Self-reported and measured stress related responses associated with exposure to wind turbine noise.

The current study was the first to assess stress reactions associated with wind turbine noise (WTN) exposure using self-reported and objective measures. Randomly selected participants, aged 18-79 yr (606 males; 632 females), living between 0.25 and 11.22 km from wind turbines, were exposed to outdoor calculated WTN levels up to 46 dBA (response rate 78.9%). Multiple regression modeling left the great majority (77%-89%) of the variance in perceived stress scale (PSS) scores, hair cortisol concentrations, resting blood pressure, and heart rate unaccounted for, and WTN exposure had no apparent influence on any of these endpoints. PSS scores were positively, but weakly, related to cortisol concentrations and resting heart rate (Pearson r = 0.13 and r = 0.08, respectively). Across WTN categories, modeled mean PSS scores ranged from 13.15 to 13.84 (p = 0.8614). Modeled geometric means for hair cortisol concentrations, resting mean systolic, diastolic blood pressure, and heart rate were 150.54-191.12 ng/g (p = 0.5416), 113.38-116.82 mmHg (p = 0.4990), 67.98-70.34 mmHg (p = 0.5006), and 68.24-70.71 bpm (p = 0.5223), respectively. Irrespective of WTN levels, diastolic blood pressure appeared to be slightly (2.90 mmHg 95% CI: 0.75,5.05) higher among participants highly annoyed by blinking lights on turbines (p = 0.0081). Collectively, the findings do not support an association between exposure to WTN up to 46 dBA and elevated self-reported and objectively defined measures of stress.

Hair cortisol concentration is unaffected by basic military training, but related to sociodemographic and environmental factors.

The analysis of hair cortisol concentrations (HCC) is a promising new biomarker for retrospective measurement of chronic stress. The effect of basic military training (BMT) on chronic stress has not yet been reported. The aim of this study was to investigate the effect of 10-week BMT on HCC, while further exploring the role of known and novel covariates. Young healthy male recruits of the Swiss Army participated twice, 10 weeks apart, in data collection (1st examination: n = 177; 2nd examination: n = 105). On two occasions, we assessed HCC, perceived stress and different candidate variables that may affect HCC (e.g. socioeconomic status, meteorological data). Military training increased perceived stress from the first to the second examination, but did not affect HCC. In line with this, there was no correlation between HCC and perceived stress ratings. This could be interpreted as a missing influence of mainly physical stress (e.g. exercise) on HCC. In contrast, significant correlations were found between HCC and ambient temperature, humidity and education. Future studies should control for meteorological data and educational status when examining HCC.

Hair cortisol as a novel biomarker of HPA suppression by inhaled corticosteroids in children.

BACKGROUND: Asthma is the most common chronic condition in childhood, and the recommended pharmacotherapy for long-term control includes the use of inhaled corticosteroids (ICS). ICS were designed to act at the site of inflammation in the lung, thus decreasing systemic absorption and reducing the risk of adverse effects associated with corticosteroid use (e.g., HPA suppression and its consequent effects). Available data show that measurement of hair cortisol successfully reflects endogenous cortisol levels. We sought to examine whether hair cortisol measurements can be used to identify HPA suppression surrounding ICS therapy in children with asthma. METHODS: Hair samples were collected from the vertex posterior region of the head of 18 asthmatic children. We compared their hair cortisol concentration during ICS use with the concentration prior to ICS use. RESULTS: During ICS therapy, median hair cortisol levels were twofold lower compared with the period of no ICS use (median 89.8 ng/g vs. 198.2 ng/g, P = 0.0015). CONCLUSION: Hair cortisol is an effective biomarker of the HPA suppression associated with ICS therapy and can be a sensitive tool for determining systemic effects of ICS use and monitoring adherence. Future research is needed to characterize the effect of untreated asthma on hair cortisol concentrations, if any.

Toward standardization of hair cortisol measurement: results of the first international interlaboratory round robin.

