To stage or not to stage?-A cost minimization analysis of sacral neuromodulation placement strategies.

AIMS: Sacral neuromodulation (SNM) is a standard therapy for refractory overactive bladder (OAB). Traditionally, SNM placement involves placement of an S3 lead with 1-3 weeks of testing before considering a permanent implant. Given the potential risk of bacterial contamination during testing and high success rates published by some experts, we compared the costs of traditional 2-stage against single-stage SNM placement for OAB. METHODS: We performed a cost minimization analysis using published data on 2-stage SNM success rates, SNM infection rates, and direct reimbursements from Medicare for 2017. We compared the costs associated with a 2-stage vs single-stage approach. We performed sensitivity analyses of the primary variables listed above to assess where threshold values occurred and used separate models for freestanding ambulatory surgery centers (ASC) and outpatient hospital departments (OHD). RESULTS: Based on published literature, our base case assumed a 69% SNM success rate, a 5% 2-stage approach infection rate, a 1.7% single-stage approach infection rate, and removal of 50% of non-working single-stage SNMs. In both ASC ($17 613 vs $18 194) and OHD ($19 832 vs $21 181) settings, single-stage SNM placement was less costly than 2-stage placement. The minimum SNM success rates to achieve savings with a single-stage approach occur at 65.4% and 61.3% for ASC and OHD, respectively. CONCLUSIONS: Using Medicare reimbursement, single-stage SNM placement is likely to be less costly than 2-stage placement for most practitioners. The savings are tied to SNM success rates and reimbursement rates, with reduced costs up to $5014 per case in centers of excellence (≥ 90% success).

Contribution of structured therapeutic play in a nursing care model for hospitalised children. / Contribuição do brinquedo terapêutico estruturado em um modelo de cuidado de enfermagem para crianças hospitalizadas.

Objective To analyse how therapeutic play structured in a nursing care model contributes to the care of hospitalised children. Method This is a qualitative study based on convergent care research (CCR). Seven children participated in the study. Data were collected in September and October of 2014 by means of interviews with open-end questions and participant observation of therapeutic and dramatic play sessions and/or instructional play sessions based on the stages "Welcoming/Playing/Concluding" of the nursing model Care with Play. Data were analysed according to the analysis and interpretation stages of the CCR. Results The following three categories emerged: Meanings attributed by the child to hospitalisation and its influence on nursing care; Perception of the therapeutic procedures through therapeutic play, and Importance of the family in care. Final considerations It is concluded that the application of therapeutic play structured in the care model contributes to systematic and specialised nursing care.

Contribuição do brinquedo terapêutico estruturado em um modelo de cuidado de enfermagem para crianças hospitalizadas / Contribución del juego terapéutico estructurado en un modelo de atención en el cuidado de niños hospitalizados / Contribution of structured therapeutic play in a nursing care model for hospitalised children

RESUMO Objetivo Analisar como o Brinquedo Terapêutico estruturado em um Modelo de Cuidado de Enfermagem contribui no cuidado à criança hospitalizada. Método Trata-se de uma Pesquisa Convergente Assistencial (PCA), de abordagem qualitativa. Participaram do estudo sete crianças. A coleta de dados foi realizada entre setembro e outubro de 2014, por meio de entrevista aberta e de observação participante de sessões de BT dramático e/ou instrucional através das etapas “Acolhendo/Brincando/Finalizando” do Modelo de Cuidado de Enfermagem Cuidar Brincando. Os dados foram analisados de acordo com as fases de análise e interpretação da PCA. Resultados Três categorias: Significados atribuídos pela criança à hospitalização e sua influência no cuidado de enfermagem, Percepção quanto aos procedimentos terapêuticos por meio do brinquedo terapêutico e Importância da inserção da família no cuidado. Considerações finais Conclui-se que aplicar o BT estruturado em um Modelo de Cuidado pode contribuir para um cuidado de enfermagem sistematizado e especializado.

