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Introduction: Mindfulness Meditation is a complementary and alternative medicine (CAM) modality growing in popularity. Currently, mindfulness is under-studied regarding efficacy; however, it offers a potentially accessible way to contribute to symptom management in chronic pain conditions. The purpose of this integrative review was to examine the literature for the use of mindfulness as symptom management strategy for persons diagnosed with the chronic pain condition, fibromyalgia. Methods: Six scientific databases were searched, using various keywords. Inclusion criteria were: (a) fibromyalgia, (b) English language, (c) experimental research designs; (d) adults age ≥ 18 years, and (e) mindfulness. Results: Seven studies were reviewed. Most interventions were completed over several months in the form of multiple group sessions lasting several hours each. Evaluations of effectiveness varied by study, but variables most commonly demonstrating improvement from mindfulness were anxiety, depression, sleep-related symptoms, coping and perceived stress. Mechanisms by which these outcomes may have been mediated included increases in self-compassion and psychological flexibility. Discussion: There is insufficient evidence to recommend mindfulness as an effective way to manage all fibromyalgia symptoms; however, promise lies in its usefulness addressing mood- and sleep-related symptoms. We suggest that further, more rigorous, research is warranted.

Fibromyalgia (FM) is a chronic noncommunicable disorder characterized by a constellation of symptoms that include fatigue, depression and chronic pain. FM affects 2%–8% of the U.S. population, 2% of the global population, with 61%–90% of FM diagnoses attributed to women. Key causal factors leading to the development and severity of FM-related symptoms have not yet been identified. The purpose of this article is to report relationships among identified metabolites and levels of fatigue, depression, pain severity, and pain interference in a sample of 20 women with FM. In this secondary analysis, we conducted global metabolomic analysis and examined the data for relationships of metabolite levels with self-reported symptoms of fatigue, depression, pain severity, and pain interference. Results revealed six metabolites (6-deoxy-hexose; pantothenic acid; ergothioneine; l-carnitine; n-acetylserotonin; butyrobetaine) and their associated metabolic pathways such as carnitine synthesis, lipid oxidation, tryptophan metabolism, beta-alanine metabolism and pantothenic and Coenzyme-A biosynthesis that were either positively or inversely related to pain severity, pain interference, or both. The preliminary data presented suggest that metabolites representing energy, amino acid, or lipid classification may be associated with pain symptom severity and interference in women with FM. Future work will confirm these findings in a large, comparative cohort, targeting metabolites and metabolite pathways to better understand the relationships of metabolites and symptomology.

A nontargeted plasma metabolomic analysis was conducted to compare differentially expressed metabolites in women with and without fibromyalgia (FM) using data and samples collected from two parent studies in women with FM (n = 20) and comparative data collected from newly recruited age-matched women (n = 20). Blood plasma samples were analyzed for metabolite content using liquid chromatography mass spectrometry. Consolidation of positive and negative ion mode metabolomics data with fold change (>2 or

The capabilities students need for success during and beyond higher education extend far beyond specific discipline skills to include the development of productive mindsets, the management of life circumstances and the way they relate to others and identify with their profession. The provision of support for these capabilities at university can be both diverse in scope and diffuse in delivery. Consequently, the development of streamlined and integrated evaluation strategies to measure the extent to which these capabilities are being successfully delivered can be challenging. This paper describes how one Australian university used a collaborative process to design an evaluation framework for student learning services. The framework, a first for this university, represents the breadth of student support, including a typology of support for learning: connectedness, mindsets, self-management, professional identity and academic capabilities. These terms, coined as dimensions, form the scaffold of university-wide delivery of support for learning initiatives.

Chronic graft-versus-host disease (cGVHD) remains a significant late effect issue for allogeneic hematopoietic cell transplantation (allo-HCT) survivors, contributing to morbidity and mortality. The etiology of cGVHD is not well elucidated. Owing to a lack of early diagnostic tests and pathophysiology ambiguity, targeted treatments remain limited. Biomarkers for prediction, control response, or prognostication have not yet been identified. Metabolomics, the quantification of metabolites, is a potential biomarker of cGVHD but has not been evaluated in this population. In this study, we examined global metabolites of stored plasma to identify differentially expressed metabolites of individuals discordant for cGVHD following allo-HCT. A descriptive, comparative, cross-sectional study design was used to examine differentially expressed metabolites of plasma samples obtained from 40 adult allo-HCT recipients (20 with cGVHD and 20 without cGVHD) from 2 parent studies. Metabolomics profiling was conducted at the University of Florida's Southeast Center for Integrative Metabolomics. Full experimental methods followed a previously published method. All statistical analyses were performed by a PhD-prepared, trained bioinformatics statistician. There were 10 differentially expressed metabolites between participants with cGVHD and those without cGVHD. Differential metabolites included those related to energy metabolism (n = 3), amino acid metabolism (n = 3), lipid metabolism (n = 2), caffeine metabolism (n = 1), and neurotransmission (n = 1). Serotonin had the greatest fold change (21.01). This study suggests that cGVHD may be associated with expanded cellular energy and potentially mitochondrial dysfunction. The differential metabolic profile between patients with and without cGVHD indicates metabolic perturbations that merit further exploration as potential biomarkers of cGVHD. These findings support the need for further examination using a larger, prospective study design to identify metabolomic risk factors that may signal the need for earlier preventive measures and earlier treatment to reduce cGVHD.