BACKGROUND: The importance of hair cortisol as a long-term retrospective measure of systemic cortisol exposure is being increasingly recognized, and over recent years, the field of hair cortisol analysis has seen rapid expansion with laboratories around the globe, integrating hair cortisol analysis into their study designs. These laboratories use different methods of analysis, and presently, no attempt has been made to compare them. To move toward clinical utilization of this novel method, international benchmark reference values must be established. For that end, 4 leading laboratories in hair cortisol testing set up a protocol for comparison of the methods used by them. METHODS: Four immunoassay methods and 2 liquid chromatograph-mass spectrometry (LC-MS/MS) methods were compared by analyzing the same hair samples representing the low, intermediate, and high ranges of hair cortisol concentrations (HCC). RESULTS: HCC determined by the 4 immunoassay methods were highly and positively intercorrelated (r(2) between 0.92 and 0.97; all P < 0.0001) in all comparisons of individual laboratories. Additionally, each laboratory's immunoassay HCC had significant positive correlations (r(2) between 0.88 and 0.97; all P < 0.0001) with each of the 2 LC-MS/MS methods, which produced practically identical results. CONCLUSIONS: This study indicates that laboratories using immunoassays can use a correction factor that will convert results into standard LC-MS/MS equivalents.

Hair cortisol concentrations in higher- and lower-stress mother-daughter dyads: A pilot study of associations and moderators.

Hair cortisol concentrations (HCC) are receiving increased attention as a novel biomarker of psychophysiological responses to chronic stress, with potential relevance for psychopathology risk research. We examined the validity of HCC as a marker of psychosocial stress in mother (M(age) = 37.87 years)-daughter (M(age) = 7.62 years) dyads characterized by higher (n = 30) or lower (n = 30) maternal chronic stress. Additionally, we examined whether early care moderated similarity of HCC levels within dyads. Higher-stress mothers had significantly lower HCC compared to lower-stress mothers, consistent with other research showing that chronic stress leads to blunted HPA axis activity over time. Further, HCC in daughters were significantly and positively associated with previously assessed salivary cortisol stress reactivity. Finally, mother-daughter HCC associations were significantly moderated by negative parenting styles, such that associations became stronger as quality of parenting decreased. Findings overall indicate that HCC may be a useful marker of cortisol responses to chronic stress.

Associations of hair cortisol concentration with self-reported measures of stress and mental health-related factors in a pooled database of diverse community samples.

A pooled database from diverse community samples was used to examine the associations of hair cortisol concentration (HCC) with self-reported stress and stress-linked mental health measures, including depression, anxiety, alcohol and drug use, disability and experiences with aggression. As part of innovative research using a mobile laboratory to study community mental health, data were pooled from five sub-studies: a random sample of the general population (n = 70), people who had received treatment for a mental health and/or substance use problem (n = 78), family members of people treated for mental health and/or substance use problems (n = 49), community volunteers who sometimes felt sad or blue or thought they drank too much (n = 83) and young adults in intimate partner relationships (n = 44). All participants completed a computerized questionnaire including standard measures of perceived stress, chronic stress, depression, anxiety, hazardous drinking, tobacco use, prescription drug use, illicit drug use, disability and intimate partner aggression. HCC was significantly associated with use of antidepressants, hazardous drinking, smoking and disability after adjusting for sub-study and potential confounders (sex, body-mass index, use of glucocorticoids and hair dyed). In addition, preliminary analyses suggest a significant curvilinear relationship between HCC and perceived stress; specifically, HCC increased with higher perceived stress but decreased at the highest level of stress. Overall, HCC was associated with mental health-related variables mainly reflecting substance use or experiencing a disability. The relationship between HCC and self-reported stress is unclear and needs further research.

The detection of cortisol in human sweat: implications for measurement of cortisol in hair.

