipuncture. One question assessed how
`frightened a subject was by the sight of a
`needle or
`by
`having blood drawn.
`Another question inquired how much
`pain was associated with a shot of
`penicillin or other drug. These questions
`were not telated to endocrine response.
`However, they also were asked to check
`any of the following symptomsthat they
`had experienced during or after having
`bleod
`drawn:
`fainting,
`nausea,
`lightheadedness, dry mouth, urge to
`
`30
`
`Journal of HumanStress
`
`March, 1975
`
`

`

`ROSE and HURST
`
`Table3
`
`HIGH RESPONSE
`
`YES
`
`NO
`
`any value in first hr.
`25 ng./ml,
`
`all values in first hr.
`
`<5ng./ml.
`
`CORTISOL RESPONSE
`
`YES
`
`any value
`in first hour
`>16ug%
`
`NO
`
`all values
`in first hour
`< 16 ug%
`
`Fisher's Exact Test
`
`move bowels, increased sweating, or cold
`hands or feet. There was a significant
`correlation between the numberof symp-
`toms checked andthe individual’s mean
`cortisol during the first hour of the first
`catheterization experience (r = .53, n=
`15, p<05). Figure 5 shows the higher
`cortisol
`levels for the individuals who
`checked more symptoms,A similar result
`was
`found for growth hormone re-
`sponses. Individuals who checked 0 items
`had significantly lower values than those
`who checked one or more symptoms (on
`log transform data,
`t = 3.14, df = 13,
`p <.01).
`This questionnaire was given after the
`first catheterization,
`in an attempt
`to
`avoid biasing the individuals’ responses
`by “‘suggesting’’ symptoms or distress
`during the catheterization experience.It
`was possible that
`the subjects merely
`reported what
`they had experienced
`during the preceding few hours. If this
`was so, it suggests that the reporting of
`
`distress may be a good reflection of en-
`docrine response to catheterization.
`In
`contrast, this has not been the case in
`other
`studies where simple measures
`assessing symptomatic distress did not
`predict endocrine response.'*
`
`DISCUSSION
`
`There were significant differences in
`our
`subjects’
`endocrine response
`to
`venous catheterization. Twelve out of 29
`men (41 percent) studied had a cortisol
`response with values 216.0 micrograms
`per 100 milliliters during the first hour
`following catheterization. Similarly, 13
`out of 29 (45 percent) had a S nanogram
`per milliliter or higher level of growth
`hormone duringthis first hour. Eight of
`the 12 men hadelevations in both growth
`hormone
`and
`cortisol. However,
`in
`examining the mean cortisol response of
`the group in the second hour, the plasma
`levels fell and were no longersignificantly
`elevated in comparison to those observed
`
`March, 1975
`
`Journal of Human Stress
`
`31
`
`

`

`ENDOCRINE RESPONSES TO CATHETERIZATION
`
`
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`
`32
`
`Journal of HumanStress
`
`March, 1975
`
`
`
`

