Cortisol secretory activity in older people in relation to positive and negative well-being

Secretion of the hormone cortisol, a physiological correlate of affect, has been studied mostly in relation to negative states, especially stress. By contrast, policy initiatives aimed at older populations now routinely emphasise well-being and a 'positive ageing' perspective. In this study, we examined diurnal salivary cortisol profiles from 50 active seniors recruited into a wider community research project (mean age 74 years; 34 F/16 M). Participants' wrist activity was continuously monitored by actimeters in their homes over a 48 h period. During this time two diurnal cycles of cortisol data were collected (8 samples per day); with actimeter data providing a compliance check in regard to timing of self-administered saliva collections. Prior to the trial, participants had completed the GHQ-30 which was scored separately to yield both positive and negative well-being scores which matched closely normative data from over 6000 cases in a large survey. Our data suggest that positive and negative psychological well-being are quite strongly and inversely correlated. However, neither on their own was associated with basal levels of cortisol. Rather, for cortisol secretion in the 45-min period following awakening, but not during the rest of the day, we found a significant interaction between positive and negative well-being (p<0.024). Further analysis of this interaction showed that among participants low on negative well-being, higher positive well-being was significantly associated with lower cortisol; equally, among participants high on positive well-being, lower negative well-being was significantly associated with lower cortisol. Thus, a powerful synergy seemed to be operating in this early morning period such that cortisol secretion was 27% lower in participants with both higher-than-average positive well-being and lower-than-average negative well-being (comprising 34% of the sample). We conclude that cortisol secretion in the first 45 min following awakening is distinct from the rest of the day and most able to discriminate well-being states.

Attitudes of general dental practitioners in the UK to the use of composite materials in posterior teeth

OBJECTIVE

To determine the opinions and current methods used in placing posterior composite restorations by general dental practitioners.

SETTING

The study was completed by general dental practitioners randomly selected from across the UK.

METHOD

A questionnaire was devised to gain this information. It was sent to 500 UK dentists chosen at random from the general dental register, with an explanatory letter and reply-paid envelope.

RESULTS

Two hundred and sixty-seven replies were received. Sixty-one percent of dentists felt amalgam use had decreased over the last five years, 75% felt posterior composite use had increased. Regarding choice of posterior material, almost all cited clinical indication as the most influential factor while patient's aesthetic demands (89%),wish for a certain material (78%) and the dentist's confidence using a certain restorative material (76%) were contributing factors. Regarding the techniques used, contemporary techniques were employed although there was confusion regarding the need for rubber dam and the most appropriate method of lining the cavity. A case scenario of a pregnant patient who required treatment found that 66% of respondents would place a restoration other than a temporary dressing, with 16% placing an amalgam restoration.

CONCLUSIONS

The majority of dentists surveyed place load bearing posterior composite restorations regularly. Their choice of restorative material is influenced by clinical indications and the patient's aesthetic demands. The techniques used were appropriate, although there was confusion around the need for rubber dam and the most appropriate method to line the cavity. There was also confusion in relation to the most appropriate materials for use in pregnancy.

A reference dataset for circular dichroism spectroscopy tailored for the βγ-crystallin lens proteins

Circular dichroism (CD) spectroscopy is a powerful solution technique for the study of protein secondary structure. As hierarchical euclidean clustering analyses of high quality crystallin synchrotron radiation circular dichroism (SRCD) spectral data can be separated into structural groups based solely on spectral information, the technique can potentially be improved to more accurately determine secondary structures and monitor conformational changes in crystallins. Secondary structure estimates can be determined through use of reference datasets of circular dichroism spectra from proteins with determined crystal structures. As with any empirical method, the accuracies of the analyses are dependent upon how closely the reference dataset characteristics match those of the protein to be studied. To date, crystallin proteins have not been well analysed by CD because existing reference datasets do not contain good representations of their structural characteristics. This work describes a betagamma-crystallin specific reference dataset, CRYST175, which was created solely for the study of betagamma-crystallin secondary structures. Prediction accuracy was assessed for the new dataset using several deconvolution algorithms and it was found to substantially outperform existing more general reference datasets.

