The association between empathy and burnout in medical students: a systematic review and meta-analysis.

BACKGROUND: Burnout levels in medical students are higher than in other student groups. Empathy is an increasingly desired outcome of medical schools. Empathy is negatively associated with burnout in physicians. Our objective was to quantitatively review the available literature on associations between empathy and burnout in medical students, and to explore associations between specific empathy aspects (cognitive and affective) and burnout sub-dimensions (emotional exhaustion, depersonalization and personal accomplishment). METHODS: A comprehensive search of the literature published up until January 2024 was undertaken in the PubMed, EMBASE, CINAHL, The Cochrane Library, and PsycINFO databases. Two independent reviewers screened 498 records and quality-rated and extracted data from eligible studies. The effect size correlations (ESr) were pooled using a random-effects model and between-study variation explored with meta-regression. The review was preregistered with PROSPERO (#CRD42023467670) and reported following the PRISMA guidelines. RESULTS: Twenty-one studies including a total of 27,129 medical students published between 2010 and 2023 were included. Overall, empathy and burnout were negatively and statistically significantly associated (ESr: -0.15, 95%CI [-0.21; -0.10], p < .001). When analyzing sub-dimensions, cognitive empathy was negatively associated with emotional exhaustion (ESr: -0.10, 95%CI [-0.17; -0.03], p = .006) and depersonalization (ESr: -0.15, 95%CI [-0.24; 0.05], p = .003), and positively associated with personal accomplishment (ESr: 0.21, 95%CI [0.12; 0.30], p < .001). Affective empathy was not statistically significantly associated with emotional exhaustion, depersonalization or personal accomplishment. Supplementary Bayesian analysis indicated the strongest evidence for the positive association between cognitive empathy and personal accomplishment. Response rate and gender moderated the relationship so that higher response rates and more male respondents strengthen the negative association between empathy and burnout. CONCLUSION: Greater empathy, in particular cognitive empathy, is associated with lower burnout levels in medical students. This appears to be primarily driven by cognitive empathy's positive association with personal accomplishment. PROTOCOL REGISTRATION: #CRD42023467670.

Conjunctivitis in adult patients with moderate-to-severe atopic dermatitis: results from five tralokinumab clinical trials.

BACKGROUND: Tralokinumab, a fully human IgG4 monoclonal antibody that specifically binds with high affinity to interleukin-13, effectively reduces moderate-to-severe atopic dermatitis (AD) when given every 2 weeks. The incidence of conjunctivitis is elevated vs. placebo, but severity and aetiology have not been examined. OBJECTIVE: To analyse conjunctivitis data recorded in five randomized, placebo-controlled trials of tralokinumab in adult patients with moderate-to-severe AD. METHODS: Overall, 2285 adults with AD were studied up to 16 weeks. Cochran-Mantel-Haenszel weights were applied to calculate the adjusted incidence of adverse events. RESULTS: The incidence of conjunctivitis was higher (7·5%) with tralokinumab than with placebo (3·2%). Most events were mild or moderate in severity, and 78·6% and 73·9% of events resolved during the trial in the tralokinumab and placebo groups, respectively. Two (1·4%) events led to the permanent discontinuation of tralokinumab. An increased incidence of conjunctivitis, regardless of treatment group, was associated with more severe baseline AD, and history of allergic conjunctivitis/atopic keratoconjunctivitis, as well as the number of atopic comorbidities. LIMITATIONS: This analysis reports events up to week 16 only, with limited confirmation of conjunctivitis and its aetiology by an ophthalmologist, and insufficient reporting of ophthalmic treatments. CONCLUSIONS: Treatment with tralokinumab was associated with an increased incidence of conjunctivitis vs. placebo, but these cases were mostly mild and transient.

Development and preliminary validation of the Adolescent Psoriasis Quality of Life instrument: a disease-specific measure of quality of life in adolescents with psoriasis.

