Stresshyperglykämie bei kranken Katzen: Eine retrospektive Studie über 4 Jahre

Between January 1997 and December 2000 blood glucose concentrations were measured in 2278 sick cats at the time of their initial presentation at the hospital. In 827 cats (36%) hyperglycemia (blood glucose >8 mmol/l) was documented, 1388 cats (61%) had normal blood glucose levels, 63 cats (3%) were hypoglycemic. In 674 of 827 cats (81.5%) no further investigations were performed and the veterinarian judged the hyperglycemia to be stress related. In 153 of the 827 cats (18.5%) blood glucose measurements were repeated and/or serum fructosamine concentrations evaluated. In 106 cats (69%) stress hyperglycemia and in 47 (31%) diabetes mellitus was then diagnosed. Blood glucose concentrations in cats with stress hyperglycemia were between 8.1 and 60.4 mmol/l (Median 10.3), in cats with diabetes mellitus between 8.5 and 70.0 (Median 27.7). Blood glucose concentrations in cats with diabetes mellitus were significantly higher than in cats with stress hyperglycemia. Cats with stress hyperglycemia suffered from a variety of different diseases, the most frequently encountered were surgical problems, neoplasia, heart diseases, upper and lower urinary tract diseases. Blood glucose concentrations in cats with heart diseases and in cats with neoplasia was higher than in cats with other disorders, however, the difference was not significant. Cats with diabetes mellitus were significantly more frequent male castrated than cats with stress hyperglycemia. Cats with stress hyperglycemia were significantly older than cats with normoglycemia.

Biology and therapy of fibromyalgia. Stress, the stress response system, and fibromyalgia

Stress is a state of disharmony, or threatened homeostasis. A stressor could have a psychological origin or a biological origin. Societies have become more intricate with industrialization, and modern individuals try to adapt to the new defiance by forcing their stress response system. The main component of the stress response network is the autonomic nervous system. The present article reviews current knowledge on autonomic dysfunction in fibromyalgia. Sympathetic hyperactivity has been consistently described by diverse groups of investigators. Fibromyalgia is proposed to be a sympathetically maintained neuropathic pain syndrome, and genomic data support this contention. Autonomic dysfunction may also explain other fibromyalgia features not related to pain.

IACUC issues associated with amphibian research

Numerous species of amphibians are frequently utilized as animal models in biomedical research. Despite their relatively common occurrence as laboratory animals, the regulatory guidelines that institutional animal care and use committees (IACUCs) must employ provide little in the way of written standards for ectothermic animals. Yet, as vertebrates, laboratory amphibians are covered by the National Research Council Guide for the Care and Use of Laboratory Animals and the Public Health Service (PHS) Policy for federally funded research. This article focuses on three issues that are relevant to IACUC oversight of the use of amphibians in research: (1) recommended educational requirements of investigators and animal care staff engaged in research with amphibians, (2) zoonoses and other issues of occupational health importance, and (3) indicators of stress and disease. Addressing these issues should enable investigators, IACUCs, and animal care staff to meet the regulatory expectations of the PHS and accrediting bodies such as the Association for Assessment and Accreditation of Laboratory Animal Care International.

The relationship between stress and hair cortisol in healthy pregnant women

PURPOSE

Stress has been shown to cause a large range of adverse fetal effects. This pilot study is the first attempt to examine cortisol level in the hair of pregnant women and assess its potential as a biomarker of gestational stress.

PATIENTS AND METHODS

Twenty-five healthy pregnant women, in whom hair cortisol levels and the Perceived Stress Scale (PSS) were measured and correlated.

RESULTS

Maternal hair cortisol levels, ranging between 0.06 and 0.23 nmol/g of hair correlated positively and significantly with measures of perceived stress (ranging between 2-22); (Rs=0.47) (P < 0.05).

CONCLUSIONS

Our findings corroborate recent primate studies with induced stress, and suggest that hair cortisol is a potential biomarker of chronic stress in pregnancy. This new long term biological marker may have important implications in research and clinical practice.

Methods to quantify intermittent exercises

The purpose of this study was to quantify intermittent training sessions using different types of exercise. Strength, sprint, and endurance sessions were performed until exhaustion. These sessions were quantified by the product of duration and heart rate (HR) (i.e., training impulse (TRIMP) and HR-zone methods), by the product of duration and rate of perceived exertion (RPE-based method), and a new method (work endurance recovery (WER)). The WER method aims to determine the level of exercise-induced physiological stress using the ratio of cumulated work - endurance limit, which is associated with the naparian logarithm of the ratio of work-recovery. Each session's effects were assessed using blood lactate, delayed onset muscle soreness (DOMS), RPE, and HR. Because sessions were performed until exhaustion, it was assumed that each session would have a similar training load (TL) and there would be low interindividual variability. Each method was used to compare each of the TL quantifications. The endurance session induced the higher HR response (p < 0.001), the sprint session the higher blood lactate increase (p < 0.001), and the strength session the higher DOMS when compared with sprint (p = 0.007). TLs were similar after WER calculations, whereas the HR- and RPE-based methods showed differences between endurance and sprint (p < 0.001), and between endurance and strength TL (p < 0.001 and p < 0.01, respectively). The TLs from WER were correlated to those of the HR-based methods of endurance exercise, for which HR was known to accurately reflect the exercise-induced physiological stress (r = 0.63 and r = 0.64, p < 0.05). In addition, the TL from WER presented low interindividual variability, yet a marked variability was observed in the TLs of HR- and RPE-based methods. As opposed to the latter two methods, WER can quantify varied intermittent exercises and makes it possible to compare the athletes' TL. Furthermore, WER can also assist in comparing athlete responses to training programs.

Caregiver burden in multiple sclerosis: the impact of neuropsychiatric symptoms

BACKGROUND

We studied the level of distress in caregivers of patients with recently diagnosed multiple sclerosis (MS), and their relation to clinical characteristics.

METHODS

Caregivers of patients with MS and Parkinson's disease completed measures of distress and quality of life. MS patients underwent neurological, neuropsychiatric and neuropsychological examinations. Multivariate regression analyses were used to explore the relationship between patient variables and caregiver distress.