Widening participation (WP) in higher education (HE) is an increasingly important policy issue, with interventions to increase participation from minority ethnic, low-income and other under-represented groups undertaken in HE sectors in many countries. In the UK there is a large amount of WP activity but a lack of robust evidence of its effectiveness. This article presents a systematic review in the topic area of WP in HE. We included studies of systematic review, randomised controlled trial (RCT) and quasi-experimental (QE) designs, and assessed evidence of the effectiveness of university access strategies and approaches in relation to the participation of disadvantaged students at university. We searched for, quality appraised and synthesised the international evidence, that is, evidence published in any country, in the English language. The findings from 4 systematic reviews and 12 experimental studies (4 RCTs, 4 RDDs and 4 QEDs) are presented as narrative syntheses in a series of thematic sub-topics. We found some evidence of effectiveness for a number of university access interventions. ‘Black box’ WP programmes (those with multiple elements in a single programme) and financial incentives were found to be effective. However, much of the evidence had design limitations and the majority were conducted in the US. The article concludes with research recommendations in relation to UK interventions, including suggested designs for future quasi-experimental evaluation.

Background Although rheumatology nursing has been shown to be effective in managing patients with rheumatoid arthritis, patient outcomes sensitive to nursing interventions (nursing sensitive outcomes) have not been systematically studied. Objectives The objective of this study was to identify and delineate relevant patient outcomes measured in studies that reported nursing interventions in patients with rheumatoid arthritis. Design A systematic search was conducted from 1990 to 2016. Inclusion criteria were (i) patients with rheumatoid arthritis, (ii) adult population age ≥16years, (iii) nurse as part of the care team or intervention delivery, (iv) primary research only, (v) English language, and (vi) quantitative studies with nursing sensitive outcomes. Data sources Medline, CINAHL, Ovid nursing, Cochrane library and PsycINFO databases were searched for relevant studies. Review methods Using the predetermined inclusion/exclusion criteria, nine reviewers working in pairs assessed the eligibility of the identified studies based on titles and abstracts. Papers meeting the inclusion criteria were retrieved and full texts were further assessed. Critical Appraisal Skills Programme tools were used to assess the quality of the included studies. Data on nursing sensitive outcomes were extracted independently by two reviewers. The Outcome Measures in Rheumatology comprehensive conceptual framework for health was used to contextualise and present findings. Results Of the 820 articles retrieved, 7 randomised controlled trials and 3 observational studies met the inclusion criteria. Seventeen nursing sensitive outcomes were identified (disease activity, clinical effects, pain, early morning stiffness duration, fatigue, patient safety issues, function, knowledge, patient satisfaction, confidence in care received, mental health status, self-efficacy, patient attitude/perception of ability to control arthritis, quality of life, health utility, health care resources, death). These fitted into 10 health intervention domains in keeping with the pre-specified conceptual framework for health: disease status, effectiveness, safety, function, knowledge, satisfaction, psychological status, quality of life, cost, death. A total of 59 measurement instruments were identified comprising patient reported outcome measures (n=31), and biologic measures and reports (n=28). Conclusions This review is notable in that it is the first to have identified, and reported, a set of multidimensional outcome measures that are sensitive to nursing interventions in rheumatology specifically. Further research is required to determine a core set of outcomes to be used in all rheumatology nursing intervention studies.

Many women with breast cancer experience symptoms of pain, fatigue, and depression, collectively known as psychoneurologic (PN) symptoms, during and after chemotherapy treatment. Evidence that inflammatory dysfunction related to cancer and its treatments contributes to the development and persistence of PN symptoms through several interrelated pathways is accumulating. However, a major limiting factor in more precisely identifying the biological mechanisms underlying these symptoms is the lack of biological measures that represent a holistic spectrum of biological responses. Metabolomics allows for examination of multiple, co-occurring metabolic pathways and provides a systems-level perspective on biological mechanisms that may contribute to PN symptoms. Methods: In this pilot study, we performed serum metabolome analysis using liquid chromatography high-resolution mass spectrometry of global and targeted metabolomics from the tryptophan pathway from archived samples from 19 women with early-stage breast cancer. We used paired t tests to compare metabolite concentrations and Pearson’s correlation coefficients to examine concomitant changes in metabolite concentrations and PN symptoms before and after chemotherapy. Results: Levels of pain, fatigue, and depression increased after chemotherapy. Compared with pre-chemotherapy, global metabolites post-chemotherapy were characterized by higher concentrations of acetyl-l-alanine and indoxyl sulfate and lower levels of 5-oxo-l-proline. Targeted analysis indicated significantly higher kynurenine levels and kynurenine/tryptophan ratios post-chemotherapy. Symptoms of pain and fatigue had strong associations with multiple global and several targeted metabolites. Conclusion: Results demonstrated that metabolomics may be useful for elucidating biological mechanisms associated with the development and severity of PN symptoms, specifically pain and fatigue, in women with early-stage breast cancer.

Blended and flipped classroom pedagogical models are recognised as having the potential to deepen and enrich student learning while also being a more engaging learning experience (Partridge, Ponting, & McCay, 2011). E-learning platforms and blended pedagogies have transformed the higher education landscape, changing how teaching and learning occur along with learner expectations about the nature of their learning experience. Active-learning, collaborative learning, blended pedagogies and flexibility in deciding where, when and how they engage have now become mainstreamed (Gaebel, Kupriyanova, Morais, & Colucci, 2014). In the peer leader training and development landscape, blended pedagogical approaches are typically not applied; however, if adopted, they have the potential to similarly transform the learning experience. This article describes a student-centred blended and flipped classroom model of peer leader training that aims to establish a more flexible, connected, coherent and deeper student learning experience.