BACKGROUND: Hair cortisol analysis has been shown to be an effective measure of chronic stress. Cortisol is assumed to incorporate into hair via serum, sebum, and sweat sources; however, the extent to which sweat contributes to hair cortisol content is unknown. METHODS: Sweat and saliva samples were collected from 17 subjects after a period of intensive exercise and analyzed by salivary enzyme-linked immunosorbent assay (ELISA). Subsequently, an in vitro test on exposure of hair to hydrocortisone was conducted. Residual hair samples were immersed in a 50-ng/mL hydrocortisone solution for periods lasting 15 minutes to 24 hours, followed by a wash or no-wash condition. Hair cortisol content was determined using our modified protocol for a salivary ELISA. RESULTS: Postexercise control sweat cortisol concentrations ranged from 8.16 to 141.7 ng/mL and correlated significantly with the log-transformed time of day. Sweat cortisol levels significantly correlated with salivary cortisol concentrations. In vitro hair exposure to a 50-ng/mL hydrocortisone solution (mimicking sweat) for 60 minutes or more resulted in significantly increased hair cortisol concentrations. Washing with isopropanol did not affect immersion-increased hair cortisol concentrations. CONCLUSIONS: Human sweat contains cortisol in concentrations comparable with salivary cortisol levels. This study suggests that perfuse sweating after intense exercise may increase cortisol concentrations detected in hair. This increase likely cannot be effectively decreased with conventional washing procedures and should be considered carefully in studies using hair cortisol as a biomarker of chronic stress.

Cultural and socio-economic conditions as factors contributing to chronic stress in sub-Saharan African communities.

Stress is known to contribute to overall health status. Many individuals in sub-Saharan Africa are believed to be stressed about their employment, income, and health. This study aimed to investigate hair cortisol as a biomarker of chronic stress in settlement communities in Kenya. Hair samples were collected from 108 volunteers from settlement communities in Kenya. An enzyme-linked immunosorbent assay technique was used to measure hair cortisol concentrations. In parallel, a health survey was completed. The mean ± SD for the cortisol concentration in the hair of volunteers from the settlement communities in Naivasha was 639 ± 300 ng/g, which was higher than found for a Caucasian reference group (299 ± 110 ng/g; one-way ANOVA, P = 0.0003). There were no differences in hair cortisol concentrations between members of slum settlements adjacent to large floriculture farms in Naivasha (Karagita, Kamere/Kwa Muhia/DCK, and Kasarani) compared with those well-removed from all floriculture in Mogotio (Mogotio and Westlands/Katorongot). However, hair cortisol concentrations were significantly higher in females, divorced volunteers, those who made below minimum wage, and those who reported feeling unsafe collecting water or using sanitation facilities within these 2 settlement groups. We found no evidence for increased chronic stress (measured by hair cortisol content) between members of slum settlements adjacent to versus distant to large floriculture farms. Cultural and socio-economic conditions that prevail in much of sub-Saharan Africa were found to be factors contributing to chronic stress.

Hair cortisol as a biomarker of stress in the 2011 Libyan war.

PURPOSE: There is a substantial body of research that utilizes saliva cortisol levels to examine wartime stress; however, there is a paucity of literature that utilizes hair cortisol levels, which allows for long-term assessment of chronic stress, to investigate the stress of war. The present study aimed to evaluate changes in hair cortisol concentrations before, during, and after the 2011 Libyan war. METHODS: This study examined hair cortisol concentrations of young adult women who were living in Tripoli, Libya during the 2011 war. The participants were recruited at the campus of Tripoli University. Participants needed to have at least 24 cm of hair and to have resided in Tripoli before, during and after the 2011 Libyan war. Hair was sectioned to reflect 3 month windows of cortisol exposure corresponding to periods before, during and after the war. Hair cortisol concentrations were quantified using a modified salivary ELISA test. The women were also asked to complete the Perceived Stress Scale pertaining to the post-war period. RESULTS: Median hair cortisol concentrations in the post-war period (226.11 ng/g; range 122.95-519.85 ng/g) were significantly higher than both the pre-war (180.07 ng/g; 47.13-937.85 ng/g) and wartime (186.65 ng/g; 62.97-771.79 ng/g) periods (P<0.05). The mean PSS score (24) was in the range of "much higher than the mean" for this test and the vast majority of participants were either in the "much higher than the mean" or "slightly higher than the mean" ranges. Hair cortisol determination suggests that in Tripoli, the post-war period appears to have been more stressful than the war itself. This is consistent with the fact that during the war the civilian participants were not directly involved with warfare, nor were they targeted by the international coalition fighting Gaddafi. In contrast, the post-war period was characterized by chaos and total lack of authority, with the participants exposed to injury, lack of food and destruction. CONCLUSION: This study documents the utility of hair cortisol levels to retrospectively assess stress before, during, and after an armed conflict.

