Adrenalin, noradrenalin and heart rate responses to psychosocial stress in young adults born preterm at very low birthweight

OBJECTIVE

Adults born preterm at very low birthweight (VLBW; ≤ 1500 g) have high levels of cardiovascular risk factors and altered responses to psychosocial stress including higher blood pressure and lower cortisol. Our aim was to investigate adrenalin (A), noradrenalin (NA) and heart rate (HR) responses to psychosocial stress in adults born preterm at VLBW.

DESIGN AND PARTICIPANTS

We studied 50 young adults, aged 19-27 years, born at VLBW and 39 term-born controls, group-matched for age, sex and birth hospital. They underwent a standardized psychosocial stress test, the Trier Social Stress Test (TSST).

MEASUREMENTS

During TSST, A, NA (baseline and 0, 10 and 90 min after stress) and HR were measured. Data were analysed with mixed-effects and linear regression models, adjusted for age, sex, body mass index, hormonal contraception, time of day and highest parental educational attainment.

RESULTS

Baseline concentrations, peak after stress, increments and area under the curve for A and NA were similar in VLBW and control groups. In women, NA concentrations were 27.7% lower (95% CI; 3.1-52.2) in VLBW compared with control women; in men, there was no significant difference. A concentrations were similar for VLBW and control groups in both sexes. Mean HR at baseline, task and HR reactivity was also similar in VLBW and control groups.

CONCLUSIONS

Very low-birthweight women seem to have a lower NA response to stress compared with term-born peers. If replicated, this could be a protective characteristic for cardiovascular diseases.

Blunted hypothalamic-pituitary-adrenal axis and insulin response to psychosocial stress in young adults born preterm at very low birth weight

BACKGROUND

Young adults born preterm at very low birth weight (VLBW, ≤1500 g) have higher levels of cardiovascular risk factors, including impaired glucose regulation, than their term-born peers. This could be mediated through altered hypothalamic-pituitary-adrenal axis (HPAA) response to stress.

OBJECTIVE

To compare HPAA, glucose and insulin responses provoked by psychosocial stress in VLBW subjects versus a comparison group of term-born controls.

DESIGN AND PARTICIPANTS

We studied 54 unimpaired young adults, aged 19-27 years, born at VLBW and a comparison group of 40 adults born at term, group-matched for age, sex and birth hospital, from one regional centre in southern Finland. The participants underwent a standardized psychosocial stress test (Trier Social Stress Test, TSST).

MEASUREMENTS

In conjunction with TSST, we measured salivary cortisol, plasma ACTH, cortisol, glucose and insulin. Data were analysed with mixed-effects model and multiple linear regression analyses.

RESULTS

Baseline concentrations for cortisol, ACTH, insulin and glucose were similar in VLBW and comparison groups. During TSST, analysed with mixed-effects model, overall concentrations of plasma cortisol were 17·2% lower (95% CI; 3·5 to 28·9) in the VLBW group. The VLBW group also had lower salivary (P = 0·04) and plasma cortisol (P = 0·02) responses to TSST. Insulin and glucose concentrations correlated with changes in cortisol concentrations. Accordingly, VLBW subjects had 26·5% lower increment in insulin (95% CI; 9·8-40·1). Analyses were adjusted for age, sex, body mass index, hormonal contraception, menstrual cycle phase, time of day and parental education.

CONCLUSIONS

VLBW adults have lower HPAA responses to psychosocial stress than term-born controls. This is accompanied by a lower insulin response.

Higher levels of physical activity are associated with lower hypothalamic-pituitary-adrenocortical axis reactivity to psychosocial stress in children

CONTEXT

Children who undertake more physical activity (PA) not only have more optimal physical health but also enjoy better mental health. However, the pathways by which PA affects well-being remain unclear.

OBJECTIVE

To address this question, we examined whether objectively measured daytime PA was associated with diurnal hypothalamic-pituitary-adrenocortical axis (HPAA) activity and HPAA responses to psychosocial stress.

DESIGN AND SETTING

We conducted a cross-sectional study in a birth cohort in Helsinki, Finland.

PARTICIPANTS

We studied 258 8-year-old children.

MAIN OUTCOME MEASURES

PA was assessed with wrist-worn accelerometers. Overall PA and percentage of time spent in vigorous PA (VPA) were categorized by sex into thirds. Salivary cortisol was measured diurnally and in response to the Trier Social Stress Test for Children.

RESULTS

The children in different PA groups did not show differences in diurnal salivary cortisol (P > .10 for overall PA and VPA). Children with the highest levels of overall PA or VPA showed no, or only small, increases over time in salivary cortisol after stress (P = .10 and P =.03 for time in analyses of PA and VPA, respectively), whereas children belonging to the lowest and intermediate thirds showed significant increases over time in salivary cortisol after stress (P ≤ .002 for time in the analyses of overall PA and VPA).

