Osteopathic Manipulative Treatment (OMT) has been used for more than 100 years to enhance the physiologic process of labor and delivery by normalizing pelvic structures and providing adequate blood supply to the uterus. Since maternal morbidity and mortality is a major health concern for developing countries, it was desirable to explore the benefits of OMT. After IRB approval by the Virginia College of Osteopathic Medicine and Virginia Tech, the research was conducted in Santo Domingo, Dominican Republic at Hospital Maternidad Nuestra Señora de la Altagracia to determine the relationship of OMT during labor and delivery on rates of cesarean section and perineal lacerations/ episiotomies. Qualifying candidates received the next sequentially numbered envelope with a randomized number assigning her to either the treatment or control group. Staff physicians at the hospital provided care to women in the control group according to their standard protocol. Four Osteopathic Physicians and one pre-doctoral OMM fellow performed OMT on women during the first and second stages of labor and performed their deliveries. There were 33 parturients in the OMT Treatment group and 32 in the control, for a total of 65 in the trial. The results of a logistic regression analysis using Wald criterion, with a statistical significance of alpha = 0.05, indicated treatment group reduction of rates of episiotomies in the primiparous (P = .04) and marginal significance in the combined primiparous and multiparous population (P = .05). The percentage of episiotomies in the primiparous treatment group was 35.29% and 75% in the control group. The percentage of episiotomies in the combined primiparous and multiparous groups were 15.15% in the treatment group and 37.5% in the control group. The cesarean rate for the treatment group was 9.09% and 18.75% for the control group (P = 0.098). The percentages of grade I & II perineal lacerations were 15.15% for the treatment group and 12.5% for the control group (P = 0.55) due to the extensive use of episiotomies in the control group. There were composite calculations made of the total number of parturients who had either a cesarean section, an episiotomy, or a perineal laceration so that overall maternal morbidity in each group could be compared. In the combined groups, there were fourteen total parturients (42.42%) who had undergone one of the three outcomes measures in the treatment group and twenty-one (65.63%) in the control group. This brings an odds ratio of 0.200 and a significant P value of 0.0235. Though cross-cultural issues made it difficult to perform the research as originally intended, there is evidence that Osteopathic Obstetrics provides benefit to parturients. A multi-institutional randomized controlled trial is proposed as the next step for the evaluation of OMT during labor and delivery. / Ph. D.

Obstetrical intervantion`s goal is to normalize an abnormal or pathological course of labour. In a certain case (e.g. fetal distress) this is not fully achievable. Then the goal is to accelerate the delivery without inadequate increase of risk of maternal or neonatal trauma. The aim of this dizertation thesis was to offer an up-to-date definition and to outline a proper performance of these interventions. Therefore, it was necessary to properly and timely describe the labour layout in which the accoucheur and/or the parturient happen to occurr when an intervention is to take place. It was essential to describe the quantity of perineal loading as well as to define the main vector of perineal strain and deformation. Based on the range of this deformation it was subsequently possible to adequately describe and execute some obstetrical interventions (e.g. a variety of types of episiotomy) or to evaluate a variety of modifications by means of computational modelling (e.g. manual perineal protection) that might have so tiny nuances between each other or differences that are difficult to measure because the clinical evaluation is impossible due to interindividual imprecision or very short duration of the intervention. We described the maximum strain on the perineal surface during vaginal delivery that...