Human hair cortisol analysis: comparison of the internationally-reported ELISA methods.

PURPOSE: Recently, hair cortisol has become a topic of global interest as a biomarker of chronic stress. Different research groups have been using different methods for extraction and analysis, making it difficult to compare results across studies. A critical examination of the reported analytical methods is important to facilitate standardization and allow for a uniform interpretation. METHODS: This study qualitatively compared four published procedures from laboratories in Germany, the Netherlands, USA and Canada. Multiple aspects of their procedures were compared. RESULTS: A major difference among the laboratories was the ELISA kit used: the Canadian laboratory used the kit from ALPCO Diagnostics (Salem, MA, USA), the American laboratory used the kit from DRG International (Springfield, NJ, USA), the German laboratory used the kit from DRG Instruments GmbH (Marburg, Germany), or IBL (Hamburg, Germany), and the Dutch used the kit from Salimetrics (Suffolk, UK). In addition, there are noted differences in hair mass used as well as washing and extraction procedures. The range of hair cortisol levels determined in healthy volunteers by the four groups was within 2.3-fold: Koren, 46.1 pg/mg; Van Rossum, 29.72 pg/mg; Kirschbaum, 20 pg/mg and Laudenslager ~ 27 pg/mg. CONCLUSIONS: The relative similarities in hair cortisol values in volunteers among the four laboratories should facilitate a quality assurance exchange program, as a necessary step toward clinical use of this novel test.

Health systems in context: a systematic review of the integration of the social determinants of health within health systems frameworks.

OBJECTIVE: To systematically review and analyze various ways that health systems frameworks interact with the social determinants of health (SDH), as well as the implications of these interactions. METHODS: This was a review of the literature conducted in 2012 using predetermined criteria to search three comprehensive databases (PubMed, the Cochrane Database for Systematic Reviews, and the World Bank E-Library) and grey literature for articles with any consideration of the SDH within health systems frameworks. Snowball sampling and expert opinion were used to include any potentially relevant articles not identified by the initial search. In total, 4,152 documents were found; of these, 27 were included in the analyses. RESULTS: Five main categories of interaction between health systems and SDH emerged: Bounded, Production, Reciprocal, Joint, and Systems models. At one end were the Bounded and Production models, which conceive the SDH to be outside the health system; at the other end, the Joint and Systems models, which visualize a continuous and dynamic interaction. CONCLUSIONS: Considering the complex and dynamic interactions among different kinds of organizations involved in and with the health system,the Joint and Systems models seem to best reflect these interactions, and should thereby guide stakeholders in planning for change.

Code Status Documentation Availability and Accuracy Among Emergency Patients with End-stage Disease.

