The effect of mindfulness interventions on stress in medical students: A systematic review and meta-analysis.

BACKGROUND: Medical students have high levels of stress, which is associated with higher incidents of burnout, depression, and suicide compared to age-matched peers. Mindfulness practices have been shown to reduce stress among medical students. PURPOSE: The purpose of this systematic review and meta-analysis was to examine if mindfulness interventions have an overall effect on stress outcomes in the high-stress population of medical students globally, particularly given the wide variety of interventions. Any intervention designed to promote mindfulness was included. METHODS: A comprehensive literature search was completed to include multiple databases, ancestry, and hand-searching and 35 studies were included. Standardized mean difference effect sizes (ES) were synthesized across studies using a random-effects model for changes in stress levels in medical students ≥ 18. Moderator analyses were performed to explore variations in effects by participant and intervention characteristics. RESULTS: Mindfulness interventions significantly improved stress among medical students in both the two-arm studies (d = 0.370, k = 19, n = 2,199, 95% CI 0.239-0.501, p < .001) and one-arm pre-post studies (d = 0.291, k = 30, n = 18 (two cohorts from Dyrbye et al), 95% CI 0.127-0.455, p = 0.001). Moderator analyses found trends in less hours and less required practice resulted in better improvement in stress. CONCLUSIONS: This study further confirms that despite a wide variety of mindfulness interventions for medical students around the world, they produce an overall small-to-moderate effect on stress reduction. Future research looking at the most effective protocols for high-stress medical students would be beneficial.

Prevalence, characteristics and measurement of somatic symptoms related to mental health in medical students: a scoping review.

INTRODUCTION: Somatic symptoms related to mental health in medical students are under-researched, with nothing on the topic being published in the United States in over three decades. This scoping review is the first of its kind to explore the prevalence, type and severity of somatic symptoms induced by stress, anxiety, depression and burnout amongst medical students, with the objective of describing the significance and breadth of this issue. METHODS: PRISMA-ScR guidelines were used to guide this review. A comprehensive search was performed of 22 databases, followed by bibliographic and hand searching. Inclusion criteria were published, peer-reviewed articles with a sample of medical students and at least one measure of somatic symptoms related to mental health, in English or with an English-language translation. Excluded were review, companion and editorial articles. Coding was done by an experienced coder trained in systematic review techniques. Two authors reviewed each article. RESULTS: Twenty-nine articles met inclusion criteria, representing 16 countries, 31 schools/teaching hospitals and 9,887 medical students. The prevalence of somatic symptoms ranged from 5.7 to 80.1%, and somatic symptoms were overwhelmingly found to be significantly correlated with mental ill-health. Somatic symptoms included back pain, neck pain, headaches, sleep disturbances and functional gastrointestinal disorders. Eleven different outcome measures were used, with varying degrees of validity and reliability, which were compared and assessed. CONCLUSIONS: Somatic symptoms appear strongly correlated with mental ill-health in medical students, and are likely highly prevalent. This review highlights the need for further research on somatic symptoms of mental ill-health in medical students, particularly in the United States, and the addition of larger, multi-institutional cohorts to expand our understanding of prevalence, incidence and inciting factors of somatic symptoms. Longitudinal studies tracking somatic symptoms' effect on career trajectory and professional burnout levels are also needed. Finally, future research should explore interventions for reducing physical symptom burden in medical students.

This scoping review is the first of its kind to explore the breadth and depth of knowledge on the presence, prevalence, type and severity of somatic symptoms related to stress experienced by medical students across the globe, and if or how physical symptoms of stress have been addressed thus far.Medical students are known to have chronically high levels of stress, but somatic symptoms of stress are not well researched in this population, particularly in the United States, where no research has been done on this topic in over three decades.This scoping review finds that across many different countries, medical students consistently report high rates of physical symptoms, including musculoskeletal pain and gastrointestinal disorders, which are highly correlated with stress and other mental health conditions.This review provides the first initial assessment of the outcome measures used for somatic symptoms related to mental health.Further research on the impact of physical symptoms in medical students, and how this might relate to medical students' mental health and eventual career burnout, is warranted.