BACKGROUND: No age-appropriate and disease-specific instrument currently exists to measure health-related quality of life in adolescents with psoriasis (patients aged 12-17 years). OBJECTIVES: To develop and provide preliminary validation of the Adolescent Psoriasis Quality of Life instrument. METHODS: Qualitative interviews with adolescents with psoriasis, parents of adolescents with psoriasis, and healthcare professionals informed the development of an initial item pool for the instrument, which was subsequently refined through cognitive interviews. Finally, data from an independent sample of adolescents with psoriasis (n = 50) were used for item reduction, scale construction and initial validation, using a combination of techniques from classical test theory and Rasch modelling. RESULTS: Rich qualitative data concerning health-related quality of life in adolescents with psoriasis (from 18 adolescents, 14 parents and four healthcare professionals), combined with cognitive interview testing (n = 12), resulted in a 41-item draft version. Item reduction led to the final version, a 17-item instrument consisting of two subscales showing good fit to their respective Rasch models: psychosocial impact (12 items) and the impact of physical symptoms and treatment (five items). All a priori stated hypotheses regarding construct validity were supported. Both subscales and the total scale showed acceptable test-retest reliabilities (intraclass correlations 0·97, 0·89 and 0·96) and internal consistencies (Cronbach's α 0·94, 0·81 and 0·95). CONCLUSIONS: The preliminary form of the Adolescent Psoriasis Quality of Life instrument shows promising psychometric properties. It can be used in daily clinical practice and research to support a patient-centred approach and inform treatment planning. What's already known about this topic? Health-related quality of life (HRQoL) instruments should be targeted towards narrowly defined age groups, as life contexts of children, adolescents and adults may differ substantially. Dermatology-specific instruments have been used to measure HRQoL in adolescents with psoriasis, but it is not known whether these instruments accurately capture all relevant HRQoL aspects in adolescent psoriasis. Age-appropriate and psoriasis-specific instruments may be more sensitive for HRQoL issues experienced by this unique group. What does this study add? The Adolescent Psoriasis Quality of Life instrument represents the first age-appropriate and disease-specific instrument for measuring HRQoL in adolescents (12-17 years old) with psoriasis. It is intended for use in daily clinical practice to support dermatologists and other healthcare professionals in providing optimal care for adolescents with psoriasis.

Effects of psychological interventions on systemic levels of inflammatory biomarkers in humans: A systematic review and meta-analysis.

The purpose of the present investigation was to systematically review randomized controlled trials examining the effects of psychological interventions on inflammatory biomarkers in adult populations and to quantitatively analyze those effects by meta-analysis. Two researchers independently searched key electronic databases, selected eligible publications, extracted data, and evaluated methodological quality. Nineteen randomized controlled trials examining a total of 1510 participants were included. The overall combined effect size from pre to post psychological intervention on pro-inflammatory biomarker levels was statistically significant, showing an attenuating effect, although of a small magnitude (s' g = 0.15, p = .008, CI [0.04-0.26]). However, this effect was not maintained into the follow-up period (g < -0.01, p = .964, CI [-0.19-0.18]). Looking at the individual biomarkers assessed across studies, only C-reactive protein (CRP) was found to significantly decrease following psychological intervention. A number of moderation analyses were conducted, none of which reached statistical significance. However, the numerically largest - and significant - within-group effect size was obtained for the group of studies that had preselected participants based on elevated psychological distress (g = 0.29, p = .047). In conclusion, psychological interventions appear efficacious in reducing pro-inflammatory biomarker levels. Future studies are recommended to carefully select individuals based on inflammatory (e.g., the presence of low-grade inflammation) and/or psychological (e.g., psychological distress) criteria.

Health-related quality of life in adolescents with psoriasis: an interview-based study.

BACKGROUND: Psoriasis is a common skin disease affecting the physical, psychological and social well-being of patients and their families. Most research so far has been limited to adults, and little is known about the qualitative experiences of young people with psoriasis. OBJECTIVES: To provide an in-depth understanding of the impact of psoriasis on adolescents' health-related quality of life (HRQoL). METHODS: Patients and their parents were recruited from a dermatology outpatient clinic, the Danish National Birth Cohort and the Danish Psoriasis Association. Thirty-six semistructured interviews were conducted with adolescents with psoriasis aged 12-17 years (n = 18), their parents (n = 14) and health professionals working with psoriasis (n = 4). Interviews were digitally recorded, transcribed verbatim and analysed using inductive thematic analysis. RESULTS: The participants reported psoriasis-related HRQoL challenges within six main themes: physical symptoms, feeling different, psoriasis-related worry about the future, increased attention, attempts to conceal skin, and treatment-related frustrations and worry. Taken together, a broad range of the reported difficulties appeared to arise from appearance-related concerns. The impact of psoriasis and its treatment on the adolescents' daily lives varied considerably. CONCLUSIONS: This first in-depth, qualitative study of HRQoL in adolescents with psoriasis provides a conceptual framework for understanding the impact of psoriasis and its treatment on the physical, psychological and social aspects of their daily lives.