`

`during the second catheterization ex-
`perience, Also, there were only two in-
`dividuals who had cortisol
`levels 2 16
`micrograms per 100 milliliters during the
`second catheterization experience.
`It is of note that no differences were
`observed between morning and afternoon
`cortisol
`samples during the first
`catheterization experience. Afternoon
`cortisol
`levels were observed
`to be
`significantly lower than morning samples
`only during the second catheterization
`experience. One may conclude that the
`response to the initial catheterization
`eliminated the lower average level of cor-
`tisol in the afternoon. This is consistent
`with the findings of Weitzman et al'’
`and de Lacerda et al,'* who reported
`that although thereis a clear diurnalfall
`present in the afternoon, cortisol may be
`secreted in episodic bursts throughout
`the day or night.
`to
`responses
`Growth
`hormone
`catheterization seemed to be much more
`complex, As noted,
`there was great
`variability in growth hormone levels
`during the first hour of catheterization.
`The lowest cortisol value observed, out of
`approximately 116 samples collected on
`all subjects during the first hour, was 6.1
`micrograms per 100 milliliters; and the
`highest was 30.5 micrograms per 100
`milliliters, By comparison,
`the lowest
`growth hormone observed was <0.5
`nanogramsper milliliter; and the highest
`was 68.5 nanograms per milliliter. Com-
`pared to cortisol, growth hormone values
`were obsetved to fluctuate much more
`rapidly and to show a greater amplitude
`of change. These observations, combined
`with the more logarithmic distribution of
`growth hormone values, suggest that the
`response of this hormoneto catheteriza-
`tion may be more of an “‘all or none”’ re-
`lease than the response of cortisol, with
`very large episodic bursts.
`
`ROSE and HURST
`
`Growth hormone response tended to
`parallel cortisol
`response to first
`catheterization experience. However,
`although there was a clear tendency for
`growth hormonelevels to drop during the
`second catheterization, the drop was not
`of statistical significance. The result was
`related in part to the large degree of
`variability between and within subjects.
`Wewere interested in whether or not
`individuals who described themselves as
`more anxious — or, more specifically, as
`more fearful or distressed about veni-
`puncture — would have higher endo-
`crine responses to catheterization. The
`reporting of anxiety, as measured by the
`short form of the Taylor Manifest Anxiety
`Scale, did not correlate with either
`growth hormone or cortisol
`response.
`However,
`those individuals who stated
`they had more symptomsassociated with
`venipuncture
`did
`show significantly
`higher levels of both cortisol and growth
`hormone. Even though these questions
`were asked of the subjects after theirfirst
`catheterization experience, we did find
`that those wholisted an increased num-
`ber of symptoms as occurring during
`their just completed catheterization ex-
`perience did tend to have a greater en-
`docrine response.
`It is now possible to collect blood con-
`tinuously from individuals who
`are
`engaged in their daily routine activities.
`Therefore, we are in a much better
`position to study how individuals differ in
`their endocrine responses to a variety of
`real life situations, and thus to answer a
`number of important psychoendocrine
`questions.
`From the data presented in this study,
`it appeared that the levels of cortisol or
`growth hormone during thefirst 60 to 80
`minutes following initial catheterization
`may be elevated due to the response to
`catheterization itself, However, following
`
`March, 1975
`
`Journal of Human Stress
`
`33
`
`

`

`ENDOCRINE RESPONSES TO CATHETERIZATION
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`34
`
`Journal of HumanStress
`
`March, 1975
`
`

`

`ROSE and HURST
`
`
`
`
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`
`March, 1975
`
`Journal of Human Stress
`
`35
`
`
`

