Measuring Salivary Cortisol to Assess the Effect of Natural Environments on Stress Level in Acute Patients With Severe Brain Injuries: An Exploratory Study

BACKGROUND

Salivary cortisol is a safe and non-invasive measure of hypothalamic-pituitary-adrenal axis function and is used as a biomarker of the human stress response. Natural environments are recognized to contribute to help reduce the effect of stress.

OBJECTIVE

To determine the feasibility of a salivary cortisol collection protocol for acute severely brain-injured patients, and to explore the influence of exposure to natural settings on salivary cortisol concentration as an index of stress level.

METHODS

An exploratory study on 17 acute patients with severe brain injury was performed. We collected salivary samples in a closed hospital ward and a therapeutic garden at the start of the session and after 30 minutes of rest time. Physiological parameters, level of communication, and subjective well-being were also assessed.

RESULTS

The primary objectives regarding the feasibility of the protocol were met overall. We found no significant differences in cortisol values when including the whole population. However, cortisol values were significantly higher in the indoor environment in patients with communication attempts.

CONCLUSIONS

A salivary collection protocol with brain-injured patients in the acute phase is feasible and safe, and this type of measurement could pave the way for future research supporting the benefits of nature as an additional resource in their neurorehabilitation.

Salivary cortisol as a biomarker of stress in surgical patients

Background

Surgical stress and pain result in activation of hypothalamus-pituitary-adrenal axis. The aim of this study was to establish the effects of postoperative pain and various modalities of analgesic administration on salivary and serum cortisol levels, as well as to establish the validity of salivary cortisol as a stress indicator in surgical patients.

Methods

A randomized controlled trial involved 60 patients scheduled for elective abdominal aortic aneurysm surgery. Patients were randomly divided into two groups depending on the model of postoperative analgesia. The first group (MI - morphine intermittently) included patients given morphine doses 0.1 mg/kg/6h s.c. intermittently. The second group (MPCA - morphine patient-controlled analgesia) included patients who received morphine via the PCA system - intravenous administration of morphine adjusted to a dose of 1 mg per shot and a lockout interval of 6 minutes.

Evaluation of Stress Response in Middle-Aged Male Diabetic Hypertensive Patients

CONTEXT

Stress triggers a cascade of reactions that alter the organism's dynamic steady state. There is a scarcity of interventional studies that show cortisol variability upon stress over time in groups of patients with chronic noncommunicable diseases and comorbidities.

OBJECTIVE

We aimed to examine salivary cortisol changes in the cognitive stress response of patients with hypertension and diabetes mellitus (HT&DM) and patients with hypertension (HT) and to determine differences between them.

METHODS

The study was conducted using a stress test of solving an arithmetic task in 62 patients with HT&DM and HT who were being treated in the outpatient clinic of the Medical Pharmacology and Clinical Pharmacology Department in Istanbul University, Istanbul Medical Faculty Hospital.

RESULTS

There was no statistically significant difference between the HT&DM and HT groups for systolic blood pressure (SBP) and diastolic blood pressure (DBP) values (P = .331 and P = .058). When measured by repeated ANOVA, salivary cortisol level [F (1.842, 60) = 8.771, P < .0001], SBP [F (2.185, 60) = 12.080, P < .0001], DBP [F (2.793, 60) = 6.043, P = .001], and heart rate [F (2.073, 60) = 13.259, P < .0001] were statistically significant for the main effect (time), while the effect of the group × time interaction factor was statistically not significant (P = .773; P = .751; P = .713 and P = .506, respectively).

CONCLUSION

The arithmetic problem-solving task used with the HT&DM and HT patients was useful as an acute stress test in the laboratory environment. There was no statistically significant difference for group × time interaction factor between the HT&DM and HT groups; however, the salivary cortisol and BP values increased significantly after acute stress within each group.

How Valid Are Cortisol and Galvanic Skin Responses in Measuring Student Stress During Training? Comment on the Psychological Effects of Simulation Training

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Authors' Response to the Validity of Cortisol and Galvanic Skin Responses for Measuring Student Stress During Training

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Salivary testosterone and cortisol levels in borderline personality disorder before and after a 12-week group dialectical behavior therapy intervention

Background

Borderline Personality Disorder (BPD) is a chronic, debilitating, and difficult to treat condition. BPD has recently been linked to steroid hormone dysregulation and medical conditions characterized by disturbed androgen metabolism. This study aimed to investigate cortisol and testosterone levels in BPD, and changes in hormones following psychological treatment.

Methods

Participants with BPD (n = 33) completed a 12-week Dialectical Behavior Therapy group program. Pre and post salivary testosterone and cortisol were analyzed. Baseline hormones in the BPD group were compared to age-and-sex matched controls (n = 33). Non-parametric tests were utilized to investigate group differences, pre-post treatment hormone and symptom changes, and associations between symptoms and hormone levels.