Suspected non-adherence and weekend versus week day differences in the awakening cortisol response

The pronounced rise in cortisol following awakening holds promise as a bio-marker of variables in the psychosocial domain, but its investigation also presents methodological challenges, which we attempted to address in this study. Forty-eight healthy, young students participated and were instructed to collect saliva 0, 15, 30 and 45 min post awakening on two consecutive normal weekdays and two consecutive weekend days (order counterbalanced). Participants' awakening cortisol response (ACR) profiles differed between the weekdays and weekend with trend analysis revealing a steeper rise on weekdays compared to the weekend. These differences were not accounted for by weekday/weekend differences in awakening time and state stress or by perceived stress over the previous month. Total salivary-free cortisol secretion (area under the cortisol curve (AUC)) over the 4 study days was negatively correlated with the measure of longer term stress and awakening time. The mean 4-day rise in cortisol (mean increase: MnInc) was also negatively correlated with awakening time. This awakening time effect was not mediated by stress or vice versa, since both were independent predictors of cortisol. In an attempt to address the ubiquitous problem of non-adherence to the requested saliva sampling regime, known to distort the shape of the ACR, suspected non-adherence (SNA) was examined by identifying instances of profiles showing no cortisol rise from the waking sample to either the 15 or 30 min sample post awakening. Analysis controlling for SNA status had no effect upon the observed associations with Perceived Stress Scale (PSS) and awakening time however it abolished the otherwise highly significant flatter profile at weekends.

Post-awakening cortisol secretion during basic military training

Salivary free cortisol concentrations in the first 30 min after awakening were assessed in 12 healthy army recruits at the beginning, middle and end of an 11-week intensive physical training course. To ensure strict adherence to protocol saliva collection was supervised and collected on each sampling day immediately on waking and again 15 and 30 min later. Self-rated psychological assessments of state levels of stress, arousal and fatigue were performed in the evening of each sampling day. A within-subjects repeated-measures analysis of participants who completed the course (12 of the original 20) showed a significant main effect of cortisol concentration across all three sampling points after awakening (F((2,22))=54.516, p<0.0001) and a significant main effect of weeks into the training course (F((3,33))=4.390, p=0.010). Further analysis of this effect of measurement-week revealed that at weeks 3 and 6 total cortisol secretion estimated by area under the curve was lower (F((3,33))=4.602, p=0.008) compared to the beginning and end of the course. Surprisingly self-reported stress, arousal and fatigue did not differ significantly across weeks, despite the large dropout rate (40%) and self-evident pressures of the course. We conclude that when controlling for many confounding variables, including participant adherence, post-awakening cortisol levels are sensitive to stressful challenge over a period of weeks.

Recent Insights into Interactions of Deferoxamine with Cellular and Plasma Iron Pools: Implications for Clinical Use

Despite the availability of deferoxamine (DFO) for more than three decades, its rates of interaction with cellular iron pools in different tissues, and the effects of its pharmacokinetics on the interaction with plasma iron pools, remain incompletely understood. The positive charge of DFO, together with the negative resting potential in vertebrate cells, favors cellular uptake, whereas the low lipophilicity and high molecular weight counter this effect. The findings presented suggest a facilitated uptake of DFO into hepatocytes, being several hundred-fold faster than into red cells. Antibodies that selectively recognize ferrioxamine (FO) show that initial hepatocellular iron chelation is cytosolic, but later transposes to lysosomal and ultimately canalicular compartments. Strong FO staining is visible in myocytes within 4-8 h after commencing a subcutaneous DFO infusion, indicating effective chelation of myocyte iron. A methodology was developed to study the interaction of DFO and its metabolites with plasma iron pools by stabilizing DFO with aluminum ions, thereby preventing iron shuttling from non-transferrin-bound iron (NTBI) onto DFO after plasma collection. DFO removes only about a third of NTBI rapidly, and NTBI is rarely cleared completely. Increasing DFO dosing does not increase NTBI removal, but instead leads to a greater rebound in NTBI on cessation of intravenous infusion. Thus, intermittent infusions of high-dose DFO are less desirable than continuous infusions at low doses, particularly in high-risk patients. Here the benefits of continuous DFO on heart function occur before changes in T2*-visible storage iron, consistent with early removal of a toxic labile iron pool within myocytes.

