Volume 39 Number 1 March 2019

and International Inter-professional Wound Care Group

Official Journal of The World Council of Enterostomal Therapists®

WCET® Journal

A world of expert professional nursing care for people with ostomy, wound or continence needs

Editorial Our Journal: Meeting a diversity of needs

News and views Around the WCET® world

Case study Chemotherapy-induced pyoderma gangrenosum

Validation and inter-rater reliability of inexpensive, mini, no-touch infrared surface thermometry devices as an assessment tool for prediction of wound-related deep and surrounding infection

Case study The importance of a holistic approach to stoma care: A case review

The correlation between stigma and adjustment in patients with a permanent colostomy in the Midlands of China

“ I was impressed straight away. It fitted the curve of my hernia.”

Almost a year after his ileostomy was performed in 2015 following an eight year struggle with colitis, Steve developed a grapefruit-sized hernia around his stoma.

The products he used initially were uncomfortable, and he experienced leakage and skin irritation. Creases around the adhesive were common, and Steve worried about the baseplate staying on, especially when exercising.

As an active member of the IBD community, he learned about a new product specially designed for outward areas – SenSura Mio Concave. He tried it and was impressed by how well the curved star-shape fit his body. Its un-conventional shape made it easy to apply with less creasing and folding.

For Steve, who works as a delivery driver, feeling comfortable and worrying less about leakage is a big factor when choosing an appliance.

Whether he’s working, at the gym or swimming with his kids, SenSura Mio Concave gives him the feeling of security and confidence he needs to enjoy life, without worrying about his stoma.

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“ It gave me confidence that it was going to stay where it was supposed to.”

The Coloplast logo is a registered trademark of Coloplast A/S. © 2019-01. All rights reserved Coloplast A/S, 3050 Humlebaek, Denmark.

CPOC_SMio_Concave_Launch_Ad_210X270.indd 1 05-02-2019 17:40:44

1www.wcetn.org

WCET® Journal

Editorial BoardJournal Editor

Jenny Prentice PhD, BN, RN, FAWMAPerth, Australia Email editor@wcetn.org

Executive Editor Emeritus Elizabeth A Ayello, USA Associate Editor, IIWCG content Hiske Smart, UAE

Assistant Editors Judy Pullen, Ostomy, UK Kevin Woo, Continence, Canada Sarah Lebovits, Ostomy, USA

Lupita Lobo Cordero, MexicoSandra Guerrero Gamboa, Columbia

Svatava Nova’kova’, Czech RepublicIngunn Aamot, Norway

Supun Prageeth Samarakoon, Sri LankaAyise Karadag, Turkey

Translators

Sharon Baranoski, USACarmel Boylan, Australia

Eva Carlsson, SwedenPankaj Choudvary, India

Jill Cox, USALori Henderson, USA

Chi Keung Peter Lai, Hong KongDiane Maydick, USA

Daniel O’Neill, USAR Gary Sibbald, Canada

Erica Thibault, USAMichelle Lee Wai-Kuen, Hong Kong

Board members

Aims and scopeThe WCET® Journal is the peak international scholarly journal for ostomy, wound and continence nurses worldwide. It is the offical journal of the World Council of Enterostomal Therapists and the International Inter-professional Wound Care Group.

The journal globally supports specialist nurses in ostomy, wound and continence care, as well as medical and allied health professionals and researchers, to disseminate their clinical expertise, knowledge and research to promote evidence-based, patient-centred, high quality care for persons living with ostomy, wound or continence needs.

It serves as a vehicle for on-going professional education and practice updates, with all articles subject to blind review by international experts in the field of the submitted work. All manuscripts are submitted and reviewed in English, the first language of the World Council of Enterostomal Therapists.

A printed copy of the Journal is posted (individually addressed) to all WCET® members in over 65 countries. It is also published in Chinese, Spanish and French, on separate electronic platforms including the original English, to cater for members who speak these languages more fluently than English.

The primary aim of the journal is to advance the care of people with ostomy, wound or continence needs by:

• providing professional development for ostomy, wound and continence nurses, related medical and allied health professionals and other relevant parties

• communicating knowledge and information about ostomy, wound and continence disease processes, conditions and associated preventions and treatments

• advocating for the interests of nurses, health professionals and persons with ostomy, wound or continence needs

• supporting and integrating practice development, research, quality improvement and innovation

• setting guidelines and recommending standards for nurses and health professionals caring for people with ostomy, wound or continence needs

• promoting inter-professional collaboration in the assessment and management of persons with ostomy, wound or continence needs

• doing all such other things as are incidental or conducive to the attainment of the Mission of the WCET®.

The scope of articles published in the journal include

• Original research

• Case studies

• Literature reviews

• Translating research and knowledge into practice

• Clinical practice guidelines

• Reviews of research and practice

• Commentaries and editorials

• Educational supplements

• Updates on recent relevant research from other sources

• Book reviews.

Conflicts of interest and ethical considerationsThe WCET® Journal follows the International Committe of Medical Journal Editor’s  Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals.

Statements about potential conflicts of interest, including funding sources, must be made for all manuscripts. A disclosure form can be generated and completed on the ICMJE website and uploaded as part of the manuscript submission on ScholarOne. Alternatively, full disclosure details can be made in the title page.

All research should be conducted in accordance with the Helsinki Declaration and the methods section should include a statement indicating that the research was approved by the relevant authority. Research and case studies involving human subjects must include assurance that informed consent was obtained from each patient. Any research using animals must include a statement of assurance that all animals received humane care.

Aims and scopeConflicts of interest Ethical considerations

2 WCET® Journal Volume 39 Number 1 March 2019

World Council of Enterostomal Therapists®

An Association of Nurses Registered Charity 1057749

PresidentElizabeth A Ayello PhD, RN, CWON,ETN, MAPWCA,FAAN

Faculty, Excelsior CollegeSchool of Nursing 209–14 82nd Avenue Hollis Hills, NY 11427, USAEmail president@wcetn.org

Vice-PresidentLaurent O Chabal RN, ETN, UAS Lecturer Centre de Stomathérapie

Ensemble Hospitalier de la Côte Chemin du Crêt 21110 Morges, SwitzerlandEmail vicepresident@wcetn.org

TreasurerAlison Crawshaw RGN, BSc, ENB216

Independent Clinical Nurse Specialist 92 Lasswade Road Edinburgh, EH16 6SU United Kingdom Email treasurer@wcetn.org

EXECUTIVE OFFICERS

EducationDenise HibbertRGN, MSc-WHTR, BSc, DipHE, ONC, STN, FSSCRS Editorial Board of Annals of Saudi Medicine (ASM)

Senior Lecturer, AlFaisal University, Riyadh Saudi ArabiaEmail education@wcetn.org

Publications and CommunicationsKaren Bruton RN BScN MCISc-WH NSWOC WOCC(C)

Outpost Nursing: First Nations Communities, Northern OntarioBritish Columbia, CanadaEmail publications@wcetn.org

Norma N Gill FoundationArum Ratna Pratiwi

Head Dept of Nursing Development Wound Care Coordinator, Siloam Hospitals Surabaya Indonesia Email nngf@wcetn.org

CHAIRPERSONS OF STANDING COMMITTEES

Dee Waugh RN, RM, ET

PO Box 44598Claremont 7735, South AfricaEmail congressliaison@wcetn.orgSkype dee.waugh1

CONGRESS AND MEETING COORDINATOR1000 Potomac Street NWSuite 108Washington, DC 20007United States of AmericaTel +1 202 567-3030 Fax +1 202 833-3636 Email admin@wcetn.org

WCET® CENTRAL OFFICE

WCET® INTERNATIONAL DELEGATESAUSTRALIAHelen Richards

AUSTRIAAedlheid Anzinger

BAHRAIN, KINGDOM OFEman AIJahmil

BELGIUMBrigitte Crispin

BOTSWANAChabo Lelaka

BRAZILSee Hee Park Kim

CAMEROONFranck Wanda, MD

CANADAKimberly Anne LeBlanc

CHILEHeidi Marie Hevia Campos

CHINAHui Ying Qin

COLOMBIASandra Guerrero-Camboa

COSTA RICAAndrés Campos Vargas

CROATIAMarija Hegedus Matetic

CZECH REPUBLICIva Otradovcova

DENMARKJette Kundal

EGYPTMohamed Badr

ESTONIAJanne Kukk

FINLANDAnn-Cristin Smidslund-Rastas

FRANCEMartine Pages

GERMANYHans-Juergen Markus

HONG KONGSiu Ming (Susan) Law

HUNGARYTimea Csiszar

INDIAHemlata Gupte

INDONESIASaldy Yusuf

IRANSetareh Azizi Elizeh

IRELANDMarianne Doran

ISRAELRuthi Efargan

ITALYGian Carlo Canese

JAPANHitomi Kataoka

KENYAPatrick Mutuma Kiambi

KOREA, SOUTHID needed

KUWAITReda Mahboub

MACAUKit Weng Ho

MALAYSIAMohd Rahime Bin Ab Wahab

MAURITIUSSneha Callychurn

MEXICOGuadalupe Maria Lobo Cordero

NAMIBIALaura Obbes

NEPALShanti Bajracharya

NETHERLANDSKitty Peeten

NEW ZEALANDFrancesca Martin

NIGERIAOgbonna Martina Nwadinkpa

NORWAYGrethe Foelstad Lund

OMANSaid Almujaini

PAKISTANGulnaz Tariq

PERUCatherine Bernabel

PHILIPPINESRhyan Hitalla

POLANDMagdalena Leyk-Kolanczak

PORTUGALIsabel Maria Ribeiro Morais Araujo Santos

PUERTO RICOElsa Santiago

QATARID needed

ROMANIACristina Ghiran

RUSSIAMaria Golubeva

SAUDI ARABIAHajer Alsabaa

SERBIAŽivka Madzic

SINGAPOREChoo Eng Ong

SLOVENIAAnita Jeler Slatner

SOUTH AFRICAMonica Franck

SPAINID needed

SRI LANKADammalage Udena Athua Kumara

SWEDENEva Bengtsson

SWITZERLANDClaire Genoud

TAIWANWen-Pei Huang

THAILANDYuwadee Kestsumpun

TOGOVincent Kokou Kouami

TURKEYAyise Karadag

UNITED ARAB EMIRATESBeji George

UNITED KINGDOMMaddie White

UNITED STATESMichele (Shelly) Burdette-Taylor

VIETNAMLam Nguyen Thi

ZIMBABWERudo Mutekedza

Dansac TRE seal is more than just a seal – with three levels of protection, the Dansac TRE seal has been designed to help keep skin naturally healthy.

AdhesionDesigned to provide a

secure, flexible seal to protect the skin from stoma fluid and

to be easy to remove.

AbsorptionHelps absorb excess moisture

to maintain skin’s natural balance without the seal losing internal or

external strength.

pH balanceDesigned to help

manage the skin-damaging effects of digestive

enzyme activity.

SEALING IN SKIN HEALTH

The Dansac logo and Dansac TRE are trademarks of Dansac A/S©2017 Dansac A/S

P12o

f-74

-300

© 20

17 D

ansa

c A/S

Dansac TRE seal is more than just a seal – with three levels of protection, the Dansac TRE seal has been designed to help keep skin naturally healthy.

AdhesionDesigned to provide a

secure, flexible seal to protect the skin from stoma fluid and

to be easy to remove.

AbsorptionHelps absorb excess moisture

to maintain skin’s natural balance without the seal losing internal or

external strength.

pH balanceDesigned to help

manage the skin-damaging effects of digestive

enzyme activity.

SEALING IN SKIN HEALTH

The Dansac logo and Dansac TRE are trademarks of Dansac A/S©2017 Dansac A/S

P12o

f-74

-300

© 20

17 D

ansa

c A/S

WEAVING CULTURE & EXPERTISE TO OFFER THE BEST PATIENT CARE

www.wcet-ascnuk2020.com

We hope to see YOU at the WCET®-ASCN UK 2020 Joint Congress in Glasgow, Scotland, voted the ‘World’s Friendliest City’!

The 2020 Joint Congress Organising Committee is pleased to announce that Denise Hibbert, WCET® Education Committee Chairperson and Wendy Osborne, ASCN UK Education O�icer are serving as the Scientific Committee Chairs of the 2020 Joint Congress. We look forward to their contributions.

Please take note of these important dates:15 September 2019: Call for abstracts

October 2019: Registration opens28 February 2020: Abstract submission deadline

For up to date Joint Congress information please visit

5www.wcetn.org

The World Council of Enterostomal Therapists® Journal

ISSN 0819-4610 Published quarterlyCopyright ©2019 by the

World Council of Enterostomal Therapists®

ANNUAL SUBSCRIPTION RATESNon-member individuals £60

Institutions £120

PUBLISHED QUARTERLY BY

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Tel +61 8 6154 3911 Email admin@cambridgemedia.com.au

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Email simonh@cambridgemedia.com.auCopy Editor Rachel Hoare

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World Council of Enterostomal Therapists® Journal

The World Council of Enterostomal Therapists® Journal is indexed in the Cumulative Index to Nursing and Allied Health Literature.

Disclaimer Opinions expressed in the WCET ® Journal are those of the authors and not necessarily those of the World Council of Enterostomal Therapists®, the editor or the editorial board.

WCET ®: a world of expert professional nursing care for people with ostomy, wound or continence needs.

Contents

Editorial Our journal: Meeting a diversity of needs 6

News and views Around the WCET® world 7

Case study Chemotherapy-induced pyoderma gangrenosum 9 Michelle Wai Kuen Lee, Steven Kar Kay Chan, Amy Choi Ching Fong & Kristie Wai Sze Ho

Validation and inter-rater reliability of inexpensive, mini, no-touch infrared surface thermometry devices as an assessment tool for prediction of wound-related deep and surrounding infection 18 Hiske Smart, Eman Al Jahmi, Ebrahim Buhiji & Sally-Anne Smart

Case study The importance of a holistic approach to stoma care: A case review 23 Melanie C Perez

The correlation between stigma and adjustment in patients with a permanent colostomy in the Midlands of China 33 Fang-fang Xu, Wei-hua Yu, Mei Yu, Sheng-qin Wang & Gui-hua Zhou

Book review 40

Volume 39 Number 1 March 2019

The WCET® Journal has a strategic Sustaining Journal Partnership with these companies. Their commitment to supporting the Journal with advertising helps the WCET® to achieve its mission.

The WCET ® mission is to lead the global advancement of specialised professional nursing care for people with ostomy, wound or continence needs

NON-EDITORIAL WCET ® CORRESPONDENCEWCET® Central Office1000 Potomac Street NW Suite 108 Washington, DC 20007 United States of America Tel +1 202 567-3030 Fax +1 202 833-3636 Email admin@wcetn.org

Connect with us free on Skype — search for wcetoffice to connect with us or leave an Instant Message.

Remittances and notification of change of address to be directed to the WCET ® Central Office (address above).

6 WCET® Journal Volume 39 Number 1 March 2019

Editorial

Our journal: Meeting a diversity of needs

Collaboratively the WCET® Board and the journal publisher and editor are addressing MEDLINE indexing criteria to achieve our goal of being granted MEDLINE indexed status. In addressing the required criteria, we have for the first time, as published within this issue, stated the aims and scope of the journal, which are broadly reflective of the ethos of the WCET®.

On reflection of the stated aims and scope it highlights the diverse nature of the specialty of wound ostomy and continence nursing; the diverse challenges specialists in these fields face across the globe and within our respective countries, health services and health educational systems. Finally, it highlights the diverse range of peoples we care for with wound, stoma or continence issues within vastly different cultural and societal norms.

The diversity of something is defined by the fact that it contains very many different elements1. Diversity according to Queensborough Community College “is a reality created by individuals and groups from a broad spectrum of demographic and philosophical differences …along the dimensions of race, ethnicity, gender, sexual orientation, socio-economic status, age, physical abilities, religious beliefs, political beliefs or other ideologies”2.

Diversity is also an inherent factor in healthcare that encompasses a range of differences in relation to patient demographics (disease process, gender, age, culture, and education) that in combination result in dissimilar needs and preferences, which may create both barriers and opportunities3. Leadership with healthcare organisations and professional bodies is required to assist health professionals to deal with the challenges of diversity in healthcare4.

Within our specialty, even our titles including enterostomal therapists (ET) and stomal therapy, stoma care, tissue viability, continence care or wound ostomy and continence (WOC) nurses indicates diversity. Whatever our titles, as nurses who are charged with providing effective evidenced-based, safe, person-centred care we are also expected to be able to manage diversity on a day to day basis by understanding, valuing and integrating a person’s individual and differing needs and situations into the plan of care5.

WCET® as a professional body is committed to supporting life-long learning of nurses in our speciality globally through provision of the WCET® Journal. The scope of articles published within the journal reflects the diverse and often complex

nature of wound, ostomy and continence nursing. The benefits of shared expertise through publication within the Journal assists with managing diversity by providing insight into how patient, health service, educational or political barriers maybe ameliorated or provide opportunities for improvement across these arenas and assist with the practicalities of clinical care.

The range of topics within this current issue speak to the diverse and complex problems wound, ostomy and continence nurses deal with from a clinical, research and humanitarian perspective. Lee et al discuss the phenomena of drug induced Pyoderma gangrenosum, while Perez describes the complexity of managing multiple ostomies and fistula in a patient with bowel and bladder cancer. The association between ostomy adjustment and stigma within a Chinese population are identified by Xu et al. Point of care technology is explored by Smart et al whose exploratory research sought to validate no-touch infrared surface thermometry devices ability to predict wound-related infection.

We also celebrate our diversity through the continuing partnership with the International Interprofessional Wound Care Group (IIWCG) for which the WCET® Journal also serves as their official journal.

Translation of the journal into Chinese, and later this year into other languages, specifically for WCET® members further demonstrates the WCET® Board’s commitment to acknowledging and meeting the diverse needs of its membership.

With Kind Regards

Jenny Prentice

REFERENCES1. Collins English Dictionary https://www.collinsdictionary.com/

dictionary/english/diversity accessed 8th March 2019

2. Queensborough Community College, Queensborough University New York. http://www.qcc.cuny.edu/diversity/definition.html accessed 8th March 2019.

3. Celik H, Abma TA, Widdershoven GA & van Wijmen FCB et al. Implementation of diversity in healthcare practices: Barriers and opportunities. Patient Education and Counselling 71 (2008) 65–71.

4. The Sullivan Commission. The Sullivan Commission on Diversity in the Healthcare Workforce. U.S. Secretary of Health and Human Services. 2004, Atlanta, GA.

5. National health Service: Education for Scotland. Equality Diversity. www.effectivepractitioner.nes.scot.nhs.uk accessed 8th March 2019

For referencing Prentice J. Our journal: Meeting a diversity of needs. WCET® Journal 2019; 39(1):6DOI https://doi.org/10.33235/wcet.39.1.6

7www.wcetn.org

News and views

DREAMS REALISEDWhile I may live in New York, a city that never sleeps, it does not mean that I don’t dream. Beginning with Norma Gill, her steadfast board of volunteers and the many pioneers who shaped the WCET®, our association is built on their dreams and hopes for an association that would change the world for patients with ostomy, wound and continence care needs.

One of their dreams was to create a journal that would be of benefit to WCET® members. Over the years the journal has grown and changed. The feedback that you provided the executive board was that you wanted the journal to be MEDLINE indexed. The executive board has implemented a plan to apply for MEDLINE indexing. Our publisher, Greg Paull, and journal editor, Jenny Prentice, are working diligently to achieve this. You will notice that this issue of the journal looks different from past journal issues as they implement necessary requirements for MEDLINE indexing.