Results

Participants with BPD had significantly higher testosterone levels than controls. Mean testosterone levels in females with BPD were double that of female controls. Testosterone and cortisol levels were related, and some BPD symptoms were associated with with hormone levels. BPD symptoms reduced significantly with treatment, however pre to post hormone levels did not change.

Conclusions

This study supports an association between BPD symptoms and neuroendocrine dysfunction at baseline, however we found no reduction in hormone dysfunction post treatment. Further research into relationships between stress signaling and neuroendocrine disturbances in BPD may inform aetiological and treatment models.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12618000477224. Registered on 3 April 2018.

Changes in Salivary Oxytocin Level of Term Pregnant Women after Aromatherapy Footbath for Spontaneous Labor Onset: A Non-Randomized Experimental Study

BACKGROUND

Aromatherapy is usually used to stimulate labor. However, its specific physiological effects have been scarcely examined. We evaluated whether an aromatherapy footbath increases oxytocin levels in term pregnant women.

METHODS

In this quasi-experimental study, low-risk term pregnant women in Japan underwent aromatherapy using a footbath (1) infused with clary sage and lavender essential oils, (2) infused with jasmine oil, or (3) with no infused oils (control group). The primary outcome was the salivary oxytocin level. The secondary outcomes were uterine contractions and cortisol levels.

RESULTS

In the clary sage and lavender group (n = 28), the oxytocin level increased significantly after the footbath (p = 0.035). The jasmine group (n = 27) and control group (n = 27) exhibited trends toward a respective increase and decrease in the oxytocin level; however, the changes in the oxytocin levels between the clary sage and lavender group and the control group showed no significance difference. There were no significant differences in the changes in the uterine contractions and cortisol levels between the experiment and control groups.

CONCLUSIONS

The changes in the oxytocin levels in the clary sage and lavender group did not differ significantly with those in the control group, possibly because of the small sample size. Further studies are required to examine the effects of repeated aromatherapy footbaths to stimulate labor.

The Influence of Urban Gardening Activities on Participants' Perceived Restorativeness, Resilience, Sense of Community and Stress

This study aimed to investigate the influence of urban garden activities on participants' perceived restorativeness, resilience, sense of community, and stress reduction. A total of ninety individuals who agreed to participate in the experiment were divided into experimental and control groups. To collect data, 16 sessions of urban garden activities were conducted every two weeks from May to November 2022. Perceived Restorativeness Scale, Connor-Davidson Resilience Scale, Sense of Community Index, and Brief Encounter Psychosocial Instrument were employed to measure participants' psychological effects. To evaluate physiological effects, salivary cortisol tests were performed. The results of the study revealed that urban gardening activities influenced on participants' physiological and psychological reactions in positive ways.

Salivary cortisol as a marker for assessing the problem-focused coping style of stressed students during the first year of university: An experimental study

Background and Aims

First-year students encounter substantial stress when they enter university. Their mental health often depends upon how well they cope with the stress of university life. Salivary components are well known to reflect the stress status of the students; however, the relationship between salivary components and coping styles remains unknown.

Methods

In this study, 54 healthy first-year students voluntarily completed a questionnaire that addressed three different coping styles: problem-focused, emotion-focused, and escape-focused. We simultaneously collected salivary samples from students in the classroom and measured concentrations of salivary cortisol and α-amylase by enzyme-linked immunosorbent assays over 4 months.

Results

We examined the relationship between coping style and salivary cortisol concentrations and found that the mean salivary cortisol concentrations were significantly lower in students who had a higher Likert-type score for the problem-focused coping style than in students who had a lower score. The difference in the mean cortisol concentrations between the two groups increased over time. However, we observed no apparent correlation between α-amylase concentrations and Likert scores of the three coping styles.

Conclusion

These results suggest that salivary cortisol concentrations might reflect the stress-coping status, particularly involving the problem-focused coping style.

Prevalence of anxiety depression and stress among first year medical students in Tamilnadu

The present study was to evaluate the examination stress of the first year MBBS students, prior to their university exam by assessing the mood parameters and cortisol level. A cross sectional study was conducted in 150 students of Indira Medical College, Thiruvallur from January to February 2022. The assessment methods implemented were Self-administered, pre-designed questionnaire of DASS 10 scale scoring 0-40, and salivary cortisol by using quantitative ELISA on relaxed (before exam) and stressed (on day of exam) students with prior consent. Respondent data were analysed using the independent t-test and Odds ratio logistic regression analysis was done for strength of association by using (SPSS) version 26.0 and the level of significance *p≤0.05. The prevalence of stress (43%), anxiety (35%), depression (22%) and level of cortisol (2.61±0.41 and 5.14±0.35) between relaxed and stressed respectively were significantly increased due to examination stress despite any significant change in academic performance. Odds ratio of stress (95% CI 2.153), anxiety (3.038), depression (2.513) and salivary cortisol (2.872) were significantly high in stressed. Female students were found to be more susceptible to stress than male students due to examination (p≤0.001**). This study suggests that the medical education and examination are unavoidable stressor in first year students. This could be prevented by providing stress reduction interventions and orientation programmes which could improve student mental well-being and reduce the psychological distress.