RESUMEN Objetivo Objetivo de analizar como Juego Terapéutico estructurado en un modelo de atención de enfermería ayuda en el cuidado de niños hospitalizados. Método Se trata de una investigación cualitativa del tipo convergente asistencial. Participaron del estudio siete niños. Los datos fueron recolectados entre septiembre y octubre de 2014, por medio de entrevistas abiertas y observación participante de sesiones de juguete terapéutico dramático y de instrucción por los pasos “Acogiendo/Jugando/Finalizando” del Modelo de Atención de Enfermería Cuidar Jugando”. Los datos se analizaron de acuerdo a las fases de análisis e interpretación. Resultados Tres categorías: Significados atribuidos por el niño a la hospitalización y su influencia en los cuidados de enfermería, Percepción acerca de los procedimientos terapéuticos a través del juego y La Importancia de la inserción de la familia en la atención terapéutica. Consideraciones finales La aplicación de la BT estructurada en un modelo de atención puede contribuir a un cuidado de enfermería especializada y sistematizadas.

ABSTRACT Objective To analyse how therapeutic play structured in a nursing care model contributes to the care of hospitalised children. Method This is a qualitative study based on convergent care research (CCR). Seven children participated in the study. Data were collected in September and October of 2014 by means of interviews with open-end questions and participant observation of therapeutic and dramatic play sessions and/or instructional play sessions based on the stages “Welcoming/Playing/Concluding” of the nursing model Care with Play. Data were analysed according to the analysis and interpretation stages of the CCR. Results The following three categories emerged: Meanings attributed by the child to hospitalisation and its influence on nursing care; Perception of the therapeutic procedures through therapeutic play, and Importance of the family in care. Final considerations It is concluded that the application of therapeutic play structured in the care model contributes to systematic and specialised nursing care.

The impact of psychological stress on wound healing: methods and mechanisms.

Converging and replicated evidence indicates that psychological stress can modulate wound-healing processes. This article reviews the methods and findings of experimental models of wound healing. Psychological stress can have a substantial and clinically relevant impact on wound repair. Physiologic stress responses can directly influence wound-healing processes. Furthermore, psychological stress can indirectly modulate the repair process by promoting the adoption of health-damaging behaviors. Translational work is needed to develop innovative treatments able to attenuate stress-induced delays in wound healing.

Cytokines, infections, stress, and dysphoric moods in breastfeeders and formula feeders.

OBJECTIVE: To analyze relationships between stress, moods, and immunity in breastfeeding compared to formula-feeding mothers. DESIGN: A cross-sectional study of 181 healthy mothers, exclusively breastfeeding or formula feeding, studied at 4 to 6 weeks after childbirth. SETTING: Mothers were recruited in the postpartum unit of the hospital and then visited in their homes once at 4 to 6 weeks after childbirth for data collection. MAIN OUTCOME MEASURES: Stress, mood, infection symptoms, and serum levels of interferon-gamma and interleukin-10 were measured. RESULTS: Formula-feeding mothers had evidence of decreased interferon-gamma and a decreased serum Th1/Th2 ratio (interferon-gamma/interleukin-10) when perceived stress, dysphoric moods, and negative life events were high, an effect consistent with depression of cellular immunity. However, women who were breastfeeding did not show these relationships. CONCLUSIONS: The data suggest that breastfeeding confers some psychoneuroimmunological benefit to mothers, perhaps through prolactin or hypothalamic-hypophyseal-adrenocortical axis stress refractoriness.

Social interactions, stress, and immunity.

This review summarizes the endocrine and immune changes induced by an experimental model for social stress that is termed SDR. Further, the differences between this stressor and other chronic stress models in mice are compared and contrasted. Individual differences in the response to SDR are described and discussed in the context of the unique characteristics of this stressor and the importance of a variety of behavioral and environmental factors in modulating the response to social stress. The collection of data indicates that mice facing a social stressor may use different behavioral coping responses based on the environmental conditions and previous experiences. These different adaptational responses are reflected in their behavioral, endocrine, and immune changes in response to the stressor [7], [8]. In conclusion, although generally it is understood that chronic stressors suppress immune function and increase a host's susceptibility to disease, this may not be dogma. For example, under conditions in which individuals face the chance of being injured, which may be a chronic or reoccurring likelihood, it may be an adaptive advantage to maintain or even enhance an immune response. The development of GCR after SDR may be such a mechanism, allowing animals to heal injuries and clear invading bacteria in the presence of the anti-inflammatory stress hormones. Thus, individual differences in response to SDR are associated with specific behavioral strategies that can have substantive implications for host resistance to infectious disease.