RESULTS

Caregivers of patients with MS experienced high levels of distress and reduced quality of life related to caregiving. The level of distress was similar to that reported by elderly spouses of patients with longstanding Parkinson's disease. Psychiatric symptoms and cognitive impairment in patients with MS were associated with caregiver's distress and quality of life, even after controlling for level of disability (all p values <0.01). Patients' physical impairment was associated with caregiver distress, but not with caregiver quality of life.

CONCLUSION

Caregivers of patients with MS experience high levels of distress and reduced quality of life. Psychiatric symptoms and cognitive impairment contributed significantly to caregiver distress, over and above the effect of disability due to neurological symptoms.

Extremity movements help occupational therapists identify stress responses in preterm infants in the neonatal intensive care unit: a systematic review

BACKGROUND

Accurate assessment and treatment of pain and stress in preterm infants in neonatal intensive care units (NICU) is vital because pain and stress responses have been linked to long-term alterations in development in this population.

PURPOSE

To review the evidence of specific extremity movements in preterm infants as observed during stressful procedures.

METHODS

Five on-line databases were searched for relevant studies. For each study, levels of evidence were determined and effect size estimates were calculated. Each study was also evaluated for specific factors that presented potential threats to its validity.

RESULTS

Eighteen studies were identified and seven comprised the review. The combined sample included 359 preterm infants. Six specific movements were associated with painful and intrusive procedures.

CLINICAL IMPLICATIONS

A set of specific extremity movements, when combined with other reliable biobehavioural measures of pain and stress, can form the basis for future research and development of a clinical stress scale for preterm infants.

Cognitive activation theory of stress, sensitization, and common health complaints

According to the cognitive activation theory of stress (CATS), a formal system of systematic definitions, the term "stress" is used for stress stimuli, the stress experience, the nonspecific, general stress response, and the experience of the stress response. The stress response is normal, healthy, and necessary alarm. If sustained there may be a risk of illness and disease. The level and duration of the alarm depend on the expectancy of the outcome of stimuli and the specific responses available for coping. The most common health complaints are subjective health complaints like muscle pain, tiredness and mood changes. These are normal aches of short duration and low intensity for most people. For some the pains and complaints are substantial and longlasting with serious implications for functioning. There are no sharp or obvious limits in the distribution of health complaints, separating "normal" and endurable pain and complaints, and intolerable complaints that need professional help. These conditions are most often unspecific, and are the most common reason for encounters with health professionals, and the most frequent reason for sick leave and disability. There is a striking comorbidity for all these conditions. This may be explained by psychobiological sensitization within neural loops, maintained by sustained activation, which has been suggested as a mechanism for these conditions.

Neurophysiologic methods to measure stress during survival, evasion, resistance, and escape training

Training in Survival, Evasion, Resistance, and Escape (SERE) is required for U.S. military members at high risk of capture. This physically and psychologically demanding course is considered an analog to the stress imposed by war, captivity, and related events, thus offering a unique and unprecedented medium in which to systematically examine human stress and performance during a realistically intense operational context. Operational stress is multifaceted, manifesting cerebral, neuroendocrine, cardiac, and cognitive characteristics, and necessitating an integration of multiple methods of measurement to appropriately characterize its complexity. Herein we describe some of our present research methods and discuss their applicability to real-time monitoring and predicting of key aspects of human performance. A systems approach is taken, whereby some of the "key players" implicated in the stress response (e.g., cerebral, neuroendocrine, cardiac) are briefly discussed, to which we link corresponding investigative techniques (fMRI, acoustic startle eye-blink reflex, heart rate variability, and neuroendocrine sampling). Background and previous research with each investigative technique and its relationship to the SERE context is briefly reviewed. Ultimately, we discuss the operational applicability of each measure, that is, how each may be integrated with technologies that allow computational systems to adapt to the performer during operational stress.

Potential paradigm for assessments of biomedical technologies in the operational environment

The U.S. Army Medical Research and Materiel Command Cognitive Performance, Judgment, Decision-making Research Program (CPJDRP) was initiated in part to prevent/mitigate performance shortfalls associated with cognitive-psychological combat stressors such as workload, fatigue, sleep, and nutritional aspects. An Operational Processes and Cognitive Mapping Focus Team (OPCMFT) was established for the purposes of integrating laboratory-based research into operational environments, embedding metrics into appropriate operational platforms, and providing an operational perspective to research that may veer off pragmatic and utilitarian courses. The OPCMFT's goal as originally formulated in 2004 was to determine operational requirements and test environments for evaluating cognitive performance metrics and models, pharmacological countermeasures, and neurocognitive monitors for the purpose of sustaining warfighter cognitive performance in operational environments (2). This preface first reviews the OPCMFT's major deliverables as developed from the CPJDRP workshop in 2005 (6). Next, a gap/needs analysis of cognitive research products and test and evaluation platforms is presented. Lastly, a summary of each of the three articles-one on the role and mitigation of stress, a second on the development of intellectual ability norms and statistical methods to interpolate an individual's post-morbid capabilities, and a third on a specific measure to assess physiological reactions to cognitive stressors--illustrates how each contributes to the effort to help improve warfighter cognitive performance. The preface authors emphasize the need for an integrated research program focused on the Battle Laboratory (1) with a solid infrastructure and an integration of the operational end-user, human factors, medical practitioners, and research and development expertise.

Ischemic heart disease

Because of changing demographics, increasing numbers of patients with IHD are presenting for noncardiac surgery, and the risks of perioperative morbidity and mortality are significant. The Lee Cardiac Risk Index is applicable in defining perioperative cardiac risk: however, ACC/AHA guidelines may not be applicable comprehensively. The role of biomarkers in risk stratification still needs to be defined. Structured management protocols that help assess, diagnose, and treat patients with IHD preoperatively are likely to help decrease postoperative morbidity and mortality, but clearly are not applicable to all patients. Augmented hemodynamic control with beta-blockers or alpha-2 agonists and modulating inflammation by statins can play an important role in improving outcomes in many patients with IHD; preoperative coronary revascularization may be of limited value. Intraoperative anesthetic management that minimizes hemodynamic perturbations is important; however, the choice of a particular technique typically is not critical. Of critical importance is the postoperative management of the patient. Postoperative myocardial injury should be identified, evaluated, and managed aggressively. Secondary stresses such as sepsis, extubation, and anemia, which can increase demand on the heart, should be treated or minimized. Clearly, optimal care of the patient with IHD entails closely coordinated assessment and management throughout the preoperative, intraoperative, and postoperative phases, if one is to optimize short- and long-term outcomes.

