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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Childhood and adolescent cancer survivors &#40;CACSs&#41; are at increased risk of chronic disease associated with environmental factors throughout their lifespan&#46; There is growing evidence that contact with nature &#40;CWN&#41; may have beneficial effects on health and its application in CACSs could contribute to improving their health and wellbeing&#46; Spending time in natural spaces has an impact on health through effects on the cardiovascular&#44; renal&#44; respiratory&#44; endocrine&#44; immune and nervous systems&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Several hypotheses have been proposed to attempt to explain the mechanisms underlying the nature-health interaction&#46; Neuroinflammation&#44; which affects immunosurveillance&#44; is among the most studied&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This is due to the use of saliva biomarkers of meta-inflammation&#44; such as cortisol&#44; &#945;-amylase and immunoglobulin A&#44; whose success stems from the ease and non-invasiveness of sample collection&#46; Few studies have been conducted on CACSs&#44; but an improvement on health-related quality of life has been described in association with CWN&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Chronic inflammation can have an impact on immunosurveillance by causing persistent alterations in the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system&#44; which in turn have an impact on the health of CACSs&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Therefore&#44; interventions in nature in the context of cancer treatment&#47;recovery can be an adjuvant environmental health and lifestyle measure aimed at strengthening the immune system and mitigate delayed adverse effects of treatment&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present a quasi-experimental&#44; controlled pre-post intervention pilot study on the use of CWN in CACS&#46; Participants engaged in an &#8220;Educaventura&#8221; &#40;an experience in nature&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; lasting 2&#46;5&#160;h in the Valle-Carrascoy Regional Park in Murcia&#44; Spain&#46; Before the intervention&#44; we collected data on anthropometric and sociodemographic variables&#44; the level of nature connectedness and scores on health-related quality of life &#40;Pediatric Quality of Life Inventory &#91;PedsQL&#93;&#41; and the stress and difficulties questionnaire&#46; On the day of the intervention&#44; we collected samples of saliva before and after to measure the levels of cortisol&#44; amylase and immunoglobulin A by enzyme immunoassay&#46; We conducted a descriptive statistical analysis with the software package SPSS &#40;version 16&#41;&#44; using the Shapiro-Wilk test to assess normality&#44; the Wilcoxon signed-rank test for paired samples&#44; the &#967;<span class="elsevierStyleSup">2</span> test and the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The participants were 9 childhood and adolescent cancer survivors &#40;cases&#41;&#44; recruited from the environmental and community health programme for the long-term follow-up of paediatric cancer survivors &#40;known as PLASESCAP&#44; the acronym of the programme&#8217;s name in Spanish&#41; and 7 of their siblings &#40;controls&#41;&#46; We observed a decrease in cortisol of 11&#37; in cases and 37&#37; in controls &#40;cases&#58; <span class="elsevierStyleItalic">P &#61;</span> &#46;260&#59; controls&#58; <span class="elsevierStyleItalic">P &#61;</span> &#46;028&#41;&#44; a decrease in &#945;-amylase of 75&#46;93&#37; in cases and 51&#46;73&#37; in controls &#40;cases&#58; <span class="elsevierStyleItalic">P &#61;</span> &#46;008&#59; controls&#58; <span class="elsevierStyleItalic">P &#61;</span> &#46;612&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The differences were statistically significant &#40;<span class="elsevierStyleItalic">P</span>&#160;&#60;&#160;&#46;05&#41; for the levels of cortisol in controls and the levels of &#945;-amylase in cases&#46; These differences corresponded to decreases in the levels of cortisol and &#945;-amylase during exposure to forest environments&#44; consistent with the findings of Hunter et al&#46; &#40;2019&#41; who estimated reductions of 21&#46;3&#37; in cortisol levels and 28&#46;1&#37; in &#945;-amylase levels in a log-transformed model that varied as a function of the duration and quality of the exposure to nature&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The levels of immunoglobulin A increased by 59&#37; in both groups &#40;cases&#58; <span class="elsevierStyleItalic">P &#61;</span> &#46;859&#59; controls&#58; <span class="elsevierStyleItalic">P &#61;</span> &#46;237&#41;&#46; This humoral immunity barrier is known to protect against viral infection and other diseases and is very important for CACS&#46; Changes in innate and cell-mediated immunity have been described in association to nature exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">This is the first published study on CWN in CACSs with an experimental approach&#46; Our findings suggest that short interventions in nature could decrease neuroinflammation and improve mucosal immunity in CACSs&#46; This are encouraging results that justify further research in larger samples&#44; controlling for confounders and with a more thorough assessment of the effects of CWN on CACS and other chronically ill patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0025" class="elsevierStylePara elsevierViewall">Benefits of Contact With Nature in the Child and Adolescent Population with Chronic Illness Study of the Environment and Human Health Laboratory &#40;EH2-Lab&#41; &#40;IMIB-Universidad de Murcia&#41;&#46; Environmental Health Patterns in Children and Adolescents in the Region of Murcia Project&#44; funded by the Sociedad de Pediatr&#237;a del Sureste de Espa&#241;a &#40;<span class="elsevierStyleGrantSponsor" id="gs0005">SPSE</span>&#44; Society of Paediatrics of SE Spain&#41; &#40;FFIS-DF-2022-36&#41;&#46; Healthy Neurodevelopment&#44; Healthy Ecosystems Programme funded by the Plan Nacional Sobre Drogas &#40;<span class="elsevierStyleGrantSponsor" id="gs0010">PNSD</span>&#44; National Plan on Drugs&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Journal Information
Vol. 99. Issue 5.
Pages 356-357 (1 November 2023)
Vol. 99. Issue 5.
Pages 356-357 (1 November 2023)
Scientific Letter
Full text access
Effects of forest therapy on salivary biomarkers (cortisol, amylase and IGA) in pediatric cáncer survivors: an experimental study
Efectos de la terapia de bosque sobre biomarcadores salivales (cortisol, amilasa e IGA) en supervivientes de cáncer pediátrico: estudio experimental
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Francisco Díaz-Martíneza,b,c, Miguel Felipe Sánchez-Saucoa,b,c, Esteban Orenes-Piñeroc,d, Isabel Martínez-Romerac,e, Juan Antonio Ortega-Garcíaa,b,c,
Corresponding author
ortega@pehsu.org