Objectives Fatigue is one of the most common symptoms associated with chronic noncommunicable diseases, and it may also increase cognitive impairment. However, associations between fatigue and cognitive impairment in chronic illnesses remain unclear. Therefore, the purpose of this systematic review was to examine research that investigated associations between level of fatigue and cognitive status. Methods PubMed/Medline, PsycINFO, CINAHL, and Cochrane Database were searched for articles published between 2012 and 2018 using search terms fatigue, cognition, and various iterations of these terms. Study quality was assessed by the Joanna Briggs Institute Critical Appraisal Checklist tool. Results Of 1799 citations, 10 studies in samples of individuals with cancer, multiple sclerosis, neurosarcoidosis, and chronic fatigue syndrome met the inclusion criteria. Fatigue was found to be significantly correlated with cognitive impairment in one cancer-related study ( r = –.480, p Discussion There is insufficient evidence examining the relationship between fatigue and cognitive impairment in patients with chronic illnesses. As a result, more studies are needed that examine potential relationships between these two symptoms in order to develop effective treatments for individuals living with a chronic noncommunicable disease.

Objective Fatigue and cognitive dysfunction are major concerns for women with early-stage breast cancer during treatment and into survivorship. However, interrelationships of these phenomena and their temporal patterns over time are not well documented, thus limiting the strategies for symptom management interventions. In this study, changes in fatigue across treatment phases and the relationship among fatigue severity and its functional impact with objective cognitive performance were examined. Methods Participants (N = 75) were assessed at five time points beginning prior to chemotherapy to 24 months after initial chemotherapy. Fatigue severity and impact were measured on the Brief Fatigue Inventory. Central nervous system (CNS) Vital Signs was used to measure performance based cognitive testing. Temporal changes in fatigue were examined, as well as the relationship between fatigue and cognitive performance, at each time point using linear mixed effect models. Results Severity of fatigue varied as a function of phase of treatment. Fatigue severity and its functional impact were moderate at baseline, increased significantly during chemotherapy, and returned to near baseline levels by 2 years. At each time point, fatigue severity and impact were significantly associated with diminished processing speed and complex attention performance. Conclusions A strong association between fatigue and objective cognitive performance suggests that they are likely functionally related. That cognitive deficits were evident at baseline, whereas fatigue was more chemotherapy dependent, implicates that two symptoms share some common bases but may differ in underlying mechanisms and severity over time. This knowledge provides a basis for introducing strategies for tailored symptom management that vary over time.

Introduction Chronic pain is a global public health problem, which impairs the physical, mental and social well-being of afflicted individuals. Distraction-based interventions have been posited as one approach to divert attention away from noxious stimulation and thereby modulate the severity of pain. The current review aimed to identify studies that explicitly used distraction-based interventions for patients with chronic pain. Methods The review methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Databases including PubMED, EMBASE, PsychINFO, and CINAHL were searched using combinations of keywords. Studies from the last decade (2005–2015) were included if they (a) were published in English, (b) used experimental or quasi-experimental designs, (c) explicitly used distraction as an intervention for pain, and, (d) evaluated measures of pain pre-post intervention. Results A total of 12 studies that examined distraction-based interventions for chronic pain were included in this review. Most interventions were evaluated in adults with chronic pain conditions, such as fibromyalgia, and involved a combination of activities including internal and external distraction techniques. There was wide variation in the implementation of interventions, particularly in the use of practice sessions, dose frequency and duration. Conclusion Distraction was not sufficiently elaborated upon in the theoretical frameworks. Directions for future research are discussed including the use of standardized pain, symptom, and outcome measures and tailored intervention approaches based on the individual’s level of distractibility. Strategies to target the individual’s distraction threshold could lead to greater precision in delivery of effective interventions to reduce pain.

The major therapeutic approach for treating fibromyalgia (FM), a chronic widespread pain syndrome, is pharmacotherapy-centered symptom management. Complexity of treatment often leads to multiple medication prescriptions. While there is no current alternative to the probable need for polypharmacy in this patient population, there remains concern related to potential side effects and adverse drug events. In this secondary analysis of data on medications taken collected from two parent studies, all medications were broken down into the following categories: opioid, nonopioid, antidepressant, anticonvulsant, muscle relaxant, and benzodiazepine. The impact on pain severity and pain interference of these medication categories as well as perceived stress, fatigue, and depression scores was assessed. Baseline pain severity ( p = .0106) and pain interference ( p = .0002) were significantly correlated with opioid use as compared to nonopioid use. A multivariate regression with backward elimination resulted in a model for pain severity with one significant predictor variable, fatigue ( p < .0001); pain interference had three significant predictor variables: opioid use ( p = .04), fatigue ( p < .0001), and depression ( p = .04). While future studies should further address the utility of opioids and examine the role of polypharmacy as part of symptom management strategies for individuals with FM, study findings suggest that, for those who suffer chronic widespread pain as the predominant symptom experience, a challenge equally as perplexing for nurses and nursing research alike as managing the pain lies in addressing the fatigue and depression in this patient population.