CONCLUSIONS

These results suggest that children with lower levels of daytime PA have higher HPAA activity in response to stress. These findings may offer insight into the pathways of PA on physical and mental well-being.

Poor sleep and cardiovascular function in children

We investigated whether sleep quantity and quality were related to 24-hour ambulatory blood pressure and cardiovascular reactivity in children. We studied term-born, healthy 8.0-year olds (SD: 1.4 years) without sleep-disordered breathing (231 and 265 children provided valid data for analyses of ambulatory blood pressure and cardiovascular reactivity, respectively). Sleep was registered with an actigraph for 6 nights on average (SD: 1.2; range: 3 to 13 nights). Ambulatory blood pressure was measured for 24-hours (41% nonschool days) with an oscillometric device. The children underwent the Trier Social Stress Test for Children, during which blood pressure, electrocardiography, and thoracic impedance were recorded and processed offline to give measures of cardiovascular and autonomic function. Neither quantity nor quality of sleep was related to 24-hour ambulatory blood pressure or cardiovascular reactivity after accounting for major covariates (sex, age, height, body mass index, and parental education). Although lower sympathetic nervous system activation and higher cardiac activation under stress were found in the group of children who slept for short duration when they were compared with the average sleep duration group, these associations were not significant after correction for multiple testing and were not seen in linear regression models of the effects of sleep duration. These findings do not support the mainstream of epidemiological findings, derived from samples more heterogeneous in age, sociodemographic characteristics, and health, suggesting that poor sleep is associated with an unhealthy cardiovascular phenotype.

Childhood separation experience predicts HPA axis hormonal responses in late adulthood: a natural experiment of World War II

BACKGROUND

Animal models have linked early maternal separation with lifelong changes in hypothalamic-pituitary-adrenocortical (HPA) axis activity. Although this is paralleled in human studies, this is often in the context of other life adversities, for example, divorce or adoption, and it is not known whether early separation in the absence of these factors has long term effects on the HPA axis.

AIMS

The Finnish experience in World War II created a natural experiment to test whether separation from a father serving in the armed forces or from both parents due to war evacuation are associated with alterations in HPA axis response to psychosocial stress in late adulthood.

METHOD

282 subjects (M=63.5 years, SD=2.5), of whom 85 were non-separated, 129 were separated from their father, and 68 were separated from both their caregivers during WWII, were enlisted to participate in a Trier Social Stress Test (TSST), during which we measured salivary cortisol and, for 215 individuals, plasma cortisol and ACTH concentrations. We used mixed models to study whether parental separation is associated with salivary and plasma cortisol or plasma ACTH reactivity, and linear regressions to analyse differences in the baseline, or incremental area under the cortisol or ACTH curves.

RESULTS

Participants separated from their father did not differ significantly from non-separated participants. However, those separated from both parents had higher average salivary cortisol and plasma ACTH concentrations across all time points compared to the non-separated group. They also had higher salivary cortisol reactivity to the TSST. Separated women had higher baselines in plasma cortisol and ACTH, whereas men had higher reactivity in response to stress during the TSST. Participants who had experienced the separation in early childhood were more affected than children separated during infancy or school age.

CONCLUSIONS

Separation from parents during childhood may alter an individual's stress physiology much later in adult life.

Poor sleep and altered hypothalamic-pituitary-adrenocortical and sympatho-adrenal-medullary system activity in children

CONTEXT

Neuroendocrine alterations, with well-known links with health, may offer insight into why poor sleep is associated with poor health. Yet, studies testing associations between sleep and neuroendocrine activity in children are scarce.

OBJECTIVE

The aim of this study was to determine whether actigraphy-based sleep pattern is associated with hypothalamic-pituitary-adrenocortical axis and sympatho-adrenal-medullary system activity in children.

DESIGN AND SETTING

We conducted a cross-sectional study in a birth cohort in Helsinki, Finland.

PARTICIPANTS

We studied 282 8-yr-old children.

MAIN OUTCOME MEASURES

We measured diurnal salivary cortisol and salivary cortisol and alpha-amylase (a sympatho-adrenal-medullary system marker) responses to the Trier Social Stress Test for Children (TSST-C).

RESULTS

Children with short (<or=7.7 h) vs. average sleep duration (7.8-9.3 h) displayed higher cortisol awakening response and nadir (P < 0.042). Those with low (<or=77.4%) vs. average-high sleep efficiency (>77.4%) displayed higher diurnal cortisol levels across the entire day (P < 0.03), higher cortisol levels after the TSST-C stressor (P < 0.04), and higher overall alpha-amylase levels across the entire TSST-C protocol (P < 0.05). The effects were not confounded by factors that may alter sleep or hormonal patterns.