Another WCET® dream is to better serve the needs of our members, for many of whom English is not their first language. While WCET® has increased educational resources such as our webinars in languages other than English, except for when authors have provided a manuscript in their own language, articles in the WCET® Journal are mainly in English. Those who have responded to the membership survey have clearly told the executive board of the dream of having the WCET® Journal in languages other than English, especially Chinese.

Not only is this important to the executive board, but the use of multiple languages is very special to me personally. This is because I live in New York City, where over 800 languages are spoken. And in the borough of Queens where I live, the most languages are spoken, and different cultural foods can be found, in an area called the “The World’s Borough”. Living in such a diverse place, I am used to hearing and seeing many languages all around me. One of my dreams, which is also shared by the executive board, therefore has been to increase the number of languages in which the WCET® Journal is published.

Vanna Bonta, writer and actress said “dreams are the food of human progress”. Let me share with you the progress that the WCET® has made to making that dream a reality. Drum roll please... the executive board is pleased to announce that beginning with this first issue of 2019, the WCET® Journal will be published in Chinese as well as in English.

Around the WCET® world

Translation of a scholarly journal into another language is expensive. Through the financial support of several Chinese Journal Partners – Top Medical, Hollister, Calmoseptine and Welland – and also with the WCET® providing some funding, the cost to transform the English language journal into Chinese and build the necessary electronic platform has been realised. Even if you don’t read Chinese, I hope you will celebrate this progress and change.

The executive board is also looking at the costs and the process to have the journal available in even more languages. All this fits with the WCET® strategic plan to be a global association that is addressing the needs and different languages of our members. While financial constraints would make it impossible to do this for all languages that our members speak and read, look for more dreams realised in 2019 as we add other language versions of the WCET® Journal.

Regardless of what language the journal will be in, the content will be the same. The executive board is very excited about this and hope you are too. So, look for more news about this in upcoming issues of the journal.

Besides the otherwise obvious language change, we hope you will enjoy the redesign of the WCET® Journal and the WCET® BullETin, which is now the official magazine for WCET® members. Our publisher and his design team have done an amazing job — thank you, Greg, and all at Cambridge Media.

While we will keep dreaming of other ways to enhance the WCET®, be assured that the executive board’s strategic plan for association progress is firmly planted in the reality of action to continue to provide you with the best membership benefits possible.

Let us know what you think.

Sincerely

Elizabeth Ayello

LES RÊVES SE RÉALISENTCe n’est pas parce que je vis à New York, ville dont on dit qu’elle ne dort jamais, que je ne rêve pas. Depuis Norma Gill, son conseil de bénévoles inébranlables et les nombreux pionniers qui ont façonné le WCET®, notre association se construit sur leurs rêves et leurs espoirs afin de devenir une organisation qui change la vie des personnes stomisées, souffrant de plaies et/ou de troubles de la continence.

For referencing World Council of Enterostomal Therapists®. WCET® Journal 2019; 39(1):7-8

8 WCET® Journal Volume 39 Number 1 March 2019

Un de leurs rêves était de créer un journal qui puisse être au bénéfice des membres du WCET®. Au fil des ans le journal a grandi et a changé. Les retours au Comité Exécutif que vous nous avez fait remonter était que vous vouliez voir le journal être référencé MEDLINE. Le Comité Exécutif a donc mis en place un plan d’action afin d’obtenir cette indexation. Notre éditeur Greg Paull et l’éditorialiste du journal Jenny Prentice travaillent avec diligence pour atteindre cet objectif. Vous le constaterez, ce numéro du journal est différent de ses numéros précédents ; ce dernier incluant les changements nécessaires à l’obtention de ce référencement MEDLINE.

Un autre rêve du WCET® est de répondre encore mieux aux besoins de nos membres, dont nombres d’entre eux n’ont pas l’Anglais comme première langue. Bien que le WCET® a développé des ressources pédagogiques, comme nos séminaires en lignes, dans d’autres langues que l’Anglais  ; les articles publiés dans le Journal du WCET® sont le souvent en Anglais, à l’exception de ceux qui nous été transmis par leurs auteurs dans leur langue maternelle. Ceux qui ont complété notre enquête de satisfaction, traduite en différentes langues, ont clairement exprimé le rêve d’avoir le Journal du WCET® dans d’autres langues que l’Anglais, et en particulier en Chinois.

Ce n’est pas seulement important pour le Comité Exécutif mais cela a aussi une résonnance toute particulière pour moi. En effet, je vis à New York où plus de 800 langues y sont parlées, et tout spécialement dans le quartier du Queens où je réside. Ce quartier est appelé «  le quartier du Monde  », la plupart de ces différentes langues y sont parlés et de la nourriture venant de différentes cultures peut y être trouvée. Vivant dans un lieu aussi diversifié, je suis habituée à entendre et voir parler ces différentes langues. Ainsi un de mes rêves de voir augmenter le nombre de langues dans lequel le Journal du WCET® est publié, est aussi partagé pour le Comité Exécutif.

L’écrivain et actrice Vanna Bonta disait que « le progrès humain se nourrit des rêves  ». Je me permets de partager avec vous les progrès fait par le WCET® pour que ce rêve puisse devenir réalité. Le Comité Exécutif du WCET® est heureux de vous annoncer qu’a compté du numéro 1 du Journal du WCET® de 2019, ce journal sera publié en Chinois et en Anglais.

Réaliser une traduction d’une revue scientifique coûte cher. Grâce au soutien financier de Top Médical, Hollister, Calmoseptine et Welland, partenaires pour cette version traduite du journal, (mais aussi grâce à des fonds provenant du WCET®), il a été possible de transformer le journal de l’Anglais en Chinois et de créer la plateforme électronique qui lui était nécessaire. Même si vous ne lisez pas le Chinois, j’espère que vous célébrerez cette avancée et ce changement.

Le Comité Exécutif est en train d’investiguer les coûts et les processus qu’il serait nécessaire d’effectuer pour avoir le journal traduit dans d’autres langues. Cela répond au plan stratégique du WCET® qui est une association Mondiale qui souhaite répondre aux besoins de ses membres qui parlent d’autres langues. Bien que les contraintes financières vont limiter les possibilités de pouvoir proposer le journal dans toutes les

langues parlées et lues par nos membres, vous assisterez à la réalisation d’autres rêves en 2019 alors que nous ajouterons d’autres versions du journal en d’autres langues.

Quelle que soit la langue utilisée, le contenu du journal sera le même. Cette concrétisation rend le Comité Exécutif très enthousiaste et nous espérons que vous le serez aussi. Alors restez connectés afin d‘avoir plus d’informations sur ce point dans les prochains numéros du journal.

Mise à part ces changements évidents en lien avec la langue utilisée, nous espérons que vous apprécierez aussi le nouveau design du journal et du bullETin du WCET®, bullETin qui est devenu maintenant le magazine officiel des membres du WCET®. Notre éditeur et son équipe de design ont fait un travail formidable- Merci Greg ainsi qu’à toute l’équipe de Cambridge Media.

Alors que nous allons continuer à rêver sur d’autres façon de faire progresser le WCET®, soyez assurés que le plan stratégique du Comité Exécutif pour y arriver est fermement ancré dans la réalité et dans les mesures à prendre afin de continuer à pouvoir vous faire bénéficier des meilleurs avantages possibles d’être membres.

Merci de nous transmettre votre opinion.

Sincèrement

Elisabeth Ayello

Traduction par Laurent Chabal

9www.wcetn.org

Chemotherapy-induced pyoderma gangrenosum

INTRODUCTIONPyoderma gangrenosum (PG) is a refractory, painful, non-infectious, ulcerative and inflammatory skin condition, which was first described by Brocq in 19161. In 1930, Brunstring et al. named it pyoderma gangrenosum2. It is commonly associated with underlying systemic diseases and occurs most frequently between 40 and 60 years old1,3-6. Typical PG can occur on any skin surface, but is most commonly seen over lower limbs and often leaves cribriform scars after the wounds have healed2,7.

ABSTRACTPyoderma gangrenosum (PG) is a refractory, painful, non-infectious, ulcerative and inflammatory skin condition. Approximately 50% of patients with PG showed an existing systemic disease, such as inflammatory bowel conditions, haematological disorders, rheumatoid diseases or hepatopathies. Some patients developed PG following acute trauma or injury in a process known as pathergy. In the other cases, PG is characterised by isolated skin lesions with unknown causes and classified as idiopathic. However, in recent decades, PG has been reported in patients treated with certain medications. In this manuscript, we report two cases of PG, which were triggered by chemotherapy in patients with myelodysplastic syndrome (MDS) and chronic myelomonocytic leukaemia (CMML).

Case study

Michelle Wai Kuen Lee*Nurse Consultant, Wound and Stomal Therapy, Department of Surgery, Queen Mary Hospital, Hong Kong Email leewkmichelle@gmail.com

Steven Kar Kay ChanAPN, Wound and Stomal Therapy, Department of Surgery, Queen Mary Hospital, Hong Kong

Amy Choi Ching FongAPN, Wound and Stomal Therapy, Department of Surgery, Queen Mary Hospital, Hong Kong

Kristie Wai Sze HoAPN, Central Nursing Division, Queen Mary Hospital, Hong Kong

* Corresponding author

Approximately 50% of patients with PG showed an existing systemic disease, such as inflammatory bowel conditions, haematological disorders, rheumatoid diseases or hepatopathies1,8. Some patients developed PG following acute trauma or injury in a process known as pathergy2,9-11. In the other cases, PG is characterised by isolated skin lesions with unknown causes and classified as idiopathic12. However, in recent decades, PG has been reported in patients treated with certain medications. In the review by Wu et al.13, 43 cases of drug-induced PG were identified. To follow is a report of two cases of PG, which were triggered by chemotherapy in patients with myelodysplastic syndrome (MDS) and chronic myelomonocytic leukaemia (CMML).

Case 1A 58-year-old female was diagnosed with MDS. MDS is a collection of pathologically and cytogenetically distinct bone marrow disorders characterised by peripheral blood cytopenias and will result in an increased risk of bleeding and infectious complications14. In addition, these patients have a tendency to develop acute myeloid leukaemia (AML)14,15. Azacitidine, a chemical analogue of cytosine, is a chemotherapy drug used to treat conditions that affect the blood and the bone marrow. This was given via subcutaneous injection for the patient for one week. On day 8, the patient developed non-neutropenic septic shock and multiple skin lesions were noted over her abdomen (injection site), which required admission to the intensive care unit. Initially the lesions were erythematous, which rapidly progressed into blisters and finally skin necrosis

Keywords Pyoderma gangrenosum, chemotherapy, azacitidine.

For referencing Lee MWK et al. Chemotherapy-induced pyoderma gangrenosum. WCET® Journal 2019; 39(1):9-17

DOI https://doi.org/10.33235/wcet.39.1.9-17

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occurred. The wounds were well circumscribed, with a ring-shaped large ulceration and elevated oedematous borders (Figure 1).

Wound culture indicated there was no particular bacterial, fungal or mycobacterial organisms. The wound biopsy demonstrated inflammatory neutrophilic dermatosis. A dermatologist was consulted and PG was finally diagnosed. Methylprednisolone 50  mg daily was commenced orally. One month following oral steroid therapy, the edge of the wound remained violaceous and it was evident that the PG was still active (Figure 2). Cyclosporine, an immunosuppressant medication, and doxycycline, a broad-spectrum antibiotic of the tetracycline class, were added to the treatment regimen. Subsequently, the wounds were less violaceous in appearance and epithelialisation was noted from the edge (Figure 3). In addition, less pain was experienced by the patient. Methylprednisolone was then decreased gradually to 5  mg with cyclosporine 70  mg and doxycycline 100  mg daily as a maintenance dose. The patient was discharged from the hospital afterwards and wound care was continued by the community nurse every alternate day.

Two months later, the patient ’s general condit ion deteriorated and her white blood cells were found to be in a rising trend during follow-up in the haematology clinic. After discussion with the patient and her family members, the patient was admitted to the hospital again and decitabine cycle 1 was given intravenously. Decitabine is another DNA methyltransferase depleting drug for the treatment of MDS16. Unfortunately, two weeks following the introduction of this

medication, the patient reacted with neutropenic fever again and a flare-up of PG eventuated (Figure 4). Methylprednisolone 30  mg daily and cyclosporine 40  mg twice a day were recommenced, with recognised improvement in the wound (Figure 5). Dosage of both drugs was gradually decreased as the improvement continued. Conversely, another two months later, PG flared up again after decitabine cycle 2 was given. A high dose of methylprednisolone and cyclosporine were recommenced. However, the patient’s prolonged neutropenic state complicated her deteriorating health and she passed away two months following active treatment.

Case 2A 72-year-old male was diagnosed with CMML. CMML is a pathologically heterogeneous disease with overlapping morphologic features of both myelodysplastic syndromes and myeloproliferative neoplasms17. It is accompanied by bone marrow dysplasia, cytopenias and hepatosplenomegaly18. As a result of the patient having progressive anaemia and thrombocytopenia, azacitidine was commenced. The first cycle of azacitidine was well tolerated by the patient. Four days into his second cycle, multiple erythematous, painful pustular plaques with violaceous borders appeared initially on the left lower limb, then became generalised over his abdomen, chest wall and shoulder (Figure 6–9).

An incisional wound biopsy over the abdomen and left lower limb demonstrated diffuse dense infiltration of the dermis and superficial subcutaneous tissue by polymorphs with focal fat necrosis. The overall features were consistent with neutrophilic dermatosis and indicative of PG. Microbiological studies of the

Figure 1 Figure 2 Figure 3

Figure 4 Figure 5

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Figure 6 Figure 7 Figure 8

Figure 9

wounds were negative for both aerobic and anaerobic bacterial growth. However, the patient developed a neutropenic fever and multiple antibiotics were given. In the presence of a depressed immune system, the sepsis could not be controlled and the patient died two weeks following the commencement of treatment.

DISCUSSIONAzacitidine (AZA) is a DNA methyltransferase inhibitor, which has been shown to improve overall survival in patients with MDS and its sub-types19-21. However, AZA-induced demethylation of DNA may cause epigenetic changes, which lead to increased interferon production and cytoskeletal rearrangements; these changes may support the pathogenesis of AZA-induced PG by upregulating inflammation and neutrophil migration13. This side effect had been demonstrated in individual reports and literature21-23. The report of two patient case studies have also demonstrated AZA-induced PG.

Azacitidine can be administered by using intravenous or subcutaneous routes. However, it was known that skin lesions, ecchymosis, petechiae and skin induration following subcutaneous injection could be developed in up to 97% of patients23-24. Azacitidine-induced injection site PG was rare, but a single case was reported recently by Roy et al.21. In case study 1, the patient suffered from injection site complications following eight days of treatment. Some literature reported that changing the needle with no azacitidine residue before injection could reduce the incidence of injection-site reactions but control studies measuring this were limited24.

Another drug used in case study 1 was decitabine. It is a DNA methyltransferase (DNMT1)-depleting drug approved for treatment of MDS. In 2017, Saleh and Saunthararajah reported successfully treated MDS-induced PG by using decitabine25. However, PG relapsed in case study 1 during the treatment of decitabine. Further studies concerning the relationship between PG and decitabine are warranted.

Wound managementTopical therapy is a significant issue in all the patients with PG but there is no consensus in the management of these wounds1,26. The treatment is largely empirical and depends on the severity and extent of the lesions. The overall goals of local wound management are to reduce lesion inflammation,

decrease pain and promote wound healing1-2. Some topical drugs, such as the application of tacrolimus, have been reported, where wounds show no further extension, regression of the inflammatory border and pain relief. However, patients’ serum creatinine was increased27-28. Therefore, systemic absorption should be closely monitored and a clinical trial in this area is suggested to measure the risk and benefits of the topical drug.

The literature has indicated moist wound management to be the cornerstone in managing PG wounds as it can improve wound-related pain, facilitate autolytic debridement and promote angiogenesis8. Various dressings, such as polyurethane foam, Hydrofiber and alginate dressings, are documented in individual PG wound management with resolving erythema, flattened epibole edges and pain relief1,29. In the first case, the Hydrofiber dressing had been tried but the patient could not tolerate it because of severe pain. It might be due to the hydrophilic effect of the dressing. In addition, because of less exudate of the wound, the dressing adhered to the wound bed and increased pain on removal. This might also increase the potential to trigger pathergy30. Hydrogel dressings are formulations of water, polymers and

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other ingredients. They are designed to hydrate the wound tissue, keep nerve endings moist to reduce pain and maintain a moist environment for cell migration31. In light of there being no bacterial growth within the tissues of the PG wounds for our two patients, Hydrogel with a tulle dressing were applied to facilitate autolytic debridement and reduce pain. On the other hand, although the underlying cause of PG is non-infectious, most of the patients are prescribed corticosteroids; therefore, caution should be made to prevent bacterial infection. The wounds were closely monitored for clinical signs of infection, such as erythema, warmth, increased pain, increased exudate and malodour30. Although skin flora was identified from the wound in the later stage of case 1, it was assessed that topic antimicrobial wound dressings were not necessary.

In view of the potential pathergy in the development and acceleration of the condition, both of the reported cases did not receive any surgical intervention nor conservative sharp wound debridement during the treatment period1. The evidence has shown that effective management of the systemic disease often results in improvement of the skin ulcerations1,2,26. Therefore, apart from local wound care, systemic corticosteroids and cyclosporine are recommended as first-line systemic agents for the management of patients with PG32.

Pain controlApart from vegetative variants, patients with PG almost entirely experience debilitating pain26. The source of pain may be multifactorial, but in most cases it is associated with the inflammatory process and the subsequent grave ulcer33. Repeated manipulation of the wound, such as wound cleansing and trauma during wound dressing removal, is a source of distress for patient33. Therefore, addressing the patient’s pain level is crucial in treatment efficacy. Both our patients in the case studies received analgesic, Tramadol, 50  mg every six hours orally, if necessary with an additional dose during wound dressing changes in order to achieve adequate pain control. Conversely, when patients' disease and inflammation are well controlled by systemic therapy and appropriate wound management, pain may subside gradually.

CONCLUSIONThe pathogenesis of PG still remains uncertain, although current evidence suggested that it has an autoimmune aetiology with defects in immune regulation of the inflammatory response. PG is also associated with various systemic conditions such as inflammatory bowel disease, haematological disorders, and autoimmune arthritis. Pathergy is an exaggerated response to minor trauma in patients with PG. However, chemotherapy is another possible triggering factor, which should be considered, particularly in patients receiving specific drug treatments. The two case studies demonstrated this serious side effect of azacitidine. Early recognition of this complication is important to avoid undue delays in the treatment of the underlying malignancy, but also to initiate appropriate therapy against PG.

CONFLICT OF INTERESTThe authors declare no conflicts of interest.

FUNDINGThe authors received no funding for this study.

REFERENCES1. Butcher M. Pyoderma gangrenosum: a diagnosis not to be missed.

Wounds UK 2005. Available from: https://www.wounds-uk.com/resources/details/pyoderma-gangrenosum-a-diagnosis-not-to-be-missed-1. Accessed on 03/07/2018.

2. Teagle A & Hargest R. Management of pyoderma gangrenosum. J R Soc Med 2014; 107(6):228–36.

3. von den Driesch P. Pyoderma gangrenosum: a report of 44 cases with follow-up. Br J Dermatol 1997; 137:1000.