Surgical stress index reflects surgical stress in gynaecological laparoscopic day-case surgery

BACKGROUND

Monitoring of analgesia remains a challenge during general anaesthesia. The surgical stress index (SSI) is derived from the photoplethysmographic waveform amplitude and the heart beat-to-beat interval. We evaluated the ability of SSI to measure surgical stress in patients undergoing gynaecological laparoscopy. Our hypothesis was that while keeping State Entropy (SE) at a predetermined level, SSI would be higher in patients receiving a beta-blocking agent (esmolol) than in those receiving an opioid (remifentanil) during laparoscopy.

METHODS

Thirty women undergoing gynaecological laparoscopy were assigned randomly to receive esmolol (n = 15) or remifentanil (n = 15). Anaesthesia was induced with propofol and fentanyl and maintained with desflurane and nitrous oxide 50% in oxygen to keep SE at 50(5). The infusion of esmolol or remifentanil was started before laparoscopy and adjusted to keep the systolic blood pressure at -20 to +10% from the preoperative value.

RESULTS

During the fentanyl phase, before surgery, both groups behaved similarly, with an increase in SSI after intubation. In the patients receiving esmolol, the SSI reacted to the initial incision (P < 0.05), and remained high after trocar insertion (P < 0.05). In patients receiving remifentanil, it did not react to the initial incision, but increased after trocar insertion (P < 0.05), and it remained lower both after incision (P < 0.05) and after trocar insertion (P < 0.05).

CONCLUSION

SSI was higher in patients receiving esmolol. The index seems to reflect the level of surgical stress and may help guide the use of opioids during general anaesthesia.

Salivary cortisol response in mother-infant dyads at high psychosocial risk

OBJECTIVES

The aim of the present study was to investigate the adrenocortical response to diaper change in mother-infant dyads with psychosocial risk factors.

MATERIAL AND METHODS

Twenty-two mother-infant pairs with well-defined psychosocial problems were included. The mother-infant pairs were treated for 6 weeks in a daycare programme to improve attachment. Salivary cortisol was measured before and after a diaper change during the first and last weeks of enrollment in the programme. Mothers' sensitivity towards their infants' signals was measured using a scale from 1 (highly insensitive) to 9 (highly sensitive) according to Ainsworth.

RESULTS

Median salivary cortisol increased in 15 out of 22 infants after the first diaper change. The increase was most pronounced in the group of infants below 3 months of age (n = 15) where median salivary cortisol increased 170% after the first diaper change (P < 0.05) and decreased 19% after the last diaper change (not significant). Out of these 15 infants, 11 showed an increase in salivary cortisol in response to the first diaper change while four out of 15 did so in response to the last diaper change (P < 0.05). The salivary cortisol response did not change over time in infants aged 3 months or above. A mother's sensitivity to her child increased significantly (P < 0.001) from the first to the last week. In mothers, median salivary cortisol decreased 38% after the first diaper change (P < 0.05) and 57% after the last diaper change (P = 0.001).

DISCUSSION

A diaper change is normally not perceived as stressful. The stress response caused by a diaper change may illustrate an insufficiency in the mother-infant relationship before treatment. Professional support improved the mothers' sensitivity and stabilized the stress response to diaper change in the youngest infants.

Assessment of surgical stress during general anaesthesia

BACKGROUND

Inadequate analgesia during general anaesthesia may present as undesirable haemodynamic responses. No objective measures of the adequacy of analgesia exist. We aimed at developing a simple numerical measure of the level of surgical stress in an anaesthetized patient.

METHODS

Sixty and 12 female patients were included in the development and validation data sets, respectively. All patients had elective surgery with propofol-remifentanil target controlled anaesthesia. Finger photoplethysmography and electrocardiography waveforms were recorded throughout anaesthesia and various waveform parameters were extracted off-line. Total surgical stress (TSS) for a patient was estimated based on stimulus intensity and remifentanil concentration. The surgical stress index (SSI) was developed to correlate with the TSS estimate in the development data set. The performance of SSI was validated within the validation data set during and before surgery, especially at skin incision and during changes of the predicted remifentanil effect-site concentration.

RESULTS

SSI was computed as a combination of normalized heart beat interval (HBI(norm)) and plethysmographic pulse wave amplitude (PPGA(norm)): SSI = 100-(0.7*PPGA(norm)+0.3*HBI(norm)). SSI increased at skin incision and stayed higher during surgery than before surgery; SSI responded to remifentanil concentration changes and was higher at the lower concentrations of remifentanil.

CONCLUSIONS

SSI reacts to surgical nociceptive stimuli and analgesic drug concentration changes during propofol-remifentanil anaesthesia. Further validation studies of SSI are needed to elucidate its usefulness during other anaesthetic and surgical conditions.

[Experiences from a stress clinic. A pilot study]

INTRODUCTION

The aim of the study was to develop a multi-disciplinary stress management program for employees with long-term stress.

METHODS

In a two-year period, 66 people active in the labour market were referred to the stress clinic at an occupational medicine clinic. All but 10 went through the program for four months and were further evaluated after one year regarding employment, symptoms and salivary cortisol. The program consisted of 1) an evaluation of symptoms of depression and stress, 2) stress management consultations, 3) introduction to relaxation techniques and physical exercise and 4) in some cases contact to the work place for adjustments or referral to psychiatric evaluation. Physiological measures such as maximal oxygen uptake, blood pressure, cholesterol, HDL, TSH, HbA1C, fasting glucose and fibrinogen were carried out at baseline and after four months. Salivary cortisol was measured at baseline, after four months and one year. As a control group 24 people with similar symptoms referred to the Clinic of Occupational Medicine were used.

RESULTS

A significantly larger number of people in the study group (82%) than in the control group (42%) were employed after one year. There was no difference between the two groups regarding the prevalence of stress symptoms during the follow-up period, even though the prevalence decreased significantly. However, the prevalence of depression was significantly lower after one year in the study group (4%) compared to the control group (40%). Maximum oxygen uptake increased and fibrinogen decreased significantly in four months. The rise in salivary cortisol from awakening until 30 minutes later increased significantly during one year and correlated with symptoms of depression.