Acceptability of the Mantram Repetition Program to Reduce Stress in Adolescent Survivors of Pediatric Cancer or Brain Tumors.

A mixed-methods approach was used to explore the acceptability of the Mantram Repetition Program (MRP) to reduce stress in adolescents with a history of pediatric cancer or brain tumor. Five male participants diagnosed at ages 1-14 years and currently, ages 13-18 years, completed assessments of stress, anxiety, and sleep disturbance and were interviewed about the acceptability of a mantram repetition intervention. Adolescent survivors reported low to moderate levels of stress, anxiety, and sleep disturbance. Data indicate that the MRP is acceptable among adolescent survivors of pediatric cancer and brain tumors, and face-to-face intervention delivery is preferred.

Personality and Spirituality as Predictors of Mental Health and Salivary Alpha-Amylase Activity in Breast Cancer Survivors.

OBJECTIVES: To determine the relative predictive validity of personality and spirituality for mental health and salivary alpha-amylase (sAA) in breast cancer (BC) survivors. SAMPLE & SETTING: 23 BC survivors participated in a single-group, cross-sectional study. METHODS & VARIABLES: Predictor variables included personality and spiritual variables. Outcome variables included subjective physical and mental health outcomes and sAA, a neuroimmune biomarker. RESULTS: Hierarchical regressions indicated that (a) conscientiousness and forgiveness independently predict 38% and 11% of variance in mental health scores, respectively; and (b) conscientiousness and forgiveness independently predict 15% and 24% of the variance in sAA, respectively. Consistent with psychoneuroimmunology theory, personality and spiritual variables independently influence subjective mental health and neuroimmune activity in BC survivors. IMPLICATIONS FOR NURSING: Nurses should be aware of BC survivors' personality characteristics and spiritual dispositions so that distinct interventions can be offered to promote mental health and reduce stress-related neuroimmune inflammation.

Associations between religious and spiritual variables and neuroimmune activity in survivors of breast cancer: a feasibility study.

PURPOSE: Chronic stress is associated with neuroimmune inflammation and adverse outcomes in breast cancer survivors. Some breast cancer survivors rely on religious and spiritual (R/S) variables to manage stress after breast cancer treatment. A spiritually based psychoneuroimmunological (PNI) model of health suggests that R/S variables influence neuroimmune activity; however, these associations are not well-established. A pilot study was conducted to assess the feasibility of studying associations between R/S variables and neuroimmune biomarkers in breast cancer survivors. METHOD: Salivary alpha-amylase (sAA) and interleukin-6 (IL-6) were sampled among women previously treated for breast cancer. The primary aim was to assess feasibility and acceptability of the sampling protocol. A secondary aim explored associations between sAA, IL-6, R/S variables, and health outcomes. RESULT: Forty-one women completed the study. Biomarker sampling yielded 246 acceptable specimens used for analysis. SAA was detectable in 96% of specimens and IL-6 was detectable in 44% of specimens. The R/S variables with the strongest associations to sAA were spiritual self-rank (rs = .39; p < .05) and forgiveness (rs = .40; p < .05). The R/S variable with the strongest association to salivary IL-6 was positive congregational support (rs = .42; p < .05). CONCLUSION: Feasibility and acceptability of the sampling protocol were confirmed. Reference ranges for sAA and IL-6 for female breast cancer survivors are presented. Results suggest that spiritual beliefs and religious practices are associated with neuroimmune activity, adding credence to a spiritually based PNI model of health. Findings lay the foundations for future R/S-based interventions to promote health and well-being in breast cancer survivors.

Rural-Urban Differences in Neuroimmune Biomarkers and Health Status Among Women Living With Breast Cancer.