Sleep disturbance in psoriasis: a case-controlled study.

BACKGROUND: Sleep is essential for daytime functioning and health. Given the physical symptoms of psoriasis, a higher prevalence of sleep disorders can be expected. So far, the studies examining sleep disturbance in psoriasis have been of less-than-optimal methodological quality and with mixed results. OBJECTIVES: To examine the prevalence of sleep disturbance in patients with plaque psoriasis compared with a control group, to evaluate associations with health-related quality of life (HRQoL) and examine possible disease-related predictors of disturbed sleep. METHODS: We used a cross-sectional, case-controlled design. Participants included 179 consecutively recruited patients with plaque psoriasis and 105 controls. Measures included psoriasis severity (Psoriasis Area and Severity Index); HRQoL (Dermatology Life Quality Index); insomnia severity [Insomnia Severity Index (ISI)]; sleep quality [Pittsburgh Sleep Quality Index (PSQI)]; stress (Perceived Stress Scale); itch (Itch Severity Scale); and depressive symptoms (Beck Depression Inventory). Analyses included group comparisons and regression analyses to identify predictors of sleep disturbance. RESULTS: A total of 25% of patients with psoriasis reported clinical insomnia (ISI > 15), compared with 10·5% of controls. In all, 53·6% of patients with psoriasis were poor sleepers (PSQI > 5), compared with 21·9% of controls. Itch was statistically significantly associated with all sleep-related outcomes. CONCLUSIONS: A higher proportion of patients with psoriasis experience poor sleep than controls from the general population. Itch was the main predictor of impaired sleep. Improved control of psoriasis with decreased itch may improve sleep disturbance in psoriasis.

Mindfulness-based cognitive therapy (MBCT) is cost-effective compared to a wait-list control for persistent pain in women treated for primary breast cancer-Results from a randomized controlled trial.

OBJECTIVE: To investigate the cost-effectiveness of mindfulness-based cognitive therapy (MBCT) compared to a wait-list control group for pain in women treated for breast cancer. METHODS: A total of 129 women were randomly allocated to MBCT or a wait-list control group. The primary outcome was the minimal clinically important difference (MCID) on pain intensity (≥2 point reduction on an 11-point Numeric Rating Scale). Analyses were conducted from the health care system perspective and included data on health care utilization and pain medication retrieved from national registries for the period from baseline (T1) to 6 months postintervention (T4). Bootstrap simulations were used to estimate confidence intervals for the incremental cost and effect measures, and cost-effectiveness acceptability curves. In sensitivity analyses, we replaced dropouts with last-observation-carried-forward and tested consequences of higher costs of the intervention. RESULTS: The intervention cost was 240€ per participant. The average total cost from T1 to T4 in the MBCT group was 1706€ compared with 2436€ in the control group (mean difference: 729€, P = .07). More women in the MBCT group (N:19/36; 52.8%) than in the control group (N:14/48; 29.2%) achieved an MCID in pain intensity (OR=2.71, P = .03). The MBCT was cost-effective with a probability of 85% with a value of an additional women achieving MCID set to zero remained cost-effective with a probability of 70% to 82% when smaller effect and higher MBCT costs were assumed. CONCLUSIONS: Our results suggest that MBCT is a cost-effective pain intervention for women treated for breast cancer. Future studies could include utility measures, indirect costs, and active control groups to increase the generalizability and pragmatic value of the results.

Clinical and psychological moderators of the effect of mindfulness-based cognitive therapy on persistent pain in women treated for primary breast cancer - explorative analyses from a randomized controlled trial.