Salivary cortisol in preterm infants: Validation of a simple method for collecting saliva for cortisol determination

BACKGROUND AND AIMS

The increased use of salivary cortisol as a biomarker of stress and/or diurnal rhythms has facilitated research of Hypothalamic-pituitary-adrenocortical (HPA)function. Saliva collection remains problematic with preterm infants. The twofold purpose of this study is to 1) establish validity of the filter paper method for saliva collection and 2) apply the filter paper method for saliva collection to preterm infants.

DESIGN AND MEASURES

Whole saliva was collected from six normal adult subjects to create a pool. Validation measures included comparison of levels obtained from whole saliva and filter paper, an evaluation of storage effects, assessing spiking recovery, and measurement of linearity of dilution. In the application study, saliva was collected every three hours, before feedings for three consecutive days from 26 hospitalized preterm infants. Diurnal variation in cortisol was examined using hierarchical linear modeling and individual calculation of diurnal pattern using an accepted technique.

RESULTS

Validation studies revealed acceptable recovery of whole saliva from filters, no effect of room temperature storage of filters for up to six months, and acceptable linearity of dilution up to 4. Saliva from preterm infants was easily collected. Only 2% of the samples were lost due to inadequate wetting of the filters. An inverse association was found between postconceptional age and one-minute APGAR scores and infant cortisol levels. Variable daily cortisol patterns and no discernable rhythm were found for this sample; however, four infants appeared to show atypical diurnal pattern.

CONCLUSIONS

The filter paper method is a valid method of saliva collection that is feasible to use with preterm infants.

Comparison of skin conductance with entropy during intubation, tetanic stimulation and emergence from general anaesthesia

BACKGROUND

The number of skin conductance fluctuations (NSCF) expresses sympathetic skin nerve activity. The response entropy (RE) measures electromyographic and electroencephalographic activity in the forehead. The state entropy (SE) measures mainly electroencephalographic activity. When the suppression of frontal muscular activity is complete, RE is equal to SE. RE-Delta is defined as SE minus RE. The purposes of this study were to examine whether NSCF and RE-Delta correlate with signs of clinical stress during intubation and tetanic noxious stimulation and to elucidate how rapidly and accurately entropy and NSCF react during emergence from general anaesthesia.

METHODS

Twenty women scheduled for gynaecological laparotomy were studied. During intubation in remifentanil and propofol general anaesthesia, NSCF and RE-Delta were correlated with the clinical stress score. After a wash-out period, two series of tetanic stimuli were given, the first with (R+) and the second without (R-) remifentanil infusion. The tetanic pre-stimuli periods were compared with the tetanic post-stimuli periods, and R+ was compared with R-. During emergence, the responses of entropy and skin conductance were related to the time of extubation.

RESULTS

NSCF correlated well with the clinical stress score during intubation (r(2)= 0.73, P < 0.0005). RE-Delta showed a weaker correlation (r(2)= 0.33, P= 0.007). During tetanic stimuli, the NSCF pre-stimuli level was lower than the post-stimuli level (P < 0.001), and the NSCF R+ response was lower than the NSCF R- response (P= 0.002). RE-Delta did not show similar differences. During emergence, RE reacted before NSCF and SE (P= 0.003).

CONCLUSION

NSCF was better than RE-Delta for the measurement of clinical stress during intubation, and was sensitive to tetanic stimuli at different opioid analgesic levels, by contrast with RE-Delta. Both modalities were able to predict emergence at the end of anaesthesia, but RE was more rapid.

Assessment of slow-breathing relaxation technique in acute stressful tasks using a multipurpose non-invasive beat-by-beat cardiovascular monitoring system

Recently, several studies revealed that daily slow-breathing exercise lowered blood pressure and increased baroreflex sensitivity. With this interesting finding, we have been contemplating to design a compact breath-controllable device for relaxation to stress reaction during daily living for home as well as ambulatory use, as a final goal, towards reduction of cognitive hemodynamic disorders, hypertension, and acute stress-induced hemodynamic disorders. The present study thereby describes, as a first step, to design a prototype system combining a compact multipurpose non-invasive beat-by-beat cardiovascular monitor developed previously with a wrist-type vibrator to make a respiration rhythm, and to assess an effect of slow-breathing relaxation on the cardiovascular hemodynamics in response to acute stressful conditions. The cardiovascular hemodynamic monitor can measure beat-by-beat systolic (SBP), mean (MBP) and diastolic (DBP) pressure in a finger based on the volume-compensation method, cardiac output (CO) by the electrical admittance method and the other hemodynamic-related parameters (e.g., total peripheral resistance (TPR=MBP/CO), heart rate (HR), respiratory rate, pulse wave velocity, etc.). The wrist-type vibrator can give various breathing rhythms quietly to a subject using a small vibration motor. The stressful tasks loaded to healthy volunteers (3 males, 23-34 yrs.) in the experiments were cold pressor and arithmetic ones as a representative of daily passive and active coping tasks, respectively, under conditions with (respiratory rate of 6 1/min) and without breath control.. The results showed that the slow-breathing technique could have a significant effect on improvement of the hemodynamic changes following the acute stressful tasks, especially in the passive coping task.

Is a nappy change stressful to neonates?

OBJECTIVES

Infants in neonatal intensive care (NICU infants) are often cared for in a stressful environment that includes potentially painful or stressful interventions. The aim was to investigate whether NICU infants have different pattern of stress and pain responses than healthy newborns when challenged by a non-painful everyday care routine.

METHODS

NICU infants born at 23-38 weeks gestation (n=39) were compared to healthy full-term newborns (n=30). Cortisol concentrations in saliva were determined before and 30 min after a standardised nappy change. The premature infant pain profile (PIPP) and the neonatal infant pain scale (NIPS) were evaluated before, during, directly after, 3 min after, and 30 min after the nappy change. The investigation was performed on two different occasions, first between postnatal days 2-7 and then between postnatal days 10-18.

RESULTS

NICU infants had higher median baseline salivary cortisol levels compared to full-term newborns on both occasions (17.1 nmol/L vs. 6.2 nmol/L p<0.01 and 8.5 nmol/L vs. 2.4 nmol/L p<0.01, respectively). Salivary cortisol decreased in response to the second nappy change in NICU infants (p=0.01). NICU infants had higher PIPP scores during both nappy changes (p<0.001 for both occasions) and more sustained increases in PIPP and NIPS up to 30 min after the nappy changes compared to full-term newborns.