The relationship between diurnal cortisol slope and cognitive development among children maltreated as infants

Little is known about the role of hypothalamic-pituitary-adrenal (HPA) axis functioning for children's cognitive development, especially among vulnerable groups. The current study explores the relationship between diurnal cortisol slope and cognitive outcomes among children at the ages of 5 and 6 who have been maltreated as infants and involved with child protective services, using data from the National Survey of Child and Adolescent Well-Being (NSCAW) I (N=158). Multiple regression analyses showed that a greater decline in salivary cortisol from morning to evening was positively associated with scores on applied problems and expressive communication, even after adjustment for confounding. It was also associated with lower odds of cognitive disability. There were null associations with letter-word identification, passage comprehension, auditory comprehension, matrices, and vocabulary. Results suggest that children involved with child protective services as infants, and thus exposed early to likely 'toxic' levels of stressors, may face dysregulation of the HPA axis and particular difficulties in some aspects of cognitive function. Potential explanations and implications for policy are discussed.

Late-Night Salivary Cortisol Cut-Offs for Diagnosis of Cushing Syndrome using Second-Generation Electrochemiluminescence Immunoassay Kits

CONTEXT

Late-night salivary cortisol (LNSC) is a simple and reliable screening test for Cushing syndrome (CS). With improved analytical performance of the current second-generation electrochemiluminescence immunoassay (ECLIA; Elecsys Cortisol-II; Roche Diagnostics), there is a need to revisit the LNSC cut-off, especially in a South-Asian population.

OBJECTIVE

To derive LNSC cut-offs for diagnosis of CS using second-generation ECLIA kits DESIGN: Diagnostic accuracy study METHODS: We prospectively recruited 155 controls aged 18-60 years, including, normal-weight [BMI <25 kg/m² and no hypertension or diabetes (n=53)] and overweight/obese [BMI 25-30 kg/m² and hypertension and/or diabetes (n=52) or BMI ≥30 kg/m² with/without comorbidities (n=50)] participants. All participants submitted LNSC samples collected at home; overweight/obese controls additionally underwent dexamethasone suppression test to exclude CS. We also reviewed records of adults with endogenous CS (cases, n=92) and a valid LNSC result using the same method.

RESULTS

The 95^th percentile for LNSC in controls was 6.76 nmol/L. The mean ± SD LNSC levels were 40.47 ± 49.63 nmol/L in cases and 3.37 ± 1.18 nmol/L in controls (p<0.001). Receiver operating characteristic (ROC) analysis showed excellent diagnostic performance of LNSC for CS, with area under curves (AUCs) of 0.994 (cases vs. all controls) and 0.993 (cases vs. overweight/obese controls), respectively. The best diagnostic performance was achieved at cut-offs ≥6.73 nmol/L (sensitivity: 97.8%, specificity: 94.8%) and ≥7.26 nmol/L (sensitivity: 97.8%, specificity: 95.1%), respectively.

CONCLUSIONS

LNSC measured using second-generation ECLIA demonstrated high diagnostic accuracy for CS. Based on this study, we propose a LNSC cutoff ≥6.73 nmol/L to diagnose CS. This article is protected by copyright. All rights reserved.

A Study of Diurnal Cortisol Adaptations in Sleep-Deprived Firefighters During a 72-Hour Work Shift: A Case Series