Background: The need for reliable, valid tools to measure patient-reported outcomes (PROs) is critical both for research and for evaluating treatment effects in practice. The Patient-Reported Outcomes Measurement Information System Fatigue-Short Form v1.0-Fatigue 7a (PROMIS F-SF) has had limited psychometric evaluation in various populations. Objectives: The aim of the study is to examine psychometric properties of PROMIS F-SF item responses across various populations. Methods: Data from five studies with common data elements were used in this secondary analysis. Samples from patients with fibromyalgia, sickle cell disease, cardiometabolic risk, pregnancy, and healthy controls were used. Reliability was estimated using Cronbach’s alpha. Dimensionality was evaluated with confirmatory factor analysis. Concurrent validity was evaluated by examining Pearson’s correlations between scores from the PROMIS F-SF, the Multidimensional Fatigue Symptom Inventory-Short Form, and the Brief Fatigue Inventory. Discriminant validity was evaluated by examining Pearson’s correlations between scores on the PROMIS F-SF and measures of stress and depressive symptoms. Known groups validity was assessed by comparing PROMIS F-SF scores in the clinical samples to healthy controls. Results: Reliability of PROMIS F-SF scores was adequate across samples, ranging from .72 in the pregnancy sample to .88 in healthy controls. Unidimensionality was supported in each sample. Concurrent validity was strong; across the groups, correlations with scores on the Multidimensional Fatigue Symptom Inventory-Short Form and Brief Fatigue Inventory ranged from .60 to .85. Correlations of the PROMIS F-SF with measures of stress and depressive mood were moderate to strong, ranging from .37 to .64. PROMIS F-SF scores were significantly higher in clinical samples compared to healthy controls. Discussion: Reliability and validity of the PROMIS F-SF were acceptable. The PROMIS F-SF is a suitable measure of fatigue across the four diverse clinical populations included in the analysis.

Fibromyalgia syndrome (FMS), one of the most common rheumatic disorders, is estimated to affect up to 15 million people in the United States, 80% to 90% of whom are women. The syndrome is characterized by the presence of chronic widespread pain and various concurrent symptoms, which may include fatigue, cognitive disturbances (memory problems, difficulty concentrating, confusion), distressed mood (anxiety, depression), nonrestorative sleep, and muscular stiffness. Symptom management appears to be best addressed using a multimodal approach, with treatment strategies tailored to the individual. While medication may provide adequate symptom relief for some patients, experts generally recommend integrating both pharmacologic and nonpharmacologic approaches. Some patients may benefit from the adjunctive use of complementary and alternative medicine (CAM) modalities. Because symptom remission is rare and medication adverse effects can complicate symptom management, well-informed nursing care practices and patient education are essential. This article describes the existing treatment guidelines, discusses pharmacologic and nonpharmacologic approaches (including CAM-based modalities), and outlines nursing approaches aimed at enhancing patient self-management.

Background The number of adults who survive a critical illness involving admission to an intensive care unit is increasing. These survivors have an increased risk of developing impairments in cognition, physical function and psychological health. Objective This integrative literature review examined the literature for studies exploring the relationships among two or more of the variables of interest, i.e. cognitive, physical, and psychological symptoms (depressive, anxiety, or posttraumatic stress) in intensive care unit survivors post-hospital discharge. Methods A literature search was conducted using PubMed, CINHAL and PsycINFO databases. Findings While all 13 studies included in the review explored some aspect of a relationship among the variables of interest, none explored associations among all three variables. Five studies explored physical function and psychological symptoms, four studies explored cognitive impairment and psychological symptoms and five studies explored the association among different psychological symptoms. Inconsistencies were found in the study designs, follow-up time frames, patient populations and measures used. Conclusions Further research using well-designed methodologies and standardized instruments is warranted. Gaining a better understanding of the relationships among these impairments has the potential to contribute to the development of screening guidelines, preventative strategies, and treatments.

Key wordsChronic liver disease, symptom clusters, symptom management, symptomsAbstractPurpose: Chronic liver disease affects over 30 million people worldwide, and despite advances in medical management that have increased survival, a majority of these individuals report multiple symptoms that severely impair function and quality of life. The purpose of this integrative review was to examine and summarize the current literature focused on self-reported symptoms in individuals with chronic liver disease in order to inform the development and delivery of symptom management strategies in clinical practice.Design and Methods: Combinations of search terms related to the symptom experience were used to search three electronic databases. Inclusion criteria were empirical studies that measured self-reported symptoms in populations with chronic liver disease published in English between 2003 and 2014. The literature search initially yielded 112 results; 26 quantitative studies met the inclusion criteria.Findings and Conclusions: The symptom of fatigue was commonly reported across chronic liver disease populations and was often found to co-occur with other distressing symptoms, including depression, sleep disturbance, pain, cognitive impairment, and dizziness associated with autonomic dysfunction. Due to the high prevalence and persistence of these "core" symptoms, the use of core symptom measures integrated longitudinally across populations would inform the development and delivery of symptom management interventions as well as enhance the ability of nurses to incorporate population-level symptom management programs.Clinical Relevance: Nurses play an important role in symptom assessment and may use the findings from the integrative review to incorporate core symptom measures across chronic liver disease populations and advance the development and delivery of symptom management interventions.Chronic liver disease (CLD) is a condition characterized by damage to hepatocytes that can alter normal liver function, with advanced stages of disease marked by fibrosis and cirrhosis (Lozano et al., 2012). The trajectory of CLD can originate from a wide range of etiologies, including viral hepatitis, autoimmune hepatitis, nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH), cholestatic diseases (primary biliary cirrhosis [PBC] and primary sclerosing cholangitis [PSC]), alcohol-related liver disease, as well as genetic conditions (hemochromatosis and alpha-1-antitrypsin deficiency). Importantly, NAFLD/NASH is now the number one cause of liver disease in Western countries, whereas the prevalence of other CLD subtypes have remained stable or even decreased (World Gastroenterology Organisation, 2012). Presently CLD is one of the ten leading causes of death worldwide and can affect all ages, genders, and racial and ethnic groups, as well as socioeconomic classes; however, lower socioeconomic groups and disadvantaged individuals are disproportionately affected (National Institutes of Health, 2009).Advances in the medical management of CLD have substantially improved the rate of survival by preventing or delaying disease progression; however, a majority of individuals living with CLD frequently report multiple symptoms that significantly impair quality of life and functional capacity (Elliot, Frith, Pairman, Jones, & Newton, 2011; Patanwala et al., 2010). The impact of these symptoms, which include fatigue and cognitive impairment, was once thought to be directly related to the pathophysiological consequences of cirrhosis and endstage liver disease (Swain, 2006). However, with more people living long-term with CLD, it is now recognized that symptoms can occur throughout the disease course, are frequently unrelated to disease severity, and often do not improve with treatment of the underlying disease process (Newton & Jones, 2012).Nurses play a significant role in the assessment of symptoms and provision of symptom management strategies for individuals with CLD. …