Corresponding author.
a Pediatric Environmental Health Speciality Unit of the Region of Murcia, Department of Pediatrics, Clinical University Hospital 'Virgen de la Arrixaca,' University of Murcia, Murcia, Spain
b Environmental and Human Health Laboratory (EH2-Lab), Murcian Institute of Health Research (IMIB), University of Murcia, Murcia, Spain
c Global Alliance for Rewilding Child and Adolescent Health (GreenRooting.org), Spanish Association of Pediatrics, Madrid, Spain
d Department of Biochemistry and Molecular Biology, University of Murcia, IMIB Arrixaca, Murcia, Spain
e Department of Pediatric Hemato-Oncology, La Paz University Hospital, Madrid, Spain
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Dear Editor:

Childhood and adolescent cancer survivors (CACSs) are at increased risk of chronic disease associated with environmental factors throughout their lifespan. There is growing evidence that contact with nature (CWN) may have beneficial effects on health and its application in CACSs could contribute to improving their health and wellbeing. Spending time in natural spaces has an impact on health through effects on the cardiovascular, renal, respiratory, endocrine, immune and nervous systems.1 Several hypotheses have been proposed to attempt to explain the mechanisms underlying the nature-health interaction. Neuroinflammation, which affects immunosurveillance, is among the most studied.2 This is due to the use of saliva biomarkers of meta-inflammation, such as cortisol, α-amylase and immunoglobulin A, whose success stems from the ease and non-invasiveness of sample collection. Few studies have been conducted on CACSs, but an improvement on health-related quality of life has been described in association with CWN.3 Chronic inflammation can have an impact on immunosurveillance by causing persistent alterations in the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system, which in turn have an impact on the health of CACSs.4 Therefore, interventions in nature in the context of cancer treatment/recovery can be an adjuvant environmental health and lifestyle measure aimed at strengthening the immune system and mitigate delayed adverse effects of treatment.

We present a quasi-experimental, controlled pre-post intervention pilot study on the use of CWN in CACS. Participants engaged in an “Educaventura” (an experience in nature) (Fig. 1) lasting 2.5 h in the Valle-Carrascoy Regional Park in Murcia, Spain. Before the intervention, we collected data on anthropometric and sociodemographic variables, the level of nature connectedness and scores on health-related quality of life (Pediatric Quality of Life Inventory [PedsQL]) and the stress and difficulties questionnaire. On the day of the intervention, we collected samples of saliva before and after to measure the levels of cortisol, amylase and immunoglobulin A by enzyme immunoassay. We conducted a descriptive statistical analysis with the software package SPSS (version 16), using the Shapiro-Wilk test to assess normality, the Wilcoxon signed-rank test for paired samples, the χ2 test and the Mann–Whitney U test.