Seventy percent of US firefighters are overweight or obese. The combination of sleep deprivation and exposure to traumatic events during 72-hour work shifts, commonly employed in emergency responders, is thought to put firefighters at high risk for a variety of stress-related diseases and suicide. Previous studies suggest that the cortisol awakening response (CAR) may be increased in sleep-deprived emergency responders. This case series was designed to investigate the variations in CAR and associations with measurements of salivary cortisol and testosterone, blood glucose and triglyceride, and blood pressure during a 72-hour work shift. Measurements were made at 08:00 and 20:00 in five participants (one normal weight normotensive, three obese hypertensive, and one morbidly obese normotensive male). Data were characterized by the regression statistic R² computed from the relationship between diurnal measurement and concentration, with significance at R²≥0.4. The predominant AM CAR adaptation response consisted of no significant 72-h change (flat response) in salivary cortisol (R²<0.4), found in three of the five participants (60%). The normal-weight participant's 72-h AM CAR adaptation was characterized as incremental (R²=0.91), and markedly different than that of the four obese firefighters who exhibited either a flat response (R²<0.4, 60%) or, in one subject, a decremental response (R²=0.40, 20%). The predominant 72-h PM cortisol adaptation was found to be decremental (R²=0.78-0.97) in three of the five participants (60%), including the normal weight subject (R²=0.78). Diurnal salivary cortisol and testosterone exhibited normal physiological circadian variations (P=0.01, AM>PM and P=0.1, AM>PM, respectively). Blood glucose and triglyceride also showed physiological circadian variations (P=0.02 AM<PM and P=0.002 AM<PM, respectively). Diurnal variation of systolic BP was found to be not significant (P=0.2). The flat AM CAR adaptation exhibited in three of four obese hypertensive firefighters may represent a blunted adaptation response, akin to the responses reported for survivors of suicide. These findings suggest that diurnal variations in salivary cortisol and testosterone, blood glucose, and triglyceride may be useful biochemical markers for identifying stress-related adaptations to 72-hour work shifts. Future studies should be designed to correlate diurnal variations in biomarkers with the risk of developing stress-related diseases and suicide in firefighters.

Expanding the use of salivary cortisol as a non-invasive outpatient test in the dynamic evaluation of suspected adrenal insufficiency

Background

Adrenal insufficiency (AI) is potentially life-threatening, and accurate diagnosis is crucial. The first-line diagnostic test, the adrenocorticotrophic hormone (ACTH) stimulation test, measures serum total cortisol. However, this is affected in states of altered albumin or cortisol-binding globulin levels, limiting reliability. Salivary cortisol reflects free bioactive cortisol levels and is a promising alternative. However, few studies are available, and heterogenous methodologies limit applicability.

Methods

This study prospectively recruited 42 outpatients undergoing evaluation for AI, excluding participants with altered cortisol-binding states. Serum (immunoassay) and salivary (liquid chromatography tandem mass spectrometry) cortisol levels were sampled at baseline, 30 min, and 60 min following 250 µg synacthen administration. AI was defined as a peak serum cortisol level <500 nmol/L in accordance with guidelines.

Results

The study recruited 21 (50%) participants with AI and 21 without AI. There were no significant differences in baseline characteristics, blood pressure, or sodium levels between groups. Following synacthen stimulation, serum and salivary cortisol levels showed good correlation at all timepoints (R2 = 0.74, P < 0.001), at peak levels (R2 = 0.72, P < 0.001), and at 60 min (R2 = 0.72, P < 0.001). A salivary cortisol cut-off of 16.0 nmol/L had a sensitivity of 90.5% and a specificity of 76.2% for the diagnosis of AI.

Conclusion

This study demonstrates a good correlation between serum and salivary cortisol levels during the 250 µg synacthen test. A peak salivary cortisol cut-off of 16.0 nmol/L can be used for the diagnosis of AI. It is a less invasive alternative to evaluate patients with suspected AI. Its potential utility in the diagnosis of AI in patients with altered cortisol-binding states should be further studied.

Comparison of distraction techniques using salivary biomarkers during local anaesthesia administration in children aged 3-5 years: A clinical study

Aim

In paediatric dentistry, pain is adversely influenced by a child's level of anxiety. Ironically, the most common form of pain control used in dentistry, local anaesthesia, can itself produce anxiety. One of the techniques to overcome a child's anxiety is using distraction. The aim of the present study was to evaluate the effectiveness of distraction techniques, i.e. audio distraction (AD) and audio-visual distraction (AVD) by measuring salivary stress biomarker (salivary cortisol and salivary alpha-amylase) levels in 3-5 year-old children.

Materials and Methods

Forty children aged 3-5 years were divided randomly into two groups; (Group I = AD, Group II = AVD). Cotton pellets were placed in the lingual vestibule to collect a sample of saliva. Children were then asked to wear overhead phones in the AD group, connected to a phone, and rhymes were played. In AVD, a cartoon movie was shown to the children using AV glasses. Simultaneously, local anaesthesia was administrated to children, after which another saliva sample was collected. Biomarker estimation was done using ELISA. Fisher's exact test was used for statistical analysis.

Results

Statistically significant results were seen with Group II compared to Group I (cortisol-P = 0.009; salivary alpha-amylase-P = 0.03).

Conclusion

Both distraction techniques are effective in reducing stress but compared to AD, AVD is more efficacious.