4. Bennett ML, Jackson JM, Jorizzo JL et al. Pyoderma gangrenosum. A comparison of typical and atypical forms with an emphasis on time to remission. Case review of 86 patients from 2 institutions. Medicine (Baltimore) 2000; 79:37.

5. Binus AM, Qureshi AA, Li VW & Winterfield LS. Pyoderma gangrenosum: a retrospective review of patient characteristics, comorbidities and therapy in 103 patients. Br J Dermatol 2011; 165:1244.

6. Saracino A, Kelly R, Liew D & Chong A. Pyoderma gangrenosum requiring inpatient management: a report of 26 cases with follow-up. Australas J Dermatol 2011; 52:218.

7. Brooklyn T, Dunnill G & Probert C. Diagnosis and treatment of pyoderma gangrenosum. BMJ 2006; 333:181–4.

8. Wollina U. Pyoderma gangrenosum — a review. Orphanet Journal of Rare Diseases 2007; 2:19. doi:10.1186/1750-1172-2-19.

9. Cairns BA, Herbst CA, Sartor BR et al. Peristomal pyoderma gangrenosum and inflammatory bowel disease. Arch Surgery 1994; 129:769.

10. Esnault P, Dompartin A, Moreau A, Caraes B & Leroy D. Recurring postoperative pyoderma gangrenosum. Int J Dermatol 1995; 34:647–50.

11. Bennett ML, Jackson JM, Jorizzo JL, Fleischer AB Jr, White WL & Callen JP. Pyoderma gangrenosum. A comparison of typical and atypical forms with an emphasis on time to remission. Case review of 86 patients from 2 institutions. Medicine 2000; 79:37–46.

12. Konopka CL, Padulla GA, Ortiz MP, Beck AK, Bittencourt MR & Dalcin DC. Pyoderma gangrenosum: a review article. J Vasc Bras 2013; 12(1):25–33.

13. Wu BC, Patel ED & Ortega-Loayza AG. Drug-induced pyoderma gangrenosum: a model to understand the pathogenesis of pyoderma gangrenosum. Br J Dermatol 2017; 177:72–83.

14. Sekeres MA, Schoonen WM, Kantarjian H et al. Characteristics of US patients with myelodysplastic syndromes: results of six cross-sectional physician surveys. J Natl Cancer Inst 2008; 100:1542–1551.

15. Montalban-Bravo G & Garcia-Manero G. Myelodysplastic syndromes: update on diagnosis, risk-stratification and management. Am J Hematol 2018; 93(1):129–147. doi: 10.1002/ajh.24930.

16. Saleh MFM & Saunthararajah Y. Severe pyoderma gangrenosum caused by myelodysplastic syndrome successfully treated with decitabine administered by a noncytotoxic regimen. Clin Case Rep 2017; 5(12):2025–2027.

17. Harrington AM, Schelling LA & Ordobazari A. Immunophenotypes of chronic myelomonocytic leukemia (CMML) subtypes by flow cytometry. Am J Clin Pathol 2016; 146:170–181.

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18. Abramson Cancer Center. Chronic Myelomonocytic Leukemia. Retrieved from: https://www.pennmedicine.org/cancer/types-of-cancer/leukemia/chronic-myelomonocytic-leukemia/what-is-cmml. Accessed on 15 October, 2018.

19. Fenaux P, Mufti GJ, Hellstrom-Lindberg E et al. Efficacy of azacitidine compared with that of conventional care regimens in the treatment of higher-risk myelodysplastic syndromes: a randomised, open-label, phase III study. Lancet Oncol 2009; 10(3):223–32.

20. Leone G, Teofili L, Voso MT & Liiubbert M. DNA methylation and demethylating drugs in myelodysplastic syndromes and secondary leukemias. Haematological 2002; 87:1324–41.

21. Roy C, Adam JP, Morin F et al. Azacitidine-induced pyoderma gangrenosum at injection sites in a patient with myelodysplastic syndrome. Curr Oncol 2018; 25(1):e103–e105.

22. Tseng E, Alhusayen R, Sade S, Buckstein R & Prica A. Pyoderma gangrenosum secondary to azacitidine in myelodysplastic syndrome. Br J Haem 2015; 169(4):461.

23. Gravina GL, Festuccia C, Marampon F et al. Biological rationale for the use of DNA methyltransferase inhibitors as new strategy for modulation of tumor response to chemotherapy and radiation. Molecular Cancer 2010; 9:305.

24. Santini V, Fenaux P, Mufti GJ et al. Management and supportive care measures for adverse events in patients with myelodysplastic syndromes treated with azacitidine. Eur J Haematol 2010; 85(2):130–8.

25. Saleh MFM & Saunthararajah Y. Severe pyoderma gangrenosum caused by myelodysplastic syndrome successfully treated with decitabine administered by a noncytotoxic regimen. Clin Case Rep 2017; 5(12):2025–2027.

26. Miller J, Yentzer BA, Clark A, Jorizzo JL & Feldman SR. Pyoderma gangrenosum: A review and update on new therapies. J Am Acad Dermatol 2010; 62:646–54.

27. Pitarch G, Torrijos A, Mahiques L, Sanchez-Carazo JL & Fortea JM. Systemic absorption of topical tacrolimus in pyoderma gangrenosum. Acta Derm Venereol 2006; 86:64–5.

28. Ghislain PD, De Decker I & Lachapelle JM. Efficacy and systemic absorption of topical tacrolimus used in pyoderma gangrenosum. Br J Dermatol 2004; 150:1052–3.

29. Conwell P, Mikulski L, Moran D, Tramontozzi M & William W. Pyoderma gangrenosum treatment: a steroid-free option. Ostomy Wound Manage 2004; 50(5):26–8.

30. Angel DE & van Rooyen JL. The challenges of managing patients with pyoderma gangrenosum: three case reports. Wound Practice & Research 2016; 24(1):48–58.

31. Carville K. Wound Care Manual. 6th edn. Australia: Silver Chain Foundation, 2012, pp. 218–219.

32. Ahn C, Negus D & Huang W. Pyoderma gangrenosum: a review of pathogenesis and treatment. Expert Rev Clin Immunol 2018; 14(3):225–233.

33. Dunwoody CJ, McCann SA & Zumbo M. Pyoderma gangrenosum: a case study for pain management in dermatology nursing. Dermatol Nurs 2000; 12:313–4.

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RÉSUMÉLe pyoderma gangrenosum (PG) est une affection cutanée réfractaire, douloureuse, non infectieuse, ulcérante et inflammatoire. Près de 50% des patients atteints de PG ont une maladie systémique telle qu’une maladie inflammatoire des intestins, des troubles hématologiques, une maladie rhumatoïde ou hépatique. Quelques patients développent un PG suite à un traumatisme ou une plaie aigue selon un processus pathologique connu. Dans d’autres cas, le PG est caractérisé par des lésions cutanées isolées dont la cause est inconnue, appelées alors idiopathiques. Cela dit, dans les dernières décennies, le PG a été décrit chez des patients suivant certains traitements médicamenteux. Dans cet article, nous présentons deux cas de patients atteints de PG, patients suivant des traitements de chimiothérapie - un pour un syndrome myélodysplasique (SMD) et l’autre pour une leucémie myélomonocytaire chronique (LMMC).

Michelle Wai Kuen Lee*Infirmière consultante, spécialisée en stomathérapie et soins de plaies, Département de chirurgie.Hôpital Reine Marie, Hong KongEmail leewkmichelle@gmail.com

Steven Kar Kay ChanInfirmier en pratiques avancées, spécialisé en stomathérapie et soins de plaies, Département de chirurgie. Hôpital Reine Marie, Hong Kong

Amy Choi Ching FongInfirmière en pratiques avancées, spécialisée en stomathérapie et soins de plaies, Département de chirurgie. Hôpital Reine Marie, Hong Kong

Kristle Wai Sze HoInfirmière en pratiques avancées, spécialisée en stomathérapie et soins de plaies, Département de chirurgie. Hôpital Reine Marie, Hong Kong

*Auteur correspondantTraduction par Laurent Chabal

Mots clef Pyoderma grangrenosum, chimiothérapie, azacitidine

Pour le référencement Lee MWK et al. Du pyoderma gangrenosum induit par chimiothérapie. WCET® Journal 2019; 39(1):9-17

DOI https://doi.org/10.33235/wcet.39.1.9-17

Étude de cas

Du pyoderma gangrenosum induit par chimiothérapie

INTRODUCTIONLe pyoderma gangresosum (PG) est une affection cutanée réfractaire, douloureuse, non infectieuse, ulcérante et inflammatoire, qui a été décrite pour la première fois en 1916 par Brocq1. En 1930, Brunstring et al. lui ont donné son nom2. Il est en général associé à une maladie sous-jacente qui se manifeste le plus souvent chez des patients qui ont entre 40 et 60 ans1,3-6. Le PG peut survenir sur n’importe où sur la peau, mais il se manifeste le plus souvent sur les membres inférieurs. Il laisse des cicatrices à l’aspect ciblé une fois la plaie cicatrisée2,7.

Près de 50% des patients atteints de PG ont une pathologie systémique telle qu’une maladie inflammatoire des intestins, des troubles hématologiques, une maladie rhumatoïde ou hépatique1,8. Quelques patients développent un PG suite à un traumatisme ou une plaie aigue selon un processus pathologique connu2,9-11. Dans d’autres cas, le PG est caractérisé par des lésions cutanées isolées dont la cause est inconnue, appelées alors idiopathiques12. Cela dit, lors de ces dernières décennies, le PG a été décrit chez des patients suivant certains traitements médicamenteux. Dans la revue de littérature effectuée par Wu et al.13, 43 cas de PG induits par des médicaments ont été identifié. Suite à ce travail, notre article présente deux cas de patients atteint de PG, patients suivis pour traitement de chimiothérapie - un pour un syndrome myélodysplasique (SMD) et l’autre pour une leucémie myélomonocytaire chronique (LMMC).

Premier casIl s’agit d’une femme de 58 ans diagnostiquée pour un SMD. Le SMD regroupe diverses pathologies de la moelle osseuse à la génétique cellulaire distincte. Il est caractérisé par une cytopénie périphérique engendrant un risque accru d’hémorragies et de complications infectieuses14. De plus, ces patients ont tendance à développer une leucémie myéloïde aigue (LMA)14,15. L’azacitidine, un analogue synthétique de la cytosine, est un médicament de chimiothérapie utilisé pour traiter les affections sanguines et de la moelle osseuse. Il est administré une fois par semaine par voie sous-cutanée. A J8 la patiente a eu un choc septique sans neutropénie et a développé de multiples lésions cutanées sur l’abdomen (site des injections sous-cutanées) qui l’ont conduite à être transférée aux soins intensifs. Au départ ces lésions étaient

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érythémateuses, mais elles ont rapidement évolué en phlyctènes puis en nécrose. Les plaies étaient bien délimitées, en larges ulcérations circulaires, aux berges surélevées et œdématiées (voir photo 1).

Le prélèvement de la plaie n’a pas indiqué de présence bactérienne, fongique ou en mycobactéries. La biopsie de la plaie a démontré la présence d’une dermatose inflammatoire avec présence de neutrophiles. C’est finalement la consultation d’un dermatologue qui a permis de diagnostiquer la présence du PG. De la méthylprednisolone 50 mg jour per os a été introduite. Un mois après le début de la corticothérapie orale, les berges de la plaie restaient violacées et il était évident que le PG était toujours actif (voir photo 2). La cyclosporine, un immunosuppresseur, et la doxycycline, un antibiotique à largue spectre de la classe des tricyclines, ont été ajouté au traitement mis en place. De fait, la plaie est devenue moins violacée et de l’épithélialisation a pu être observé sur ses berges (voir photo 3). De plus, le patient avait moins mal. La méthylprednisolone a été graduellement diminué à 5 mg jour, alors que 70 mg de cyclosporine et 100 mg de doxycycline continuaient à être donné chaque jour. La patiente a pu ensuite quitter l’hôpital et les soins de plaies ont été poursuivi à domicile un jour sur deux.

Deux mois plus tard, les conditions générales de la patiente se sont détériorées et un suivi en hématologie a détecté une tendance à la hausse de ses globules blancs. Après discussion avec la patiente et sa famille, elle a été ré-hospitalisé et un premier cycle de décitabine a été administré par voie intraveineuse. La décitabine est un autre

inhibiteur des méthyltransférases de l’ADN utilisée pour le traitement des SMD16. Malheureusement, deux semaines après son introduction, la patiente a développée de la fièvre sur neutropénie accompagnée d’une flambée du PG (voir photo 4). La méthylprednisolone a dû être augmentée à 30 mg jour et la cyclosporine à 40 mg deux fois par jour. Cela a permis à la plaie de s’améliorer (voir photo 5). Les dosages des deux médicaments ont été progressivement diminué alors que l’amélioration de la situation se poursuivait. Deux mois plus tard, le PG a de nouveau flambé et un second cycle de décitabine a dû être donné. Le haut dosage de méthylprednisolone et de cyclosporine ayant dû être réintroduit, la neutropénie de la patiente a perduré et a détérioré son état général: elle est décédée deux mois après ce traitement intensif.

Deuxième casIl s’agit d’un homme de 72 ans diagnostiqué pour une LMMC. La LMMC est un ensemble de maladies hétérogènes regroupant différentes pathologies ayant des formes morphologiques semblables. Elle regroupe des syndromes myélodysplasiques et des néoplasies myéloprolifératives17. Elle est accompagnée de dysplasies de la moelle osseuse, de cytopénies et d’une hépatosplénomégalie18. De ce fait, ce patient a développé une anémie progressive et une trombocytopénie ; et un traitement d’azacitidine a été débuté. Ce premier cycle d’azacitidine a été bien toléré par le patient. Au quatrième jour de son second cycle, de multiples érythèmes et des pustules en plaques douloureuses et aux berges violacées sont apparus  ; d’abord sur les membres inférieurs,

Photo 1 Photo 2 Photo 3

Photo 4 Photo 5

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puis généralisés sur son abdomen, son torse et jusqu’aux épaules (voir photo 6 à 9).

Des biopsies réalisées sur l’abdomen et la jambe gauche ont démonté une infiltration dense et diffuse de globules blancs polymorphes dans le derme et le tissu sous-cutané superficiel avec la présence de foyers de nécrose dans l’hypoderme. La caractéristique globale présentant une dermatose avec présence de neutrophiles a signifié la présence du PG. Les recherches microbiologiques des plaies n’ont pas montré la présence de bactéries aérobies ou anaérobies. Malgré tout le patient a développé un état fébrile sur neutropénie et de nombreux antibiotiques ont dû été donnés. Face à la déficience de son système immunitaire, le sepsis n’a pas pu être réduit et le patient est décédé deux semaines après le début des traitements.

DISCUSSIONIl a été démontré que le traitement d’azacitidine (AZA), inhibiteur des méthyltransférases de l’ADN, augmente l’espérance de vie des patients atteints de SMD ou de ses sous-types19-21. Cela dit, l’AZA va conduire à une déméthylsation de l’ADN qui peut causer des changements épigénétiques, faisant augmenter la production d’interférons et engendrant des réarrangements du cytosquelette. Ces changements peuvent induire du PG dont la physiopathologie est liée à l’AZA, et ce suite à un dérèglement inflammatoire et à la migration des neutrophiles qu’il provoque13. Ce traitement a des effets secondaires individuels que décrit la littérature21-23. Notre étude de cas a démontré la survenue d’un PG suite à la prise d’AZA chez deux patients.

L’azacitidine peut être administrée soit par voie intraveineuse soit par voie sous-cutanée. La littérature relève que jusqu’à 97% des patients, qui l’ont reçu par voie sous-cutanée, vont développer des lésions cutanées, des ecchymoses, des pétéchies et/ou des indurations de la peau23-24. Un PG se développant sur le site d’injection de l’azacitidine est rare, un seul a cas a été récemment rapporté par Roy et al.21. Dans le cas de notre première situation, le patient a souffert de complications sur le site d’infection du médicament après 8 jours de traitement. Quelques études suggèrent que de changer l’aiguille avant de réaliser l’injection (la nouvelle

aguille ne contenant pas de résidu d’azacitidine) pourrait réduire l’incidence des réactions sur le site d’injection. Les études contrôle qui pourraient le corroborer sont malheureusement limitées24.

L’autre médicament qui a été utilisée dans le premier cas présenté est la décitabine. C’est aussi un inhibiteur des méthyltransférases de l’ADN (MDN1) utilisé pour traiter les SMD. En 2017, Saleh et Saunthararajah ont rapporté le succès de ce traitement chez des patients atteints de SDM et ayant un PG induit25. A noter dans notre premier cas, le PG a repris alors que la personne était sous traitement de décitabine. D’autres études sur les relations entre PG et décitabine seraient donc à mener.

Soins de plaiesLes soins locaux est un problème important pour tous les patients atteints de PG et il n’y a pas de consensus sur la gestion ce type de lésion1,26. En la matière, les soins de plaies sont largement empiriques et dépendent tant de la sévérité que de l’étendue des lésions. Les buts généraux de ces soins sont de réduire l’inflammation de ces lésions, d’en diminuer les douleurs ainsi que de promouvoir la cicatrisation1-2. L’usage

Photo 6 Photo 7 Photo 8

Photo 9

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d’agents topiques telle que l’application de méthadone a été tenté lorsque les plaies étaient stabilisées. Elle semble avoir conduit à une régression de l’inflammation des berges de la plaie ainsi qu’à une diminution des douleurs  ; et ce alors que les patients voyaient leur taux de créatinine augmenter27-28. L’absorption systémique doit donc être contrôlée avec attention et l’expérience clinique suggère de bien mesurer les couts-bénéfices de l’usage d’un tel traitement.

La littérature indique de la cicatrisation en milieu humide contrôlé est la pierre angulaire des traitements de plaies de PG puisqu’elle permet de réduire les douleurs liées à la plaie, facilite le débridement autolytique et promeut l’angiogenèse8. De nombreux pansements comme les hydrocellulaires, les hydrofibres et les alginates sont utilisés dans les soins de plaies de PG. Ils sont décrits pour réduire l’œdème, aplanir les berges et diminuer la douleur1,29. Dans la première situation, l’hydrofibre a été essayé mais la patiente ne l’a pas toléré car cela lui causait d’importantes douleurs. C’était peut-être liée à l’effet hydrophile du pansement. De plus, à cause du faible exsudat de la plaie, le pansement adhérait au lit de la plaie ce qui provoquait des douleurs à son retrait. Le déclenchement de la maladie en a pu être aussi favorisé30. Les hydrogels sont des pansements à base d’eau, de polymères et autres composants. Ils ont pour but d’hydrater la plaie, préserver l’humidité des terminaisons nerveuses et donc de réduire la douleur, ainsi que de maintenir un milieu humide contrôlé pour favoriser la migration celluliare31. En relation avec le fait que les plaies de nos deux patients atteint de PG n’étaient pas infectées, l’utilisation d’hydrogel protégé par un tulle a permis de faciliter le débridement autolytique et de réduire les douleurs. D’un autre côté, comme les causes sous-jacentes au PG étant non infectieuses, la plupart des patients sont traités par corticostéroïdes. De ce fait, la prévention des infections bactériennes sera de mise. Les plaies étaient évaluées régulièrement quant aux signes cliniques de l’infection, tels que l’érythème, la chaleur, l’augmentation des douleurs, des exsudats et des odeurs30. Dans le premier cas, la flore cutanée périlésionnelle a été investiguée un peu plus tard, et il s’est avéré qu’aucun pansement topique antimicrobien n’était nécessaire.