BACKGROUND: Because of chronic emotional and psychosocial stressors following breast cancer (BC) treatment, BC survivors are at risk of neuroimmune dysfunction in survivorship. Rural BC survivors experience more health disparities than urban BC survivors. Rural-urban residence as a variable on neuroimmune activity in extended BC survivorship continuum has not been explored. OBJECTIVE: To report the feasibility of studying relationships between neuroimmune activity and perceived health in rural and urban BC survivors. METHODS: Data from a pilot study of BC survivors (n = 41) were analyzed. Participants were rural (n = 16) and urban (n = 25). Participants completed Medical Outcomes Study Short-Form Version 2 Health Survey questionnaires and provided salivary specimens for analysis of salivary α-amylase (sAA), cortisol, and interleukin 6 (IL-6). Rural-Urban Commuting Area Codes were used to determine rural or urban residence. RESULTS: Differences in immune activity were observed between rural and urban BC survivors (U = 34, P < .05). No rural-urban group differences in neuroendocrine activity were observed. Relationships were observed between perceptions of mental health and sAA (P < .05) in rural BC survivors and between perceptions of mental health and IL-6 (P < .05) in urban BC survivors. Interleukin 6 was positively associated with perceptions of physical health (P < .05) in rural BC survivors. CONCLUSION: Pilot data suggest rural-urban residence may be a factor in relationships between neuroimmune function (ie, sAA and IL-6) and perceived health status, particularly social functioning in women with BC. Additional studies with powered designs are indicated. IMPLICATIONS FOR PRACTICE: Although evidence is limited, data support the feasibility of studying relationships between sAA and IL-6 and perceptions of health in women with BC.

Mind-Body Interventions in the Management of Chronic Cancer Pain.

OBJECTIVES: To describe mind-body interventions used in the management of chronic cancer pain including their mechanisms of action, dosing, and delivery methods based on available evidence to date. DATA SOURCES: Peer-reviewed publications. CONCLUSION: Further high-quality research is needed to establish the effectiveness and mechanisms of actions for mind-body interventions in chronic cancer pain management. IMPLICATIONS FOR NURSING PRACTICE: Mind-body interventions for chronic cancer pain management are generally safe and well-accepted by individuals with cancer. Nurses need to be knowledgeable about these interventions to explain their level of effectiveness and any safety issues with patients.

Rigor and Reproducibility: A Systematic Review of Salivary Cortisol Sampling and Reporting Parameters Used in Cancer Survivorship Research.

Salivary cortisol is a commonly used biomarker in cancer survivorship research; however, variations in sampling protocols and parameter reporting limit comparisons across studies. Standardized practices to provide rigor and reproducibility of diurnal salivary cortisol sampling and reporting are not well established. Previous systematic reviews examining relationships between diurnal salivary cortisol and clinical outcomes have resulted in mixed findings. It remains unclear which sampling protocols and reporting parameters offer the greatest utility for clinical research. This review examines diurnal salivary cortisol sampling protocols and reporting parameters to evaluate whether a standardized approach is recommended. A comprehensive search of intervention studies among adult cancer survivors including diurnal salivary cortisol resulted in 30 articles for review. Sampling protocols ranged from 1 to 4 days with the majority of studies sampling cortisol for 2 days. Sampling instances ranged from 2 to 7 times per day, with the majority collecting at 4 time points per day. Diurnal cortisol slope and cortisol awakening response (CAR) were the most commonly reported parameters associated with clinical outcomes. Flattened cortisol slopes, blunted CARs, and elevated evening cortisol concentrations were associated with poorer psychosocial and physiological outcomes. Based on our review, we propose that a rigorous, standardized diurnal salivary cortisol sampling protocol should include sampling at key diurnal times across ≥3 consecutive days to report diurnal cortisol parameters (i.e., CAR and slope) and objective measures of participant protocol adherence. Diminishing budgetary resources and efforts to minimize participant burden dictate the importance of standardized cortisol sampling protocols and reporting parameters.

A systematic review of interventions to improve adherence to endocrine therapy.