Hair Cortisone Predicts Lower Stress-induced Salivary Cortisol Response: Resting-state Functional Connectivity Between Salience and Limbic Networks

Previous studies revealed that high long-term hypothalamic-pituitaryadrenal (HPA) axis activity measured by the hair cortisol concentrations predicts lower acute stress cortisol response and reported the influences of hair cortisol on brain activity during acute stress exposure. However, considering that long-term HPA axis activity has a close relationship with the brain's resting-state functional connectivity (RSFC), the current study aimed to explore the role of RSFC between limbic and salience network in this relationship. Seventy-seven healthy participants underwent resting-state imaging scans before performing the acute ScanSTRESS task. Saliva samples were collected to assess the levels of acute stress salivary cortisol. Hair samples were also collected, and the corticosteroid concentration extracted from these samples were used as a biomarker of long-term HPA axis activity. High hair cortisone (HairE) levels predicted lower acute stress cortisol response. Moreover, high HairE levels were significantly correlated with enhanced RSFC between limbic and salience networks, while RSFC was negatively associated with acute stress cortisol response. Importantly, the RSFC between left insula and left parahippocampus mediated the association between HairE and acute cortisol stress response. Taken together, this study uncovers the important role of RSFC between salience and limbic networks in the long-term relationship between HairE and acute cortisol response and contributes to a deeper understanding of the individual differences in acute stress response.

Physical and Mental Effects of Foot Baths Among Women in Labor: Protocol for a Pre-Post Test Experimental Design

BACKGROUND

Foot baths are used in complementary and alternative therapy to improve the duration and quality of sleep and reduce tension, anxiety, fatigue, and confusion. They are also known to improve the frequency of labor contractions and to increase their duration in women; thus, they are commonly used by midwives in clinical settings in Japan. However, the physical and mental effects of foot baths during labor are unknown.

OBJECTIVE

This study aims to assess the physical and mental effects of foot baths based on biomarker levels and self-administered questionnaires.

METHODS

A single-arm pre-post test trial design is being used in this study, and the study is being conducted at a general hospital in Tochigi Prefecture, Japan. The target study population is women in the first stage of labor, the phase when the uterus starts to contract and when the cervix dilates to 10 cm, or those undergoing labor induction. Participants who meet the eligibility criteria are recruited, and written informed consent is obtained from them. They are asked to answer the questionnaire and to collect 1.5 mL of saliva in 2 microtubes each, before and after the intervention. The intervention is foot baths for 15-20 minutes using a foot bath device. Data on delivery, such as gestational age, gravidity, parity, diagnosis following the last vaginal examination, and presence or absence of membrane rupture, are retrieved from the medical records. The primary outcomes are salivary cortisol levels before and after the foot baths. The secondary outcomes are levels of relaxation and comfort, labor pain, body warmth, vital signs, and interval of labor pain before and after the foot baths, which are assessed using a numerical rating scale. A paired t test or Wilcoxon signed-rank test will be performed to compare the data for salivary cortisol levels and numerical rating scale scores.

RESULTS

Data collection started on April 1, 2022. As of October 2022, we had enrolled 10 participants. Because of the COVID-19 pandemic in Japan, it is difficult for medical personnel to freely interact with women in labor until the results of the COVID-19 polymerase chain reaction test are available in the research facility, complicating the recruitment process.

CONCLUSIONS

This is the first prospective study to assess the effects of foot baths using a biomarker during the first stage of labor. The findings on the effects of foot baths on women in labor will provide novel insights that may improve the outcomes of delivery. A randomized controlled trial to investigate the effects of foot baths to obtain robust evidence should be conducted in the future.

TRIAL REGISTRATION

University Hospital Medical Information Network-Clinical Trial Registry UMIN000046539; https://tinyurl.com/2wwj7dns.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/39985.

Which animal-to-feeding-place ratio at time-controlled hay racks is animal appropriate? Preliminary analysis of stress responses of horses

Introduction

Automated feeding systems offer numerous advantages for animals and humans, but the associated benefits and risks can often only be seen under practical conditions. The space allowance (~80 cm per horse) at time-controlled hay racks for horses in group housing, unlike at partitioned feeding stands or transponder-controlled feed stations, currently falls below the required individual distance between the horses, which can result in a high level of aggression between the horses due to the lack of partitions between them. Hence, a feed-through at a time-controlled hay rack cannot be equated with a feeding place. In this preliminary study, we therefore aimed to determine the minimum animal-to-feeding-place ratio (AFR) at time-controlled hay racks that would provide adequate individual distances between the horses.

Methods

To do so, we assessed behavioral and physiological parameters (via video behavioral observations and salivary cortisol measurements) of up to 28 horses in a loose housing system. Over 2 observation days per treatment, four AFRs were investigated in a balanced sequence: 1:1.2, 1:2, 1:3, and C (single feeding in familiar surroundings as a control).