Made available in DSpace on 2014-06-11T19:28:04Z (GMT). No. of bitstreams: 0 Previous issue date: 2010-03-03Bitstream added on 2014-06-13T18:57:12Z : No. of bitstreams: 1 oliveira_jz_me_botfm.pdf: 1081861 bytes, checksum: 92c0e3a4a446049c9479176e65569d5f (MD5) / Fundação Pio Xii - Barretos / O aumento considerável de pessoas no mundo acometidas por câncer, associado ao prolongamento da vida, em decorrência das avançadas tecnologias utilizadas no tratamento, reforça a importância de se utilizar a qualidade de vida como uma medida importante dos tratamentos realizados. Para os pacientes com câncer de reto, com tumores muito próximos aos esfíncteres anais ou envolvendo essas estruturas, a amputação abdominoperineal do reto continua sendo o principal tratamento. Como alternativa à colostomia abdominal para pacientes selecionados, a colostomia perineal, segundo a técnica de Alcino Lázaro, tem sido empregada com resultados satisfatórios. No entanto, esses pacientes terão que realizar a auto irrigação para o resto da vida, garantindo a continência intestinal. Assim, o objetivo deste estudo foi avaliar as complicações cirúrgicas e a qualidade de vida dos pacientes submetidos à amputação abdominoperineal do reto com colostomia abdominal, ou com colostomia perineal que se auto irrigam, seguindo um novo método de irrigação e avaliar a eficácia desse novo método. Foi realizado um estudo transversal, após aprovação do Comitê de Ética em Pesquisa do Hospital do Câncer de Barretos, entre junho de 2009 a novembro de 2009. A qualidade de vida foi avaliada utilizando dois questionários desenvolvidos pela European Organization for Research and Treatment of Câncer (EORTC), sendo um específico para câncer (EORTC QLQ-C30) e outro específico para câncer de reto (EORTC QLQ-CR38). Um total de 38 pacientes foram incluídos, sendo 21 com colostomia perineal e 17 com colostomia abdominal. Em relação às características sócio demográficas, clínicas e terapêuticas, os grupos foram semelhantes no que diz respeito à idade, sexo, cor, estado civil, escolaridade, renda, ocupação, estádio clínico,... / The considerable increase of people in the world suffer from cancer, associated with prolongation of the life in result of the advanced technologies used in the treatment, reinforces the importance of using quality of life as an important measure of the carried through treatments. For patients with rectal cancer, with tumors very close to the anal sphincter or involving these structures, amputation abdominoperineal of the rectum continues being the main treatment. As an alternative to abdominal colostomy for selected patients, a perineal colostomy, using the technique of Alcino Lázaro, has been used with satisfactory results. However, these patients will have to perform self-irrigation for the rest of your life, guaranteed bowel continence. The aim of this study to evaluate the surgical complications and the quality of life of patients who underwent the abdominoperineal amputation of the rectum and either had an abdominal colostomy or a perineal colostomy and self-irrigation through a new method of irrigation and evaluate the effectiveness of this new method. After official approval from the Ethics Committee in Research of the Cancer Hospital of Barretos, Brazil, a cross-sectional study with prospective data collection of 38 patients was carried out from June 2009 to November 2009. The quality of life was evaluated through two questionnaires developed by the European Organization for Research and Treatment of Cancer (EORTC): one was specific for cancer (EORTC QLQ-C30) and the other one was specific for rectal cancer (EORTC QLQ-CR38). A total of 38 patients were included, 21 with perineal colostomy and 17 with abdominal colostomy. Regarding socio-demographic, clinical and therapeutic characteristics, the groups were similar in age, gender, race, marital status, education, income, occupation, clinical... (Complete abstract click electronic access below)