CONCLUSIONS

NICU infants have higher baseline salivary cortisol than healthy full-term newborns. There is a change in baseline cortisol by age in both groups. Full-term infants as well as NICU infants show an increased pain response to a standardised nappy change.

Skin conductance as a measure of pain and stress in hospitalised infants

BACKGROUND

Reliable and valid methods of measuring pain responses in infants continue to be sought as a means of evaluating the effectiveness of pain reduction strategies. Skin conductance has recently been shown to be a promising physiological indicator of pain and stress in premature and term infants.

AIM

To evaluate changes in skin conductance in hospitalised infants under different environmental conditions and during both painful and non-painful procedures.

METHODS

Measurements of skin conductance activity were made in infants under three different environmental temperature conditions (open cot, incubator and overhead radiant heater), during the routine non-painful nursing procedure of either nappy change or oral feeding, and whilst undergoing the painful procedure of heel lancing for blood sampling.

RESULTS

Skin conductance activity in 21 infants was studied on 43 separate occasions. Skin conductance activity was highly variable between infants but did not differ significantly under the three environmental conditions. Routine nursing care did not result in a significant increase in skin conductance activity above baseline; however, on cessation of care there was a significant reduction to levels below baseline (p < 0.05). Conversely, during the heel lance procedure, skin conductance activity significantly increased upon lance (p < 0.05) and remained elevated following completion of the procedure. There were no statistically significant differences between skin conductance activity changes from baseline as a result of routine nursing care compared to that of the heel lance procedure.

CONCLUSION

Due to large variability in skin conductance activity further studies are needed before this technology can be recommended as a clinically useful indicator of pain and stress in neonates.

Revalidation of the postpartum stress scale

AIMS AND OBJECTIVES

The purpose of this study was to test further and validate the postpartum stress scale developed for Taiwanese women.

BACKGROUND

The postpartum stress scale was developed to measure postpartum stress in Taiwanese women. However, over the last decade, the social context in Taiwan has changed and several items in the scale needed to be re-examined.

DESIGN

Non-experimental quantitative research with repeated measures at the first and fifth week of the postpartum period was conducted for this study.

METHODS

A proportional stratified quota was used to sample from the 10 hospitals and six clinics with the highest birth rates in Kaohsiung, Taiwan. Participants were 505 and 518 postpartum women at each time point, respectively.

RESULTS

Factor analysis at two points in time identified three attributes of postpartum stress: (a) maternal role attainment, (b) lack of social support, and (c) negative body changes. The Cronbach's alphas at each time point were 0.94 and 0.92, respectively.

CONCLUSIONS

The results support the postpartum stress scale as a validated instrument that has been conceptualized, created, and tested with Taiwanese postpartum women.

RELEVANCE TO CLINICAL PRACTICE

This study was done in the hope that women experiencing specific postpartum stressors would be detected and subsequently helped by supportive nursing intervention that provides stressor-specific coping resources.

Mass spectrometric profiling - a diagnostic tool in fish?

The development of rapid and sensitive diagnostic tools to assess the effect of stressors on organisms is a principal objective of environmental proteomics. This study is focused on evaluating the potential of using surface-enhanced laser desorption/ionisation time-of-flight mass spectrometry (SELDI-TOF MS) to assess stress in Atlantic salmon (Salmo salar). Plasma and mucus samples were taken from fish that had previously been maintained in a range of high density conditions, together with control fish maintained under low density conditions. Samples were collected during the post-density stress period for protein profile analysis. The mass spectra were analysed to evaluate reproducibility and to search for condition specific changes in protein expression. Multivariate analysis of the peak relative intensity data indicated a segregation of the data into three entities in accordance with the density level fish had been subjected to during the density stress period. This segregation was seen in both plasma and mucus data.

Analysis of endogenous cortisol concentrations in the hair of rhesus macaques

Short-term changes in activity of the hypothalamic-pituitary-adrenocortical (HPA) system are routinely assessed by measuring glucocorticoid or metabolite concentrations in plasma, saliva, urine, or feces. However, there are no current methods for determining long-term (i.e., weeks or months) activity of this system. Herein, we describe the development and validation of a simple procedure for measuring cortisol concentrations in the hair of rhesus macaques. This procedure involves two brief isopropanol washes of the hair strands to remove surface contaminants, subsequent powdering of the washed and dried hair, a 24-h methanol extraction followed by evaporation of the solvent and reconstitution of the extract in assay buffer, and finally analysis of the extracted cortisol by a sensitive and specific enzyme immunoassay. Our results confirm the specificity of the procedure for cortisol, show that proximal and distal segments of hair do not differ in their cortisol concentration, and demonstrate that a significant and prolonged stressful experience produces a significant increase in hair cortisol. This new procedure should be valuable for assessing baseline HPA activity in nonhuman primates (and, with appropriate validation, in other species as well) over relatively long periods of time, and also for monitoring chronic stress that might be associated with various experimental manipulations.

Entspannung für Tinnitusbetroffene durch Photostimulation

The therapeutic effect of applying photic stimulation was evaluated in a sample of 17 patients with chronic tinnitus. The employed optical stimulation technique triggers the activity of brain waves and induces deep relaxation characterized by increased EEG activity in the theta and delta spectrum. The expected therapeutic effect beyond relaxation was a decrease in subjective tinnitus distress and further improvements in well-being. All patients received ten applications of photic stimulation, each lasting 30 min. Every application markedly increased the peripheral blood circulation, thus indicating a relaxation effect. The emotional and cognitive impairments as well as the subjective tinnitus distress significantly decreased during treatment while sleep disturbances showed a tendency towards improvement. Overall, tinnitus distress markedly decreased and general well-being improved. The photic stimulation technique is proposed as a relief for tinnitus patients who do not respond to conventional relaxation techniques.

Stress monitoring of ambulance personnel during work and leisure time

OBJECTIVES

The aim of the present study was to assess physiological and subjective stress markers during a 24-h ambulance work shift and during the next two work-free days, and relate these parameters to self-reported health complaints.

METHODS

Twenty-six ambulance personnel were followed during a 24-h work shift and during the next two work-free days with electrocardiogram, cortisol assessments and diary notes. The ambulance personnel also performed tests of autonomic reactivity before and at the end of the work shift. The subjects were categorized into two groups according to their number of health complaints.