Au regard des potentiels développements de la maladie et de la progression rapide de celles-ci, aucune intervention chirurgicale, de débridement conservatif aux instruments n’a été réalisé sur l’un ou l’autre de ces cas. L’évidence a montré que l’efficacité des traitements systémiques de la maladie se manifeste par l’amélioration des lésions cutanées1,2,26. Ainsi, mis à part les soins des plaies locaux, le traitement par corticostéroïdes et cyclosporine au niveau systémique sont recommandés comme étant le traitement de première ligne à prescrire pour ces patients atteints de PG32.

Gestion de la douleurMis à part des situations de soins de patients en état végétatif, les personnes atteintes de PG souffrent presque toutes de douleurs très invalidantes26. La cause de ces douleurs peut être multifactorielle, mais dans la plupart des cas elle est reliée

au processus inflammatoire et aux ulcérations importantes qui en découlent33. La réfection fréquente des pansements, tel que le nettoyage de la plaie et/ou le retrait douloureux des pansements, est pour le patients une source de détresse psychologique33. Le traitement de la douleur du patient est donc capital pour l’efficacité de la prise en soins. Dans nos deux situations, les patients ont reçu des antalgiques. Du Tramadol 50 mg per os aux six heures, avec au besoin une dose supplémentaire administrée lors de la réfection du pansement, était donné afin de réduire efficacement les douleurs. En général, si la maladie et le statut inflammatoire du patient sont bien maitrisés par des traitements systémiques et des soins de plaies appropriés, les douleurs associées devraient diminuer graduellement.

CONCLUSIONLa pathogénicité du PG reste incertaine même si les données probantes actuelles suggèrent qu’il s’agirait d’une maladie auto-immune présentant des déficits dans la régulation immunologique de la réponse inflammatoire. Le PG est aussi associé à de nombreuses conditions systémiques tels que des maladies inflammatoires de l’intestin, des troubles hématologiques et de l’artérite auto-immune.

Cette pathologie est exacerbée lorsque le patient atteint de PG subit de petits traumatismes. De plus, les produits de chimiothérapie peuvent être des agents déclencheurs à prendre en considération, en particulier chez des patients recevant déjà d’autres traitements médicamenteux. Nos deux cas cliniques démontrent de sérieux effets secondaires à l’azaticidine. La détection précoce de ces complications est importante afin d’éviter tout retard de prise en soins de la pathologie sous-jacente, tout comme pour débuter au plus vite les traitements adaptés du PG.

CONFLIT D’INTÉRÊTLes auteurs déclarent n’avoir aucun conflit d’intérêt

FINANCEMENTLes auteurs déclarent n’avoir eu recourt à aucun financement pour réaliser leur étude de cas.

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ABSTRACTIndustrial infrared thermometry devices are large and, despite being less expensive than the current gold standard Exergen Dermatemp medical infrared thermometer, are still not affordable enough to ensure unrestricted and consistent use of this assessment modality in regular wound-related day-to-day practice. An increased skin surface temperature differentiation of 3°F associated with a wound has a positive predictive ability to detect deep or surrounding wound infection. This study hypothesised that inexpensive, pen- or pocket-sized, no-touch surface infrared thermometry devices will be equal in ability to detect a 3oF increased skin temperature compared to the Exergen Dermatemp infrared device and be reliable in the hands of any wound assessor. The odds of the control and other thermometers to detect a 3oF temperature difference, irrespective of the raters, were achieved in all five of the mini thermometers tested, with a correct temperature difference prediction that occurred in 90.933% of the times (odds determined 9/10). As a result of this study mini, no-touch infrared thermometry, to detect a 3oF temperature difference in wound assessment to determine tendency, could be implemented into primary health care clinics, rural clinics, day-to-day hospital practice and standard outpatients departments at a small financial cost, regardless of which thermometer is put to use.

For referencing Smart H et al. Validation and inter-rater reliability of inexpensive, mini, no-touch infrared surface thermometry devices as an assessment tool for prediction of wound-related deep and surrounding infection. WCET® Journal 2019; 39(1):18-22

DOI https://doi.org/10.33235/wcet.39.1.18-22

INTRODUCTIONThe use of no-touch infrared surface thermometry is validated in the assessment of wounds to determine the status of bacterial burden and a subsequent provoked host response, by determining an increased 3 degree Fahrenheit (3°F) surface difference when measured against an opposing limb or body area, as determined by Fierheller1. Medical-grade infrared surface thermometry devices are large and expensive, putting routine use of this assessment modality into advanced wound care units only and out of reach for clinicians in everyday practice. A recent study by Mufti, Coutts and Sibbald2 has validated the use of industrial hand-held surface infra-red thermometers against the current gold standard Exergen Dermatemp device. Industrial devices are large and, despite being less expensive than this medical infrared thermometer, are still not affordable enough to ensure unrestricted and consistent use of this assessment modality in regular wound-related day-to-day practice. In validating inexpensive, pen- or pocket-sized, no-touch infrared devices, this modality can be made accessible to any clinician (interprofessional) dealing

Validation and inter-rater reliability of inexpensive, mini, no-touch infrared surface thermometry devices as an assessment tool for prediction of wound-related deep and surrounding infection

Hiske Smart*RN, MA(Nur), PG Dip WHTR (UK), IIWCC(Can) Clinical Nurse Specialist, Wound Care and Hyperbaric Oxygen Therapy Unit, King Hamad University Hospital, Kingdom of BahrainEmail hiske.smart@khuh.org.bh

Eman Al JahmiRN, MSc(Nur), IIWCC (South Africa) Wound Care Practitioner, Wound Care and Hyperbaric Oxygen Therapy Unit, King Hamad University Hospital, Kingdom of Bahrain

Ebrahim BuhijiMD, MB (Egypt), MSc Wound Management (UK), IIWCC(UAE) Wound Care and Hyperbaric Oxygen Therapy Unit, King Hamad University Hospital, Kingdom of Bahrain

Sally-Anne SmartBSc Hons (Actuarial Science), BSc (Actuarial & Financial Mathematics), TASSA, University of Pretoria, South Africa (MSc Candidate Actuarial Science)

* Corresponding author

Original article

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with wounds on a regular basis, without compromising on infection control measures.

BACKGROUNDThe challenge to clinicians in a subgroup of patients with an impaired inflammatory response is that clinical markers of localised infection (redness, swelling, exudate, lack of movement, pain, heat), present only when the infection is already overwhelming the patient’s host response3,4. In the validation study to determine superficial and deep tissue infection markers for the chronic wound5, the highest significance to detect deep tissue infection, was achieved by identifying an increased skin surface temperature differentiation of 3°F. This marker achieved an eight times more likely predictive ability to detect deep tissue infection than any other marker in the STONEES© criteria set (size increased, temperature difference, Os probing to bone, new breakdown and necrotic tissue, erythema flare, exudate or smell)5.

The temperature differentiation is done by obtaining the highest skin surface temperature reading, 1cm away from the skin in a perpendicular position, measured on the wound edge. That reading is then compared to a reading taken in the same manner on a similar area of an opposing limb or skin area1. This method establishes a temperature difference tendency. The increased surface temperature obtained, with two additional other criteria added from the STONEES© set is validated to be predictive of deep or surrounding wound infection5 opposed to critical colonisation6.

In validating the least costly and most readily available skin surface thermometry devices against the Exergen Dermatemp in a similar design to Mufti et al.2, the quick assessment ability of wound-related deep tissue infection can be made available to all clinicians, regardless of resource restrictions that may apply to certain clinical environments.

It is important to note that infrared skin surface measurement is different from physiological infrared measurement used to detect fever, which in adults7 is less reliable than in the paediatric population8. Infrared surface thermometry is done without a physiological conversion factor built into the modality; it is utilised in engineering, electromechanical environments and the building industry and has been well-researched since the early 1960s. Currently industrial research is focussed on nuclear reactor safety9, operational machine surface temperatures and critical deviations as part of safety measures.

The clinical grade Exergen Dermatemp infrared surface thermometer is sold at a price that ranges from US$700 to US$900 (BD 265–340) per piece. The industrial thermometers tested by Mufti et al.2 ranged from US$80to US$100 (BD 30–37) per piece. The devices used in this study cost no more than US$20 (BD 7.5), with three devices priced at US$10 or less (BD 3.6). Due to the cost of one Exergen Dermatemp, clinicians have overlooked their ability to ensure fast and efficient wound assessment for identification of wound surface bacterial burden reaction. By having access to a more affordable

modality, timely intervention can be quicker to prevent wound deterioration due to a deep wound infection being identified too late.

METHOD, DESIGN AND SAMPLINGHypothesisInexpensive, mini (pen- or pocket-sized), no-touch surface infrared thermometry devices are equal in ability to detect a 3°F increased skin temperature compared to the gold standard Exergen Dermatemp infrared device.

Objectives of the study• To compare five inexpensive no-touch surface infrared

thermometers (Mastercraft 0574568-4, Infrared 68199, Infrared EM512, Infrared DT8220 and Infrared H10140 with a distance to spot ratio of 1:1 or more) against the Exergen Dermatemp clinical infrared surface thermometer (distance to spot ratio 1:1).

• To determine the precision of measurement of the inexpensive, pen- or pocket-sized, no-touch surface infrared thermometry devices compared to the skin temperature obtained by the Exergen Dermatemp device. (This would predict if the inexpensive devices are similar to the Exergen Dermatemp in measurement).

• To determine the accuracy of inexpensive, pen- or pocket-sized, no-touch surface infrared thermometry devices in detecting a 3°F increased skin temperature compared to the Exergen Dermatemp device. (This would predict if the difference detected by the Exergen Dermatemp can be detected by the inexpensive devices as well).

• To determine the inter-rater reliability of professionals using this modality by measuring consistency of temperature difference obtained by three investigators. (This would predict the chance/odds of any clinician to obtain a correct assessment compared to the control).

The study took place in the hyperbaric and wound care unit of King Hamad University Hospital, in the Kingdom of Bahrain, where the use of no-touch infrared skin surface thermometry is a standard assessment modality with every dressing change procedure. This was a prospective cross-sectional study that included all consecutive consenting patients with either a new wound or an existing wound treated as part of the patient load of this unit for a period of one month. Three clinicians were doing six measurements (one control and five test devices) per patient at the same time. They followed one after the other, after the hot spot and contra-lateral spot was identified by rater 1, who is the clinical specialist of the unit. The two other raters were a doctor and a registered nurse, both working in the wound care unit.

Study sample inclusion and exclusion criteriaInclusion: All patients with a wound who attend for a regular dressing change at the unit were eligible for a once-only inclusion into this study.

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Exclusion: Patients who were unable due to their condition or unwilling due to time constraints to give signed informed consent for five added measurements being done apart from the standard Exergen Dermatemp infrared reading that is mandatory for every visit. Patients who were already assessed with the five devices compared to the Exergen Dermatemp and already included in the study.

Design and sample sizeThe sample size reached 100 patients with 300 thermometer readings obtained for each device and 1800 thermometer measurements done in total.

DATA COLLECTION METHODS, INSTRUMENTS USED AND MEASUREMENTSPatients who have given signed and informed consent had all previous dressing materials removed and all exudate wiped clean from the wound bed with all standard wound care procedural preparations in place as per standard dressing change protocol.

Data collection procedure• The Dermatemp measurement was done on the wound

edge in Fahrenheit before any cleansing of the wound bed occurs to prevent cooling down of the wound edges due to the cleansing fluid. The highest reading obtained by the first rater at the wound edge on intact skin served as the test reading and was recorded on the data collection sheet. The warmest spot was marked on the skin with a small dot from an operating room pen.

• The reading on the exact mirror image side of the limb or body part was taken as reading two, recorded as reading opposing limb and was marked with a small dot to determine the temperature differentiation.

• All five of the small devices marked 1–5 were set to measure surface temperature in Fahrenheit and were then respectively used in the order 1–5, with the first measurement on dot 1 and second reading on dot 2 for each thermometer. Each temperature reading recorded in the same manner as for the Exergen Dermatemp on the data collection sheet until readings from all six devices were collected for one patient (see Figure 1).

• In order to determine inter-rater reliability and inter-professional variations, this procedure was then to be repeated two times more times to include three testers (two RNs, one MD) who stayed consistent for the duration of the study.

• Added data on the collection sheet was patient gender, age, diagnosis and any important adverse factors affecting healing for later analysis.

RESULTSThe help of a statistician was acquired for data analysis as more than one statistical method was needed to determine the fine variations of both the devices and the inter-rater reliability testing.

Comparison of infrared thermometersWhen the raw temperature measurement variation observed by each thermometer was compared to each other using a paired T-test (test to determine whether mean values are significantly different from one another) the p-values observed showed some deviation (depicted in Table 1).

With each of these five T-tests, the null hypothesis (that the measurement of the control is not significantly different from any other thermometer) is rejected in thermometers 2, 4 and 5 at a 95% significance level. Thus, we can conclude that in absolute precision there was deviation and significant variation in the exact performance of these thermometers.

As the assessment of elevated skin temperature to determine deep and surrounding infection forms part of a bundle (NERDS© and STONEES©)5, the aim of infrared thermometry is

Thermometer comparison on precise raw measurement P value

Control Thermometer 1 Infrared 68199 orange 0.0358 (CI .95%)

Control Thermometer 2 Mastercraft 0574567-4 <0.0001(CI .95%)

Control Thermometer 3 Blue infrared EM512 0.0043(CI .95%)

Control Thermometer 4 Grey pen/orange H10140 <0.0001(CI .95%)

Control Thermometer 5 Red pen DT8220 <0.0001(CI .95%)

Table 1: Thermometers compared to the Exergen Dermatemp as control

#Control #2#3#5#4 #1Figure 1: The thermometers tested in this study

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to determine a greater than 3°F difference to have a positive test result. Therefore, the thermometers tested do not have to reproduce the exact raw temperature value compared to the control, but should definitely be able detect a temperature difference of 3°F to make it a viable measurement modality in a clinical practice setting. That was the next test done on this dataset.

The odds of the control and other thermometers to detect a 3°F temperature difference (either both >=3 or both<3) for each of the respective raters is depicted in Table 2. The finding was that, irrespective of the raters, all five of the mini thermometers were able to make the correct call to detect a 3°F temperature difference in 90.933% of the times, giving it a success odd of 9/10.

Interpretability of thermometersPaired T-tests were performed to determine whether there were statistically significant differences in the averages achieved by the three raters (test to determine whether mean values are significantly different from one another) as depicted in Table 3. The p-values were recorded in the table and had to be more than 0.05 to show consistency and similarity.

In the control measurement and each of the measurements of thermometers 1 and 3, there were no statistically significant differences detected in the mean observed by the three raters. There were statistically significant differences in the measurements from thermometer 2 (rater 1 and 2), thermometer 4 (rater 1 and 3) and thermometer 5 (rater 1 and 2; rater 1 and 3).

The best performing thermometers, in relation to the Exergen Dermatemp, were thermometers 1 and 3 with performance that was consistent irrespective of the user. Variations based on the user were, however, observed for thermometers 2, 4 and 5 shown in p-values lower than 0.05.

DISCUSSIONThe high odds of the mini infrared thermometer devices to detect a 3°F temperature difference and the level of inter-rater reliability achieved to determine that difference in this study opens more clinical options to incorporate this modality into standard wound care practice for comprehensive wound assessment. With minimal teaching given to the raters, apart from reading the brochure of the device, our raters could achieve a clinically correct thermometry assessment compared to the gold standard device 9 out of 10 times.

Of the mini devices tested (Table 4) there were two that were more consistent between users and compared very favourably to the control thermometer value, both on raw temperature measurement precision and 3°F prediction ability. Thermometer 1 had a distance to spot range of 8:1 (best as well for infection control maintenance) that could have added in the precision of measurement and a very comfortable hand grip that had added to stability. Thermometer 3, despite having a distance to spot ratio of 1:1, had performed consistently as well. Despite being small and compact, it fitted the hand of the clinician snugly that added to device stability when aiming to obtain the measurement.

Rater 1 Rater 2 Rater 3 Average

Control vs T1 0.91 0.9 0.89 0.9

Control vs T2 0.93 0.89 0.87 0.896667

Control vs T3 0.92 0.93 0.92 0.923333

Control vs T4 0.95 0.92 0.89 0.92

Control vs T5 0.92 0.9 0.9 0.906667

Average 0.926 0.908 0.894 0.90933

Table 2: The ability to correctly predict a 3°F difference

Rater 1 vs Rater 2 Rater 1 vs Rater 3 Rater 2 vs Rater 3

Control Exergen Dermatemp 0.4821 0.1137 0.2632

Thermometer 1 Infrared 68199 orange 0.6759 0.4683 0.6098

Thermometer 2 Mastercraft 0574567-4 0.0119* 0.0614 0.7037

Thermometer 3 Blue infrared EM512 0.218 0.0648 0.2689

Thermometer 4 Grey pen/orange H10140 0.2459 0.0205* 0.1597

Thermometer 5 Red pen DT8220 0.0011* 0.0357* 0.341

Table 3: Paired T-test p-values to determine differences between raters with each thermometer. (* Values lower than 0.05 showing statistically significant differences)

22 WCET® Journal Volume 39 Number 1 March 2019

  Manufacturer Convenience factors (size and form factor)

Price range Distance to spot ratio

Control Exergen Dermatemp Gold standard US$700 1:01

Thermometer 1 Infrared 68199 orange Hand size pocket US$17 8:01

Thermometer 2 Mastercraft 0574567-4 Hand size pocket US$20 1:01

Thermometer 3 Blue infrared EM512 Hand size pocket US$7 1:01

Thermometer 4 Grey pen/orange H10140 Pen size US$10 1:01

Thermometer 5 Red pen DT8220 Pen size US$10 1:01

Table 4: The distinguishing factors of each thermometer

Both of these devices also had legible numerical displays for easy reading of a value from a distance.

The pen-type thermometers all had a distance to spot ratio of 1:1, had the largest deviations between raters and highest error factor on precision. These devices have very small display screens that made it difficult to read accurately from a distance. Most of the mini devices used button batteries that added to cost over the longer term as the life time of the batteries was limited and depleted by the end of the study.

When it came down to accuracy in the ability to detect a 3°F temperature difference, all of the thermometers as well as all of the raters could achieve that 90.9% of the time (odds 9/10). These cost-conscious, mini infrared devices could be used to start to bridge a gap in practice and empower the clinician in resource-restrained environments to also be able to utilise non-invasive surface thermometry in assessment for the presence of deep and surrounding wound infection. This would substitute the subjective assessment of clinicians who are using the back of their hand as a touch indicator on patient skin to detect temperature differences10, by providing a quantifiable and comparable alternative.

CONCLUSIONMini, no-touch infrared thermometers could be used to detect a 3°F temperature difference to add in comprehensive wound assessment, regardless of which device is chosen. There is a high reliability that the clinician will detect that difference with 90.9% accuracy each time, regardless of which mini infrared device is used.

CONFLICT OF INTERESTThe authors declare no conflicts of interest.

FUNDINGThe authors received no funding for this study.

REFERENCES1. Fierheller M. A clinical investigation into the relationship between

increased peri-wound skin temperature and local wound infection in patients with chronic leg ulcers. Adv Skin Wound care 2010 Aug; 23(8):369–79.