Made available in DSpace on 2014-06-12T16:29:01Z (GMT). No. of bitstreams: 2 arquivo5712_1.pdf: 3234461 bytes, checksum: 00c3fd0dd5a23bf6e3820175688c4e68 (MD5) license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) Previous issue date: 2007 / A hipermobilidade da junção uretrovesical responde por aproximadamente 95% dos casos de incontinência urinária de esforço e a ultra-sonografia transvulvar vem sendo usada cada vez mais para estudar a mobilidade da junção uretrovesical e da uretra proximal. No tratamento da incontinência urinária de esforço as colpossuspensões retropúbicas mais conhecidas são as de Burch e Marshall-Marchetti-Krantz, sendo a primeira considerada o padrão ouro. A combinação das duas técnicas no tratamento da incontinência urinária de esforço foi referida em uma série de casos com percentual de cura de 96%, mas suas repercussões na mobilidade da junção uretrovesical e uretra proximal são desconhecidas. Com o objetivo de estudar por meio da ultrasonografia transvulvar as modificações da junção uretrovesical e da uretra proximal promovidas pela cirurgia combinada de Marshall-Marchetti-Krantz e Burch, 32 pacientes com incontinência urinária de esforço foram selecionadas. O método do estudo consistiu em fazer exame ultrasonográfico transvulvar em todas as pacientes antes da cirurgia e 30 dias após. O exame foi feito para avaliar a distância pubo-uretral, o comprimento da uretra proximal, a distância horizontal e vertical da junção uretrovesical, os seus deslocamentos, estando a paciente em repouso e durante a manobra de Valsalva. A cirurgia de Marshall-Marshall-Krantz-Burch reduziu a distância pubouretral e a distância horizontal da junção uretrovesical, no repouso e no esforço; Aumentou o comprimento da uretra proximal no repouso e no esforço; Aumentou a distância vertical da junção uretrovesical no esforço, sem interferir durante o repouso. Pelos resultados obtidos pode-se concluir que a cirurgia de Marshall-Marchetti-Krantz-Burch reduziu significantemente a mobilidade vertical e horizontal da junção uretrovesical, sem elevar a junção uretrovesical

Av de kvinnor som genomgår vaginalförlossning drabbas 85% av förlossningsbristningar, och följderna av dessa kan variera från lätta besvär till svåra komplikationer. En förutsättning för att kvinnan ska få rätt behandling är en korrekt diagnostik. Majoriteten av bristningarna handläggs av barnmorskor, och tidigare forskning har visat att kunskapen och kompetensen inom området varierar. Studiens syfte var att kartlägga svårigheter i barnmorskors arbete med att undersöka och bedöma vaginalbristningar efter förlossning. En enkätundersökning med barnmorskor som handlagt 72 förlossningar på en mellanstor förlossningsklinik vid ett svenskt sjukhus genomfördes under en period av 7 veckor. Resultatet visade att de vanligaste hindren vid granskning av bristningar var blödning och smärta hos patienten och de vanligaste svårigheterna var att identifiera strukturer och vävnader i bristningen. I en fjärdedel av fallen tog handläggande barnmorska stöd av kollega eller läkare, och några barnmorskor skattade sin kunskap och kompetens inom området som otillräcklig. Behovet av kollegialt stöd och av fortbildning och träning uttrycktes hos barnmorskor med både kort och lång erfarenhet. Det finns ett behov av fortsatt forskning om blödning som hinder för bedömning av förlossningsbristningar och av utvärdering av smärtlindringsmetoder. / Of all women undergoing vaginal birth, 85% sustain some form of perineal trauma and the consequences vary from smaller problems to severe complications. An accurate diagnosis of the trauma is necessary for it to be adequately treated. A majority of the perineal and vaginal ruptures are managed by midwives, and earlier research has shown that there is a considerable variation in midwives knowledge and skills concerning perineal trauma. The aim of this study was to explore difficulties in midwives examinations and assessments of perineal trauma following vaginal birth. A survey with midwives attending 72 births within a medium- sized Swedish birth-clinic, was conducted in a period of 7 weeks. The most common obstacles in assessing perineal ruptures, were the patient ́s bleeding and pain. The largest difficulties in assessment were identifying the structures and anatomy within the rupture. In one case out of four, peer support from midwife colleague or doctor was sought, and there were cases of midwives estimating their competence as non-sufficient. The need for peer support and continuous training and education was expressed in cases with midwives having short and long experience. There is a need for further research in the focus on bleeding as an obstacle in assessment of perineal trauma, and a need for further evaluation of the anaestethical methods used in management of them.