RESULTS

In general, stress markers did not show differences between the work shift and leisure time. However, a modest deviation in heart rate variability pattern and higher morning cortisol values during work in comparison with work-free days were observed in personnel with many health complaints.

CONCLUSIONS

Subjective and physiological characteristics of ambulance personnel did not indicate distinctive stress during the 24-h work shift. Relationships between frequent health complaints and specific work-related factors require further prospective studies.

The effects of Guillain–Barré syndrome on the close relatives of patients during the first year

OBJECTIVE

To study the impact of Guillain-Barré Syndrome (GBS) on the psychosocial functioning of the closest relative and on family functioning during the first year after GBS.

METHOD

At 1 (=T1), 3 (=T3), 6 (=T6), and 12 months (=T12) after the onset of GBS, relatives of patients received the General Health Questionnaire (GHQ28) and the Family Assessment Device (FAD). Sixty-three relatives returned the GHQ28 at all four designated intervals. At T1 the relatives also received a questionnaire that contained questions on the impact on their daily life. The answers to these questions yielded a Daily Living Impact index. From the 110 relatives, 86 returned this questionnaire.

RESULTS

72% of the 86 relatives reported one or more problems in daily living. At T1 the scores of the GHQ subscales ranged from normal to mildly disturbed. The relatives showed significant improvement in their somatic complaints and anxiety during the first half year. Social dysfunction remained somewhat less than normal, severe depression was not found. At T1 and T3 the scores of the GHQ28 and some subscales differed significantly depending on the severity of the functional status of the patient, but not at T6 and T12. Relatives of patients with severe residua at 1 month score worse on the GHQ28 and most subscales at 6 months. The FAD was normal at all moments measured.

CONCLUSIONS

Psychological morbidity of close relatives is significantly higher in the first months after the onset of GBS. The patient's condition has an important impact on the psychosocial functioning of close relatives. Therefore, a family approach is recommended to neurologist and other medical personnel during the first period of the disease. Also patient support groups may play a beneficial role for the relatives of GBS patients.

Evaluation of a potential stress effect in rat adjuvant arthritis by using a new and efficient plethysmograph

We describe the basis of a new design for a user-friendly and easily reproduced mercury-displacement plethysmograph. This system was validated using the rat adjuvant-induced arthritis model in female Lewis rats. Furthermore, 2 different caging systems were evaluated to ensure that caging did not have an effect on disease progression and severity. These groups were evaluated further under frequent- and infrequent-handling conditions. Housing had less effect on the amount of swelling seen during the disease than did the amount of handling. Frequent handling significantly reduced the degree of paw swelling. Frequently handled, arthritic rats housed 5 rats per cage in the Box B system also lost a biologically significant amount of weight by the end of the study. Therefore, we do not recommend housing more than 4 rats per cage under these conditions.

Strategies for salivary cortisol collection and analysis in research with children

Salivary cortisol has emerged in pediatric research as an easy-to-collect, relatively inexpensive, biologic marker of stress. Cortisol is highly variable and is responsive to a wide range of factors that should be considered when incorporating this measure into research with children. Strategies for sample collection include: (1) standardizing the time for sample collection, including baseline samples; (2) using consistent collection materials and methods; (3) controlling for certain drinks, foods, medications, and diagnoses; and (4) establishing procedures and protocols. Other strategies for laboratory analyses include: (1) selecting the appropriate assay and laboratory; (2) identifying units of measure and norms; and (3) establishing quality controls. These strategies control extraneous variables and produce reliable and valid salivary cortisol results.

Endocrine markers of severity and prognosis in critical illness

The cellular processes that unfold in critical illness involve a variety of circulating substances, that may provide clinically relevant insight into the severity and outcome. Among hormonal markers, cortisol, several thyroid-related substances, as well as natriuretic peptides are discussed in this review. Glucose and lipids constitute metabolic markers, the identification and treatment of the former has been of particular importance. Among immune markers, both proinflammatory and anti-inflammatory cytokines, such as interleukin-6, contribute essential prognostic information. Finally, the complement and coagulation pathways also provide unique insight into this complex and heterogeneous process.

[Serum amyloid A as an effective marker for the assessment of surgical trauma and risk of post-operative complications]

OBJECTIVE

To analyze relations among acute phase reactants in a group of 40 women operated for uterine myom by laparoscopy and open surgery.

DESIGN

Prospective study.

METHODS

Plasma concentrations of C-reactive protein (CRP), serum amyloid A (SAA) and interleukin 6 (IL-6) were measured together with leukocytes in blood before operation, 24 and 72 hours post operation, respectively.

RESULTS

Leukocytes and IL-6 displayed minimal response and decreased quickly after operation to preoperative levels. Concentrations of CRP and SAA remained increased after operation. There were no relationships between leukocytes and acute phase reactants. Normal leukocytes 72 hours post operation were found in 1/3 of women with increased at least one acute phase reactants and in 1/4 of women with increased at least two markers. Typ of surgery, surgical stress and length of surgery were related to the concentration of CRP, IL-6 and SAA.

CONCLUSION

Changes in SAA 24 hours after operation are similar to CRP and IL-6. Surgical stress, length of operation and possible risk 72 hours after operation are best predicted by CRP and SAA (at that time IL-6 and leukocytes are practically normal). Maximal increase was found for SAA concentrations. Thus SAA seems to be suitable marker of early postoperative complications.

Reliability and construct validity of the Malay version of the Job Content Questionnaire (JCQ)

The JCQ has been shown to be a valid and reliable instrument to assess job stress in many occupational settings worldwide. In Malaysia, both the English and validated Malay versions have been employed in studies of medical professionals and laboratory technicians, respectively. The present study assessed the reliability and construct validity of the Malay version of the JCQ among automotive workers in Malaysia. Fifty workers of a major automotive manufacturer in Kota Bharu, Kelantan consented to participate in the study and were administered the Malay version of the JCQ. Translation (English-Malay) and back translation (Malay-English) of the JCQ was made to ensure the face validity of the questionnaire. Reliability was determined using Cronbach's alpha for internal consistency, whilst construct validity was assessed using exploratory factor analysis (principal component with varimax rotation). The results indicate that the Cronbach's alpha coefficients were acceptable for decision latitude (job control or decision authority) (0.74) and social support (0.79); however, it was slightly lower for psychological job demand (0.61). Exploratory factor analysis showed 3 meaningful common factors that could explain the 3 theoretical dimensions or constructs of Karasek's demand-control-social support model. In conclusion, the results of the validation study suggested that the JCQ scales are reliable and valid for assessing job stress in a population working in the automotive industry. Further analyses are necessary to evaluate the stability and concurrent validity of the JCQ.