Results

We found that the horses expressed less aggressive behavior, especially those behaviors with a high risk of injury such as biting and kicking, when there were three times as many openings as there were horses at time-controlled hay racks, as compared with only 20% more openings or twice as many openings as there were horses [lineal mixed model: F (3, 4) = 7.411; adjusted R 2 = 0.733; p (AFR_1:2) = 0.06, p (AFR_1:3) = 0.02, p (AFR_C) = 0.01]. The salivary cortisol levels during feeding decreased more strongly with more generous AFRs [p (AFR_metric) = 0.02]. The factors hierarchy and individual showed no influence. In contrast, the day of the experiment and the associated weather conditions, despite randomized selection, influenced both the behavioral and the physiological parameters.

Discussion

The results of this preliminary study indicate that the investigated time-controlled hay racks must provide at least three times as many feeding places as there are horses to ensure that neighboring horses can keep their individual distance and stress-free feeding is possible. Further studies on more farms and different types as well as arrangement of hay racks are proposed.

Effects of the therapy shift from cortisone acetate to modified-release hydrocortisone in a group of patients with adrenal insufficiency

OBJECTIVE

Patients with adrenal insufficiency (AI) may be exposed to supraphysiological glucocorticoids levels during standard treatment with cortisone acetate (CA) or immediate-release hydrocortisone (IR-HC). Recent studies, predominantly including patients in IR-HC treatment, suggested that modified-release hydrocortisone (MRH) provide a more physiological cortisol rhythm, improving metabolic control and quality of life. Our primary aim was to assess clinical and biochemical modifications in patients shifted from CA to MRH.

DESIGN/METHODS

We designed a retrospective longitudinal study, enrolling 45 AI patients (22 primary and 23 secondary AI) treated exclusively with CA thrice daily, shifted to MRH once daily; 29/45 patients concluded at least 18-months follow-up (MRH-group). We recruited 35 AI patients continuing CA as a control group (CA-group). Biochemical and clinical data, including metabolic parameters, bone quality, and symptoms of under- or overtreatment were collected. In 24 patients, a daily salivary cortisol curve (SCC) performed before and one month after shifting to MRH was compared to healthy subjects (HS).

RESULTS

No significant changes in glycometabolic and bone parameters were observed both in MRH and CA-groups during a median follow-up of 35 months. A more frequent decrease in blood pressure values (23.1% vs 2.8%, p=0.04) and improvement of under- or overtreatment symptoms were observed in MRH vs CA-group. The SCC showed a significant steroid overexposure in both CA and MRH-groups compared to HS [AUC (area under the curve) = 74.4 ± 38.1 nmol×hr/L and 94.6 ± 62.5 nmol×hr/L respectively, vs 44.1 ± 8.4 nmol×hr/L, p<0.01 for both comparisons], although SCC profile was more similar to HS in MRH-group.

CONCLUSIONS

In our experience, patients shifted from CA to equivalent doses of MRH do not show significant glycometabolic modifications but blood pressure control and symptoms of over-or undertreatment may improve. The lack of amelioration in glucose metabolism and total cortisol daily exposure could suggest the need for a dose reduction when shifting from CA to MRH, due to their different pharmacokinetics.

Effect of receiving mobile text messages on cortisol concentrations in students at the University of the Free State

Background

Texting has become central to social life, with adverse effects on physiological functioning. Research into the impact of texting on cortisol secretion is limited.

Aim

Thus study aimed to determine how receiving mobile text messages affected salivary cortisol concentrations and investigate the moderating effects of stress, anxiety and depression on cortisol secretion.

Setting

Undergraduate physiology students attending physiology lectures at the Faculty of Health Sciences, University of the Free State, 2016.

Methods

An experimental, crossover, quantitative design was used. Participants were involved over two consecutive days, receiving mobile text messages (intervention) on one day and acting as their own control on the other. Self-reported data on stress, anxiety, depression and subjective experience of the study, and saliva samples were collected. Text frequency and wording (neutral, positive, negative) were varied among participants.

Results

Forty-eight students participated in the study. Salivary cortisol concentrations did not differ significantly between the intervention and control days. High anxiety levels were associated with increased cortisol concentrations. No associations with cortisol concentrations were documented in low to moderate anxiety, stress, depression or how participants experienced the intervention. There were no significant differences between text frequency, text emotion and change in cortisol concentrations on the intervention day.

Conclusion

Receiving mobile text messages did not elicit a significant cortisol response in participants.

Contribution

Findings added to the body of knowledge about the effect of texting on student learning by measuring salivary cortisol concentrations in a lecture setting, with investigation into the moderating effects of stress, anxiety, depression and participants' subjective experience.