Vid en vaginal förlossning är det vanligt förekommande att kvinnor drabbas av perinealbristningar. Perinealbristningar kan uppstå spontant vid en födsel men även på grund av yttre orsaker, som vid instrumentell förlossning. Perinealbristningar kan medföra komplikationer, och eftersom det är vanligt med perinealbristningar ville författarna förstå hur kvinnor upplever att bristningen och dess konsekvenser inverkar på deras dagliga liv. Därför var syftet att beskriva kvinnors upplevelser av sitt dagliga liv efter en perinealbristning i samband med vaginal förlossning. Metoden som valdes för att besvara syftet var en litteraturöversikt, som inkluderande 15 vetenskapliga artiklar. Analys av artiklarna utfördes enligt integrerad analys. I resultatet identifierades två kategorier samt tillhörande underkategorier. Kategorierna kom att kallas “En perinealbristnings påverkan på det dagliga livet och “Kontakt med vården efter en perinealbristning”. Resultatet visade att en perinealbristning i samband med vaginal förlossning medförde påverkningar i det dagliga livet. Kvinnor beskrev upplevelser av att leva med smärta och inkontinens, samt hur perinealbristningens besvär inverkade på deras självförtroende, sexuella funktion och tankar på framtida förlossning. I resultatet framkom även upplevelser angående brister från vården gällande information om bristningen, samt att kvinnor inte upplevde sig betrodda av vårdpersonal. Slutsatsen som kan påvisas genom denna litteraturöversikt är att kvinnor kan uppleva sig begränsade och känna en förlust av kontroll i sitt dagliga liv efter en perinealbristning. Barnmorskor har en viktig roll i arbetet för kvinnor efter att de drabbats av en perinealbristning. / During a vaginal delivery its common for women to suffer from a perineal tear. Perineal tear can occur spontaneously at birth but also due to external causes, such as instrumental delivery. Perineal tears can lead to complications, and since perineal tears are common, the authors wanted to understand how women experience the perineal tear and their consequences affecting their daily lives. Therefore, the aim of this study was to describe women's experiences of their daily lives after a perineal tear in connection with vaginal delivery. The method chosen to answer this aim was a literature review, which included 15 scientific articles. Analysis of the articles was performed according to integrated analysis. In the result, two categories and associated subcategories were identified. The categories came to be called "The impact of a perineal rupture on the daily life" and “Contact with care after a perineal rupture". The results showed that a perineal rupture in connection with vaginal delivery had an impact on daily life. Women described experiences of living with pain and incontinence, as well as how perineal rupture affected their self-confidence, sexual function and thoughts of future childbirth. The results also revealed experiences regarding lack of information from the care regarding information about the rupture, and that women did not feel trusted by care staff. The conclusion that can be demonstrated through this literature review is that women may feel limited and feel a loss of control in their daily lives after a perineal rupture. Midwives play an important role in the work of women after suffering from a perineal rupture.

Background: Pelvic floor muscle (PFM) training is recommended as first line conservative management for stress urinary incontinence (SUI). The fundamental issue of how to optimally contract the PFM has not previously been investigated. An effective voluntary PFM contraction is known to positively influence the bladder neck and urethra which are urethrovesical (UV) structures associated with continence. The PFM may be globally or selectively contracted according to cue to instruction. The main research question was to investigate which cue to instruction for a PFM contraction has the potential to optimise position of UVSs following a brief period of practice in continent nulliparous pre-menopausal women (aiming to provide normative data) and parous menopausal women with previously unreported SUI. Hypotheses: Posterior or combined cues for instruction of PFM contraction are more influential in optimising UV position (UVP) during PFMC following brief practice than an anterior cue. Posterior or combined cues are