CONCLUSIONS

Poor sleep may signal altered neuroendocrine functioning in children. The findings may offer insight into the pathways linking poor sleep with poor health.

Blood pressure responses to psychosocial stress in young adults with very low birth weight: Helsinki study of very low birth weight adults

Young adults born prematurely with very low birth weight (</=1500 g) have higher blood pressure than do their counterparts born at term. We tested whether they also have higher blood pressure reactivity to psychosocial stress, which may be a more-specific predictor of long-term cardiovascular morbidity. Systolic and diastolic blood pressure levels for 44 very low birth weight adults (mean age: 23.1 years; SD: 2.3 years) and 37 control subjects (mean age: 23.6 years; SD: 2.0 years) were measured through noninvasive finger photoplethysmography during a standardized psychosocial stress challenge (Trier Social Stress Test). Baseline and task values and their difference (ie, reactivity) served as outcome variables. In comparison with the control group, the very low birth weight group had 7.9 mm Hg higher diastolic blood pressure during the task and 4.8 mm Hg higher diastolic reactivity, with adjustment for gender and age, height, and BMI at testing. A similar trend was seen for systolic blood pressure during the baseline period and the task, but the group differences were not statistically significant. Our results indicate that very low birth weight is associated with elevated blood pressure reactivity to psychosocial stress and, therefore, may increase the risk of cardiovascular morbidity.

Childhood growth and cardiovascular reactivity to psychological stressors in late adulthood

OBJECTIVE

Specific childhood growth patterns relate to risk of cardiovascular (CV) disease later in life, but the underlying mechanisms are unclear. We studied whether CV reactivity, a predictor of CV disease risk, is associated with childhood growth trajectories.

METHODS

A total of 144 (77 women and 67 men) participants of the Helsinki Birth Cohort Study born 1934-1944, whose height and weight were recorded repeatedly during the first 11 years, underwent the Trier Social Stress Test at the average age of 63 years. Beat-to-beat blood pressure was monitored via noninvasive finger photoplethysmograph (Finometer), and CV reactivity scores were determined as the mean increment from baseline.

RESULTS

In both women and men, systolic blood pressure (SBP) reactivity increased by 3.8 mmHg (95% CI 0.8-6.9) and diastolic BP (DBP) reactivity by 1.4 mmHg (95% CI 0.0-2.8) for every standard deviation increase in gain in body mass index (kg m(-2)) between 7 and 11 years. By contrast, effects of height gain were dissimilar between sexes. In women, higher DBP reactivity was associated with a slow gain in height between 0 and 2 years, whilst in men higher SBP reactivity was associated with a slow gain in height between 2 and 7 years, which was preceded by a more rapid gain in height between 0 and 2 years. Adjusting for adult body size, body size at birth or childhood socio-economic status did not change the results.

CONCLUSIONS

We found that growth during childhood is associated with CV reactivity to stress later in adulthood. Early life programming of CV reactivity may partly underlie the link between early growth and CV disease.

Body size at birth predicts hypothalamic-pituitary-adrenal axis response to psychosocial stress at age 60 to 70 years

BACKGROUND

Studies in humans and animals have suggested intrauterine programming of hypothalamic-pituitary-adrenal axis (HPAA) function as an important mechanism in linking fetal life conditions with adult disease.

OBJECTIVE

Our aim was to assess how body size at birth, a marker of intrauterine conditions, is associated with hypothalamic-pituitary-adrenal axis response to psychosocial stress in late adulthood.

DESIGN AND SETTING

We conducted a clinical study in the Helsinki Birth Cohort.

PARTICIPANTS

Two hundred eighty-seven men and women born between 1934 and 1944 whose birth measurements and gestational age came from hospital records participated in the study.

MEASUREMENTS

We measured salivary cortisol and, for 215 individuals, plasma cortisol and ACTH concentrations in conjunction with a standardized psychosocial stressor (Trier Social Stress Test).

RESULTS

There was a linear relationship between low birth weight and low plasma ACTH but no linear relationship with cortisol. There were, however, quadratic relationships between birth weight and salivary (mixed model P = 0.001) and plasma cortisol (P = 0.005) but not with plasma ACTH (P = 0.1). The lowest peak salivary cortisol concentrations were seen in the lowest third of birth weights (adjusted for gestational age and sex): 12.9 nmol/liter (95% confidence interval of mean 11.2-15.0), compared with 17.1 nmol/liter (14.8-19.8) in the middle and 14.1 nmol/liter (12.6-15.7) in the highest third of birth weights. Corresponding figures for plasma cortisol were 418 nmol/liter (380-459), 498 nmol/liter (455-545), and 454 nmol/liter (428-482), and for plasma ACTH 8.17 pmol/liter (6.98-9.57), 12.42 pmol/liter (10.64-14.51), and 11.50 (10.06-13.14), respectively. Results for areas under the curve were similar.