2. Mufti A, Coutts P & Sibbald RG. Validation of commercially available infrared thermometers for measuring skin surface temperature associated with deep and surrounding wound infection. Adv Skin Wound Care 2015 Jan; 28(1):11–16.

3. Sibbald RG, Goodman L, Woo KY et al. Special considerations in wound bed preparation 2011: an update©. Adv Skin Wound Care 2011 Sep; 24(9):415–36.

4. Gardner SE, Frantz RA & Doebbeling BN. The validity of the clinical signs and symptoms used to identify localized chronic wound infection. Wound Repair Regen 2001; 9:178–86.

5. Woo K & Sibbald RG. A cross-sectional validation study of using NERDS and STONEES to assess bacterial burden. Ostomy Wound Manage 2009; 55(8):40–8.

6. Hurlow J & Bowler PG. Clinical experience with wound biofilm and management: a case series. Ostomy Wound Manage 2009; 55(4):38–49.

7. Vernon GI. Non-contact infrared thermometers. Br J Gen Pract 2014 Dec; 64(629):615.

8. Teran C, Torrez-Llanos J, Teran-Miranda T, Balderrama C, Shah N & Villarroel P. Clinical accuracy of a non-contact infrared skin thermometer in pediatric practice. Child Care Health Dev 2012; 38:471–6.

9. Habera J, Kashida MN, Borhanib N et al. Infrared imaging of temperature profiles in microreactors for fast and exothermic reactions. Chem Eng J 2013; 214:97–105.

10. Murff RT, Armstrong DG, Lanctot D, Lavery LA & Athanasiou KA. How effective is manual palpation in detecting subtle temperature differences? Clin Podiatr Med Surg 1998; 15:151–4.

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The importance of a holistic approach to stoma care: A case review

ABSTRACTThis case review discusses the importance of providing a holistic approach to the care of a patient with two stomas and an enterocutaneous fistula. In this case, the stomas and fistula significantly affected the patient; not just physically but emotionally and socially. The different challenges that arose in pouching a high-output ileostomy, enterocutaneous fistula and ileal conduit with Foley catheter in situ are explored. It also delves into the various options for discharging a patient with complex ostomy complications requiring different needs and resources. Finally, it aims to highlight the therapeutic comprehensive care the stomal therapy nurse provided to the patient and their family.

Case study

INTRODUCTIONIn 2014, bladder cancer was the eleventh most diagnosed cancer in Australia1. There were 2094 males and 654 females with new cases of bladder cancer diagnosed1. Meanwhile, in the same year colorectal cancer was the third most commonly diagnosed cancer and there were 6886 females and 8368 males with new cases of colorectal cancer2. In the general population, it is still unknown whether there is an association between urologic cancer and colorectal cancer3. It is rare for patients to have synchronous carcinoma of the bladder and colorectum4. Urologic cancer patients with other primary malignancies may be on the rise due to increased exposure to numerous environmental causative agents, increased worldwide incidence of obesity and an ageing population4. This paper explores the case of a 63-year-old man diagnosed with bladder and bowel cancer and the complications he developed post-surgery.

Keywords Holistic approach, complex care needs, ileostomy, ileal conduit, enterocutaneous fistula.

For referencing Perez MC. The importance of a holistic approach to stoma care: A case review. WCET® Journal 2019; 39(1):23-32

DOI https://doi.org/10.33235/wcet.39.1.23-32

Pre-operative counselling and stoma site marking are recommended to prepare patients for life with a stoma, to choose an optimal location, and to reduce potential surgical complications post-operatively and other future problems5. In the event of an emergency procedure, the patient’s stoma site is often not able to be marked and education about living with a stoma is not provided. Marking a patient for a stoma in an emergency may not always be possible and subsequently a stoma that is poorly positioned is likely to reduce the quality of life of the patient6. Factors that may influence where the surgeon might position the stoma during emergency surgery are: sepsis; oedema; inflammation of the bowel; nature of any underlying disease; an unstable and deteriorating patient; and time constraints. In addition, with patients in a supine position it is difficult to determine skin folds, assess body mass index and creation of the stoma is often delegated to a junior member of the surgical team. Common long-term complications associated with emergency ostomy surgery are skin problems, stenosis, prolapse, parastomal hernias, side fistulae and increased length of hospital stay7,8.

In addition to any stomas and their location, other sequelae of emergency ostomy surgery that may contribute to the patient’s ability to self-care and be discharged in a timely manner relate to a lack of pre-operative counselling, ability to see the stoma, management of the stoma and appliance and psychosocial issues7,9.

Melanie C PerezBSN, RN, STN, Grad Cert (Stomal Therapy), Grad Dip (Acute Care), MN (Acute Care)St George Public Hospital, Kogarah, NSW, AustraliaEmail Melanie.Perez@health.nsw.gov.au

24 WCET® Journal Volume 39 Number 1 March 2019

CASE REVIEWPatient overview and presenting complaintMr TA is a 63-year-old gentleman who presented to the facility with rectal bleeding and haematuria, on a prior background of both colorectal and bladder cancer. His medical history includes hypertension and diabetes mellitus type 2 . He underwent an emergency anterior resection requiring formation of end colostomy and cystectomy with formation of an ileal conduit.

Post-operative complications

Intra-abdominal sepsisPost-operatively, Mr TA developed intra-abdominal sepsis, requiring three exploratory laparotomies for abdominal washouts. He subsequently developed ischaemia of his small and large bowel. The surgeon estimated less than 2 metres of small bowel remained and consequently an ileostomy was formed on the right side of the abdomen. The surgeon was not able to accurately measure the length of the small bowel due to the patient’s condition at the time of the operation.

Ileostomy locationThe ileostomy was fashioned approximately 2 centimetres in distance from the ileal conduit at 12 o’clock position. The location of the ileostomy had a huge impact on the care of the stomas, pouching processes, and patient’s ability to self-care of his stomas.

Fistulae developmentMr TA developed a fistula from his ileal conduit that began leaking urine into his abdomen. To divert urine from the ileal conduit, bilateral nephrostomies were created. Unfortunately, an enterocutaneous fistula also erupted from his midline wound dehiscence that proceeded to discharge 3 to 6 litres of faecal output per day. Initially, the impression was the enterocutaneous faecal fistula would heal with time, but this did not occur. After approximately seven months, an attempt to endoscopically close the site of the fistula leakage was unsuccessful.

Cancer recurrenceA biopsy taken during the endoscopic procedure showed recurrent colonic disease. It was at this stage that a collective decision was made not to pursue any further surgical

intervention. Due to the multiple laparotomies and ensuing complications, this patient’s journey has been full of challenges, both for the patient and the health care providers.

ChallengesThe major challenges faced by Mr TA and staff were the proximity of the stomas, high faecal and fistula outputs, stomal complications and protection of the peristomal and peri-wound skin.

Ileostomy: In Mr TA’s case his ileostomy created dual challenges, which were a combination of the ileostomy spout being flush to the skin as well as the high output from the ileostomy.

Ileal conduit: Additionally, his ileal conduit was retracted, necessitating insertion of a Foley catheter to prevent stenosis.

Fistula: Mr TA’s mid-abdominal enterocutaneous fistula, which had three openings, was draining 3–6 litres of faecal fluid daily.

Stoma locations: All the stomas were near each other (Figure 1).

INTERVENTIONS: STOMA AND FISTULA MANAGEMENT STRATEGIES

Peristomal skin careThe peristomal skin was cleansed with warm water from the tap, dried with chux (a soft woven cloth) and CavilonTM No Sting Skin Barrier wipes were applied to the skin for protection. In some instances, Stomahesive® Protective Powder was used if the skin was eroded to provide further protection and encourage healing.

Pouching strategiesMeasurements were obtained of the diameters of the stomas and enterocutaneous fistula to find the pouches that would best suit individual management of each of the stomas and fistula, which were in very close proximity to one another. A decision was made to pouch the ileal conduit, ileostomy and fistula separately to accurately measure the output of each stoma and the fistula and to enable a better seal to prevent peristomal skin complications. It was found that the base plates of all the pouches needed to be trimmed to keep them separate and facilitate adherence to the skin (Figure 2).

The ileostomy was managed with a convex, high-output pouch that was connected to a long drainage bag to keep the bag empty. This was due to the significant amount of faecal output that was watery in consistency and classified as type 7 in accordance with the Bristol stool chart10. Attempts to regulate the faecal output with medications such as Loperamide, Lomotil, Codeine Phosphate and Octreotide subcutaneous injection all failed.

A 2-piece soft convex system was used to manage the ileal conduit in order to easily thread the Foley catheter through the base plate. And, further, the length of the high-output pouch accommodated the length of the Foley catheter when in situ.

The base of the wound pouch used to contain the fistula output was cut off-centre to keep the pouch separated from the other pouch as much as possible.

Figure 1 Ileostomy, urostomy, mid-abdominal fistula

Figure 2 Base plate of ileostomy pouch trimmed to avoid overlapping with ileal conduit

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OTHER CHALLENGES

PainOne of the issues that coincided with changing all Mr TA’s pouches was pain. It was evident from Mr TA’s facial grimaces that changing his pouches caused him considerable pain. Mr TA, however, declined any analgesia most of the time, despite receiving frequent education on the importance and use of pain relief. Even though his facial grimaces indicated he was in pain, he always stated that after the procedure, the pain resolved; therefore, he thought there was no benefit in taking pain relief.

Due to the patient experiencing pain on pouch changes, minimising the frequency of routine pouch changes was an essential strategy for this patient. The pain experienced was mostly due to the pouch adhesives, the pressure applied to his abdomen to remove the pouches, when cleaning the skin and re-applying the pouches. The revised care plan to change the pouches twice a week only or when they leaked was well tolerated by the patient. The pouches were checked daily for intactness so that potential leaks were avoided. Additionally, the staff and the patient were encouraged to keep the pouches empty to reduce the weight, tension and drag on the adhesion between the pouches and his skin.

Body image and maintaining dignityThe normal anatomy and physiology of the gastrointestinal or urinary systems are changed following creation of an ostomy11. An abdominal opening is created, allowing for the bowel, bladder or ureters to be exteriorised where the intestinal fluid or urine are diverted, the outflow of which is collected by external pouches. This results in marked changes for the individual in relation to physical appearance and day-to-day functioning of a person11. In the case of Mr TA, the impact of these changes on his body image were exacerbated thrice by the presence of three different pouches covering most of his abdomen (Figure 3).

Additionally, the output from his enterocutaneous fistula was explosive, erupting like a fountain at two points and a blowhole on another. This both embarrassed and frustrated Mr TA, who was most apologetic whenever the fistula discharged in this manner while the pouches were being changed. No matter how many times he was reassured that this was not his fault

and timing of the fistula discharging was beyond his control, he still felt helpless.

In this situation, it was important to make the mood lighter through light conversation to attempt to divert his attention from focussing on the presence and management of the fistula, which was found to be a useful strategy. This was a crucial factor in assisting Mr TA to maintain his dignity amidst the management of multiple stomas and the fistula.

Odour controlThe characteristic odour in faeces has obvious implications for patients with a stoma, which causes considerable concern when either wearing or emptying the pouch12. The odour emanating from Mr TA’s pouches was difficult to minimise, despite using some drops of eucalyptus oil in the bag. This was attributed to the frequency of emptying the pouches due to the volume, thereby removing the efficacy of the eucalyptus oil that was dropped in the pouches. This led to feelings of shame for the patient and his family that was manifested by the amount of air freshener they used within the room. Changing the pouched two times a week was found to minimise the odour, so pouch changes were routinely set every Monday and Friday. The faecal pouches used by Mr TA had a charcoal filter to minimise the odour. In addition, long drainage bags were attached to all pouches to reduce the impact of odour (Figures 4 and 5).

Discharge planning and no discharge destinationAnother issue that arose was discharge planning. It became apparent that due to the complexity of Mr TA’s care, such as the pouching changes, amount of ostomy and fistula output plus his requirements for intravenous fluids and palliative care needs, the options for a discharge destination were very limited. Returning home for Mr TA was not an option. There were not enough resources and services to cater to the patient’s needs in the community. It was found that around the area where Mr TA resides, most of the nursing homes did not have the resources to provide his daily intravenous fluid needs, and the community nurses could not undertake the changing of his pouches for an extended period.

An option to teach Mr TA and his wife to change his pouches was attempted. Three weeks were devoted to teaching Mr TA and his wife the pouching regime, but it was proven to

Figure 3 Patient’s abdomen with pouches in place

Figure 4 Flow collector used to keep the pouches empty

Figure 5 Abdomen showing location of fistula, ileal conduit and ileostomy

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be too difficult for his wife due to the technicalities of the pouching procedures and the unpredictability of when the stomas or fistula could potentially discharge. In addition, they needed suction equipment to assist with pouch changes. Further, if multiple instances of leakage occurred, they may have insufficient products to use in the home.

Nursing home options were explored three times, but after showing the nurse unit managers and more experienced staff the steps to change the pouches, they all concluded they would not be able to manage the pouching regimes within their facilities. Further, they did not have the resources and manpower to be able to handle the task. Mr TA would also need intravenous fluids to be able to replace ileostomy and fistula outputs. All efforts to support the nursing staff and nursing homes were provided through a step-by-step guide with photos on how to change the pouches. A PowerPoint presentation was also completed. The prospective facilities approached were reassured that ongoing stomal therapy support would be provided if the patient was accepted, but these strategies were to no avail.

The inability to find nursing home placement led to feelings of rejection from the patient and his family; therefore emotional support was provided by the stomal therapy nurse and social worker.

DiscussionApproximately one-fifth of all stomas are sited during emergency procedures8. The incidence of complications associated with ileal conduit is reported to range from 15% to 65% and one of the most commonly reported complications are stoma or abdominal wall-related changes that includes stoma stenosis and retraction13.

Management of any resultant post-operative complications, therefore, requires a holistic and inter-professional approach to patient care9. Ideally, ileostomy and ileal conduit stomas should protrude several centimetres from the abdominal wall. The rationale for an extended spout is due to the amount, consistency and constituents of the faecal and urinary outputs. Added to that are the challenges presented to contain and protect the skin with higher stomal outputs in the presence of flush or retracted stomas14.

The management interventions revolved around three goals: to maintain skin integrity, minimise unnecessary pain and contain the effluent. Ensuring there was a pouching plan that facilitated good adhesion of the pouches to the skin to maintain patency of the seals was one of the main goals in view of the complexity of Mr TA’s case. This would help to maintain his peristomal/fistula skin integrity. Ostomy effluent that is in contact with the skin is often the result of a less than optimal pouch fit15.

Promoting positive outcomes for patients with a stoma starts with an intact skin. This is the cornerstone of any stoma care and this was established. It is acknowledged that this was made possible by being able to access the necessary products to use, making the challenges physically achievable.

The hydrocolloid baseplates used to manage Mr TA’s stomas kept his skin integrity intact, which also assisted in preserving his dignity and body image. The pouching systems chosen were the two-piece, convex, high-output Dansac Gx plus pouches, the seals of which were maintained. The soft convexity of the base-plate mildly pushed the flush to skin ileostomy outward, preventing leaks, plus it provided a snug fit around the retracted ileal conduit. Using hydrocolloid baseplates with convexity to enhance security of pouch adhesion to protect the peristomal skin is considered best practice15.

Using the Gx plus provided a longer wear time, allowing the pouches to be changed only twice a week. Not only was this more efficient time-wise, it was more economical product wise and more importantly this prevented unnecessary pain for the patient. As the incidence and threat of stomal pouch leakage decreased, this reduced Mr TA’s anxiety and stress levels16.

The high ileostomy output was investigated, and the results were negative for any signs of infection. The quantity and content of the output, therefore, have been attributed by the treating surgical team to the small residual length and irritable nature of the bowel tissue, and his underlying malignancies. No diagnostic interventions were undertaken to identify any potential causes of intestinal insufficiency or intestinal failure. The pouching plan for the patient was effective for the whole year Mr TA was admitted and managed in our health service. The faecal ostomy/fistula output always fluctuated, despite all the medications and other interventions attempted to resolve the high output.

Apart from the physical challenges posed by management of the stomas and enterocutaneous fistula, there was Mr TA’s patient’s wellbeing to consider. Throughout all phases of his illness (pre-operatively, post-operatively and terminal care) he needed to know and feel he was supported mentally as well as physically. A higher level of psychological distress is recognised in stoma patients as they perceive a sense of loss of physical and emotional independence16.

Mr TA often refused any pain relief for the pain he experienced during pouch changes. The differences in perceptions of pain between genders, different cultural groups and those from diverse ethnic backgrounds and how they react to or tolerate pain are acknowledged, whereby some may appear to overreact and others to display relative tolerance or stoicsm17. Potentially, as Mr TA was from an ethnic background, a pastor, and being highly religious impacted his views on and use of analgesia17. Through education, counselling and care of the stomal therapy nurses the Mr TA’s anxiety was lessened16. Truly, there is an ongoing need for the patient to feel supported mentally and emotionally.

Most patients look to the health care provider for guidance on how to proceed and cope with their medical condition. A significant motivating and coping factor for patients is hope18, and this is what Mr TA held on to. To effectively cope and make decisions, hope is a critical aspect, which correlates with quality

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of life and living with a stoma7. Health care providers play a significant role in patients’ ability to cope and understand everything that is happening to them; hence, the importance of providing holistic care to patients and their family.

Additionally, the therapeutic relationship between the stomal therapy nurse and Mr TA was strengthened by the challenges that were overcome and the length of time he was cared for by the stomal therapy nurse. This provided Mr TA with some relief with regard to continuity of care and that no matter how difficult the pouching could be, the stomal therapy nurse would find a way to overcome these difficulties.

Creating a therapeutic relationship with Mr TA that was based on trust, mutual respect and a feeling of ease helped tremendously with managing this complex case. Establishing rapport early in the relationship assisted with his clinical and therapeutic management in the long term.

Promoting positive outcomes for patients with a stoma starts with an intact skin. This is the cornerstone of any stoma care and this was established. It is acknowledged that this was made possible by being able to access the necessary products to use, making the challenges physically achievable. The pouching plan for the patient has been effective for the whole year that the patient was admitted. The output has always fluctuated, despite all the medications and other interventions attempted for the care of this patient.

Mr TA was not able to be discharged home, nor was he placed in a nursing home; however, with the implementation of evidence-based ostomy and palliative care measures, towards the end of his life he remained comfortable.

CONCLUSIONThe best outcomes gained from this case were the learning experiences that came from resolving the challenges faced. This has reinforced the value of developing early therapeutic relationships between the patient, his family, stomal therapy nurse and the medical team. This case has clearly shown that being able to access different products makes the stomal therapy nurses’ task manageable. And, more importantly, the need for continuous improvement and growth of the stomal therapy services as more complicated and complex cases arise.

CONFLICT OF INTERESTThe author declares no conflicts of interest.

FUNDINGThe author received no funding for this study.

REFERENCES1. Australian Government Cancer Australia. Bladder Cancer [Internet].

Australia: Bladder Cancer Statistics; 2018 [cited 2018 Sept 4]. Available from: https://bladder-cancer.canceraustralia.gov.au/statistics

2. Australian Government Cancer Australia. Bowel Cancer [Internet]. Australia: Bowel Cancer Statistics; 2018 [cited 2018 Sept 4]. Available from: https://bowel-cancer.canceraustralia.gov.au/statistics

3. Calderwood AH, Huo D & Rubin DT. Association between colorectal cancer and urologic cancers. Arch Intern Med 2008; 168(9):1003–1009. doi:10.1001/archinte.168.9.1003.