Sleep and psychoneuroimmunology.

Personal experience indicates we sleep differently when sick. Data reviewed demonstrate the extent to which sleep is altered during the course of infection of host organisms by several classes of pathogens. One important unanswered question is whether or not the alterations in sleep during infection are of functional relevance. That is, does the way we sleep when sick facilitate or impede recovery? One retrospective, preclinical study suggests that sleep changes during infection are of functional relevance. Toth and colleagues [102] analyzed sleep responses of rabbits to three different microbial infections. Those rabbits that exhibited robust increases in NREM sleep were more likely to survive than those that exhibited long periods of NREM sleep suppression. These tantalizing data suggest that the precise alterations in sleep through the course of infection are important determinants of morbidity and mortality. Data from healthy subjects demonstrate a role for at least two cytokines in the regulation of spontaneous, physiologic NREM sleep. A second critical yet unanswered question is whether or not cytokines mediate infection-induced alterations in sleep. The hypothesis that cytokines mediate infection-induced alterations in sleep is logical based on observations of the impact of infection on levels of cytokines in the peripheral immune system and in the brain. No attempts have been made to intervene with cytokine systems in brain during the course of infection to determine if there is an impact on infection-induced alterations in sleep. Although substantial progress has been made in elucidating the myriad mechanisms by which cytokines regulate and modulate sleep, much remains to be determined with respect to mechanistic and functional aspects of infection-induced alterations in sleep.

Prenatal and postnatal maternal contributions in the infection model of schizophrenia.

Epidemiological studies have indicated that the risk of schizophrenia is enhanced by prenatal maternal infection with viral or bacterial pathogens. Recent experimentation in rodents has yielded additional support for a causal relationship between prenatal immune challenge and the emergence of psychosis-related abnormalities in brain and behaviour in later life. However, little is known about the putative roles of maternal postnatal factors in triggering and modulating the emergence of psychopathology following prenatal immunological stimulation. Here, we aimed to dissect the relative contributions of prenatal inflammatory events and postnatal maternal factors in precipitating juvenile and adult psychopathology in the resulting offspring with a cross-fostering design. Pregnant mice were exposed to the viral mimic, polyriboinosinic-polyribocytidilic acid (PolyI:C; at 5 mg/kg, intravenously), or vehicle treatment on gestation day 9, and offspring born to PolyI:C- and vehicle-treated dams were then simultaneously cross-fostered to surrogate rearing mothers, which had either experienced inflammatory or vehicle treatment during pregnancy. Prenatal PolyI:C administration did not affect the expression of latent inhibition (LI) at a juvenile stage of development, but led to the post-pubertal emergence of LI disruption in both aversive classical and instrumental conditioning regardless of the postnatal rearing condition. In addition, deficits in conditioning as such led to a pre- and post-pubertal loss of LI in prenatal control animals that were adopted by PolyI:C-treated surrogate mothers. Our findings thus indicate that the adoption of prenatally immune-challenged neonates by control surrogate mothers does not possess any protective effects against the subsequent emergence of psychopathology in adulthood. At the same time, however, the present study highlights for the first time that the adoption of prenatal control animals by immune-challenged rearing mothers is sufficient to precipitate learning disabilities in the juvenile and adult offspring.

The relationship between fatigue, psychological and immunological variables in acute infectious illness.

OBJECTIVE: The aim of this paper is to explore the longitudinal relationships between physical and psychological symptoms and immunological factors following acute infective illnesses. METHOD: Preliminary data from a prospective investigation of patients with serologically proven acute infectious illnesses due to Epstein-Barr virus (EBV), Ross River virus (RRV) or Q fever are reported. Patients were assessed within 4 weeks of onset of symptoms and then reviewed 2 and 4 weeks later. Physical illness data were collected at interview. Psychological and somatic symptom profiles were assessed by standardised self-report questionnaires. Cell-mediated immune (CMI) function was assessed by measurement of delayed-type hypersensitivity (DTH) skin responses. RESULTS: Thirty patients who had been assessed and followed over the 4-week period (including 17 patients with EBV, five with RRV and eight with Q fever) were included in this analysis. During the acute phase, profound fatigue and malaise were the most common symptoms. Classical depressive and anxiety symptoms were not prominent. Initially, 46% of cases had no DTH skin response (i.e. cutaneous anergy) indicative of impaired cellular immunity. Over the 4-week period, there was a marked improvement in both somatic and psychological symptoms, although fatigue remained a prominent feature in 63% of subjects. The reduction in reported fatigue was correlated with improvement in the DTH skin response (p = 0.001) and with improvement in General Health Questionnaire (GHQ) scores (p < 0.01). CONCLUSIONS: Acute infectious illnesses are accompanied by a range of nonspecific somatic and psychological symptoms, particularly fatigue and malaise rather than anxiety and depression. Although improvement in several symptoms occurs rapidly, fatigue commonly remains a prominent complaint at 4 weeks. Resolution of fatigue is associated with improvement in cell-mediated immunity.