BACKGROUND: Mindfulness-based intervention has been found efficacious in reducing persistent pain in women treated for breast cancer. Little, however, is known about possible moderators of the effect. We explored clinical and psychological moderators of the effect on pain intensity previously found in a randomized controlled trial of mindfulness-based cognitive therapy (MBCT) with women treated for breast cancer with persistent pain. MATERIAL AND METHODS: A total of 129 women treated for breast cancer reporting persistent pain were randomized to MBCT or a wait-list control. The primary outcome of pain intensity (11-point numeric rating scale) was measured at baseline, post-intervention, three, and six months follow-up. Proposed clinical moderators included age, axillary lymph node dissection (ALND), radiotherapy, and endocrine treatment. Psychological moderators included psychological distress [the Hospital Anxiety and Depression Scale (HADS)], the adult attachment dimensions anxiety and avoidance [the Experiences in Close Relationships Short Form (the ECR-SF)], and alexithymia [the Toronto Alexithymia Scale (TAS-20)]. Multi-level models were used to test moderation effects over time, i.e. time × group × moderator. RESULTS: Only attachment avoidance (p = 0.03, d = 0.36) emerged as a statistically significant moderator. Higher levels of attachment avoidance predicted a larger effect of MBCT in reducing pain intensity compared with lower levels attachment avoidance. None of the remaining psychological or clinical moderators reached statistical significance. However, based on the effect size, radiotherapy (p = 0.075, d = 0.49) was indicated as a possible clinical moderator of the effect, with radiotherapy being associated with a smaller effect of MBCT on pain intensity over time compared with no radiotherapy. CONCLUSION: Attachment avoidance, and potentially radiotherapy, may be clinically relevant factors for identifying the patients who may benefit most from MBCT as a pain intervention. Due to the exploratory nature of the analyses, the results should be considered preliminary.

Web-based cognitive training for breast cancer survivors with cognitive complaints-a randomized controlled trial.

BACKGROUND: Cognitive complaints are common amongst breast cancer survivors, and no standard treatment exists. The present study evaluates whether web-based cognitive training can alleviate subjectively reported and objectively assessed cognitive complaints in a sample of breast cancer survivors. The primary and secondary outcomes were an objective measure of working memory and a measure of perceived cognitive functioning. Additional outcomes were neuropsychological tests of memory, executive function, working memory and questionnaire-based assessment of anxiety, depression and somatization. METHODS: A total of 157 female breast cancer survivors were recruited from an existing cohort and through announcements in open access cancer-related Internet fora and randomly allocated to either web-based cognitive training (eCogT) with telephone support (n = 94) or a waitlist control (WLC) condition (n = 63). eCogT encompassed 30 training sessions over 6 weeks. Neuropsychological assessments were undertaken over the telephone, and questionnaire data was collected online. Data was collected at baseline, post-intervention and at 5-month follow-up. RESULTS: Mixed linear models revealed no statistically significant change in primary or secondary outcome at follow-up in either group. Statistically significant improvements (p 0.040-0.043) were found in the eCogT group for verbal learning and on a working memory test. CONCLUSIONS: Web-based cognitive training did not result in improvements of the primary or secondary outcome. Improved performance was observed on verbal learning and working memory. These effects were observed at 5-month follow-up, indicating long-term effects of training. The intervention may be applied in a clinical setting at low cost and without risk of adverse effects.© 2016 The Authors Psycho-Oncology Published by John Wiley & Sons Ltd.

Long-term subjective cognitive functioning following adjuvant systemic treatment: 7-9 years follow-up of a nationwide cohort of women treated for primary breast cancer.

BACKGROUND: There is growing concern among breast cancer (BC) patients and survivors about cognitive impairment following systemic treatments. The aim of the present study was to investigate the long-term effects of standard systemic adjuvant therapies on subjective cognitive impairment (SCI) in a large nationwide cohort of BC survivors 7-9 years after primary surgery. METHODS: Participants were recruited from the nationwide Psychosocial Factors and Breast Cancer inception cohort of Danish women treated for primary BC. SCI was assessed with the Cognitive Failures Questionnaire and women allocated to systemic treatment according to nationwide standard protocols were compared with women who had not received any systemic treatments. RESULTS: A total of 1889 recurrence-free survivors were eligible for analysis. No difference in SCI was found between survivors across standardized systemic treatment protocols when analyses were stratified by menopausal status and adjusted for possible sociodemographic and treatment-related confounders. The frequency of significant SCI in a subgroup of survivors in the age range 65-74 years was ∼7%. CONCLUSIONS: No differences in long-term SCI at 7-9 years post surgery were found between women who had received systemic therapies and those who had not. Furthermore, the observed proportion of survivors with significant SCI was comparable to normative data. These results are important to communicate to patients, survivors, and clinicians alike, especially in the light of increasing concern about cognitive impairment following systemic therapies.