4. Liu Z, Chen G, Zhu Y & Li D. Simultaneous radical cystectomy and colorectal cancer resection for synchronous muscle invasive bladder cancer and cT3 colorectal cancer: Our initial experience in five patients. J Res Med Sci 2014; 19(10):1012–5.

5. Cronin E. Stoma siting: why and how to mark the abdomen in preparation for surgery. Gastrointestinal Nursing [Internet] 2014 Apr [cited 2017 Oct 16]; 12(3):12–19. Available from: CINAHL Complete.

6. Slater R. Optimizing patient adjustment to stoma formation: siting and self-management. Gastrointestinal Nursing [Internet] 2010 Dec [cited 2017 Oct 17]; 8(10): 21–25. Available from: CINAHL Complete.

7. Qureshi A, Cunningham J & Hemandas A. Elective vs emergency stoma surgery outcomes. World J Surg Surgical Res 2018; 1:1050.

8. Pengelly S, Reader J, Jones A, Roper K, Douie WJ & Lambert AW. Methods for siting emergency stomas in the absence of a stoma therapist. Ann R Coll Surg Engl 2014; 96:216–218. doi 10.1308/003588414X13814021679717.

9. Wasserman MA & McGee MF. Preoperative Considerations for the Ostomate. Clin Colon Rectal Surg 2017; 30:157–161.

10. Blake MR, Raker JM, Whelan K. Validity and reliability of the Bristol Stool Form Scale in healthy adults and patients with diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol Ther [Internet] 2016 [cited 2019 Feb 3]; (7):693. Available from: https://login.ezproxy.utas.edu.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edsgih&AN=edsgcl.462472621&site=eds-live

11. Jayarajah U & Samarasekera D. Psychological adaptation to alteration of body image among stoma patients: a descriptive study. Indian J Psychol Med [Internet] 2017 Jan [cited 2017 Oct 31]; 39(1):63–68. Available from: Academic Search Ultimate.

12. Williams J. Flatus, odour and the ostomate: coping strategies and interventions. BJN [Internet] 2008 Jan 24 [cited 2017 Oct 31]; 17(2):S10–4. Available from: CINAHL Complete.

13. Szymanski KM, St-Cyr D, Alam T & Kassouf W. External stoma and peristomal complications following radical cystectomy and ileal conduit diversion: a systematic review. OWM 2010; 56(1):28–35.

14. Boyles A & Hunt S. Care and management of a stoma: maintaining peristomal skin health. BJN [Internet] 2016, Sep 22 [cited 2017 Oct 30]; 25(17):S14–S21. Available from: CINAHL Complete.

15. Nichols T & Purnell P. Are there advantages to barrier rings? J WCET 2014; 34(1):7–11 [Internet]. [cited 2019 Jan 28]. Available from: https://login.ezproxy.utas.edu.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edsihc&AN=edsihc.273020111481012&site=eds-live

16. Lee MWK, Wan YP, Lui TYL & Lo SKC. Quality of life, anxiety and depression levels of Chinese stoma patients in Hong Kong. WCET J [Internet] 2016 Jan [cited 2019 Jan 28]; 36(1):28–33. Available from: https://login.ezproxy.utas.edu.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=113971590&site=eds-live

17. Khan M, Raza F & Khan I. Pain: history, culture, and philosophy. Acta Med Hist Adriat [Internet] 2015, Jan [cited 2017 Oct 31]; 13(1):113–130. Available from: Academic Search Ultimate.

18. Chunli L & Ying Q. Factors associated with stoma quality of life among stoma patients. Int J Nurs Sci 2014; 1(2):196–201 [Internet] [cited 2017 Nov 1]; (2):196. Available from: Directory of Open Access Journals.

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INTRODUCTIONEn 2014 le cancer de la vessie a été le 11ème cancer le plus diagnostiqué en Australie1, en terme de nouveaux cas il avait alors touché 2094 hommes et 654 femmes1. La même année, le cancer colorectal a été le troisième cancer le plus diagnostiqué et ce dernier a représenté 6886 nouveaux cas chez les femmes et 8368 nouveaux cas chez les hommes2. Dans la population générale, le lien entre cancer urologique et cancer colorectal (CRC) reste inconnu3. Il est rare que les patients soient atteints à la fois d’un carcinome de vessie et d’un autre au niveau colorectal4. Cela dit, le nombre de patients atteints de cancer urologique et d’une autre atteinte maligne primaire peut être due à l’augmentation de l’exposition à de multiples agents environnementaux, à l’augmentation de l’incidence de l’obésité et à celle du vieillissement de la population qui est observée partout dans le monde4. Cet article explore le cas d’un homme de 63 ans diagnostiqué pour un cancer de la vessie et un cancer digestif qui a développé des complications post-chirurgicales.

L’importance d’une approche holistique dans les soins aux personnes stomisées: Une revue de cas

RÉSUMÉCette étude de cas met en évidence l’importance d’avoir une approche de soins holistique pour un patient porteur de deux stomies et d’une fistule entéro-cutanée. Dans cette situation, les stomies et la fistule l’affectent significativement, non seulement à un niveau physique, mais aussi émotionnellement et socialement. Différents défis y sont mis en lumière, tels que l’appareillage d’une iléostomie à haut débit, celle de la fistule entéro-cutanée ainsi que celle de l’urétérostomie cutanée trans-iléale qui a été appareillée avec une sonde de Foley. Ce cas explore aussi différentes options en vue de la sortie d’un patient ayant des complications stomiales complexes, avec plusieurs besoins et nécessitant de nombreuses ressources. Enfin, le but de ce cas est de mettre en évidence l’ensemble des soins mis sur pied par l’infirmière tant auprès du patient que de sa famille.

Etude de cas

Mots clefs Approche holistique, besoins en soins complexes, iléostomie, conduit iléal (urétérostomie cutanée trans-iléale, Bricker), fistule entéro-cutanée.

Pour le référencement Pérez MC. L’importance d’une approche holistique dans les soins aux personnes stomisées: Une revue de cas. WCET® Journal 2019; 39(1):23-32

DOI https://doi.org/10.33235/wcet.39.1.23-32

Il est recommandé d’effectuer une consultation préopératoire et d’y repérer la future stomie afin de préparer le patient au fait de vivre avec la stomie et de choisir la localisation optimale pour celle-ci. De ce fait les potentielles complications post-chirurgicales ou autres problèmes potentiels en seront réduits5. En cas d’urgence le repérage de la future stomie n’est souvent pas réalisé et l’enseignement préopératoire concernant la vie avec une stomie n’est pas abordée. Repérer une stomie chez un patient en urgence n’est souvent pas facile et cela peut entrainer la confection d’une stomie dans une localisation problématique. Cela pourra entrainer une diminution de la qualité de vie du patient6. En situation d’urgence, les facteurs pouvant influencer le positionnement de la stomie par le chirurgien sont: le sepsis, l’œdème, l’inflammation de système digestif, la nature de la pathologie sous-jacente, la condition instable et détériorée du patient, ainsi que les contraintes horaires. De plus, il est difficile de repérer les structures osseuses, d’évaluer l’indice de masse corporelle chez un patient en position allongée, sans compter le fait que la confection de la stomie est souvent déléguée à un chirurgien junior de l’équipe. Associées à la chirurgie en urgence, les complications stomiales et péristomiales au long terme les plus communes sont les problèmes cutanés, la sténose, le prolapsus, les hernies parastomiales, les fistulisations latérales et l’augmentation de la durée d’hospitalisation7,8.

En dehors de toutes stomies et leurs localisations, d’autres séquelles de la chirurgie d’urgence conduisant à la confection d’une stomie peuvent avoir un impact sur les capacités du patient à effectuer ses auto-soins et à pouvoir rentrer à

Mélanie C. PérezBachelor en Sciences Infirmières, Infirmière Diplômée, Infirmière Stomathérapeute, niveau certificat (Stomathérapie), niveau diplôme (Soins aigus), Master en Soins Infirmiers (Soins aigus)Hôpital public de St. George, Kogarah, Nouvelle Galle du Sud, AustralieEmail Melanie.Perez@health.nsw.gov.au

Traduction par Laurent Chabal

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domicile dans les temps. Ces dommages sont reliés au manque de consultation préopératoire, à l’incapacité de voir la stomie, de pouvoir s’en occuper ainsi que de l’appareiller comme de pouvoir faire face à ses implications psychosociales7,9.

REVUE DE CASAnamnèse du patient et présentation du casMr TA est un patient de 63 ans qui a présenté des rectorragies et une hématurie lorsqu’il est allé aux toilettes. Il avait été déjà diagnostiqué pour un cancer colorectal et un cancer de la vessie. Il a des antécédents d’hypertension artérielle et de diabète de type 2. Il a subi une résection chirurgicale antérieure en urgence qui a nécessité la confection d’une colostomie terminale et d’une urétérostomie cutanée trans-iléale.

Complications postopératoires

Sepsis intra-abdominalEn postopératoire Mr TA a développé un sepsis intra-abdominal qui a nécessité 3 reprises chirurgicales pour exploration par laparotomie et lavages abdominaux. Par la suite, il a développé une ischémie de l’intestin grêle et du colon. Le chirurgien a estimé qu’il restait moins de 2 mètres d’iléon fonctionnel et a confectionné une iléostomie sur le flanc droit de l’abdomen. Cette mesure de la longueur d’intestin grêle n’a pas pu être réalisée correctement à cause du statut du patient lors du temps opératoire.

Localisation de l’iléostomieL’iléostomie a été confectionné à environ 2 centimètres de distance de l’urétérostomie cutanée trans-iléale, celle-ci se trouvant à 12 heures. Cette localisation de l’iléostomie a eu un impact majeur sur les soins des stomies, le protocole d’utilisation des appareillages et les capacités du patient à réaliser ses auto-soins.

Le développement de la fistuleMr TA a développé une fistule depuis le conduit iléal de l’urétérostomie cutanée trans-iléale ce qui a engendré des fuites d’urine au niveau abdominal. Afin de décharger les urines de ce conduit iléal des néphrostomies bilatérales ont dû été réalisées. Malheureusement une fistule entéro-cutanée est apparue sur la déhiscence présente sur la ligne médiane. Celle-ci perdait de 3 à 6 lites de matières fécales par jour.

Initialement, nous pensions que cette fistule entéro-cutanée allait se refermer de façon conservative, mais ce ne fut pas le cas. Environ sept moins plus tard, une tentative de fermeture de la fistule par voie endoscopique a été effectuée sans succès.

Récidive du cancerUne biopsie réalisée lors d’une investigation endoscopique a démontré la récidive du cancer du colon. L’équipe s’est alors accordée pour ne plus intervenir chirurgicalement. A cause des nombreuses laparotomies et des complications qu’elles ont générées, le parcours du patient a été rempli de défis à relever tant pour lui-même que pour l’équipe soignante.

Les défisLes défis principaux que Mr TA et l’équipe soignante ont dû relever ont été la proximité des deux stomies, le haut débit de la fistule entéro-cutanée, les complications stomiales et la protection de la peau tant autour de la stomie qu’autour de la fistule.

Iléostomie: Dans le cas de Mr TA le défi de l’iléostomie était double puisque la stomie était à fleur de peau et qu’elle était à haut débit.

L’urétérostomie cutanée trans-iléale: Cette stomie était rétractée et devrait être en plus appareillée avec une sonde de Foley pour en prévenir la sténose.

La fistule: La fistule entéro-cutanée localisée sur la médiane de l’abdomen de Mr TA a été révisée chirurgicalement 3 fois et ramenait 3 à 6 litres de matières fécales liquides par jour.

La localisation des stomies: Les stomies étaient proches l’une de l’autre (voir photo 1).

INTERVENTIONS: STRATEGIES DANS LA GESTION DES STOMIES ET DE LA FISTULE

Soins de peau péristomialeLa peau péristomiale était nettoyée avec de l’eau tiède du robinet, séchée avec des linguettes douces (utilisées par les femmes). Des linguettes de protecteur cutané CavilonTM étaient ensuite utilisées. De temps à autre, de la poudre protectrice Stomahésive® était appliquée lorsque la peau était érodée afin d’en renforcer la protection et d’en promouvoir la cicatrisation.

Stratégies pour l’appareillageDes mesures étaient réalisées pour s’adapter au diamètre des stomies et de la fistule entéro-cutanée et ainsi permettre un choix de poches individualisé qui permette la meilleure gestion de chacune d’entre elles, sachant que celles-ci étaient très proches l’une de l’autre. Il a été décidé d’appareiller séparément la stomie urinaire, l’iléostomie et la fistule afin de mieux pouvoir quantifier les effluents et les haut débits de chacune d’entre elles ainsi que d’assurer une meilleure étanchéité en vue de prévenir au mieux les complications cutanées péristomiales. Chaque plaque de base devait être découpée de sorte à pouvoir séparer les poches les unes des autres et ainsi faciliter leur adhérence à la peau.

Photo 1 L’iléostomie, l’urostomie et la fistule présente sur la médiane de l’abdomen

Photo 2 La plaque de base de la poche d’iléostomie utilisée pour éviter le chevauchement avec l’appareillage de l’urostomie

30 WCET® Journal Volume 39 Number 1 March 2019

Une poche à haut débit avec un support convexe a dû être utilisée pour appareillager l’iléostomie. Celle-ci était connectée à une poche de nuit afin de permettre la vidange en continue de la poche de drainage. Ce choix a été établi au regard de la quantité très importante de matières fécales recueillies, matières qui ont toujours été classée à 7 selon l’échelle de Bristol10. Des approches médicamenteuses pour diminuer les déperditions iléales ont été tenté, avec par exemple l’usage de Lopéramide, de Lomotil, de Phosphate de codéine et d’Octréotide par injection sous-cutanée mais toutes sans succès.

Un système 2 pièces de convexité modérée a été utilisée pour appareiller l’urostomie, ceci afin de faire passer plus facilement la partie externalisée de la sonde de Foley à travers la plaque de base. De plus la grandeur de la poche à haut débit permettait d’y contenir l’ensemble de cette sonde.

Le principe pour appareiller la fistule était de réaliser une découpe du support de la poche aussi décentrée que possible afin de séparer autant que possible les différents appareillages présents.

AUTRES DÉFIS

La douleurLa douleur a été un des problèmes que Mr TA a dû surmonter lors de tous les changements de poches. Il était évident que lors des changements d’appareillages Mr TA avait un faciès qui exprimait de considérables douleurs. Cependant, la plupart du temps Mr TA refusait de prendre des antalgiques, et ce alors qu’il recevait régulièrement de l’informations sur l’importance et l’usage de ces contre-douleurs. Alors que son expression faciale indiquait qu’il avait mal, il estimait toujours que sa douleur après les soins était soulagée, pensant ainsi qu’il n’avait aucun bénéfice à prendre ses antalgiques.

A cause de la douleur ressentie lors des changements de poches, la réduction de la fréquence de changement de ces appareillages était une stratégie essentiellement à suivre. La douleur ressentie était essentiellement liée à l’adhésion des appareillages en place, la pression que nous devions appliquer sur l’abdomen pour les lui retirer, aux soins de nettoyage de la peau ainsi que lors de l’application des nouveaux appareillages. La révision du plan de soins qui visait à changer les poches seulement deux fois par semaine ou lorsqu’il y avait des fuites a

bien été tolérée par le patient. Les appareillages étaient vérifiés quotidiennement pour être sûr de leur étanchéité et prévenir tout risque de fuites. De plus, l’équipe soignante et le patient étaient encouragés à vider régulièrement les poches afin de réduire leurs poids, les tensions et les tractions d’adhésion exercées entre les poches et la peau.

Image corporelle et maintien de la dignitéL’anatomie et la physiologie normale des systèmes gastro-intestinal ou urinaire sont modifiés suite à la confection d’une stomie11. Une ouverture abdominale est réalisée afin d’externaliser l’intestin, la vessie ou les uretères là où les effluents intestinaux ou urinaires seront dérivés pour être collectés dans des poches externes. Cela va impliquer des changements pour la personne dans sa relation avec son apparence physique et son comportement au jour le jour en tant qu’individu11. Mr TA a dû faire face à trois changements de son image corporelle dont l’impact était exacerbé par la présence de trois différentes poches recouvrant une grande partie de son abdomen (photo 3).

De plus, la fistule avait un haut débit explosif et éruptif comparable à une fontaine en deux endroits et à un geyser en un autre. Mr TA était dans l’embarra, se sentait frustré et s’excusait d’autant plus que la fistule produisait de la sorte lors des changements d’appareillage. Nous avions beau essayé de le rassurer en lui disant que ce n’est pas de sa faute et qu’il n’y pouvait rien, Mr se sentait toujours impuissant.

Dans cette situation, l’importance de détendre l’atmosphère et de tenter de détourner son attention de la concentration nécessaire aux soins à la fistule et à la gestion de celle-ci s’est avéré être une stratégie utile. Ce moyen a été un élément crucial pour aider Mr TA à maintenir sa dignité dans la gestion de ses stomies et sa fistule.

Le contrôle des odeursLa caractéristique des odeurs fécales a des implications évidentes pour le patient stomisé. Elles lui causent des soucis considérables tant lors du port de la poche que lors de sa vidange12. L’odeur émanant des poches de Mr TA étaient difficiles à minimiser malgré l’ajout de quelques gouttes d’huiles essentielles d’eucalyptus dans la poche. L’efficacité de ces gouttes d’huile essentielles ajoutées était sans doute limitée par la fréquence de vidange de la poche dû au volume

Photo 3 L’abdomen du patient montrant les différentes poches en place

Photo 4 La poche de nuit permettait de collecter les effluents et de vider les appareillages en continue

Photo 5 Localisation de la fistule, de l’urostomie et de l’iléostomie sur l’abdomen

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des effluents recueillis. Ces odeurs entrainaient un sentiment de honte chez le patient et de gêne pour sa famille, cela se manifestait par le fait qu’elle renouvelait fréquemment l’air de la chambre. Le fait de changer les poches deux fois par semaine a été un moyen qui a permis de minimiser les odeurs. Ainsi tous les lundis et vendredis nous procédions systématiquement à ces changements.

Les poches digestives utilisées par Mr TA étaient munies d’un filtre à charbon pour limiter les odeurs. De plus toutes les poches étaient connectées à des poches de nuit pour réduire l’impact olfactif.

Prévision en vue de la sortie et nulle part où pouvoir allerLa suite à l’hospitalisation s’est révélée être problématique. A cause de la complexité des soins de Mr TA comme le changement des appareillages, la gestion des stomies et de la fistule à haut débit ainsi que les besoins en compensation intraveineuse comme des soins palliatifs nécessaires, il est apparu évident que les possibles lieux pour sa suite de traitements étaient très limités. Le retour à domicile de Mr TA n’était pas envisageable, il n’y avait pas assez de ressources et de services en soins communautaires qui pouvaient répondre aux besoins en soins de Mr TA. Nous avons découvert que dans la zone d’habitation de Mr TA il n’y avait pas d’infirmière à domicile qui puisse intervenir pour combler les besoins journaliers en apports intraveineux, ni ne pouvait prendre en soins les changements des différents appareillages au long terme.

L’option d’apprendre à Mr TA et à sa femme de changer les appareillages a bien été essayée. Pendant trois semaines nous avons mis notre énergie à cela, mais à cause de la nécessaire technicité des procédures et à l’impossibilité de prévoir les fuites tant au niveau des stomies que de la fistule cela s’est avéré être trop difficile pour son épouse. Ce d’autant plus qu’un système d’aspiration devait être utilisé lors des changements de poches. Enfin, à cause des multiples fuites rencontrées, ils n’auraient pas eu assez de matériel à la maison.