Confounding effects of liquorice, hydrocortisone, and blood contamination on salivary cortisol but not cortisone

Objective

To determine the effects of liquorice consumption, topical hydrocortisone, and blood contamination on salivary cortisol and cortisone concentrations.

Design and methods

Thirty healthy volunteers were randomized to a low, medium, or high dose of liquorice. Late-night saliva samples were collected using a Salivette® collection device at baseline, during 1 week of daily liquorice consumption, and during 4 weeks' washout. Saliva sampling was also performed before and after the application of topical hydrocortisone on the skin. Furthermore, in a subgroup (n = 16), saliva and venous blood were collected from each individual and mixed to achieve graded blood contamination in saliva. Salivary cortisol and cortisone were analyzed with liquid chromatography-tandem mass spectrometry.

Results

Significant increases in salivary cortisol concentrations were observed during medium- (+49%) and high-dose (+97%) liquorice intake, which returned to baseline 4 days after liquorice withdrawal. Topical hydrocortisone on fingers holding the collection swab increased salivary cortisol concentrations >1000-fold with concomitant pronounced elevation of the cortisol:cortisone ratio. Salivary cortisol increased significantly after contamination with blood ≥0.5%. Visual examination could safely detect these samples. Salivary cortisone concentrations were unaffected by liquorice consumption and blood contamination, and only marginally affected by topical hydrocortisone.

Conclusion

Liquorice, topical hydrocortisone, and blood contamination may all cause elevated salivary cortisol concentrations. Improved sampling instructions and visual examination of the sample may minimize these risks. Salivary cortisone is essentially unaffected by the different preanalytical confounders and may be used as a first-line screening test for Cushing's syndrome.

The Effects of Forest Therapy on the Blood Pressure and Salivary Cortisol Levels of Urban Residents: A Meta-Analysis

Urban residents have a higher risk of hypertension and psychological stress than rural residents. Aside from medical interventions, understanding how to control hypertension and alleviate the stress of urban populations has become a public concern. As an alternative medical measure, forest therapy has shown the effects of normalizing blood pressure (BP) and reducing stress increasingly in recent literature, but this is still inconclusive. In order to systematically verify forest therapy’s effects on the BP and mental stress of urban residents, we conducted meta-analyses to assess the changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), and salivary cortisol concentration (SCC; a stress biomarker) between the forest therapy group and urban control group. We searched 4 online databases, and 21 studies on BP involving 2270 participants and 13 studies on SCC involving 1786 participants were included. Through the meta-analysis, the mean difference and confidence interval (CI) estimates indicated that forest therapy significantly reduced participants’ SBP −3.44 (95% CI −5.74, −1.14), DBP −3.07 (95% CI −5.59, −0.54), and SCC −0.07 (95% CI −0.10, −0.04), as compared with urban control. Yet, there was substantial heterogeneity (I2 = 72.87−88.59%) among these studies. We also found that each prediction interval (PI) for SBP (95% PI −13.30, 6.42), DBP (95% PI −15.54, 9.41), and SCC (95% PI −0.18, 0.05) were all much wider than the CIs and contained values above 0. This means that forest therapy may reduce SBP, DBP, and SCC on average, but may not exclude adverse results. Meta-regression analyses showed that participants’ age and baseline SBP levels determined the heterogeneity among SBP studies. After forest therapy, older participants and those with higher baseline SBP levels had greater SBP-lowering effects. Among DBP studies, the primary source of heterogeneity was participants’ baseline DBP levels; participants with higher baseline DBP levels had greater DBP reduction. In subgroup analyses, we discovered that longer-term forest therapy programs (≥20 min) resulted in a greater reduction in BP and SCC than shorter-term forest therapy programs (<20 min). Additionally, seated viewing, walking, or multi-session programs in forests were observed to have similar effects on reducing BP and SCC. Despite extensive analyses, the study did not identify any sources of heterogeneity among forest therapy programs for lowering SCC levels. Overall, we conclude that forest therapy programs have beneficial therapeutic effects on urban residents’ physio-psychological health through lowering BP and relieving stress (reducing SCC). This finding provides solid evidence of the contribution of forest therapy to urban residents’ health and wellbeing.