Socio-demographic, treatment-related, and health behavioral predictors of persistent pain 15 months and 7-9 years after surgery: a nationwide prospective study of women treated for primary breast cancer.

The purpose of this study was to investigate and report prevalence and risk factors for persistent pain in breast cancer patients at 15 months and 7-9 years post surgery. A nationwide inception cohort study including 3343 women treated for primary breast cancer between 2001 and 2004, who returned a questionnaire 3 months post surgery. Socio-demographic and clinical information was obtained from registries. Questionnaire data on pain and health behaviors were obtained 15 months and 7-9 years post surgery. A total of 1905 women were eligible for analysis. At 15-month post surgery, 32.7 % reported pain "almost every day" or more frequently. At 7-9 years post surgery, the prevalence decreased to 20.4 %. Socio-demographic (young age, lower education, lower income, lower occupational status), treatment-related (being lymph node positive, axillary lymph node dissection (ALND), post-menopausal endocrine treatment), and health behavioral factors (smoking ≥ 10 cigarettes/day, obesity (BMI ≥ 30 and < 35), comorbidity, poor physical function) were significantly associated with pain at 15 months. Being physically active and moderate alcohol intake (<3 units/day) were negatively associated with pain. At 7-9 years post surgery, only ALND (OR:1.41, p = 0.03), post-menopausal endocrine treatment (OR:1.62, p = 0.01), poorer physical function (ORs:2.00-2.40, p = 0.003), and weight training (h/week) at 15 months (OR:1.10, p = 0.008) were significant predictors of pain when adjusting for age and pain 15 months post surgery. No socio-demographic predictors remained statistically significant. Younger age, lower socio-economic status, more invasive surgery, endocrine treatment, and adverse health behaviors emerged as risk factors for persistent pain. The influence of risk factors changed over time, suggesting a complex course of pain development and maintenance.

Risk factors for prolonged grief symptoms: A systematic review and meta-analysis.

BACKGROUND: The diagnosis Prolonged Grief Disorder (PGD) has recently been included in ICD-11 and DSM-5-TR. To identify individuals who need help coping with grief, knowledge is needed about who is at risk of developing PGD. We, therefore, conducted a comprehensive systematic review and meta-analysis of the available literature on risk factors for prolonged grief symptoms (PGS). METHODS: Based on a literature search in PsycInfo, PubMed, Web of Science, and CINAHL, we included the most frequently investigated risk factors in a meta-analysis. The effect size correlation was used as the standardized measure of the strength of the association between the risk factor and PGS. RESULTS: Based on 120 studies of 61.580 participants published between 1989 and 2023, 19 risk factors were included in the meta-analysis. For the adjusted associations, the strongest associations with PGS were pre-loss grief symptoms (ESr = 0.39, 95%CI[0.24-0.53]) and depression (ESr = 0.30, 95%CI[0.13-0.44]). Small, but statistically significant associations were observed for unexpected death, violent/unnatural death, low educational level, low income, female gender, anxious attachment style, and death of a child or partner. CONCLUSIONS: An updated overview of risk factors for PGS is presented, including their predictive strength. The results offer knowledge that can aid prevention and early identification of people at risk of PGD.

Engaging carers in neuropsychological rehabilitation for brain cancer survivors: The "I'm aware: Patients And Carers Together" (ImPACT) program.