Les possibilités de soins à domicile ont été explorées à trois reprises, mais après avoir montré les étapes des changements de poches à des infirmières responsables et à des professionnels plus expérimentés, tout le monde s’est accordé sur le fait qu’ils n’arriveraient pas à gérer ces soins. De plus, ils n’avaient pas assez de ressources humaines pour pouvoir le faire aussi souvent que nécessaire, sachant qu’en plus Mr TA aurait eu besoin de compensations intraveineuses pour combler les pertes de l’iléostomie et de la fistule. Tous les moyens de soutien aux équipes soignantes et des soins à domicile ont été utilisés avec l’usage d’un guide qui décrivait les soins pas-à-pas, comportant des photos pour montrer comment changer les appareillages, même une présentation power point a été réalisée. Les possibles de lieux de soins ont été régulièrement réassuré quant au soutien en soins de stomathérapie qui aurait été apporté si le patient avait accepté de s’y rendre, mais toutes les stratégies ont été déclinées.

L’incapacité de trouver un lieu de soins à domicile a laissé au patient et à sa famille un sentiment de rejet et un soutien psycho-émotionnel a dû être apporté par l’infirmière stomathérapeute et l’assistante sociale.

DiscussionEnviron une stomie sur cinq est repérée en urgence8. L’incidence des complicat ions associées avec une urétérostomie cutanée trans-iléale est d’environ de 15 à 65% et les complications les plus rencontrées sont liées aux changements de la stomie ou de la paroi abdominale telle que la sténose ou la rétraction stomiale13.

De fait, la gestion de toute complication postopératoire requière une approche de soins au patient holistique et inter professionnelle9.

Idéalement l’iléostomie et l’urétérostomie cutanée trans-iléale devraient être ourlées à la peau de quelques centimètres, surtout à cause de la quantité, la consistance et la composition des effluents émis qu’ils soient fécaux ou urinaires. Le défi supplémentaire est de maintenir et de protéger la peau de ces effluents à haut débit, en particulier lorsque la stomie est plane ou rétractée14.

Les interventions de soins étaient organisées autour de trois buts: le maintien de l’intégrité cutanée, la réduction de la douleur inutile et la contenance des effluents. S’assurer qu’il y ait une procédure pour les changements et les applications des appareillages qui vise à la bonne adhésion des poches à la peau et le maintien de leur étanchéité a été un des objectifs principaux au vu de la complexité de la situation de Mr TA. Cette procédure aidait au maintien de l’intégrité de la peau péristomiale et de celle autour de la fistule. L’adhésion des appareillages à la peau est nettement compromise lorsque celle-ci était en contact avec les effluents de la stomie15.

La promotion du succès pour le patient commence par la sauvegarde de son intégrité cutanée. C’est la pierre angulaire de chaque soin de stomie et cela a été démontré. Il a été reconnu que l’accès facilité aux produits nécessaires pour les faire rend ce défi atteignable.

Les plaques à base d’hydrocolloïde utilisées pour la gestion des stomies de Mr TA a permis de garder sa peau intègre, ce qui l’a aussi aidé à préserver sa dignité et son image corporelle. Les systèmes choisis ont été des poches Dansac Gx plus, deux pièces, convexes, à haut débit avec l’usage d’anneaux de joint. La convexité modérée de la plaque de base a fait ressortir en douceur l’iléostomie du plan cutané permettant de prévenir les fuites, de plus elle permettait un ajustement resserré autour de l’urostomie. L’utilisation d’une plaque convexe en hydrocolloïde qui augmente l’adhésion de la poche tout en protégeant la peau péristomiale est considéré comme faisant partie des bonnes pratiques15.

Utilisation du Gx plus favorisait le port de l’appareillage sur une plus longue durée permettant de maintenir le changement d’appareillage à seulement deux fois par semaine. Ce n’était

32 WCET® Journal Volume 39 Number 1 March 2019

pas seulement du temps gagné, mais cela permettait aussi de réduire les coûts et plus important encore de prévenir des douleurs inutiles chez le patient. Comme l’incidence et la peur des fuites diminuaient, le niveau d’anxiété et de stress de Mr TA se réduisait16.

Des investigations ont été réalisées sur l’iléostomie pour exclure une infection et en ont confirmé l’absence. La quantité et la qualité des matières fécales émises peuvent s’expliquer par la chirurgie effectuée, le restant d’intestin fonctionnel court et irritable ainsi que par la pathologie maligne sous-jacente. Aucune intervention diagnostique n’a été entreprise pour identifier une possible insuffisance ou défaillance intestinale. Les protocoles d’appareillage mis sur pied chez Mr TA ont été maintenu pendant une année, période pendant laquelle il est resté hospitalisé. Les débits de la fistule et de la stomie digestive ont toujours été fluctuant en ce en dépits des médications et autres interventions visant à en réduire les effluents.

Corrélés aux défis que posaient la gestion des stomies et de la fistule entéro-cutanée, nous devions aussi prendre en considération le bien être de Mr TA. Tout au long de son parcours de maladie (pré opératoire, postopératoire et soins de fin de vie) il avait besoin de se savoir et se sentir soutenu moralement aussi bien que physiquement. Il est reconnu que les patients stomisés ont un haut niveau de détresse psychologique alors qu’ils perçoivent leur perte d’indépendance tant au niveau physique qu’émotionnel15.

Mr TA a souvent refusé de prendre ses antalgiques alors qu’il était douloureux lors du changement des appareillages. Il est reconnu que la perception de la douleur, de comment on y réagit ou la tolère diffère selon le genre, les différents groupes culturels, les diverses origines éthiques  ; pour certains les réactions seront exacerbées alors que d’autres semblent être moins affectés voire restent stoïques17. De ce point de vue, Mr TA était un pasteur avec une forte croyance religieuse qui influençait sa vision sur la douleur et la prise des contre-douleurs17. A travers les enseignements, les conseils et les soins prodigués par l’infirmière stomathérapeute, l’anxiété de Mr TA avait diminuée15. Ce patient avait un réel besoin constant de se sentir soutenu mentalement et émotionnellement.

La plupart des patients recherchent des professionnels de soins pour les guider sur la manière de procéder et de faire face à leurs conditions médicales. L’espoir est une motivation importante pour le patient et l’aide à s’adpater18 : c’est ce dont Mr TA avait besoin. Afin de rendre possible cette adaptation et la prise de décisions qui en découle, l’espoir est un élément critique qui est corrélé avec la qualité de vie de la personne stomisée7. Les soignants jouent un rôle significatif dans les capacités du patient à faire face, à s’adapter ainsi qu’à comprendre ce qui lui arrive. Cela soulève l’importance de prodiguer des soins holistiques tant aux patients qu’à leurs proches.

De plus, la relation thérapeutique existante entre l’infirmière stomathérapeute et Mr TA a été renforcée par les défis qui ont

été relevés et la durée de séjour pendant lequel il a reçu des soins de cette dernière. Cette continuité de soins a pu apporter un peu de soulagement à Mr TA. Quelque que fut la difficulté de réaliser les appareillages, l’infirmière stomathérapeute a toujours su trouver une parade pour y faire face.

La construction d’une relation thérapeutique avec Mr TA qui était basée sur la confiance, le respect mutuel et la recherche de confort a permis de soutenir considérablement la gestion de ce cas complexe. L’établissement d’une relation de confiance précoce aidera à la gestion clinique et thérapeutique au long terme.

Promouvoir le succès des soins chez un patient passe d’abord par préserver son intégrité cutanée. C’est la pierre angulaire de tout soins à la personne stomisée et cela a été démontré. Il est reconnu que ceci passe par un accès au matériel facilité permettant ainsi à ces défis d’être relevés. Les protocoles de changement d’appareillage ont été efficace pendant toute une année, tout le temps pendant lequel le patient a été hospitalisé. Le haut débit a toujours été fluctuant quel que soit les médications et autres interventions essayés.

Mr TA n’a pas été en mesure de rentrer à domicile et n’a pas pu être institutionnalisé dans un autre lieu de soins. Cela dit, grâce à l’implémentation des soins de stomathérapie et de soins palliatifs basés sur l’évidence, il a pu vivre jusqu’à la fin de sa vie dans des conditions relativement confortable.

CONCLUSIONLe meilleur enseignement de cette situation aura été l’apprentissage par l’expérience des défis que nous avons dû relever et résoudre. Il a été renforcé par le développement précoce d’une relation thérapeutique de qualité entre le patient, ses proches, l’infirmière stomathérapeute et l’ensemble de l’équipe médico-soignante. Ce cas démontre bien que l’accessibilité aux divers produits de stomathérapie est cruciale pour rendre le travail de l’infirmière stomathérapeute réalisable. Enfin, le plus important est que les services de stomathérapie puissent s’’implémenter de façon continue et se répandre puisque les cas complexes se font de plus en plus fréquents.

CONFLIT D’INTÉRÊTLes auteurs déclarent n’avoir aucun conflit d’intérêt.

FINANCEMENTLes auteurs déclarent n’avoir eu recours à aucun financement dans le suivi de ce cas.

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Fang-fang Xu*ET nurse, Wound and Stoma Care Department, The No. 1 People’s Hospital of Hefei City, Anhui Province, China Email 784597400@qq.com

Wei-hua YuThe Director of Nursing Department, The No. 1 People’s Hospital of Hefei City, Anhui Province, China

Mei YuThe Vice-Director of Nursing Department, The No. 1 People’s Hospital of Hefei City, Anhui Province, China

Sheng-qin WangET nurse, Wound and Stoma Care Department, The No. 1 People’s Hospital of Hefei City, Anhui Province, China

Gui-hua ZhouET nurse, Wound and Stoma Care Department, The No. 1 People’s Hospital of Hefei City, Anhui Province, China

* Corresponding author

INTRODUCTIONColostomy refers to the formation of a stoma within the large bowel whereby a piece of the colon (the stoma) is diverted through an artificial opening in the abdominal wall in order to bypass a damaged part of the colon. Colostomies are commonly formed to treat disorders of the digestive system such as colorectal cancer, inflammatory bowel disease and diverticulitis or to bypass a damaged part of the colon as the result of trauma.

Colorectal cancer is the leading reason for colostomy formation. The 2014 WHO World Cancer report shows that of all cancer cases in the past five years, colorectal cancer accounted for 10.9%, second only to breast cancer (19.2%) and thirdly prostate cancer (12.1%)1. The incidence of colorectal cancer ranked fifth in all cancers in China2 and ranked fourth in the urban population in China3.

Colostomy patients lose control of their bowel movements as the method of defecation has been changed. Further, they

The correlation between stigma and adjustment in patients with a permanent colostomy in the Midlands of China

Keywords Colostomy, stigma, ostomy adjustment.

For referencing Xu F et al. The correlation between stigma and adjustment in patients with a permanent colostomy in the Midlands of China. WCET® Journal 2019; 39(1):33-39

DOI https://doi.org/10.33235/wcet.39.1.33-39

ABSTRACTObjective: To investigate the correlation between stigma and ostomy adjustment in patients with a permanent colostomy.

Methods: A total of 118 patients (male 81/female 37 with an average age 57.4±15.0) from six grade 3 hospitals of the Midlands of China with a permanent colostomy were recruited. Participants responded to a questionnaire to obtain sociodemographic data, Social Impact Scale (SIS) scores to ascertain stigma level and Ostomy Adjustment Inventory (OAI-20) scores to identify the level of psychosocial adjustment.

Results: The patients’ average SIS score was (60.7±10.4). The QAI-20 total score was (41.3±10.8). The SIS total score and SIS subscores were negatively related to the total score and subscore of QAI-20 (r=-0.222~-0.537, all P<0.01). Multiple regression analysis revealed the level of self-stoma care performed, the degree of communication with medical staff, financial insecurity and social rejection when added into the regression equation had a significant negative impact on OAI-20.

Conclusion: In comparison to the average SIS score, the SIS score in this study sample is higher than midpoint, indicating stigma is closely related to ostomy adjustment. It is suggested that health professionals need to pay more attention to patients’ expressed feelings of stigma to improve their ability to adjust to living with a colostomy.

Original article

34 WCET® Journal Volume 39 Number 1 March 2019

need to wear a colostomy bag to collect excreta and, as a result, are always worried that the colostomy bag will leak, giving off an unpleasant smell and sound. The presence of a colostomy can adversely affect patients’ daily life, sexual life and lifestyle in general as their body shape and function has changed 4-5. Some patients see their colostomy as a taboo subject and are afraid of being discovered and having to reveal they have a stoma. Patients are often too frightened or embarrassed to talk about their colostomy in public. They feel stigmatised due to the presence of their colostomy6.

Stigma is defined as a mark of perceived or actual disgrace or a feeling of being discredited that sets a person aside from others. It represents people who may be seen as unpopular due to a shortcoming or handicap. Stigma was introduced into the field of psychology by Goffman in 19637. The stigma associated with a disease refers to patients’ experience of a kind of inner shame arising from the illness. It is a feeling of being tagged or discriminated against and demeaned. It refers to alienation and avoidance by the individual by not being understood and accepted8-9. Goffman believes changes in the body, defects or deformities as well as having significant disease are characteristics of patients that make them more susceptible to feeling stigmatised. Many scholars have studied a variety of diseases that have an associated stigma, including mental illness, AIDS, cancer, incontinence, colon cancer and obesity8,10-12. MacDonald and Anderson in the United Kingdom surveyed 420 patients with rectal cancer, 256 of whom had a colostomy. Half the patients with a colostomy felt stigmatised, especially younger patients13. Smith studied 195 patients with a colostomy and found a negative correlation between the patient’s disgust at having a stoma and how they adjusted to having a colostomy and life satisfaction in general14. Danielsen et al. in Denmark found a small cohort of 15 patients with colostomies had difficulty in disclosing they had a colostomy because this may impugn their reputation. As a result, they tried to limit the variety of daily outings, imposing self-isolation6.

Disease-related stigma has become a strong predictor of disease adaptation and quality of life; however, in China research about stigma is focussed mainly on mental illness. There is almost no research on the stigma of patients with a colostomy.

Social adjustment refers to the individual’s ability to adjust to or change the environment, in which case the individual’s physical and mental state should be at an optimal state. Social adjustment is a proactive, dynamic self-adjustment process that is systemic in nature as it includes physiological, psychological, sociocultural elements and environmental aspects14. Colostomy patients face a variety of adaptation issues, including physiological, psychological and sociocultural aspects.

The level and characteristics of stigma associated with colostomy patients, as well as whether the patients’ own feelings of stigmatisation and adaptation through social

adjustment can influence each other, is worth exploring. Research on stigmatisation (perceived or actual) in relation to ostomies and people with colostomies, in particular, is currently lacking in China. Therefore, this study was designed to investigate the level of stigma and social adjustment in colostomy patients and to analyse the relationship between stigma and adaptation, and to provide an objective basis for clinical nursing interventions.

METHODSParticipantsPatients from the stoma therapy unit of six grade 3 hospitals in the Midlands of China from December 2016 to June 2017 were enrolled into this study by convenience sampling.

Inclusion and exclusion criteriaPatients were included if they:

1. were at least 18 years old;

2. had a permanent colostomy;

3. were in a rehabilitation period, having had a colostomy for one or more months;

4. were able to provide informed consent to participate in this research;

5. were able to read and understand Chinese.

Exclusion criteriaPatients with a cognitive disorder, metastatic cancer and other life-threatening serious diseases were excluded.

Survey procedureThe investigators in this study were enterostomal therapists and provincial enterostomal specialist nurses in each hospital. The authors trained the investigators how to conduct the survey. This included explaining in detail to the investigators how to convey the purpose of the survey, the methods of measurement and the details of the questionnaires used in the survey to potential study participants. Investigators followed uniform survey protocols when conducting the study. This included adopting a unified instructional language, timely feedback in response to participants’ questions, and processes for entering and validating data to ensure the accuracy of the data. Participants’ responses to the questionnaires issued were anonymous.

Measurement

Survey questionnaireThe survey questionnaire was developed by the authors. The questionnaire was comprised of 12 questions that included: age; gender; educational background; income level; house location; living state; average monthly income; length of time since surgery; types of medical payment; monthly cost of ostomy supplies; who performed the stoma care; stomal/peristomal complications; and, communication with medical staff.

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Social impact scale (SIS)The SIS is widely used in cancer and other chronic diseases to measure the associated level of stigma. The authors and investigators used the SIS to measure the level of stigma in patients with colostomies in this study. The SIS was compiled by Fife and Wright in 2000 and was translated into Chinese by Pan et al. in 200715. It consists of 24 items with four dimensions which are: social rejection; financial insecurity; internalised shame; and, social isolation. Each item scores from 1 (strongly disagree) to 4 (strongly agree). Higher scores indicate a higher level of stigma. Guan Xiao Meng et al., who used the SIS in previous studies, obtained a Cronbach’s α coefficient of 0.88316. The authors obtained Pan’s consent to use the Chinese version of the SIS tool before the study commenced. The Cronbach’s α coefficient set for this study was 0.915.

The Ostomy Adjustment Inventory (OAI-20)The OAI-20 was developed by Simmons17 et al. to assess psychological adjustment in patients with a stoma. The original scale comprised 23 items and four subfactors. Each item scored from 0 (strongly disagree) to 4 (strongly agree). Higher scores indicated better social adjustment. It was translated into a Chinese version by Gao Wen Jun et al. in 2011 to 20 items and three subfactors18. The Cronbach α coefficient in this study was 0.886.

Data analysisEpidata 3.1 (Epidata Association Freeware) was used for data entry (QES file), developing archiving protocols (REC files) and for data verification/recovery (CHK files). IBM (2011) SPSS20.0 was used for statistical data analysis.

General information was described by simple frequencies and percentages. The SIS score and OAI-20 score were described by mean, averages and standard deviations. Comparisons between groups were tested by T-test or One-Way ANOVA

analysis. Correlation between the SIS and OAI-20 scores was tested by Pearson correlation analysis.

Multiple regression analysis was used to explore the related factors affecting ostomy adjustment. P<0.05 was considered statistically significant.

RESULTSSubject demographic characteristics and stoma-related informationA total of 118 patients were enrolled in the study. The mean age of participants was57.4±15.0 years. Eighty-one [68.6%] males agreed to participate the study. Additional characteristics of the study participants are identified in Table 1.

Social impact and ostomy adjustment findingsThe average SIS scores were 60.7±10.4. The scoring rate was 63.2%. The social rejection, financial insecurity, internalised shame and the social isolation dimension scores were 21.8±4.3 (60.6%), 8.0±1.9, (66.7%), 12.7±2.5 (63.5%) and 18.2±3.6 (65%), respectively with response rates shown in brackets. Univariate analysis showed a significant difference with the SIS scores in the group regarding the different level of communication with medical staff; those who never communicated with the medical staff scored higher than other patients (Table 2).