PURPOSE/OBJECTIVES To explore women's experience of distress by asking "What do women with ovarian cancer want their spouse or significant other, family, friends, and healthcare providers to know about their experience of distress during diagnosis and treatment?" RESEARCH APPROACH Modified Glaserian grounded theory. SETTING An urban setting in the Mid-Atlantic region of the United States. PARTICIPANTS 12 women, aged 21-71 years, diagnosed with and treated for ovarian cancer. METHODOLOGIC APPROACH Constant comparative analysis of data obtained by audio recorded interviews. FINDINGS Although individual experiences differed, abstraction and conceptualization of the data supported a theory of existential assault. Participants found that the diagnosis was shocking and came "out of the blue like lightning." Their responses included seeking the best physician and treatment available, described as "no stone left unturned." Information about the disease was welcomed and unwelcomed as they shared the experience of "knowing what I don't want to know and not knowing what I want to know," and then had the added experience of sharing that information with those in their social network. Interpersonal interactions were described as "watching you watching me--we are both afraid," and "talking yet not talking about death," resulting in relationship changes and the realization that "now I have to take care of me." CONCLUSIONS Participants experienced diagnosis with and treatment for ovarian cancer as an existential assault that, with the potential for an early death, affected the individual and her relationships. INTERPRETATION Previous studies have suggested that women diagnosed with and treated for ovarian cancer experience distress. This study reports women's perceptions of their own distress.

BACKGROUND Pregnant women hospitalized with preterm labor (PTL) complications experience increased stress. Prior researchers have attempted to provide stress management strategies with use of various media players to deliver stress coping interventions. PURPOSE The purpose of this study was to examine the efficacy of a mobile device delivered stress coping app designed to reduce stress in a sample of high-risk pregnant women hospitalized with complications of PTL. METHODS A descriptive study using a prospective mixed methods one-group pre/posttest design. Fifteen pregnant women used the mobile device app for 8 consecutive days. The app included study measures, educational overview of concepts, four guided imagery audio files to be listened to daily, and a stress self-assessment scale to be used before and after each use. Measures included: Perceived Stress Scale (PSS), Visual Analog Stress Scale (VASS), Coping Self-Efficacy Scale (CSES), and semistructured interviews. RESULTS There was a significant drop in VASS scores when comparing scores before and after listening to the app (p < 0.0001). There were no significant differences between the baseline and Day 8 scores of PSS or CSES. All participants reported benefits from using the app and provided suggestions for improvement. CLINICAL IMPLICATIONS The intervention reduced immediate stress and provided a respite from the stress response in this population. Maternal child nurses may consider incorporating stress coping interventions as standard care practice.

This pilot study employed a randomized control trial that tested a relaxation and guided imagery (RGI) intervention on self-perceptions of state and trait anxiety, depression, sleep quality, and stress. Parents of offspring with developmental disabilities have been shown to have higher levels of stress than parents of typically developing offspring. This study was designed to meet the National Center for Complementary and Integrative Health (NCCIH) conceptual framework, which encourages early studies to demonstrate a measurable effect of an intervention prior to designing a largescale study. It is thus intentionally small in scale. Participants were recruited through social media advertisements posted through health and disability-related organizations. Forty-two people responded to recruitment materials, 20 participants began the study and 14 completed the study. Results showed decreased scores on levels of state and trait anxiety (State Trait Anxiety Inventory), depression (Beck’s Depression Inventory) and stress (Perceived Stress Scale-10) for the treatment group with improvements across both groups in sleep quality (Pittsburgh Sleep Quality Index). The sleep quality measurement was confounded by sleep medication use that was not measured in detail in this study. Further, participants rated the RGI intervention positively on a consumer satisfaction scale. Limitations and directions for future research are discussed, such as alterations to dependent variable completion timing.

Liver disease affects over 25 million people in the United States and, despite advances in medical management resulting in increased survival, a majority of these individuals report multiple co-occurring symptoms that severely impair functioning and quality of life. The purpose of this review is to (1) propose defining these co-occurring symptoms as a symptom cluster of chronic liver disease (CLD), (2) discuss putative underlying biological mechanisms related to CLD, including the liver–gut–brain axis and influence of the microbiome, and (3) discuss the implications for biobehavioral research in this patient population. Biobehavioral research focusing on the interrelated, and possibly synergistic, mechanisms of these symptoms may lead to the development and testing of targeted symptom management interventions for improving function and quality of life in this growing patient population.