BACKGROUND: Cognitive impairment is a common late effect in child and adult brain cancer survivors (BCS). Still, there is a dearth of research aimed at therapeutic interventions and no standard treatment options for most BCS. OBJECTIVE: To describe 1) a novel neuropsychological rehabilitation program for BCS - the "I'm aware: Patients And Carers Together" (ImPACT) program, and 2) two studies that aim to assess the feasibility of the ImPACT program in child and adult BCS, respectively. The program adapts the holistic neuropsychological approach pioneered by Leonard Diller and Yehuda Ben-Yishay to an outpatient setting. METHODS: Two feasibility studies are described: 1) A single-armed study with 15 child BCS (10-17 years) (ImPACT Child); and 2) a randomized waitlist-controlled trial with 26 adult BCS (>17 years) (ImPACT Adult). In both studies, patients will undergo an 8-week program together with a cohabiting carer. Primary outcomes (i.e., cognitive and neurobehavioral symptoms), and secondary outcomes (i.e., behavioral and psychological symptoms, e.g., quality of life, fatigue) will be assessed at four time points: pre-, mid-, and post intervention, and 8 weeks follow-up. Adult waitlist controls will be assessed at equivalent time points and will be included in the intervention group after all study assessments. Semi-structured interviews will be conducted at follow-up. EXPECTED OUTCOMES: Results will provide feasibility data in support of future larger scale trials. DISCUSSION: The findings could potentially improve the management of cognitive impairment in BCS and transform available services. The program can be delivered in-person or remotely and harnesses existing resources in patients' lives.

The efficacy of psychosocial intervention for pain in breast cancer patients and survivors: a systematic review and meta-analysis.

Persistent pain after breast cancer treatment is prevalent, and not all patients respond sufficiently to pharmacological treatment. Pain is recognized as a multi-dimensional phenomenon, which includes psychological and social components, and several clinical trials have investigated the efficacy of psychosocial interventions on pain in cancer patients and survivors. Our aim was to systematically review and quantify the existing research on the effect of psychosocial interventions on pain in breast cancer patients and survivors. Two independent raters reviewed 474 abstracts for eligibility, leading to the identification of 26 independent and eligible studies published between 1983 and 2012, which were assessed for their methodological quality and subjected to meta-analytic evaluation. A total of 1786 participants were included in the analyses. A statistically significant and robust overall effect size was found across all included studies (Hedges g = 0.37, 95 % CI: 0.20-0.40; p < 0.001). However, the effect size was considerably smaller (0.21), when adjusted for possible publication bias. Furthermore, the results were heterogeneous, and when exploring the sources of heterogeneity, studies of higher methodological quality were found to yield a more conservative effect size (g = 0.21, 95 % CI: 0.02-0.41) than studies of poorer quality (g = 0.65, 95 % CI: 0.25-1.04). The results also indicated that patient educational approaches yielded a larger effect size (g = 0.64) than relaxation-based interventions (g = 0.31, 95 % CI: -0.05-0.67) and supportive group therapy (g = 0.17, 95 % CI: 0.02-0.32). Taken together, while suggestive of psychosocial intervention as an effective tool in the management of pain among breast cancer patients and survivors, the results should be interpreted as preliminary. The methodological quality of the existing research varied considerably, and only few studies had selected patients on the basis of the presence of pain and included pain as the primary outcome.

Effects of an expressive writing intervention on cancer-related distress in Danish breast cancer survivors - results from a nationwide randomized clinical trial.

OBJECTIVE: To examine the effects of an expressive writing intervention (EWI) on cancer-related distress, depressive symptoms, and mood in women treated for early stage breast cancer. METHODS: A nationwide sample of 507 Danish women who had recently completed treatment for primary breast cancer were randomly assigned to three 20-min home-based writing exercises, one week apart, focusing on either emotional disclosure (EWI group) or a non-emotional topic (control group). Cancer-related distress [Impact of Event Scale (IES)], depressive symptoms (Beck Depression Inventory-Short Form), and negative (37-item Profile of Moods State) and positive mood (Passive Positive Mood Scale) were assessed at baseline and at 3 and 9 months post-intervention. Choice of writing topic (cancer versus other), alexithymia (20-item Toronto Alexithymia Scale), and social constraints (Social Constraints Scale) were included as possible moderators. RESULTS: Significant (p<0.01) group differences in mood change from before to immediately after each session suggested successful manipulation. Reductions over time in psychological symptoms were seen in both groups (p<0.05), but no time × group interactions were found. Choice of writing topic moderated effects on IES, with women writing about other themes showing greater reductions in cancer-related avoidance than women writing about their cancer. Fewer depressive symptoms and higher levels of positive mood were seen 3 months post-intervention in women writing about their cancer when compared with the control group. Difficulties describing feelings and externally oriented thinking (20-item Toronto Alexithymia Scale) moderated effects on positive mood and IES-total, while no moderating effects were found of social constraints. CONCLUSIONS: In concordance with the majority of previous results with cancer patients, no main effects of EWI were found for cancer-related distress, depressive symptoms, and mood. Moderator analyses suggested that choice of writing topic and ability to process emotional experiences should be studied further.