`

`ENDOCRINE RESPONSES TO CATHETERIZATION
`
`levels tended to fall.
`this initial period,
`Thelevels in the second hour did notdif-
`
`second
`and
`first
`the
`between
`fer
`experience. Thus,
`in
`catheterization
`future studies, one should be cautious
`about drawing conclusions about stimuli
`other than the catheterization experience
`itself influencing cortisol or growth hor-
`mone responses during thefirst 60 to 80
`minutes following start of catheterization.
`
`ft,
`
`Monkey,” Endocrinology. Vol. 88, April, 1971,
`p. 956,
`Brown, G.M., D.S. Schalch, and S. Reichlin.
`‘Hypothalamic Mediation of Growth Hormone
`and Adrenal Stress Response in the Squirrel
`Monkey,” Endocrinology, Vol. 89, September,
`1971, p. 694.
`. Mason, J.W., F.E. Wherry, L.L. Pennington.
`“Plasma Growth Hormone Response to Cap-
`ture and Venipuncture in Caged Monkeys,”
`Proc. Soc. Exper. Biol. Med., Vol. 147, 1974,
`p. 85,
`
`INDEX TERMS
`
`cortisol, growth hormone, catheterization, veni-
`puncture.
`
`The authors would like to acknowledge the expert
`technical help of David Sandwisch and Linda
`Livingston in the supervision and performing of the
`endocrine assays and the calm and courteous, ex-
`pert assistance of Arthur LaFleur, Richard Brown
`and Robert Reiss, in performing the venous cathe-
`terizations utilized during the described investiga-
`tion.
`
`Requests for reprints should be directed to Dr,
`Robert M. Rose, Department of Psychosomatic
`Medicine, Boston University School of Medicine,
`720 Harrison Avenue, Boston, Massachusetts
`02118.
`
`REFERENCES
`
`|, Greenwood, F.C., and J. Landon. “Growth
`Hormone Secretion in Response to Stress in
`Man,” Nature, Vol. 210, April, 1966, p. 540.
`2, Meyer, V., and E. Knobil. “Growth Hormone
`Secretion
`in
`the Unanesthetized Rhesus
`Monkey in Response to Noxious Stimuli,’ En-
`docrinology, Vol. 80, January, 1967, p. 163.
`3. Mason, J.W. “A Review of Psychoendocrine
`Research on the Pituitary-Adrenal-Cortical
`System,” Psychosom. Med., Vol. 30, 1968, p.
`576.
`
`4, Yalow, R.S., N. Varsano-Aharon, E. Echemen-
`dia, and S.A. Berson. “HGH and ACTH
`Secretory Responses
`to Stress,” J. Horm.
`Merab. Res.. Vol, 1, 1969, p. 3.
`5. Brown, G.M., D.S. Schalch, and §. Reichlin.
`“Patterns of Growth Hormone and Cortisol Re-
`sponses to Psychological Stress in the Squirrel
`
`. Greene, W.A., G. Conron, D.S. Schalch, B.F.
`Schreiner. “Psychologic Correlates of Growth
`Hormone and Adrenal Secretory Responses of
`Patients Undergoing Cardiac Catheteriza-
`tion,’ Psychosom, Med,, Vol. 32, November-
`December, 1970, p. 599.
`. Mason, J.W., L.H. Hartley, T.A. Kotchen, E.H.
`Mougey, P.T. Ricketts, L.G. Jones. “Plasma
`Cortisol and Norepinephrine Responses in An-
`ticipation of Muscular Exercise,’ Psychosom.
`Med.. Vol. 35, September-October, 1973, p.
`406.
`
`. Mason, LW. Emotions — Their Parameters
`and Measurement, *‘Emotion as Reflected in
`Patterns of Endocrine Integration,” p. 143.
`Raven Press, New York. 1975.
`. Kowarski, A., R.G. Thompson, C.J. Migeon,
`and R.M. Blizzard,
`‘Determination of In-
`tegrated Plasma Concentrations and True
`Secretion Rates of Human Growth Hormone,”
`J, Clin, Endocr., Vol. 32, March, 1971, p. 356.
`. de Lacerda, L., A. Kowarski, and C.J. Migeon.,
`“Integrated Concentration and Diurnal
`Variation of Plasma Cortisol," J. Clin. En-
`docrinol. Metab., Vol. 36, 1973, p. 227.
`. Sigmamotor Blood Withdrawal Pump, Model
`#ML 6-3, available from Sigmamotor, Inc., 40
`Elizabeth Street, Middleport, N.Y., 14105.
`. Daughaday, W.H., R.E. Adler, 1.K. Mariz, and
`D.C. Rasinski. “Measurement of the Binding
`Capacity of Corticosteroid-Binding Globulin in
`Human Plasma," J. Clin. Endocr., Vol, 22,
`July, 1962, p. 704.
`. Ruder, H.J., R.L. Guy, and M.B. Lipsett. “A
`Radioimmunoassay for Cortisol in Plasma and
`Urine,” J. Clin, Endocrinol, Metab., Vol. 35,
`1972, p. 219,
`. Rase,
`R.M., R.O, Poe, and J.W. Mason.
`“Psychological State and Body Size as Deter-
`minants of 17-OHCS Excretion,” Arch, Ini,
`Med., Vol. 121, 1968, p. 406.
`. Weitzman, E.D., D. Fukushima, C_ Nogeire, H.
`Roffwarg, T.F. Gallagher, and L. Hellman.
`"Twenty-four Hour Pattern of the Episodic
`Secretion of Cortisol in Normal Subjects,” J,
`Clin, Endocr.. Vol. 33, July, 1971, p. 14.
`
`36 ©Journal of HumanStress
`
`March, 1975
`
`