Using mental imagery with subclinical OCD to 'freeze' contamination in its place: evidence for looming vulnerability theory.

The present research examines the possibility that 'freezing' or slowing-down the rate at which threats can advance and thereby blocking a sense of looming vulnerability can reduce fears of contamination and avoidance behavior among individuals with obsessional symptoms. Mental imagery was used to reduce the rate at which threat can advance by means of instructions to imagine that contamination was 'frozen' in place and unable to move. Measures included self-reports of anxiety and worry, and indirect assessments of fear and avoidance behavior. A parallel mental imagery condition was used to examine the possibility that accentuating the spread or contamination, or its 'looming', would in turn accentuate fear and avoidance. The results, particularly of the more unobtrusive measures, indicated that freeze imagery reduced fear and avoidance for the relatively obsessional participants. In addition, support was found that it reduced fear for participants with relatively higher levels of imagination. However, the freeze imagery paradoxically seemed to sensitize the non-obsessional participants to possibilities of contamination they had not previously considered, and thus increased their fear. The results provide support for the looming vulnerability model of anxiety and suggest applications to treatment.

Psychological stress, neuroimmunomodulation, and susceptibility to infectious diseases in animals and man: a review.

This article reviews research on the role of psychological stress, personality, social support and other psychosocial factors in bacterial, viral and parasitic infections. After 100 years of research on man and animals, psychological stress is considered as a potential cofactor in the pathogenesis of infectious disease. Psychological stress seems able to alter the susceptibility of animals and man to infectious agents, influencing the onset, course and outcome of certain infectious pathologies. Many experiments have identified in neuroimmunomodulation the principal mediator of the alterations associated with conditions of stress. The development of psychoneuroimmunology has fostered in-depth study of the complex relationship between psychosocial factors, the central nervous system, the immune system and infectious disease. Although antimicrobial drugs have certainly remained the basis of all anti-infective therapy, this type of study has already led some authors to propose and experiment protocols of psychological intervention or psychoimmunotherapy in pathologies such as tuberculosis, or herpes simplex virus or human immunodeficiency virus infections. The psychoneuroimmunological approach to infectious diseases will probably grow in importance in the future not only in the setting of research in psychosomatic medicine but also in that of clinical microbiology.

Psychoneuroimmunology and health consequences: data and shared mechanisms.

There is evidence linking psychosocially mediated immunological alterations with cancer, infectious illness, and HIV progression. The data reviewed suggest that immune modulation by psychosocial stressors and/or interventions may importantly influence health status. The research literature also suggests that the impact of chronic stressors and psychosocial factors on sympathetic nervous system and endocrine function influences the immune system, thereby providing shared mechanisms that may impact on disease susceptibility and progression across a broad spectrum of disorders. A better understanding of individual vulnerability, such as occurs with aging, may help to pinpoint those at greatest risk.

Psychoneuroimmunology: stress effects on pathogenesis and immunity during infection.

The mammalian response to stress involves the release of soluble products from the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis. Cells of the immune system respond to many of the hormones, neurotransmitters, and neuropeptides through specific receptors. The function of the immune system is critical in the mammalian response to infectious disease. A growing body of evidence identifies stress as a cofactor in infectious disease susceptibility and outcomes. It has been suggested that effects of stress on the immune system may mediate the relationship between stress and infectious disease. This article reviews recent psychoneuroimmunology literature exploring the effects of stress on the pathogenesis of, and immune response to, infectious disease in mammals.