INTRODUCTION: Some patients with end-stage disease who may neither want nor benefit from aggressive resuscitation receive such treatment if they cannot communicate in an emergency. Timely access to patients' current resuscitation wishes, or "code status," should be a key metric of electronic health records (EHR). We sought to determine what percentage of a cohort of patients with end-stage disease who present to the emergency department (ED) have accessible, code status documents, and for those who do, how quickly can this documentation be retrieved. METHODS: In this cross-sectional study of ED patients with end-stage disease (eg, palliative care, metastatic malignancy, home oxygen, dialysis) conducted during purposefully sampled random accrual times we performed a standardized, timed review of available health records, including accompanying transfer documents. We also interviewed consenting patients and substitute decision makers to compare available code status documents to their current wishes. RESULTS: Code status documentation was unavailable within 15 minutes of ED arrival in most cases (54/85, or 63%). Retrieval time was under five minutes in the rest, especially when "one click deep" in the EHR. When interviewed, 20/32 (63%) expressed "do not resuscitate" wishes, 10 of whom had no supporting documentation. Patients from assisted-living (odds ratio [OR] 6.7; 95% confidence interval [CI], 1.7-26) and long-term care facilities (OR 13; 95% CI, 2.5-65) were more likely to have a documented code status available compared to those living in the community. CONCLUSION: The majority of patients with end-stage disease, including half of those who would not wish resuscitation from cardiorespiratory arrest, did not have code status documents readily available upon arrival to our tertiary care ED. Patients living in the community with advanced disease may be at higher risk for unwanted resuscitative efforts should they present to hospital in extremis. While easily retrievable code status documentation within the EHR shows promise, its accuracy and validity remain important considerations.

Simulation in the Continuing Professional Development of Academic Emergency Physicians: A Canadian National Survey.

INTRODUCTION: Simulation is becoming a popular educational modality for physician continuing professional development (CPD). This study sought to characterize how simulation-based CPD (SBCPD) is being used in Canada and what academic emergency physicians (AEPs) desire in an SBCPD program. METHODS: Two national surveys were conducted from March to June 2018. First, the SBCPD Needs Assessment Survey was administered online to all full-time AEPs across 9 Canadian academic emergency medicine (EM) sites. Second, the SBCPD Status Survey was administered by telephone to the department representatives (DRs)-simulation directors or equivalent-at 20 Canadian academic EM sites. RESULTS: Response rates for the SBCPD Needs Assessment and the SBCPD Status Survey were 40% (252/635) and 100% (20/20) respectively. Sixty percent of Canadian academic EM sites reported using SBCPD, although only 30% reported dedicated funding support. Academic emergency physician responses demonstrated a median annual SBCPD of 3 hours. Reported incentivization for SBCPD participation varied with AEPs reporting less incentivization than DRs. Academic emergency physicians identified time commitments outside of shift, lack of opportunities, and lack of departmental funding as their top barriers to participation, whereas DRs thought AEPs fear of peer judgment and inexperience with simulation were substantial barriers. Content areas of interest for SBCPD were as follows: rare procedures, pediatric resuscitation, and neonatal resuscitation. Lastly, interprofessional involvement in SBCPD was valued by both DRs and AEPs. CONCLUSIONS: Simulation-based CPD programs are becoming common in Canadian academic EM sites. Our findings will guide program coordinators in addressing barriers to participation, selecting content, and determining the frequency of SBCPD events.

Simulation in Canadian postgraduate emergency medicine training - a national survey.

OBJECTIVES: Simulation-based education (SBE) is an important training strategy in emergency medicine (EM) postgraduate programs. This study sought to characterize the use of simulation in FRCPC-EM residency programs across Canada. METHODS: A national survey was administered to residents and knowledgeable program representatives (PRs) at all Canadian FRCPC-EM programs. Survey question themes included simulation program characteristics, the frequency of resident participation, the location and administration of SBE, institutional barriers, interprofessional involvement, content, assessment strategies, and attitudes about SBE. RESULTS: Resident and PR response rates were 63% (203/321) and 100% (16/16), respectively. Residents reported a median of 20 (range 0-150) hours of annual simulation training, with 52% of residents indicating that the time dedicated to simulation training met their needs. PRs reported the frequency of SBE sessions ranging from weekly to every 6 months, with 15 (94%) programs having an established simulation curriculum. Two (13%) of the programs used simulation for resident assessment, although 15 (94%) of PRs indicated that they would be comfortable with simulation-based assessment. The most common PR-identified barriers to administering simulation were a lack of protected faculty time (75%) and a lack of faculty experience with simulation (56%). Interprofessional involvement in simulation was strongly valued by both residents and PRs. CONCLUSIONS: SBE is frequently used by Canadian FRCPC-EM residency programs. However, there exists considerable variability in the structure, frequency, and timing of simulation-based activities. As programs transition to competency-based medical education, national organizations and collaborations should consider the variability in how SBE is administered.