Figure 1.

Timeline of the "Educaventura" in the Woods educational experience in nature.

(0.1MB).

The participants were 9 childhood and adolescent cancer survivors (cases), recruited from the environmental and community health programme for the long-term follow-up of paediatric cancer survivors (known as PLASESCAP, the acronym of the programme’s name in Spanish) and 7 of their siblings (controls). We observed a decrease in cortisol of 11% in cases and 37% in controls (cases: P = .260; controls: P = .028), a decrease in α-amylase of 75.93% in cases and 51.73% in controls (cases: P = .008; controls: P = .612) (Fig. 2). The differences were statistically significant (P < .05) for the levels of cortisol in controls and the levels of α-amylase in cases. These differences corresponded to decreases in the levels of cortisol and α-amylase during exposure to forest environments, consistent with the findings of Hunter et al. (2019) who estimated reductions of 21.3% in cortisol levels and 28.1% in α-amylase levels in a log-transformed model that varied as a function of the duration and quality of the exposure to nature.5 The levels of immunoglobulin A increased by 59% in both groups (cases: P = .859; controls: P = .237). This humoral immunity barrier is known to protect against viral infection and other diseases and is very important for CACS. Changes in innate and cell-mediated immunity have been described in association to nature exposure.6

Figure 2.

Changes (pre vs post) in the analysed salivary biomarkers in cases and controls. The boxes (percentiles 25th–75th) show the median concentrations of the biomarkers, and the whiskers the minimum (5th percentile) and maximum (95th percentile) values.

CACS, childhood and adolescent cancer survivor.

*Statistically significant (P < .05).

(0.18MB).

This is the first published study on CWN in CACSs with an experimental approach. Our findings suggest that short interventions in nature could decrease neuroinflammation and improve mucosal immunity in CACSs. This are encouraging results that justify further research in larger samples, controlling for confounders and with a more thorough assessment of the effects of CWN on CACS and other chronically ill patients.

Funding

Benefits of Contact With Nature in the Child and Adolescent Population with Chronic Illness Study of the Environment and Human Health Laboratory (EH2-Lab) (IMIB-Universidad de Murcia). Environmental Health Patterns in Children and Adolescents in the Region of Murcia Project, funded by the Sociedad de Pediatría del Sureste de España (SPSE, Society of Paediatrics of SE Spain) (FFIS-DF-2022-36). Healthy Neurodevelopment, Healthy Ecosystems Programme funded by the Plan Nacional Sobre Drogas (PNSD, National Plan on Drugs).

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
A.L. Fyfe-Johnson, M.F. Hazlehurst, S.P. Perrins, G.N. Bratman, R. Thomas, K.A. Garrett, et al.
Nature and children’s health: a systematic review.
[2]
R.S. Ulrich, R.F. Simons, B.D. Losito, E. Fiorito, M.A. Miles, M. Zelson.
Stress recovery during exposure to natural and urban environments.
J Environ Psychol., 11 (1991), pp. 201-230
[3]
A. Cárceles-Álvarez, J.A. Ortega-García, F.A. López-Hernández, J.L. Fuster-Soler, A. Sanz-Monllor, R. Ramis, et al.
Environment, lifestyle behavior and health-related quality of life in childhood and adolescent cancer survivors of extracranial malignancies.
[4]
B. Cui, F. Peng, J. Lu, B. He, Q. Su, H. Luo, et al.
Cancer and stress: NextGen strategies.
Brain Behav Immun., 93 (2021), pp. 368-383
[5]
M.R. Hunter, B.W. Gillespie, S.Y.P. Chen.
Urban nature experiences reduce stress in the context of daily life based on salivary biomarkers.
Front Psychol., 10 (2019), pp. 722
[6]
L. Andersen, S.S. Corazon, U.K. Stigsdotter.
Nature exposure and its effects on immune system functioning: a systematic review.
Int J Environ Res Public Health., 18 (2021), pp. 1416
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