PURPOSE: Adherence to endocrine therapy for hormone positive breast cancer is a significant problem, especially in minority populations. Further, endocrine therapy reduces recurrence and thus mortality. However, little data are available on interventions to improve adherence. The authors conducted a systematic review to examine the impact of interventions, strategies, or approaches aimed to improve endocrine therapy adherence among women with breast cancer. A secondary aim was to determine if interventions had any cultural modifications. METHODS: Two of the authors examined articles published between 2006 and 2017 from a wide variety of databases using Covidence systematic review platform. RESULTS: In total, 16 eligible studies met criteria for review including 4 randomized controlled trials, 4 retrospective studies, and 8 with various observational designs. Eligible studies used a broad range of definitions for adherence and measured adherence by self-report, medical records, claims data, and combinations of these. All used 80% medication possession ratio as a standard for adherence. Patient information/education was the most frequent intervention strategy but did not demonstrate a significant effect except in one study. Significant results were noted when education was combined with communication strategies. CONCLUSIONS: Researchers need a standard definition for adherence and a reliable measure that is feasible to use in a variety of studies. While education may be a necessary component of an intervention, when used alone, it is not a sufficient approach to change behavior.

Religiousness, Spirituality, and Salivary Cortisol in Breast Cancer Survivorship: A Pilot Study.

BACKGROUND: Psychoneuroimmunological theory suggests a physiological relationship exists between stress, psychosocial-behavioral factors, and neuroendocrine-immune outcomes; however, evidence has been limited. OBJECTIVE: The primary aim of this pilot study was to determine feasibility and acceptability of a salivary cortisol self-collection protocol with a mail-back option for breast cancer survivors. A secondary aim was to examine relationships between religiousness/spirituality (R/S), perceptions of health, and diurnal salivary cortisol (DSC) as a proxy measure for neuroendocrine activity. METHODS: This was an observational, cross-sectional study. Participants completed measures of R/S, perceptions of health, demographics, and DSC. RESULTS: The sample was composed of female breast cancer survivors (n = 41). Self-collection of DSC using a mail-back option was feasible; validity of mailed salivary cortisol biospecimens was established. Positive spiritual beliefs were the only R/S variable associated with the peak cortisol awakening response (rs = 0.34, P = .03). Poorer physical health was inversely associated with positive spiritual experiences and private religious practices. Poorer mental health was inversely associated with spiritual coping and negative spiritual experiences. CONCLUSIONS: Feasibility, validity, and acceptability of self-collected SDC biospecimens with an optional mail-back protocol (at moderate temperatures) were demonstrated. Positive spiritual beliefs were associated with neuroendocrine-mediated peak cortisol awakening response activity; however, additional research is recommended. IMPLICATIONS FOR PRACTICE: Objective measures of DSC sampling that include enough collection time points to assess DSC parameters would increase the rigor of future DSC measurement. Breast cancer survivors may benefit from nursing care that includes spiritual assessment and therapeutic conversations that support positive spiritual beliefs.

Caregiver, patient, and nurse visit communication patterns in cancer home hospice.

OBJECTIVE: Few studies have examined the triadic communication between patients, spouse caregivers, and nurses in the home hospice setting. Thus, little is known about the types of communication patterns that unfold. The goals of the study were to, first, identify common patterns of communication in nurse-patient-caregiver home hospice visits and, second, to identify nurse, caregiver-patient dyad, and visit characteristics that predict visit communication patterns. METHOD: Nurses (N = 58) and hospice cancer patient and spouse caregiver dyads (N = 101; 202 individuals) were recruited from 10 hospice agencies. Nurses audio recorded visits to patient/caregiver homes from study enrollment until patient death. All patient, caregiver, and nurse utterances from the audio recordings were coded using an adapted Roter interaction analysis system. Using identified codes, cluster analysis was conducted to identify communication patterns within hospice visits. Logistic regression was used with demographic variables to predict visit communication patterns. RESULTS: Six visit communication patterns were identified and were defined largely by 2 dimensions: (1) either the patient, the caregiver, or the patient and caregiver dyad interacting with the nurse and (2) the relatively high or low expression of distress during the visit. Time until death significantly predicted several clusters. CONCLUSION: This study leads the way in outlining triadic communication patterns in cancer home hospice visits. Our findings have implications for nursing education, letting future nurses know what to expect, and lays the foundation for future research to determine effectiveness and interventions to improve health care communication.