Self-hypnosis for coping with labour pain: a randomised controlled trial.

OBJECTIVE: To estimate the use of epidural analgesia and experienced pain during childbirth after a short antenatal training course in self-hypnosis to ease childbirth. DESIGN: Randomised, controlled, single-blinded trial using a three-arm design. SETTING: Aarhus University Hospital Skejby in Denmark during the period July 2009 until August 2011. POPULATION: A total of 1222 healthy nulliparous women. METHOD: Use of epidural analgesia and self-reported pain during delivery was compared in three groups: a hypnosis group receiving three 1-hour lessons in self-hypnosis with additional audiorecordings to ease childbirth, a relaxation group receiving three 1-hour lessons in various relaxation methods and mindfulness with audiorecordings for additional training, and a usual care group receiving ordinary antenatal care only. PRIMARY OUTCOME: Use of epidural analgesia. Secondary outcomes included self-reported pain. RESULTS: There were no between-group differences in use of epidural analgesia-31.2% (95% confidence interval [95% CI] 27.1-35.3) in the hypnosis group, 29.8% (95% CI 25.7-33.8) in the relaxation group and 30.0% (95% CI 24.0-36.0) in the control group. No statistically significant differences between the three groups were observed for any of the self-reported pain measures. CONCLUSION: In this large randomised controlled trial of a brief course in self-hypnosis to ease childbirth, no differences in use of epidural analgesia or pain experience were found across study groups. Before turning down self-hypnosis as a method for pain relief, further studies are warranted with focus on specific subgroups.

How traumatic is breast cancer? Post-traumatic stress symptoms (PTSS) and risk factors for severe PTSS at 3 and 15 months after surgery in a nationwide cohort of Danish women treated for primary breast cancer.

BACKGROUND: The literature shows considerable between-study variation in the prevalence of post-traumatic stress symptoms (PTSS) among women with breast cancer. Our aim was, therefore, to explore the prevalence of and risk factors for cancer-related PTSS in a nationwide inception cohort of women treated for primary breast cancer. METHODS: In all, 68% of all Danish women receiving surgery for primary breast cancer between October 2001 and March 2004 completed a questionnaire at 3 months post surgery (n=3343), which included the impact of event scale (IES). In all, 94% of the disease-free women also completed a follow-up questionnaire at 15 months post surgery. Data on pre-cancer demographic, socioeconomic, and psychiatric status were obtained from national registries. The Danish Breast Cancer Cooperative Group and surgical departments provided information on disease variables, treatment, and comorbidity. RESULTS: At 3 months post surgery, 20.1% had IES total scores suggesting severe PTSS (35), compared with 14.3% at 15 months. In all, 48% with severe PTSS at 3 months also had scores above the cutoff at 15 months. Main predictors of severe PTSS at 15 months were low social status, previous physical and mental illness, axillary lymph node involvement (>3), and reduced physical functioning (PF) at 3 months. CONCLUSION: The results confirm that receiving a breast cancer diagnosis can be a significant traumatic experience, and that many women experience persistent cancer-related PTSS. Low social status, poor health status, low levels of PF, and disease severity were found to be risk factors for severe PTSS.

Social support, gender and patient delay.

BACKGROUND: The purpose of this study was to examine the relationship between perceived social support and patient delay (PD) among female and male cancer patients. METHODS: A population-based study with register-sampled cancer patients was designed. Patient delay was defined as the time interval between the patient's experience of the first symptom and the first contact with a health-care professional. Both dates were provided by the patients (n=910). The patients completed a purpose-designed questionnaire, which assessed the patient's perceptions of how the partner reacted ('Partner Avoidance' and 'Partner Support') and how others in the social network responded ('Other Avoidance' and 'Other Support') to the patient's worries about the symptoms. The associations between the social support subscales and PD were analysed separately for men and women. RESULTS: In female patients, Partner Support and Other Support were associated with shorter PD, whereas Other Avoidance was associated with longer PD. In the multivariate analysis, Other Avoidance remained associated with longer PD. Moreover, disclosure of symptoms to someone reduced the likelihood of a long PD in female patients. In male patients, none of the social support scales significantly increased or decreased the risk of a long PD in the univariate analysis, but Partner Support significantly decreased risk of a long PD in the multivariate analysis. CONCLUSIONS: The results of this study suggest that social support and avoidance from network members influence length of PD differently in male and female cancer patients. This gender difference may explain previous mixed findings obtained in this field.