A major objective of biobehavioral research is defining the mechanisms that underlie linkages among behavior, biology, health, and disease. The genomic revolution has demonstrated the importance of studying the role of the environment in (epi)genetic mechanisms. The idea that interactions between environment and genetics influence health outcomes is a central concept of the exposome, a measure of environmental exposures throughout a lifetime. Research suggests that telomere length (TL) and biologic factors involved in telomere stability may provide an understanding of the effects of gene–environment interaction on disease risk. Telomeres, thus, have become important biomarkers for aging as well as for stress-related disease. However, incorporating telomeres into biobehavioral research requires consideration of several aspects of the exposome. Internal and external modifiable and nonmodifiable exposures have the potential to influence TL. Future research utilizing the concept of the exposome will provide meaningful findings related to exposure sources as well as dosage and duration across the life span that influence telomere biology and disease occurrence. Such findings can be translated into clinical practice and may provide a basis for personalized disease prevention and treatment approaches.

Project-based learning (PBL) is an active student-centred form of instruction which is characterised by students’ autonomy, constructive investigations, goal-setting, collaboration, communication and reflection within real-world practices. It has been explored in various contexts and in different phases of schooling, from primary to higher education. The majority of the reviewed studies were based on a quasi-experimental pretest–posttest design with some baseline equivalence established but no random allocation of participants to control and experimental groups, and as a result, a causal link between PBL instruction and positive student outcomes cannot be established with certainty. Modern digital technology, group processes of high quality, teachers’ ability to effectively scaffold students’ learning and provide guidance and support, the balance between didactic instruction with in-depth inquiry methods and well-aligned assessment have been identified in the literature as facilitating factors in the implementation of PBL. The article concludes with six key recommendations considered to be essential for the successful adoption of a PBL approach in the mainstream school setting.

Background: Fibromyalgia (FMS) is a chronic pain syndrome characterized by fatigue and non-restorative sleep. Over 75% of individuals with FMS complain of fatigue and poor sleep. Purpose: The primary aim of this study was to compare 25 women with and 25 women without FMS, on fatigue; autonomic nervous system activity; perceived stress; sleep quality; and immune function. All participants complained of poor sleep, and had been referred to a sleep center for evaluation. The secondary aim was to explore the relationships among those variables within each group and compare those relationships between groups. Methods: A single stage cross-sectional design was used. Results: The FMS group reported greater fatigue, worse sleep, and more autonomic symptoms than the non-FMS group; they evidenced higher tumor necrosis factor alpha (TNF-α) levels. Non-FMS participants with obstructive sleep apnea (OSA) had higher interleukin 1-beta (IL-1β) values than the FMS group. In the FMS group, fatigue was positively correlate...

Women diagnosed with fibromyalgia (N = 72) participated in a 10-week randomized trial to examine the effectiveness of guided imagery on self-efficacy, perceived stress, and selected biobehavioral factors (FMS symptoms; immune biomarkers). Participants in both guided imagery and usual care control conditions completed measures and donated 3 cc of blood at baseline, 6- and 10-weeks. A mixed effects linear model to test for differences between groups for all behavioral and biologic variables demonstrated that after 10 weeks of daily intervention use, guided imagery participants reported statistically significant increases in self-efficacy and statistically significant decreases in stress, fatigue, pain, and depression. There were no statistically significant changes in biomarker levels, although total group C-reactive protein was elevated at baseline (4.7 mg/L), indicating an inflammatory process. Subsequent studies should be undertaken to more fully elucidate the biobehavioral aspects of nonpharmacological intervention effectiveness.

Purpose: Fatigue is one of the most common complaints experienced among the general population. Because fatigue is recognized as a biobehavioral occurrence, a biobehavioral intervention such as guided imagery may be effective in reducing self-reported fatigue. Therefore, the purpose of this study was to explore the research literature related to the use of guided imagery as a nonpharmacological mind-body intervention for the symptom of fatigue. Method: The electronic databases MEDLINE, CINAHL, PsychInfo, Psychology and Behavioral Sciences Collection and the Cochrane Library were searched from January 1980 to June 2010. Findings: Of 24 articles retrieved, eight met the inclusion criteria and were included in this systematic literature review. Findings were inconsistent regarding the effectiveness of guided imagery on fatigue. Studies varied in study length, duration of the applied guided imagery intervention, dosage, and whether the images were targeted to the purpose of the intervention. Implications: Guided imagery is a simple, economic intervention with the potential to effectively treat fatigue, thus further research is warranted using systematic, well-designed methodologies Standardizing guided imagery interventions according to total duration of exposure and targeted imagery in a variety of different populations adequately powered to detect changes will contribute to and strengthen nursing’s symptom-management armamentarium.

Recent research suggests that both the accuracy and linearity of number estimations are a source of difficulty in mathematical learning. There is also a range of evidence to suggest that children in East Asia are typically mathematically precocious compared to Western peers. Bringing these strands of work together, we discuss number line estimations involving an ability match study of children growing up in the United Kingdom and China. This article confirms that the quality of children’s number estimation is associated with some—but by no means all—early number problems. However, contrary to earlier studies, young Chinese children do not display more linear number scales in advance of (and potentially as a driver for) their math skills. Instead, their number estimations are not more accurate than those from an older Western sample with equivalent mathematical ability. The development of linearity in numerical representations takes a complex developmental path in multiple cultures.

Seventy-six librarians participated in a series of focus groups in support of research exploring the skills, knowledge and attributes required by the contemporary library and information professional in a world of every changing technology. The project was funded by the Australian Learning and Teaching Council. Text data mining analysis revealed three main thematic clusters (libraries, people, jobs) and one minor thematic cluster (community). Library 2.0 was broadly viewed by participants as being about change whilst librarian 2.0 was perceived by participants as not a new creation but just about good librarian practices. Participants expressed the general belief that personality traits, not just qualifications, were critical to be a successful librarian or information worker in the future.