Mild to Moderate Sleep Restriction Does Not Affect the Cortisol Awakening Response in Healthy Adult Males

The cortisol awakening response (CAR) is a distinct rise in cortisol that occurs upon awakening that is thought to contribute to arousal, energy boosting, and anticipation. There is some evidence to suggest that inadequate sleep may alter the CAR, but the relationship between sleep duration and CAR has not been systematically examined. Healthy males (n = 111; age: 23.0 ± 3.6 yrs) spent 10 consecutive days/nights in a sleep laboratory. After a baseline night (9 h time in bed), participants spent either 5 h (n = 19), 6 h (n = 23), 7 h (n = 16), 8 h (n = 27), or 9 h (n = 26) in bed for seven nights, followed by a 9 h recovery sleep. The saliva samples for cortisol assay were collected at 08:00 h, 08:30 h and 08:45 h at baseline, on experimental days 2 and 5 and on the recovery day. The primary dependent variables were the cortisol concentration at awakening (08:00 h) and the cortisol area under the curve (AUC). There was no effect of time in bed on either the cortisol concentration at awakening or cortisol AUC. In all the time in bed conditions, the cortisol AUC tended to be higher at baseline and lower on experimental day 5. Five consecutive nights of mild to moderate sleep restriction does not appear to affect the CAR in healthy male adults.

Differences in Weekly Training Load, Well-Being, and Hormonal Responses between European- and National-Level Professional Male Basketball Players during the Pre-Season Phase

This study aimed to compare the weekly fluctuation in training load (sRPE-load), well-being (perceived fatigue, stress, mood, sleep, and muscle soreness), and hormonal responses [testosterone (T) and cortisol (C)] during the pre-season phase in European- and national-level professional male basketball players. Twenty-one professional male basketball players belonging to European-level (n = 11, age: 25.5 ± 3.6 yr; stature: 199.2 ± 7.1 cm; body mass: 94.1 ± 8.5 kg) and national-level (n = 10, age: 23.5 ± 4.7 yr; stature: 198.0 ± 5.6 cm; body mass: 94.0 ± 8.8 kg) teams were monitored during a 5-week pre-season phase. The European-level team showed higher sRPE-load in week 5 compared to week 3 (within-team difference, p = 0.049; ES = -1.44 [-2.38, -0.5], large) and week 1 (p = 0.018; ES = 1.62 [0.64, 2.61], large), week 4 (p = 0.005; ES = 1.79 [0.78, 2.81], large) and week 5 (p = 0.001; ES = 1.96 [0.92, 3.01], large) of the national-level team. The national-level team documented the lowest sRPE-load in week 5, which was statistically different compared to week 2 (p = 0.022; ES = 1.59 [0.61, 2.58], large) and week 4 (p = 0.001; ES = 1.94 [0.9, 2.98], large) of the European-level team. Moreover, higher stress (p < 0.001; ES = 1.94 [0.93, 2.95], large) and better mood (p = 0.003; ES = 1.79 [0.8, 2.78], large) were found in week 1 compared to week 5 within the European-level team. Additionally, higher values of salivary C were found in week 1 for the European-level team compared to week 2 (p = 0.020; ES = 1.6 [0.61, 2.58], large) and week 4 (p = 0.018; ES = 1.66 [0.64, 2.67], large) of the national-level team. Our results can provide reference values for basketball practitioners regarding the fluctuations of weekly load, well-being, and hormones across the pre-season period in professional male teams competing at European and national levels.

Assessment of salivary cortisol concentrations for procedural pain monitoring in newborns

OBJECTIVES

The study aimed to evaluate the usefulness of salivary cortisol (SC) for the assessment of procedural pain intensity in preterm and term newborns.

METHODS

Three groups of neonates (term, 37⁰-41⁶ weeks; moderate to late preterm, 32⁰-36⁶; and very preterm, <32⁰) hospitalized in neonatal intensive care unit were assessed for the study. Response to nappy change, lung ultrasound (LUS), and blood sampling was analyzed. The intensity of pain was evaluated using continuous heart rate and blood oxygen saturation (SpO₂) monitoring, Neonatal Infant Pain Scale (NIPS), and SC concentrations. Saliva samples were collected before and 20 min after the procedure's end.

RESULTS

Seventy-one infants were examined: 30 term, 21 moderate to late preterm, and 20 very preterm. SC has increased significantly in response to nappy change only in very preterm newborns (2.13 ng/mL [1.55-3.68] vs. 2.84 ng/mL [1.93-9.06], p = 0.01). LUS did not affect concentrations of SC in any group. Significant increase in SC was observed after blood sampling in term and very preterm infants (2.2 ng/mL [1.45-2.92] vs. 4.29 ng/mL [3.88-5.73], p = 0.002, and 1.88 ng/mL [1.47-4.13] vs. 5.3 ng/mL [3.42-8.02], p = 0.002, respectively). A significant correlation between values of SC increase and NIPS scores was found (Spearman's rank correlation coefficient [r_s] = 0.31, p = 0.001).

CONCLUSIONS

We observed the increase in SC concentrations in response to painful stimulus. The presence of a correlation between NIPS scores and SC increase suggests that SC can be used as an objective parameter to assess pain in neonates.