The average OAI-20 scores were 41.3±10.8. The five lowest-scoring OAI-20 items identified by respondents are that because of my stoma I: limit my range of activities; am always conscious that my stoma may leak, smell, or be noisy; am always anxious about my stoma; feel that I will always be a patient; and, feel I am no longer in control of my life. Univariate analysis showed a significant difference with the OAI-20 scores in the group in relation to differences in average income, differing lengths of time post-surgery and differing levels of self-care. The SIS total score and subscores and OAI-20 total

Table 1: Characteristics of study participants

Characteristic Numbers (%)

Age ≥ 60 years of age 55 (46.6)

Live with family or others 112 (94.9)

Lived in rural areas 61 (51.7)

Middle school graduates 47 (39.8)

Middle income range 46 (41.5)

Post surgery ≤ 6 months 45 (38.1)

Surgical procedure paid by medical insurance 85 (72)

Estimated cost of stoma products between 100 and 300 Yuan per month 57 (48.3)

Self-care of ostomy (without stoma nurse support) 46 (39)

No stoma or peristomal complications 86 (72.9)

Never communicated with medical staff 54 (43.4)

36 WCET® Journal Volume 39 Number 1 March 2019

Item Group n (%) SIS score

(x±s)

F/t P OAI-20 score

(x±s)

F/t P

Gender Male 81 (68.6) 60.9±10.9 0.06 0.808 42.4±11.1 0.018 0.895

Female 37 (31.4) 60.3±9.7 42.1±11.2

60.5±8.8

Age 18~44 22 (18.6) 61.4±11.6 0.16 0.845 42.6±8.2 0.141 0.869

45~59 41 (34.7) 60.1±10.2 41.5±12.4

≥60 55 (46.6) 61.8±9.4 42.7±11.1

Educational background

Primary school 43 (36.4) 60.2±10.3 0.71 0.589 42.1±10.3 0.083 0.988

Middle school 47 (39.8) 58.3±13.3 42.8±11.6

Training school 19 (16.1) 67.0±14.8 41.8±10.8

Bachelor degree 5 (4.2) 57.3±4.6 40.2±18.3

Higher education

4 (3.4) 61.2±9.9 42.0±6.7

House location Rural area 61 (51.7) 59.9±11.2 0.39 0.533 41.2±10.2 1.234 0.269

City 57 (48.3) 62.0±8.5 43.4±11.9

Living state Single 6 (5.1) 60.0±11.9 0.76 0.556 44.0±10.0 0.675 0.611

With spouse 43 (36.4) 56.9±11.8 43.5±11.2

With spouse and children

54 (45.8) 62.0±13.9 40.5±11.2

With children 13 (11.0) 54.5±7.7 44.1±11.3

Other 2 (1.7) 62.2±10.8 46.5±0.7

Average income <500 20 (16.9) 60.9±9.3 0.79 0.531 40.5±7.9 4.034 0.004

500~1000 9 (7.6) 61.3±10.5 35.2±11.9

1000~3000 49 (41.5) 60.2±11.3 41.6±10.7

3000~5000 30 (25.4) 54.3±6.3 42.9±9.7

>5000 10 (8.5) 59.9±9.6 53.4±14.4

Postoperative time

≤6 45 (38.1) 62.4±9.9 0.88 0.454 40.0±10.2 3.085 0.030

7~12 30 (25.4) 61.7±11.2 42.3±9.9

13~36 29 (24.6) 56.6±13.0 41.9±11.9

>37 14 (11.9) 58.8±4.8 50.0±11.8

Types of medical payment

Socialised medicine

7 (5.9) 59.9±10.9 1.01 0.367 36.7±10.2 2.707 0.071

Hospitalisation insurance

85 (72.0) 63.2±10.0 43.7±11.2

At one’s own expense

26 (22.0) 63.2±9.0 39.1±9.7

Table 2: The general information and factor analysis of variance (n=118)

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Table 2 (continued): The general information and factor analysis of variance (n=118)

Monthly cost of stoma product

<100 17 (14.4) 59.0±10.3 1.35 0.264 44.1±10.8 0.682 0.508

100~300 57 (48.3) 61.9±10.9 42.9±10.4

>300 44 (37.3) 40.8±12.0

Stoma care performed by

Self 40 (33.9) 61.1±12.4 1.24 0.301 45.9±10.2 2.711 0.048

Self with little assistance

46 (39.0) 58.8±8.4 41.5±9.9

Self with much assistance

18 (15.3) 64.6±11.2 38.6±10.9

Someone else 14 (11.9) 60.8±10.3 39.1±14.5

Stomal/peristomal problem status

Yes 32 (27.1) 60.3±11.9 0.03 0.860 42.1±11.5 0.041 0.840

No 86 (72.9) 60.8±10.0 42.6±9.9

Communication with medical staff

Never 4 (3.4) 64.3±9.0 2.49 0.048 29.8±14.0 3.525 0.009

Little 7 (5.9) 60.0±10.7 43.3±9.8

General 54 (45.8) 63.6±10.4 39.9±9.6

Often 47 (39.8) 57.2±10.1 44.9±11.4

Always 6 (5.1) 57.0±6.9 49.8±11.5

Item Group n (%) SIS score

（x±s）

F/t P OAI-20 score

（x±s）

F/t P

score and the subscores were negatively correlated (r=-0.222~ -0.537, all P<0.01) (Table 3).

Multi-factor analysis shows that the level of stoma care performed by self, the degree of communication with medical staff, financial insecurity, and social rejection are risk factors of ostomy adjustment (Table 4).

DISCUSSIONThe level and characteristics of stigma in patients with permanent colostomy.

The scoring rate of SIS score and subdimension score were higher than 50% in this study, which is similar to the findings of Wu Yan19. They surveyed 230 patients with a permanent colostomy; the average SIS scores were 56.07±12.57, the scoring rate of SIS score was 58.42%, the scoring rate of subdimension was higher than 50%. The highest score found in this study was the financial insecurity dimension, perhaps because men accounted for 65.3% of respondents, middle-aged respondents accounted for 58.4% of study participants. Males bear most of the responsibility for family income in China. The middle-aged population is the highest aged bracket in the working population in China. Study participants

felt their family roles were being challenged and jobs were affected because of the stoma. As most stoma products are not included in insurance coverage in most parts of China, most colostomy patients felt some additional economic pressure. The second highest score was the social isolation dimension, which refers to loneliness, the feeling of being isolated from healthy people, being of unequal status in relationships and social interaction, which is similar to the findings of Danielsen6. Patients also described that as their body shape changed due to the colostomy, they had lost control of their bowel excretion and therefore they felt differently to other healthy people. Under the cultural atmosphere of China advocating collectivist values, people pay attention to an individual or a group’s recognition of its social status and reputation. People with a stoma are eager to obtain social recognition20, and are focussed on doing everything possible to “save face”. Colostomy patients fear “losing face” and, therefore, feeling inferior21. This study showed that patients who communicated less frequently with medical staff scored lower than other patients. Those patients who communicated frequently with medical staff are better able to master the physical care of their stoma, keep abreast of the latest information on ostomy care and are better able to cope with various psychosocial situations.

38 WCET® Journal Volume 39 Number 1 March 2019

The level of psychosocial adjustment and its correlated factors in patients with permanent colostomy

Social adjustment refers to the ability to adjust to the environment with the purpose of maintaining the best physical and mental state15. It is an active and dynamic self-adjustment process. It is also a systemic reaction, including physical, social, cultural and technical factors. Based on the score on the OAI, patients in this sample were at the medium level of adjustment, which is similar to the findings of Hu Ailing22 and Xu Qin23. In this study, the main social adjustment problems of patients with a colostomy were social activity restrictions, anxiety, pessimism, loss of self-control, and fear of leakage of the colostomy bag. The study showed that the degree of stoma self-care is an important factor in the adjustment processes, which is consistent with many studies. Patients are transferred from the hospital to the community 5–7 days after surgery. The management of the stoma and replacement of colostomy bag are activities of daily living patients will have to do for the rest of their lives. Self-care is the foundation for patients to return to society. However, the current self-care status of patients with a colostomy is not optimal. In this study, only 30.7% of patients were fully self-caring in the management of their colostomy. At present, intervention studies have been carried out in China to improve the self-care level of patients with a colostomy through such methods as telephone interventions and the peer patient program24.

This study shows that patients who are always communicating with medical professionals have higher OAI scores than other patients; this is similar to the results of Wang Miao25. The study pointed out that the health control of patients with colostomies tends to rely on health authorities and this is consistent with many related studies. It is believed that the guidance of professionals such as enterostomal therapists can improve the level of adjustment of patients with colostomies26,27. Those who are unable to communicate with health professionals are more likely to suffer from or exhibit symptoms of anxiety and depression. Therefore, enterostomal therapists should provide their hospital or outpatient contact details before the patient is discharged.

This study shows that patients’ SIS total score and subscores are negatively related to OAI-20 (–0.222~-0.537) scores. The higher the patient’s level of stigma, the lower the level of ostomy adjustment, which is similar to the finding of Dylan8, who found a significant negative correlation between the stigma, adjustment and life satisfaction. In addition, this study shows that social isolation and economic insecurity have a negative predictive effect on ostomy adjustment. The sense of social isolation makes patients think they are isolated from healthy people and that they live in an unequal state in interpersonal relationships. They are also very sensitive and minimise social activities. Patients with poor economic conditions are under more pressure as well as trying to contend with their underlying diseases and a colostomy.

SIS score Social rejection Financial insecurity

Internalised shame

Social isolation

OAI score –0.537 –0.479 –0.466 –0.289 –0.535

Anxious preoccupation –0.444 –0.395 –0.355 –0.222 –0.472

Acceptance –0.419 –0.377 –0.358 –0.274 –0.383

Social engagement –0.436 –0.389 –0.426 –0.223 –-0.416

Table 3: The correlation between SIS score and OAI-20 score

All P<0.01

Variable Unstandardised coefficients

Standardised coefficients

B Std error t P B

Constant 69.13 6.76 10.22 0.000

The level of stoma care performed by self –2.11 0.89 –2.38 0.019 –0.19

The level of communication with medical staff 3.39 1.06 2.25 0.027 0.18

Financial insecurity –1.49 0.49 –2.99 0.003 –0.27

Social rejection –1.07 0.27 –3.97 0.000 –0.36

Table 4: The multivariate analysis of influential factors of ostomy adjustment (n=118)

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CONCLUSIONThe normal defecation method of a patient who has a colostomy is interrupted as faeces are excreted through the stoma into a colostomy bag. Sometimes there is an associated noise and unpleasant smell. Leakage of the colostomy bag may occur for numerous reasons. As human excreta can trigger adverse reactions in people in general, colostomy patients may experience or at least imagine other people’s adverse reactions. Any reaction indicative of disgust may contribute to the development of feelings of stigma. The main social adjustments to overcome were social activity restrictions, anxiety, pessimism, loss of self-control, and fear of the colostomy bag leaking. The underlying disease and resulting stoma exacerbated economic pressures on some patients.

During hospitalisation it is suggested that medical staff should teach patients the skills of ostomy care and psychological adjustment methods, as well as providing written instructions for colostomy patients. At the same time, health professionals should foster continuity of care of discharged patients through improved liaison and handover to community home nurses. By hosting fraternities and lectures regularly it is hoped that more regions in China will be able to incorporate ostomy products into medical insurance schemes as soon as possible, thereby reducing the economic pressure on ostomy patients. Overall, as much support and assistance should be given to colostomy patients to help them readjust to living with a colostomy.

As the sample size of this study was small, it is recommended that a larger, multi-regional survey and interventional study on preventing feelings of stigma in colostomy patients is conducted.

CONFLICTS OF INTERESTNo conflicts of interest have been declared by the authors.

FUNDINGThe authors received no funding for this study.

REFERENCES1. Bernard WS, Christopher PW, Freddie B et al. World Cancer Report.

International Agency for Research on Cancer, WHO; 2014.

2. Ferlay J, Soerjomataram I, Ervik M et al. GLOBOCAN 2012 v1.0, Cancer incidence and mortality worldwide: IARC Cancer Base No. 11 [EB/OL]. [2014 Dec 21]. Available from: http://globocan.iarc.fr.

3. He J & Chen WQ. 2012 China Cancer Register Annual Report [M]. Beijing: Military Medical Science Press, 2012; 10.

4. Reese JB, Finan PH, Haythornthwaite JA et al. Gastrointestinal ostomies and sexual outcomes: a comparison of colorectal cancer patients by ostomy status [J]. Support Care Cancer 2014; 22(2):461–8.

5. Desnoo L & Faithfull S. A qualitative study of anterior resection syndrome: the experiences of cancer survivors who have undergone resection surgery. Eur J Cancer Care (Engl) 2006; 15(3):244–51.

6. Danielsen AK, Soerensen EE, Burcharth K et al. Learning to live with a permanent intestinal ostomy. J Wound Ostomy Continence Nurs 2013; 40(4):407–412.

7. Goffman E. Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, NJ, USA: Prentice-Hall, 1963.

8. Smith DM, Loewenstein G, Rozin P et al. Sensitivity to disgust, stigma and adjustment to life with a colostomy. J Res Pers 2007; 41:787–803.

9. Scambler C. Stigma and disease: changing paradigms. Lancet 1988; 352:1054–1055.

10. Kira IA, Lewandowski L, Ashby JS et al. The traumatogenic dynamics of internalized stigma of mental illness among Arab American, Muslim, and refugee clients. Am Psychiatr Nurses Assoc 2014; 20(4):250–266.

11. Tsai AC, Weiser SD, Steward WT et al. Evidence for the reliability and validity of the internalized AIDS-related stigma scale in rural Uganda. AIDS Behav 2013; 17(1):427–33.

12. Cataldo JK, Jahan TM & Pongquan VL. Lung cancer stigma, depression, and quality of life among ever and never smokers. Eur J Oncol Nurs 2012; 16(3):264–9.

13. MacDonald LD & Anderson HR. Stigma in patients with rectal cancer: a community study. J Epidemiol Community Health 1984; 38:284–290.

14. Andrews H & Roy C. The Roy adaptation model the definitive statement. Norwalk: Appleton & Lange, 1991; 22–59.

15. Pan AW, Chung LI, Fife BL et al. Evaluation of the psychometrics of the Social Impact Scale: a measure of stigmatization. Int J Rehabil Res 2007; 30(3):235–238.

16. Guan XM, Sun T, Yang H et al. The reliability and validity of the Chinese version of the social impact scale for stigma in patients with incontinence. J Nurs Sci 2011; (07):63–65.

17. Simmons KL, Smith JA & Maekawa A. Development and psychometric evaluation of the Ostomy Adjustment Inventory-23. J Wound Ostomy Continence Nurs 2009; 36(1):69–76.

18. Gao WJ & Yuan CR. The reliability and validity of Chinese version of stoma adaptation scale. Chinese Journal of Nursing 2011; 46(8):811–813.

19. Wu Y, Miao ZH & Xu JM. Investigation of stigma status in patients with permanent colostomy. J Nurs Res 2015; 29(2B):170–173.

20. Zhou LG. On Social Exclusion. J Society 2004; 27(3):58–60.

21. Pan RC. Through the movie “face” to see the difference between Chinese and Western views. J Movie Literature 2012; 19:48–49.

22. Hu AL. Adaptation of self-care ability and social support in patients with colostomy. Guangzhou: Sun Yat-sen University, 2008.

23. Xu Q, Cheng F, Dai XD et al. Psychological and social adaptation and related factors in patients with permanent colostomy analysis. Chinese Journal of Nursing 2010; 45(10):883–885.

24. Cheng F, Xu Q, Dai XD et al. Effects of the implementation of the internal patient plan on the self-efficacy and self-management of patients with permanent colostomy. Chinese Journal of Practical Nursing 2010; 26(1):45–47.

25. Wang M, Zhu XL, Wang CY et al. Control source, quality of life, and coping style of patients with rectal cancer and stoma. Chinese Mental Health Journal 2013; 23(10):750–753.

26. Haugen V, Bliss DZ & Savik K. Perioperative factors that affect long-term adjustment to an incontinent ostomy. J Wound Ostomy Continence Nurs 2006; 33(5):525–535.

27. Sinclair L. Young adults with permanent ileostomies: experiences during the first 4 years after surgery. J Wound Ostomy Continence Nurs 2009; 36(3):306–316.

40 WCET® Journal Volume 39 Number 1 March 2019

Book review

This book is a revision of Dr Grace Warren’s “The Care of Neuropathic Limbs, A Practical Manual” and was first published by the Parthenon Publishing Group in 1999.

IntroductionDr Warren saw that there was a need to provide a comprehensive manual on the management of neuropathic limbs. She felt it should focus on the long-term dedication required to manage this problem to prevent limb deformity and amputation. She explains the current literature is fragmented and mostly defines experiences in managing these conditions in economically rich countries. Her wide experience working in developing countries as a surgeon with a focus on prevention of amputation showed her there were many options to assist limb salvage that are overlooked that can be effective in managing neuropathy.

Content The text begins by defining the challenge of managing neuropathic limbs which now is seen largely in patients with diabetes but Dr Warren covers case studies of patients with other neuropathies. She begins with the importance of patient centred care and how a dedicated multifaceted approach can result in limb salvage.

The book continues with a very comprehensive section on assessment and studies to assess and diagnose neuropathic limbs. These assessments are very low tech such as charting sensation and radiography. This could be easily and cheaply achieved in developing countries and remote locations.

A very extensive range of interventions and treatments are described and the emphasis is very much on patient education, intervention and self-management. I believe this is one aspect that is overlooked in developed countries. I suspect many of my podiatry colleagues would be very reluctant to teach our patients to debrided their own calluses but Dr Warren explains how she does and teaches this and notes it can be very effective. Even in Australia there are very few patients that get callus or wound debridement as regularly as they require it.

Title NEUROPATHIC LIMB CARE • Diabetic Ulceration -Leprosy-Congenital Disorders-Trauma • A Practical Guide to procedures for Reducing Disabilities and Amputations

Author Grace Warren MD (with Sydney Nade MD)

Publisher George Jacksett Australia. Honeysett Press. 2018

ISBN ISBN 978-1-876158-10-1 paperback. ISBN 978-1-876158-11-8 eBook

The book finishes with useful appendices from other health professionals and adds additional insights into the management of neuropathic limbs.

This text provides a clearly written and practical guide to the management of neuropathy. It would be useful to any practitioner or patient looking to improve their understanding of these challenging conditions and as a podiatrist working with Aboriginal and Torres Strait Islander people many with neuropathic diabetic foot ulcers I think this text successfully challenges us to do more and consider how we help our patients.

The real strength in this text is for those clinicians in developing countries without access to comprehensive expensive medical care, where the clinical care advocated in this book will really make a difference.

A criticism of this book is in the section on wound care. Whilst it is a comprehensive cover of traditional wound care treatments and dressings I think it overlooks the advances made. I do understand that wound therapies can be expensive and not applicable in all settings but I think an appreciation of the principles of wound care is another skill set useful in our tool box of therapies.

Conclusion I believe this book provides a very practical guide to management of neuropathic limbs. I applaud Dr Warren, clearly her dedication and passion to practice quality patient care in many countries has paved the way for us today to continue to fight to save limbs and she provides the road map to do this.

Ruth ConnorsPodiatristTownsville Aboriginal & Islander Health ServiceQueensland, Australia

For referencing Connors R. Book review – Neuropathic Limb Care. WCET® Journal 2019; 39(1):40

DOI https://doi.org/10.33235/wcet.39.1.40

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1. Based on a survey of 140 patients. Consumer Survey of Pruritus, 2016 Hollister data on file.

2. Colwell J, Pittman J, Raizman R, Salvadalena G. A Randomized Controlled Trial Determining Variances in Ostomy Skin Conditions and the Economic Impact (ADVOCATE Trial). J Wound Ostomy Continence Nurse. 2018;45(1):37-42

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