Fibromyalgia (FM) is a chronic pain disorder affecting 2% of the population in the United States. Another 16 million Hispanics suffer from generically identified rheumatic diseases that likely include FM. Because there are few reported studies of Hispanics with FM, a pilot study using a repeated-measures pretest-posttest design investigated the effects of a 10-week mind-body intervention (visual imagery with relaxation) on symptom management. The change in means from baseline to week 10 demonstrated improvement in self-efficacy for managing pain and other symptoms and functional status. Visual imagery with relaxation is a mind-body intervention that may be used for symptom management in this population.

Background: The exciting discovery that telomere shortening is associated with many health conditions and that telomere lengths can be altered in response to social and environmental exposures has underscored the need for methods to accurately and consistently quantify telomere length. Objectives: The purpose of this article is to provide a comprehensive summary that compares and contrasts the current technologies used to assess telomere length. Discussion: Multiple methods have been developed for the study of telomeres. These techniques include quantification of telomere length by terminal restriction fragmentation—which was one of the earliest tools used for length assessment—making it the gold standard in telomere biology. Quantitative polymerase chain reaction provides the advantage of being able to use smaller amounts of DNA, thereby making it amenable to epidemiology studies involving large numbers of people. An alternative method uses fluorescent probes to quantify not only mean telomere lengths but also chromosome-specific telomere lengths; however, the downside of this approach is that it can only be used on mitotically active cells. Additional methods that permit assessment of the length of a subset of chromosome-specific telomeres or the subset of telomeres that demonstrate shortening are also reviewed. Conclusion: Given the increased utility for telomere assessments as a biomarker in physiological, psychological, and biobehavioral research, it is important that investigators become familiar with the methodological nuances of the various procedures used for measuring telomere length. This will ensure that they are empowered to select an optimal assessment approach to meet the needs of their study designs. Gaining a better understanding of the benefits and drawbacks of various measurement techniques is important not only in individual studies, but also to further establish the science of telomere associations with biobehavioral phenomena.

Fibromyalgia (FMS) is a chronic pain syndrome with a complex but poorly understood pathogenesis affecting approximately 10 million adults in the United States. The lack of a clear etiology of FMS has limited the effective diagnosis and treatment of this debilitating condition. The objective of this secondary data analysis was to examine plasma cytokine levels in women with FMS using the Bio-Plex Human Cytokine 17-plex Assay. Post hoc analysis of plasma cytokine levels was performed to evaluate patterns that were not specifieda priori. Upon examination, patients with FMS exhibited a marked reduction inTH2cytokines such as IL-4, IL-5, and IL-13. The finding of this pattern of altered cytokine milieu not only supports the role of inflammation in FMS but also may lead to more definitive diagnostic tools for clinicians treating FMS. TheTH2suppression provides strong evidence of immune dysregulation in patients with FMS.

Objectives This article reports the cross-studies analysis of projects from the P30 Center of Excellence for Biobehavioral Approaches to Symptom Management. Although the projects investigated diverse populations, a consistent theoretical and empirical approach guided each project. Methods Common data elements included the following measures of psychobehavioral variables: the PROMIS Short-Form Fatigue Scale, the Center of Epidemiologic Studies Depression Scale, and the Perceived Stress Scale. Plasma cytokines were measured as the shared biological data element. Results Data were analyzed from 295 participants with fibromyalgia ( n = 72), second trimester pregnancy ( n = 73), sickle cell anemia ( n = 60), and cardiometabolic risk ( n = 91). The mean age of participants was 35.4 years, and the most participants were female. Levels of symptoms were generally elevated across samples; the level of fatigue ranged from 18.9 to 24.7, depressive symptoms from 12.5 to 23.4, and perceived stress from 16.5 to 21.8. Intercorrelations among symptom measures and perceived stress were strong across the samples. However, correlations among psychobehavioral variables and cytokines were variable, indicating a separate relationship for the measures with cytokines. Conclusions Future work in symptom science could benefit from common data elements, including biomarkers, across populations to better develop the taxonomy of symptom profiles across conditions.

The biopsychosocial impact of a burn injury on the individual hospitalized for severe burn wounds begins at the moment of injury and extends throughout that person's life. Medical and emotional problems do not exist in clinical isolation but instead interact to confound and complicate treatment outcomes, accentuating the importance of providing optimal treatment of patients' medical illnesses without neglecting their mental distress. Identifying, and responding to, the signs and symptoms of depression is integral to the burn patient's recovery and rehabilitation.

Although depression can be a feature of acute psychosis and an aftermath of a psychotic episode (postpsychotic depression), data indicate that depressive syndromes in schizophrenia can be found years after the immediate postacute phase. Researchers acknowledge the clinical importance of recognizing that depressive symptoms are frequently described in patients diagnosed with schizophrenia. Using the framework of Antonovsky's (1972, 1987, 1992) Sense of Coherence as a guide, this article explores what nurses can do to facilitate development of generalized resistance resources (GRRs) in the physical, psychological, and emotional armamentarium of those diagnosed with schizophrenia, mood disorder not otherwise specified (NOS).