CONCLUSIONS

We found an inverse U-shaped relationship between birth weight and cortisol concentrations during psychosocial stress. The lowest cortisol and ACTH concentrations were seen in subjects with the lowest birth weights. These results support the hypothesis that both hyper- and hypocortisolism may be programmed during the fetal period.

Cardiovascular reactivity to psychological stressors in late adulthood is predicted by gestational age at birth

The relationships of body size and gestational age at birth with adult blood pressure (BP) are relatively modest compared to their stronger associations with cardiovascular disease. BP reactivity is a strong predictor of cardiovascular morbidity, and it is possible that reactivity, rather than resting level, is determined in utero. We investigated whether body size and gestational age at birth predict BP reactivity during experimentally induced psychosocial stress in late adulthood. A total of 73 men and 80 women born after 36 weeks' gestation in Helsinki, Finland, during 1934-1944 underwent the Trier Social Stress Test (TSST); a standardized psychosocial stress test consisting of a public speech and an arithmetic task. Changes in BP were monitored continuously by a non-invasive finger photoplethysmography (Finometer, FMS, Amsterdam, The Netherlands). The results showed that the most robust early determinant of BP reactivity was gestational age; however, with opposite relationships between the sexes (P for interaction <0.001). A 1-week increase in gestational age was associated with a 3.1 mm Hg (95% confidence interval (CI), 0.2 to 6.0) and 1.2 mm Hg (95% CI, -0.1 to 2.6) decreases in systolic and diastolic BP reactivity in women, but with 5.2 mm Hg (95% CI, 1.9 to 8.4) and 2.3 mm Hg (95% CI, 0.9 to 3.8) increases in men. In conclusion, normal variation in gestational age at birth predicts cardiovascular stress reactivity in later adulthood. Given that hypothalamic-pituitary-adrenal axis contributes to the regulation of autonomic nervous system function and the timing of parturition, and shows well-established sex differences, we speculate a role for early programming of this axis in explaining the findings.

Assessing patient satisfaction across the continuum of ambulatory care: a revalidation and validation of care-specific surveys

The need to develop reliable and valid measures of patient satisfaction in ambulatory care settings is underscored by the rapid growth and changes in this health care arena as well as the requirement to monitor and gauge quality of care. The purpose of this article is to provide evidence for the reliability and validity of patient satisfaction questionnaires designed specifically for three points of care across the ambulatory care continuum. These points are outpatient testing and physical therapy services, outpatient surgery, and home health care. The present effort represents an evaluation of revised questionnaires for the first two points and an initial assessment of the psychometric properties of the questionnaire for the third. The present results support the internal reliability and construct validity of each questionnaire. In addition, differences were found on select facility characteristics based on each questionnaire.

A nursing challenge: methicillin-resistant Staphylococcus aureus in long-term care

1. Methicillin-resistant Staphylococcus aureus (MRSA) are gram-positive cocci, differing from methicillin-resistant species of S epidermidis because they produce coagulase. MRSA is distinguished from methicillin-sensitive S aureus by its resistance to methicillin and other antibiotics. MRSA has not been found to be an organism of greater virulence than methicillin-sensitive strains of S aureus, but infections caused by MRSA are sometimes of greater concern because of the limited antibiotic treatment options. 2. In the past 25 years there has been an increase in the number of reported infections in patients caused by MRSA. As infections with MRSA have become more prevalent in community hospitals throughout the country, the difficulty in controlling the spread within the community hospitals has mirrored the experiences of the tertiary care centers. 3. Education regarding the transmission of microorganisms and the caregiver's role in prevention is essential for every nursing facility. Interfacility communication is essential for hospital and nursing home staff to plan and manage the care of infected or colonized residents. 4. A facility-specific MRSA policy should optimize the opportunity for infected persons to receive nursing home care--without jeopardizing other residents.

GM-1 treatment of Alzheimer's disease. A pilot study of safety and efficacy

A double-blind, placebo-controlled pilot study was conducted to evaluate the safety and efficacy of treatment of patients with Alzheimer's disease using monosialoganglioside GM-1, a neurotrophic factor. Of 46 patients enrolled, 42 completed all study requirements. Nineteen patients received 100 mg of GM-1 by daily intramuscular injection for 12 weeks. Twenty-three patients received placebo. Case evaluations were done at baseline, week 12, and week 24 and included both cognitive and psychosocial scales. Study results suggested that the treatment was safe, yet offered no overall symptomatic benefit to patients with mild-to-moderate Alzheimer's disease. Whether or not GM-1 therapy may offer protective benefit by slowing or arresting the progression of the disease remains unclear, since the results of the cognitive evaluations suggested that neither the GM-1 group nor the placebo group declined significantly during the 24-week study.