Stress, distress and outcome of assisted reproductive technology (ART): a meta-analysis.

BACKGROUND: A number of studies have investigated the relationship between psychological factors such as stress and distress (measured as anxiety and depression) and outcomes of assisted reproductive technology (ART). The results, however, are inconsistent, and the strength of any associations remains to be clarified. We conducted a systematic review and meta-analysis of the results of studies reporting on the associations between stress, anxiety, and depression and ART outcomes. METHODS: Prospective studies reporting data on associations between stress or distress in female patients and ART outcome were identified and evaluated by two independent researchers according to an a priori developed codebook. Authors were contacted in cases of insufficient data reporting. Stress was defined as perceived stress, work-related stress, minor life events or major life events, and distress was defined as anxiety or depression. RESULTS: A total of 31 prospective studies were included. Small, statistically significant, pooled effect sizes were found for stress [ESr, effect size correlation) = -0.08; P = 0.02, 95% confidence interval (CI): -0.15, -0.01], trait anxiety (ESr = -0.14; P = 0.02, 95% CI: -0.25, -0.03) and state anxiety (ESr = -0.10, P = 0.03, 95% CI: -0.19, -0.01), indicating negative associations with clinical pregnancy rates. A non-significant trend (Esr = -0.11, P = 0.06) was found for an association between depression and clinical pregnancy. For serum pregnancy tests and live birth rates, associations between trait anxiety or state anxiety were not significant. The fail safe number did not exceed the suggested criterion in any analyses, between-study heterogeneity was considerable and the mean age, mean duration of infertility and percentage of first time ART attenders in the study samples were found to moderate several of the associations. CONCLUSIONS: Small but significant associations were found between stress and distress and reduced pregnancy chances with ART. However, there were a limited number of studies and considerable between-study heterogeneity. Taken together, the influence of stress and distress on ART outcome may appear somewhat limited.

Associations between patient-reported outcomes and radiation dose in patients treated with radiation therapy for primary brain tumours.

AIM: This study aimed to explore associations between radiation dose and patient-reported outcomes in patients with a primary non-glioblastoma brain tumour treated with radiation therapy (RT), with a focus on health-related quality-of-life (HRQoL) and self-reported cognitive function. METHODS: In this cross-sectional study, 78 patients who had received RT for a non-glioblastoma primary brain tumour, underwent neuropsychological testing and completed questionnaires on HRQoL, cognitive function, fatigue, depression, anxiety and perceived stress. The study explores the association between HRQoL scores, self-reported cognitive function and radiation doses to total brain, brainstem, hippocampus, thalamus, temporal lobes and frontal lobes. In addition, we examined correlations between neuropsychological test scores and self-reported cognitive function. RESULTS: The median time between RT and testing was 4.6 years (range 1-9 years). Patients who had received high mean radiation doses to the total brain had low HRQoL scores (Cohen's d = 0.50, p = 0.04), brainstem (d = 0.65, p = 0.01) and hippocampus (d = 0.66, p = 0.01). High mean doses to the total brain were also associated with low scores on self-reported cognitive functioning (Cohen's d = 0.64, p = 0.02), brainstem (d = 0.55, p = 0.03), hippocampus (d = 0.76, p < 0.01), temporal lobes (d = 0.70, p < 0.01) and thalamus (d = 0.64, p = 0.01). Self-reported cognitive function correlated well with neuropsychological test scores (correlation range 0.27-0.54.). CONCLUSIONS: High radiation doses to specific brain structures may be associated with impaired HRQoL and self-reported cognitive function with potentially negative implications to patients' daily lives. Patient-reported outcomes of treatment-related side-effects and their associations with radiation doses to the brain and its sub-structures may provide important information on radiation tolerance to the brain and sub-structures.