Fibromyalgia (FM), characterized by chronic widespread pain, fatigue, and cognitive/mood disturbances, leads to reduced workplace productivity and increased healthcare expenses. To determine if acquired epigenetic/genetic changes are associated with FM, we compared the frequency of spontaneously occurring micronuclei (MN) and genome-wide methylation patterns in women with FM (n=10) to those seen in comparably aged healthy controls (n=42(MN);n=8(methylation)). The mean (sd) MN frequency of women with FM (51.4 (21.9)) was significantly higher than that of controls (15.8 (8.5)) (χ2=45.552; df = 1;P=1.49×10-11). Significant differences (n=69sites) in methylation patterns were observed between cases and controls considering a 5% false discovery rate. The majority of differentially methylated (DM) sites (91%) were attributable to increased values in the women with FM. The DM sites included significant biological clusters involved in neuron differentiation/nervous system development, skeletal/organ system development, and chromatin compaction. Genes associated with DM sites whose function has particular relevance to FM included BDNF, NAT15, HDAC4, PRKCA, RTN1, and PRKG1. Results support the need for future research to further examine the potential role of epigenetic and acquired chromosomal alterations as a possible biological mechanism underlying FM.

Preparing baccalaureate nursing students to deliver care to an increasingly complex patient population is an ongoing challenge for nursing educators. Wanting to provide their students with a more holistic approach to patient care, undergraduate psychiatric-mental health nursing course faculty created a clinical rotation to address the needs of psychiatric patients who also had 1 or more medical comorbidities. In this article, we describe a pilot project in which students volunteered to participate in a 24-hour clinical experience focused on assessing and addressing the mental health needs of patients admitted to a medical or surgical clinical unit. Evaluation of this approach indicates that the predominant clinical and educational model of specialized healthcare undermines a single course approach to integrated care.

Because the effects of epigenetic (gene-environment interaction) changes have been associated with numerous adverse health states, the study of epigenetic measures provides exciting research opportunities for biobehavioral scientists. However, recruitment for studies focusing on any aspect of genetics poses challenges. Multiple factors, including lack of knowledge regarding a research study, have been identified as barriers to recruitment. Strengthening the informed consent process through extended discussion has been found to be effective in recruiting for research studies in general, yet there is a paucity of information that focused on such a recruitment strategy for epigenetic studies. In this paper, we share our experiences with strategies to strengthen the informed consent process as well as provide samples of materials developed to heighten potential participants’ understanding of epigenetics, in 4 epigenetic research studies with women from diverse backgrounds experiencing a range of health issues. The combined enrollment success rate for epigenetic studies using the process was 89% with participants representing a diverse population. We posit that carefully developed recruitment scripts provided a foundation for improving potential participants’ understanding of the research project. Easy to understand illustrations of the epigenetic process provided a basis for active engagement and encouraged individual questions.

Children diagnosed with cancer experience many invasive procedures throughout diagnosis and treatment of their disease. These procedures, oftentimes a source of distress in children, can elicit a variety of anticipatory symptoms prior to the actual procedure. Although there have been efforts to develop approaches to alleviate this distress through use of distraction, relaxation, sedation, guided imagery, and hypnosis, there has not been a combination treatment that merged relaxation techniques and biofeedback within a pediatric framework. A group of 12 children diagnosed with cancer participated in a 4-session intervention combining relaxation and biofeedback. This feasibility study suggests that the combination intervention offered in a clinical setting may be beneficial to children experiencing procedural distress as a novel coping strategy.

In response to claims that the quality (and in particular linearity) of children’s mental representation of number acts as a constraint on number development, we carried out a longitudinal assessment of the relationships between number line estimation, counting, and mathematical abilities. Ninety-nine five-year-olds were tested on four occasions at three-monthly intervals. Correlations between the three types of ability were evident, but while the quality of children’s estimations changed over time, and performance on the mathematical tasks improved over the same period, changes in one were not associated with changes in the other. In contrast to the earlier claims that the linearity of number representation is potentially a unique contributor to children’s mathematical development, the data suggest that this variable is not significantly privileged in its impact over and above simple procedural number skills. We propose that both early arithmetic success and estimating skill are bound closely to developments in counting ability.

Introduction:The purpose of this pilot study was to characterize the relationships among perceived stress, pain, fatigue, depression, anxiety, biomarkers, and functional status in women with fibromyalgia syndrome (FMS) using a psychoneuroimmunological (PNI) framework.Materials and Method:Using a cross-sectional, correlational design, the authors asked 50 women diagnosed with FMS to complete the Perceived Stress Scale (PSS), Brief Pain Inventory (BPI), Brief Fatigue Inventory (BFI), Center for Epidemiological Studies—Depression scale, State–Trait Anxiety Inventory (STAI), and Functional Impact Questionnaire. The authors analyzed plasma levels of 17 cytokines using a BioPlex® assay and levels of C-reactive protein (CRP) using a high-sensitivity enzyme-linked immunosorbent assay (ELISA).Results:Compared to published guidelines (>3 mg/L reflects high inflammation), CRP levels were elevated in participating women. Perceived stress demonstrated positive correlations with pain, fatigue, depression, anxiety, and functional status and negative correlations with monocyte chemotactic protein (MCP)-1( r = −.30) and interleukin-1 beta (IL-1β; r = −.29). Pain severity correlated with macrophage inflammatory protein (MIP)-1β ( r = .29), and pain interference negatively correlated with IL-1β ( r = −.30). Fatigue negatively correlated with IL-1β ( r = −.32), interleukin-10 (IL-10; r = −.31), and granulocyte colony-stimulating factor (G-CSF; r = −.31). Depressive symptoms correlated with CRP ( r = .31).Discussion:Relationships among perceived stress and symptoms supported the PNI framework. Study findings are similar to previous studies showing that cytokines in persons with FMS do not show a consistent pattern. The elevated CRP levels suggest higher levels of generalized inflammation in the sample and provide evidence for continued development of biobehavioral interventions to address both symptoms and their biological markers over time.