Stress cardiomyopathy mimicking acute coronary syndrome: case presentation and review of the literature

Stress cardiomyopathy is a novel clinical syndrome affecting predominantly elderly female patients. It is characterized by severe reversible left ventricular dysfunction demonstrating a peculiar pattern of extensive apical wall motion abnormality known as "apical ballooning". The syndrome is typically precipitated by acute severe emotional, psychological or physical stress. It mimics acute coronary syndrome exhibiting typical clinical and electrocardiographic features of acute myocardial infarction. At angiography, however, significant coronary artery disease is invariably excluded. In the acute phase, the syndrome may be complicated by cardiogenic shock or ventricular fibrillation. Clinical data indicate that the disease is associated with an extensive increase of endogenous cathecholamine levels which may exhibit a direct toxic effect on the myocytes causing non-ischemic myocardial "stunning". This mechanism may have important implications for the management of patients in the acute phase of the disease. The prognosis of stress cardiomyopathy, however, seems favorable with recovery of global and regional myocardial function within a few weeks in the vast majority of patients. Yet, long-term outcome data in larger patient populations are lacking. We report the case of a female patient presenting with stress cardiomyopathy and review the current knowledge of the disease.

The Detrimental Effects of Allostasis: Allostatic Load as a Measure of Cumulative Stress

Since its inception in the 1980s, through further developments during the 1990s, and continuing today, the paradigm of allostatic load (AL) has becomed an important paradigm for predicting senescence and mortality. AL is a cumulative measure of the effects of multiple stressors and the process of responding to stressors on the soma. AL measurements of individuals is being tested on various samples and species and being reported across a variety of medical and social science journals. From the ISI Web of Science, all articles published between January 2000 and June 2005 with AL in any default category were obtained and transferred to Endnote. These articles, categorized as theory/review or data-driven, human or animal, and variability in risk factors used to estimate AL, are reviewed here. Only two of 90 reports were published in anthropological journals, likely, at least partly, because research on AL has focused more on western, industrialized populations where data are more easily obtained. From 2000-2005, 12 of 42 data-driven reports focused on elderly humans. Studies of animal models also are common (0 in 2000, but 4 in 2004 covering 21 species). During the last year, multiple additional potential physiological variables have been tested as measures of AL (10 to 20 in any one article). In the past half decade, AL also has been introduced to a wide range of disciplines, including psychology, anthropology, gerontology, veterinary medicine, and medical specialties, as a viable research theme. AL appears to provide a useful method for determining cumulative somatic stress such as that seen with senescence and frailty at older ages.

Stress detection in computer users through non-invasive monitoring of physiological signals

he emerging discipline of Affective Computing pursues the development of computers that could interact with their users taking their affective states into account. For example, if a computer could detect when its user is experiencing stress, it could change the colors and sounds of its user interface to try to calm him/her down. Similarly, the pace of instruction in a computer-based training system could be adapted according to the stress level sensed in the pupil. The research described in this paper aims at the development of a stress detection approach based on automatic monitoring of physiological signals in the computer user. The paper describes the three main aspects of our work: experiment setup for physiological sensing, signal processing to detect the affective state and affective recognition using a learning system. Four signals: Galvanic Skin Response (GSR), Blood Volume Pulse (BVP), Pupil Diameter (PD) and Skin Temperature (ST) are monitored and analyzed to differentiate affective states in the user, in a non-invasive fashion. Results indicate that the physiological signals monitored do, in fact, have a strong correlation with the changes in emotional state of our experimental subjects when stress stimuli are applied to the interaction environment.

The Hypothalamic-Pituitary-Adrenal Axis in Critical Illness

Severe stress, associated with critical illness, activates the hypothalamic- pituitary-adrenal (HPA) axis and stimulates the release of cortisol from the adrenal cortex. Cortisol is essential for general adaptation to stress and plays a crucial role in cardiovascular, metabolic, and immunologic homeostasis. During critical illness, prolonged activation of the HPA axis can result in hypercortisolemia and hypocortisolemia; both can be detrimental to recovery from critical illness. Recognition of adrenal dysfunction in critically ill patients is difficult because a reliable history is not available and laboratory results are difficult to interpret. The review in this article will illustrate how adrenal dysfunction presents in critically ill patients and how appropriate diagnosis and management can be achieved in the critical care setting.

Differentiation of somatizing patients in primary care: why the effects of treatment are always moderate

The heterogeneity of somatizing patients influences outcomes, especially in unselected samples in primary care. A cluster analysis was performed as secondary analysis on an existing data set of 127 somatizing patients included in a randomized controlled clinical trial. Anxiety and depression (HADS), number and intensity of physical symptoms (SOMS), physical and emotional functioning (short form of the SF-36 Health Survey), health beliefs (KKU-G), and psychological distress (General Health Questionnaire) were used for clustering. Outcome, treatment satisfaction, and diagnosis were calculated and compared for the clusters. We differentiated three groups from this analysis: one with elevated emotional and physical stress, one in which emotional stress dominated, and one with low emotional and physical stress. The three groups did not differ in diagnoses of somatoform disorders. The high-stress groups improved over time, whereas the depression and emotional-functioning scores in the low-stress group deteriorated. All patients were satisfied with the treatment provided. Deterioration in the scores of the low-stress group may be a result of a clinically valuable change process, in that patients who were initially in denial were able to open up and admit their problems. The increased satisfaction with treatment supports this interpretation. This so-called response shift must be taken into account in the planning of studies.

The influence of stress and anxiety on the response of non-surgical periodontal treatment

AIM

The aim of this study was to evaluate the influence of stress and anxiety on the response to non-surgical periodontal treatment (NPT) in patients with chronic periodontitis.

METHOD

Sixty-six patients (mean age 46.1 +/- 8 years) were assigned to three groups: control group, probing pocket depth (PPD) <or=4 mm, n=20; T1, at least four sites with PPD >or=4 and <or=6 mm, n=26; and T2, at least four sites with PPD >6 mm, n=20. Stress, state anxiety (SA) and trait anxiety (TA) and plaque index (PI), gingival index, PPD and clinical attachment level (CAL) were recorded at baseline and 3 months after NPT.