A Systematic Review of Spiritually Based Interventions and Psychoneuroimmunological Outcomes in Breast Cancer Survivorship.

Objective This is a review of spiritually based interventions (eg, mindfulness-based stress reduction) that utilized psychoneuroimmunological (PNI) outcome measures in breast cancer survivors. Specifically, this review sought to examine the evidence regarding relationships between spiritually based interventions, psychosocial-spiritual outcomes, and biomarker outcomes in breast cancer survivors. Methods A systematic search of 9 online databases was conducted for articles of original research, peer-reviewed, randomized and nonrandomized control trials from 2005-2015. Data were extracted in order to answer selected questions regarding relationships between psychosocial-spiritual and physiological measures utilized in spiritually based interventions. Implications for future spiritually based interventions in breast cancer survivorship are discussed. Results Twenty-two articles were reviewed. Cortisol was the most common PNI biomarker outcome studied. Compared with control groups, intervention groups demonstrated positive mental health outcomes and improved or stable neuroendocrine-immune profiles, although limitations exist. Design methods have improved with regard to increased use of comparison groups compared with previous reviews. There are few spiritually based interventions that specifically measure religious or spiritual constructs. Similarly, there are few existing studies that utilize standardized religious or spiritual measures with PNI outcome measures. Findings suggest that a body of knowledge now exists in support of interventions with mindfulness-breathing-stretching components; furthermore, these interventions appear to offer potential improvement or stabilization of neuroendocrine-immune activity in breast cancer survivors compared to control groups. Conclusion From a PNI perspective, future spiritually based interventions should include standardized measures of religiousness and spirituality in order to understand relationships between and among religiousness, spirituality, and neuroendocrine-immune outcomes. Future research should now focus on determining the minimum dose and duration needed to improve or stabilize neuroendocrine-immune function, as well as diverse setting needs, including home-based practice for survivors who are too ill to travel to group sessions or lack economic resources.

Perspectives of the Breast Cancer Survivorship Continuum: Diagnosis through 30 Months Post-Treatment.

This study explored breast cancer survivors' perspectives regarding their experiences of the survivorship continuum from diagnosis through 30 months post-treatment. The sample included women (N = 379) with newly-diagnosed breast cancer undergoing treatment at a Midwestern university-affiliated cancer center. Semi-structured interviews were conducted using the Lymphedema and Breast Cancer Questionnaire at time of diagnosis, post-operatively, quarterly during the first year, and then semi-annually thereafter through 30 months post-treatment. A mixed-methodology was used to analyze participants' comments. Themes central to long-term survivorship experiences included social support, positive worldviews, breast cancer and lymphedema health literacy, religious/spiritual beliefs, self-empowerment, and recovery expectations. These themes were consistent with a psychoneuroimmunological model of health in which psychosocial variables mediate stress and influence health outcomes. Qualitative data showed that social support and positive worldviews were the two themes with the most significant impact on long-term breast cancer survivorship experiences. Survivors expressed a need to advance their health care literacy in order to share ownership of breast cancer and lymphedema treatment decisions. Since breast cancer is an immune-mediated disease, long-term survivorship planning should address psychosocial factors that influence the long-term psychological distress associated with immune dysfunction.

Best Practice Guidelines in Assessment, Risk Reduction, Management, and Surveillance for Post-Breast Cancer Lymphedema.

Breast cancer-related lymphedema (LE) is a progressive, chronic disease that affects millions of cancer survivors and primarily results from surgical lymphatic vessel/node removal and radiation therapy. Patient education and support for importance of early detection is essential in helping health care providers detect lymphedema early, when there is the best chance to prevent progression. Improved imaging and surgical techniques have decreased the incidence of LE; however, effective risk-reduction and treatment have historically lacked the level of evidence necessary to standardize effective treatment. The purpose of this article is to report an extensive review of literature, including highlighted multidisciplinary studies within the past three years, in order to update best practice guidelines in assessment, risk reduction, management, and surveillance for post-breast cancer lymphedema.