Can we influence medical students' approaches to learning?

Students use three approaches to learning and studying: deep, surface and strategic. These are influenced by the learning environment. In response to the General Medical Council's report 'Tomorrow's Doctors', the second year of the medical course at the University of Edinburgh was changed to promote deep learning, with learning objectives constructed according to the SOLO taxonomy, learning methods such as problem-based learning and constructively aligned written assignments and examinations. The Approaches to Study Skills Inventory for Students (ASSIST) was used to evaluate the effect of these changes. Scores were highest for deep approaches and lowest for surface approaches and showed almost no change during the course. There are various possible explanations. The students already scored highly on deep approaches at the beginning of Year 2 and it may be difficult to increase the deep scores further, particularly over the relatively short period of the study. Alternatively, the effect of the changes in learning environment may not be strong enough to change entrenched approaches which have hitherto been successful.

A comparison of intrathecal fentanyl and diamorphine as adjuncts in spinal anaesthesia for Caesarean section

This randomised controlled trial examines the effects of fentanyl and diamorphine, alone and in combination, as adjuncts to spinal anaesthesia for Caesarean section. Ninety-nine women undergoing elective Caesarean section with spinal anaesthesia using 0.5% hyperbaric bupivacaine were randomly allocated to receive fentanyl 15 microg (F), diamorphine 0.25 mg (D), or fentanyl 15 microg plus diamorphine 0.25 mg (FD), intrathecally. All women received morphine via a patient controlled analgesia system after surgery. There was no significant difference between the groups in time to achieve a block, discomfort, ephedrine use, nausea and vomiting, pruritus and sedation during surgery. Significant differences were observed in morphine consumption 4, 8, 12 and 24 h after surgery between both F and D groups, and F and FD groups, and also at 2 h between F and FD groups. There was a significant difference in pruritus at 4 h between the F and FD group. Our results suggest that diamorphine alone provides optimum benefits during and after surgery, when used in combination with hyperbaric bupivacaine for Caesarean section.

The diurnal patterns of the adrenal steroids cortisol and dehydroepiandrosterone (DHEA) in relation to awakening

The steroid hormones, cortisol and dehydroepiandrosterone (DHEA) are the two main peripheral secretory products of the hypothalamic-pituitary-adrenal stress-neuroendocrine axis. The diurnal pattern of cortisol secretory activity has been well characterised. Various aspects of this pattern have been related to time of awakening, light exposure, psychological dimensions of affect, immune function and systemic health and well-being. DHEA is also an important adrenocortical steroid whose secretory activity has been related to immune function, psychological and health variables. The most pronounced feature of the diurnal cortisol cycle is a burst of secretory activity following awakening with a diurnal decline thereafter. We mapped DHEA secretory activity onto this cycle by measuring both steroids in saliva samples collected at distinct time points over the diurnal cycle, synchronised to awakening. Both steroids, particularly DHEA, showed stability across days of sample collection. A main distinction between cortisol and DHEA was that although DHEA was elevated in post-awakening samples compared with later in the day there was no evidence of an awakening stimulatory burst of DHEA secretory activity. Although DHEA in many respects paralleled cortisol secretory activity there was some dissociation; mean levels were positively but not tightly correlated. The secretory pattern of DHEA is very stable whereas cortisol secretory activity seems more sensitive to day-to-day variability.

The P23T Cataract Mutation Causes Loss of Solubility of Folded γD-Crystallin

Mutations in the human gammaD-crystallin gene have been linked to several types of congenital cataracts. In particular, the Pro23 to Thr (P23T) mutation of human gammaD crystallin has been linked to cerulean, lamellar, coralliform, and fasciculiform congenital cataracts. We have expressed and purified wild-type human gammaD, P23T, and the Pro23 to Ser23 (P23S) mutant. Our measurements show that P23T is significantly less soluble than wild-type human gammaD, with P23S having an intermediate solubility. Using synchrotron radiation circular dichroism spectroscopy, we have determined that the P23T mutant has a slightly increased content of beta-sheet, which may be attributed to the extension of an edge beta-strand due to the substitution of Pro23 with a residue able to form hydrogen bonds. Neither of the point mutations appears to have reduced the thermal stability of the protein significantly, nor its resistance to guanidine hydrochloride-induced unfolding. These results suggest that insolubility, rather than loss of stability, is the primary basis for P23T congenital cataracts.

