Caregivers as healthcare managers: health management activities, needs, and caregiving relationships for colorectal cancer survivors with ostomies.

PURPOSE: While the burdens and rewards of cancer caregiving are well-documented, few studies describe the activities involved in cancer caregiving. We employed a social-ecological perspective to explore the work of cancer caregiving for long-term colorectal cancer (CRC) survivors with ostomies. We focused on healthcare management, defined here as the ways in which informal caregivers participate in healthcare-related activities such as managing medical appointments and information, obtaining prescriptions and supplies, and providing transportation to obtain healthcare services. METHODS: This ethnographic study included 31 dyads consisting of long-term CRC survivors (>5 years postsurgery) and their primary informal caregivers. Survivors were members of integrated healthcare delivery systems. We interviewed participants using in-depth interviews and followed a subset using ethnographic methods. Medical record data ascertained survivors' cancer and medical history. RESULTS: We classified families into a matrix of healthcare management resources (high vs. low) and survivors' healthcare needs (high vs. low). We found that patients' healthcare needs did not always correspond to their caregivers' management activities. CRC survivors with high needs had more unmet needs when caregivers and survivors differed in the level of caregiver involvement they desired or regarded as optimal. This discrepancy was particularly evident in nonmarital relationships. CONCLUSIONS: As cancer survivors age and grow in number, it becomes increasingly important to understand how informal caregivers support survivors' well-being. Framing healthcare management as a component of caregiving provides a useful perspective that could facilitate future research and interventions to support survivors, particularly those with significant sequelae from their cancer treatment.

Patient education has a positive effect in patients with a stoma: a systematic review.

AIM: A systematic review was performed to assess whether education of patients having stoma formation improves quality of life and whether it is cost effective. METHOD: A literature search was performed to identify studies on the structured education of ostomates and outcome using the following databases: MEDLINE, Cinahl, Embase, Cochrane and PsycInfo. Inclusion criteria were: clinical studies reporting effects of educational interventions in relation to patients with a stoma. Commentaries or studies not testing an intervention were excluded. RESULTS: Seven articles met the inclusion criteria of having rigorously evaluated an educational programme related to living with a stoma. The programmes were organized in different ways and had explored various interventions. The results showed an increase in health-related quality of life, as measured using a stoma quality of life instrument (P = 0.00001) and with the Short Form 36 (SF-36) (P = 0.000-0.006), an increase in proficiency in management of the stoma (P = 0.0005), two studies pointed to a reduction in postoperative hospital stay (8 days vs 10 days, P = 0.029; and 8 days vs 14 days, P = 0.17), a significant reduction in cost in the intervention group ($US 8570.54) compared with the control group ($US 7396.90) as well as higher effectiveness scores in the intervention group (166.89) compared with the control group (110.98), a significant rise in stoma-related knowledge (P = 0.0000) and an increase in psychosocial adjustment (P = 0.000). CONCLUSION: Structured patient education aimed at patients' psychosocial needs seems to have a positive effect on quality of life as well as on cost. The interventions may be performed before, during or after hospital stay. However, the available data come from few studies with differences in interventions and in study design, and further studies are therefore needed before a final conclusion can be drawn.

[Vocational assessment of diarrhea, incontinence and stoma]. / Sozialmedizinische Wertung von Durchfall, Inkontinenz und Stoma.

The assessment of capability of work consist of measuring the patient subjective willingness to perform and his efficiency which should be objectively examined by functional diagnostic tools. On the one hand, there is the consideration of the patients psycho-mental burdens and on the other hand has to be defined the extent of organic functional restrictions. The latter is difficult to assess because diseased organs of the gastrointestinal tract are not directly involved in the efficiency of work. In chronic diarrhea purely watery diarrhea causes mobility restrictions at the place of work. In case of chronic malabsortive diarrhea, psycho-mental and physical deficits of efficiency have to be taken into account. The latter however may be almost restored by adequate substitution of macro and micro nutrients. For the clinical assessment of the severity of incontinence and ist psychosocial effects structured history sheets and working up of clinical findings and specifics function tests are necessary. The so defined degree of stool incontinence determines the restrictions of vocational efficiency. Generally persons with stoma are nearly not disabled and capable of gainful employment. This also pertains to professions with specific hygienic requirements, such as a production and distribution of foods. Persons with well applied and provided stomata should avoid severe physical burdens, unsuitable postures and periodical forms of labour like piece-work.

The role of barium enema in colostomy closure in trauma patients.

Recently, the routine use of barium enema preceding colostomy closure in trauma patients has been challenged. It has been argued that the nature of the injury should be apparent from the initial laparotomy and that the likelihood of finding an unsuspected colonic lesion in the young, previously healthy patients who constitute the majority of trauma patients is very small. We retrospectively reviewed 124 consecutive cases of patients who received colostomy takedowns for trauma. One hundred six of the patients had preoperative barium enema evaluation. 87.1 per cent of the examinations were negative, with a subsequent stoma closure complication rate of 20.4 per cent. Of the 13 positive barium enemas, 9 were falsely positive. These patients had a higher stoma closure complication rate of 39 per cent, a fact that could not be explained on the basis of their abnormal studies. The 18 patients who did not have barium enema performed did not have an increase in complications (17.6%). Barium enema failed to uncover unsuspected pertinent diagnoses, often added unnecessary delays and expense, and in no case changed the operative management. Contrast studies were found to be useful in defining anatomy in cases of known fistulas and when the takedowns were performed without the benefit of operative reports from the previous surgery.

[Costs and benefits in the follow-up of abdomino-perineal amputation of the rectum for cancer]. / Costi e benefici nel follow-up dopo amputazione addomino-perineale del retto per cancro.

A cost/benefit analysis has been carried out of the follow-up of abdomino-perineal amputation of the rectum for cancer in the light of the objectives pursuable with this practice and the diagnostic techniques available today. As regards early diagnosis of a return of the disease, it is necessary to distinguish between long-term recurrence, hepatic or pulmonary for example, in relation to their greater potential capacity for surgical exeresis and local pelviperineal recurrences which are more rarely susceptible to radical exeresis in spite of the introduction of computed tomography and nuclear magnetic resonance in the diagnostic/therapeutic routine. As for diagnosis and management of metachronous polyps as a prevention of metachronous cancer, the importance of periodic trans-stomal pancolonoscopic control of the residual colon in all patients emerges. Finally, in cost/benefit terms, the objective of a psychophysical rehabilitation of the colostomized patient is advantageous with a marked reduction in welfare expenditure for the community.

An assessment of colostomy irrigation.

One hundred patients with permanent sigmoid colostomies were surveyed to determine their satisfaction and success with the "irrigation" technique of colostomy management. Most patients who irrigate their colostomies achieve continence. Odors and skin irritation are minimized. The irrigation method is economical, time efficient, and allows a reasonably liberal diet. It avoids bulky appliances and is safe. In appropriately selected patients, the irrigation technique is the method of choice for management of an end-sigmoid colostomy.