Hair cortisol as a biomarker of stress in mindfulness training for smokers.

OBJECTIVES: Stress is a well-known predictor of smoking relapse, and cortisol is a primary biomarker of stress. The current pilot study examined changes in levels of cortisol in hair within the context of two time-intensity matched behavioral smoking cessation treatments: mindfulness training for smokers and a cognitive-behavioral comparison group. PARTICIPANTS: Eighteen participants were recruited from a larger randomized controlled trial of smoking cessation. OUTCOME MEASURES: Hair samples (3 cm) were obtained 1 month after quit attempt, allowing for a retrospective analysis of hair cortisol at preintervention and post-quit attempt time periods. Self-reported negative affect was also assessed before and after treatment. INTERVENTION: Both groups received a 7-week intensive intervention using mindfulness or cognitive-behavioral strategies. RESULTS: Cortisol significantly decreased from baseline to 1 month after quit attempt in the entire sample (d=-0.35; p=.005). In subsequent repeated-measures analysis of variance models, time by group and time by quit status interaction effects were not significant. However, post hoc paired t tests yielded significant pre-post effects among those randomly assigned to the mindfulness condition (d=-0.48; p=.018) and in those abstinent at post-test (d=-0.41; p=.004). Decreased hair cortisol correlated with reduced negative affect (r=.60; p=.011). CONCLUSIONS: These preliminary findings suggest that smoking cessation intervention is associated with decreased hair cortisol levels and that reduced hair cortisol may be specifically associated with mindfulness training and smoking abstinence. RESULTS support the use of hair cortisol as a novel objective biomarker in future research.

Chronic HPA axis response to stress in temporomandibular disorder.

PURPOSE: Perceived stress is associated with temporomandibular disorder (TMD), but whether cortisol levels are elevated in individuals with TMD is unknown. We hypothesized that cortisol concentration, a biomarker of hypothalamic-pituitary-adrenal (HPA) axis function, was elevated in TMD cases relative to controls, and that perceived stress was positively correlated with cortisol concentration. METHODS: In this case control study, TMD case status was determined by examiners using TMD Research Diagnostic Criteria. Participants (n=116) aged 18 to 59 years were recruited from within a 50 mile radius of the University of North Carolina at Chapel Hill. Following examination, cases (n=45) and controls (n=71) completed the 14-item Perceived Stress Scale using a reference interval of the past 3 months. Approximately 100 strands of hair were cut from the posterior vertex segment of their scalp. The 3 centimeters of hair most proximal to the scalp was analyzed with a commercially available salivary cortisol enzyme immunoassay adapted for hair cortisol. This length corresponds to the last 3 months of systemic HPA axis activity. RESULTS: TMD cases perceived higher stress than controls (p=0.001). However, hair cortisol concentration was lower in TMD cases than controls (p<0.001). The correlation coefficient revealed a weak negative relationship (r=-0.188) between perceived stress and hair cortisol concentration (p=0.044). In analysis stratified by case status, the relationship of perceived stress and hair cortisol concentration was non-significant for cases (p=0.169) and controls (p=0.498). CONCLUSION: Despite greater perceived stress, TMD cases had lower hair cortisol concentrations than controls and the 2 measures of stress were weakly and negatively correlated.