The effect of dawn simulation on the cortisol response to awakening in healthy participants

Bright light exposure after awakening has been shown to elevate cortisol levels in healthy participants. The present study examined the effect of dawn simulation (a treatment for seasonal affective disorder) on the cortisol response to awakening and mood. Twelve healthy participants were supplied with a dawn simulator (The Natural Alarm Clock, Outside In, Cambridge Ltd), a bedside light that increases in intensity prior to awakening to approximately 250 lux over 30 mins when an audible alarm sounds. A counterbalanced study was performed on 4 consecutive normal weekdays, two of which were control days (no dawn simulation) and two experimental (dawn simulation). Saliva samples were taken immediately on awakening then at 15, 30 and 45 minutes post awakening on all 4 study-days. Total cortisol production during the first 45 mins after awakening was found to be significantly higher in the experimental condition than in the control condition. Participants also reported greater arousal in the experimental condition and there was a trend for an association between increased arousal and increased cortisol secretory activity under dawn simulation. This study provides supportive evidence for the role of light and the suprachiasmatic nucleus in the awakening cortisol response.

The awakening cortisol response: methodological issues and significance

The awakening cortisol response (ACR) is a discrete and distinctive part of the cortisol circadian cycle. In healthy adults salivary free cortisol concentrations increase by between 50 and 160% in the first 30 min immediately post-awakening (approximate average increase of 9 nmol/l, range 4-15 nmol/l, estimated to be equivalent to about three secretory episodes). However there are no agreed norms for the absolute concentrations of free cortisol in saliva either immediately post-awakening (range of 4.7-18.5 nmol/l) or 30 min post-awakening (range of 8.6-21.9 nmol/l). This review explores reasons for these discrepancies in normative data including confounding factors such as gender, age, awakening time, light and participant adherence. Although the physiological role of the ACR has not been clearly defined evidence is discussed that suggests it is under a distinct regulatory influence, different from the rest of the diurnal cortisol secretory cycle. Despite the difficulties associated with its measurement a range of studies have demonstrated an association between the ACR and psychosocial variables, stress and health. However it remains unclear whether positive affect and good health are consistently associated with larger or smaller awakening responses. It is early days in the search for the role and significance of the ACR. Its putative role in the regulation of physiological function across the day (e.g. the immune system) and its sensitivity to psychosocial variables make it a prime candidate as an intermediary linking mind and health.

Fixed dose combinations for tuberculosis: Lessons learned from clinical, formulation and regulatory perspective

Worldwide, tuberculosis (TB) remains one of the most important communicable diseases in terms of morbidity and mortality. Its control requires multi-drug therapy for at least six months, which could lead to patient non-compliance, failure of therapy and ultimately resulting in the emergence of drug resistance. Fixed dose combinations (FDCs) in TB therapy reduce the number of tablets to be consumed and thereby increase patient compliance with recommended treatment regimens. Thus, FDCs play a significant role in preventing the emergence of drug resistance and successful treatment. However, the quality of FDCs with respect to variable bioavailability and their registration requirements are major hurdles to their implementation in national TB control programs. It is anticipated that a large global market for FDCs will encourage large-scale production and increased competition, which in turn will result in FDCs at affordable prices. The Global Drug Facility (GDF), established by the World Health Organization (WHO), aims to ensure universal uninterrupted access to quality TB drugs for implementation of directly observed treatment short-course (DOTS) in resource-poor countries. In this program, four FDCs were accepted as the drugs of first choice because of their obvious advantages in controlling TB. This demands the necessity of addressing quality and registration requirements of FDCs systematically. In light of this current knowledge on anti-TB FDCs, their dosage, combinations, available clinical studies and the experiences with TB therapy has been discussed in this article, which should serve as lessons for selection of appropriate FDCs for other diseases such as malaria and AIDS.