RESULTS

TA scores were different among groups at baseline and after NPT. TA was related to periodontitis at baseline and after NPT. PI was associated with the SA at baseline. The reduction of frequency of CAL >6 mm was correlated with TA after adjusting for confounders. Stressed subjects did not show reduction of frequency of PPD >6 mm (T1), CAL 4-6 mm and CAL >6 mm (T2).

CONCLUSIONS

The data suggest an influence of trait of anxiety and stress on the response to NPT.

[Stress and heart disease in women]

Psychosocial aspects of heart diseases have usually been studied in predominantly male patients. Growing evidence shows that the results of these studies cannot simply be generalized to women. The research on associations between psychosocial factors and heart disease, especially coronary heart disease, in women is therefore summarized in a literature review. The literature shows that women are subject to adverse cardiac effects of stress and chronic negative affects in a similar way as men. However, in women the relevant sources of distress are often found in other areas, i.e., in the family and household environment, and less often at the workplace. Especially for working mothers, the combination of professional and household work constitutes a considerable stressor.Stress is also perceived differently in men and women, and it leads to different physiological reactions. One striking example is the recently described "stress cardiomyopathy", an acute, life-threatening illness, which is often triggered by sudden emotional distress and can mainly be found in women. Women with heart disease report more psychological distress in response to their illness than men. As in men, depressive symptoms may negatively impact prognosis. Nevertheless, women receive less rehabilitation treatment than men and also benefit less from common psychological offerings. There is some evidence that women need specially developed psychosocial interventions and should not simply be treated in predominantly male stress-management groups. In clinical practice, gender-specific stressors and accompanying psychological symptoms should be discussed with the female heart patient. If needed, she should receive individualized psychosomatic treatment.

Multilevel analysis of couple congruence on pain, interference, and disability

Couple congruence on ratings of pain severity and disability were examined using hierarchical linear modeling. Older community Individuals with Chronic Pain (ICPs) and their spouses completed the Multidimensional Pain Inventory (pain severity, interference, negative spouse responses to pain), Sickness Impact Profile (physical disability, psychosocial disability), and the Mood and Anxiety Symptom Questionnaire (psychological distress). Both spouses reported on ICPs' pain and disability as well as their own psychological distress. Spousal incongruence was observed on interference and physical disability such that ICPs reported greater disability than their spouses reported for them. No significant incongruence was observed in pain severity or psychosocial disability. Predictors of couples' mean ratings of pain and disability were identified. Specifically, couples in which the ICP was female reported higher couples' ratings of pain severity and interference. ICP distress was related to higher couples' ratings of all pain and disability variables whereas spouse distress was related to higher psychosocial disability ratings. ICPs' perceptions of negative spouse responses were also positively associated with couples' ratings of physical and psychosocial disability. In terms of congruence, ICP distress was associated with incongruence on interference, physical disability, and psychosocial disability whereas spouse distress predicted incongruence on pain severity, and interference. This study suggests that understanding couples' pain outcome ratings involves an awareness of factors that might influence their perceptions and behaviors.

Clinical evaluation of hormonal stress state in medical ICU patients: a prospective blinded observational study

OBJECTIVE

To evaluate whether classification of patients as having low, moderate, or high stress based on clinical parameters is associated with plasma levels of stress hormone.

DESIGN AND SETTING

Prospective, blinded, observational study in an 18-bed medical ICU.

PATIENTS

Eighty-eight consecutive patients.

INTERVENTIONS

Patients were classified as low (n=28), moderate (n=33) or high stress (n=27) on days 0 and 3 of ICU stay, based on 1 point for each abnormal parameter: body temperature, heart rate, systemic arterial pressure, respiratory rate, physical agitation, presence of infection and catecholamine administration. The stress categories were: high: 4 points or more, moderate 2-3 points, low 1 point. Plasma growth hormone (GH), insulin-like growth factor 1 (IGF-1), insulin, glucagon, cortisol were measured on days 0 and 3.

MEASUREMENTS AND RESULTS

Plasma cortisol and glucagon were significantly higher and IGF-1 lower in high vs. low stress patients on days 0 and 3. High stress patients were more likely to have high cortisol levels (odds ratio 5.8, confidence interval 1.8-18.9), high glucagon (8.7, 2.1-36.1), and low IGF-1 levels (5.9, 1.8-19.0) than low stress patients on day 0. Moderate stress patients were also more likely to have high cortisol and glucagon levels than low stress patients. Insulin and GH did not differ significantly. Results were similar for day 3.

CONCLUSIONS

Moderate and severe stress was significantly associated with high catabolic (cortisol, glucagon) and low anabolic (IGF-1) hormone levels. The hormonal stress level in ICU patients can be estimated from simple clinical parameters during routine clinical evaluation.

Chronic mild stress (CMS) revisited: consistency and behavioural-neurobiological concordance in the effects of CMS

The chronic mild stress (CMS) model of depression has high validity but has in the past been criticized for being difficult to replicate. However, a large number of recent publications have confirmed that CMS causes behavioural changes in rodents that parallel symptoms of depression. This review summarizes studies from over sixty independent research groups that have reported decreases in reactivity to rewards, and a variety of other depression-like behaviours, in rats or mice, following exposure to CMS. Together, these changes are referred to as a 'depressive' behavioural profile. Almost every study that has examined the effects of chronic antidepressant treatment in these procedures has reported that antidepressants were effective in reversing or preventing these 'depressive' behavioural changes. (The single exception is a study in which the duration of treatment was too brief to constitute an adequate trial.) There are also a handful of reports of CMS causing significant effects in the opposite direction, termed here an 'anomalous' behavioural profile. There are six neurobiological parameters that have been studied in both 'anhedonic' and 'anomalous' animals: psychostimulant and place-conditioning effects of dopamine agonists; dopamine D2 receptor number and message; inhibition of dopamine turnover by quinpirole, and beta-adrenergic receptor binding. On all six measures, CMS caused opposite effects in animals displaying 'depressive' and 'anomalous' profiles. Thus, there is overwhelming evidence that under appropriate experimental conditions, CMS can cause antidepressant-reversible depressive-like effects in rodents; however, the 'anomalous' profile that is occasionally reported appears to be a genuine phenomenon, and these two sets of behavioural effects appear to be associated with opposite patterns of neurobiological changes.