Relationships between self-reported symptoms of infection, menstrual-cycle-related distress, and cycle phase.

This study examined the relationships between symptoms of common infectious illnesses, menstrual cycle phase, and cycle-related distress. Sixty-five women who had regular menstrual cycles and were not taking birth control pills were the convenience sample for this research. Subjects completed the Menstrual Distress Questionnaire (MDQ), the Perceived Stress Scale (PSS), and an investigator-developed symptom checklist (SCL) that inventoried symptoms of common respiratory, skin, gastrointestinal, and genitourinary infections. The subjects completed all questionnaires three times during the menstrual cycle (during menstruation, midcycle, and premenstruum). The results of the study indicated a highly significant clustering of infectious illness symptoms during the perimenstrual period compared with midcycle. There were significant relationships between scores on the MDQ and PSS and the frequency and intensity of infection symptoms throughout the cycle. Analysis of covariance (ANCOVA) of the effects of phase, PSS, MDQ, and SCL scores revealed that phasic influences were not significant when MDQ scores were controlled. PSS and MDQ scores significantly influenced symptom scores when phase was controlled, suggesting a general relationship between distress and infectious symptoms during the menstrual cycle.

[Immunology and psychiatry]. / Immunologie et psychiatrie.

This review of scientific literature comes within the interest arisen from ten years by psychoneuroimmunology, a field connecting several disciplines and illustrating in a new way the psychosomatic relationships. A first category of works has been dedicated to the study of psychiatric disorders associated with various diseases concerning immunity (systemic diseases, endocrine diseases, cancers, infectious diseases), but also to the possible effect of distressing life events on the upset activation of immune functions, or even to the discovery of predisposing personality profiles (type C profile, depressive vulnerability). A second category of works concerns the analysis of the immune disturbances associated with certain psychiatric diseases, such as depression or schizophrenia, but also with some distressing life conditions, like bereavement. Animal experimentation and human experimentation provide various informations on the factors conditioning the immunomodulating effects of stress, sometimes in the direction of an inhibition, sometimes in the direction of an activation of immune functions. Finally, several papers shed light on the immunomodulating effects of psychotropic drugs. All these works open new horizons to the scientific knowledge and let us glimpse an extension to the use of psychologic therapeutics, as well of pharmacological ones as of non pharmacological.

[Stress and susceptibility to infection]. / Stress und Infektionsbereitschaft.

The influence of various stressors upon the human immune system, was and presently is the subject of many clinically oriented as well as experimental studies. Even though it is not always clear how relevant the reported observations are in behalf to the beginning, the course and the outcome of infectious, neoplastic and autoimmune diseases, there is hardly any doubt, that stress may influence multiple aspects of the immune answer. The sensitivity of the immune system to stress factors is not merely fortuitous, but is an indirect consequence of the regulatory reciprocal influences between the immune system and the central nervous system. These interconnections seem to represent building blocks of a long-loop regulatory feedback-system, which plays an important role in the coordination of stressors and psychological influences upon the course of infections and inflammatory diseases.

Stress, affective disorders, and immune function.

Increasing scientific evidence supports age-old observations that psychosocial factors are closely associated with the pathogenesis of certain physical and mental illnesses. The immune system appears to play a primary mediating role. Whereas acute stress may initiate a transient immunologically protective response, prolonged or poorly controlled psychosocial stressors may result in depression of different components of the immune system. These responses may be related to, or independent of, changes in the neuroendocrine system. As the rather prolific literature in this infant area of psychoneuroimmunology reveals, there are many complex levels of interaction that require further investigation. There is clearly a need for long-term prospective studies that will identify individuals at risk for those numerous diseases in which psychosocial factors and impaired immune function play a pathogenic role. In addition to correlating altered immune function over time with changes in the physical environment, these studies should include psychologic profiles, life-event inventories, and psychiatric interviews in an effort to delineate the role of psychosocial factors as the stimulus for and as the response to the disease process. One of the many positive outcomes of this multifactorial approach to illness is that it will alter the physician's approach to disease and thus to patients as they are evaluated and treated in the psychosocial context in which they live. As Hippocrates said, "It is more important to know what sort of a person has a disease than to know what sort of disease a person has."