equally influential in altering UVP. Aims: Preliminary aim was to investigate the reliability and suitability of 2-DRTUS and angle of urethral inclination (AUI) for imaging of selective contraction of the PFM and ease of reading images by a non diagnostic imaging researcher. Principal aim was to investigate if there is an optimal cue to instruction for a PFM contraction in two groups of women. Study 1: pre menopausal nulliparous continent women (to provide normative data) and Study 2: post menopausal parous stress incontinent women. Secondary aims were investigation of posture; ability to selectively contract the PFM contraction; and cue preference. Method: Study 1: Twenty women who were able to effectively and selectively contract were taught the following cues: anterior; posterior; anterior and posterior combined. Following 4 weeks of practice, perineal 2-D RTUS images of three PFMC for each cue were captured in supine and standing twice (for repeatability analysis) five minutes apart. Two raters measured AUI. Data analysis was undertaken using a Customized General Linear Model (GLM) ANOVA with Bonferroni correction for interactions between all variables; subject, cue, posture and test. Seventeen data sets were available for analysis. Study 2: Methodology was based on Study 1. Twenty-one women were taught the study cues, followed the practice protocol and underwent data collection in the supine position. Twenty-one sets of data were available for analysis. Results: Reliability: ICC [1,3] for intra rater reliability was 0.957 [CI 95%: 0.946 to 0.967 p=0.000], inter rater reliability [2,1] 0.820 [CI 95%: 0.768 to 0.861] and for repeatability [1,3] 0.781 [CI 95%: 0.690 to 0.849 p=0.000] (continent) and 0.954 [CI 95%:0.931 to 0.971 p=0.000] (incontinent). Principal results Study 1: anterior vs posterior cues (difference) 3.979˚ (CI 95%: [0.503 to 7.455 p=0.021]); anterior vs combined 3.777˚ (CI 95%: [-0.099 to 6.853 p= 0.059]) posterior vs combined cues -0.602˚ (CI 95%: [-2.874- 4.078 p=1.00]). Aggregated data from tests 1 and 2: anterior vs posterior 4.240° (CI 95%: [1.213 to 7.267 p=0.003]); anterior vs posterior 3.756° (95%CI: [0.729 to 6.783 p=0.009]); posterior vs combined-6.48° (95% CI: [-3.511 to 2.542 p=1.000]). Principal results Study 2: anterior vs posterior 3.936˚ (95%CI: [0.863 to 7.008p=0.008]; 4.946˚ anterior vs combined (95%CI: [1.873 to 8.018 p=0.001]); posterior vs combined 1.010° (95%CI: -[2.062 to 4.082 p=1.000]). Aggregated analysis was anterior vs posterior 3.703˚ (95%CI: [1.639 to 5.761 p=0.000]); anterior vs combined 5.089˚ (95%CI: [3.0287 to 7.1503 p=0.000]) and posterior and combined 1.389° (95%CI: [-0.672 to 3.450 p=0.309]). Secondary results: 2-D RTUS and the AUI were found to be suitable for investigating selective PFM contraction. Posture: supine vs standing (difference) 9.496˚ (p=0.000); (posture did not affect absolute AUI). Three continent (13%) and 2 incontinent (7%) subjects were unable to selectively contract the PFM. Cue preference in both studies was posterior or combined. Conclusions: AUI was significantly narrower/optimal when instruction for PFM contraction included a posterior cue, in both continent and stress incontinent women. This is proposed to be due to optimal recruitment of puborectalis. Puborectalis may be more important in urinary continence than widely recognized. This study has provided seminal information with respect to optimal cue to contraction for a PFM contraction and will change practice. Investigation of the potential impact of these findings clinically is required. It is proposed that further understanding will lead to standardisation of PFM instruction, ease of comparability between PFM research studies, and will clarify PFM instructions for the media and lay public.

Introduction : Le système nerveux autonome (SNA) est en situation supralévatorienne, le système somatique en situation infra lévatorienne. Le sympathique assurerait les fonctions de sécrétion et le parasympahtique, les fonctions dʼérection. Le rectum est en rapport étroit avec ces éléments nerveux. La protectomie avec exérèse totale du mésorectum pour cancer est associée à des séquelles sexuelles par lésion iatrogène des nerfs pelviens.Objectifs : Étudier la physiologie et lʼanatomie topographique et structurelle de l'innervation pelvipérinéale Matériels et méthodes : Cinq pelvis de foetus et dix pelvis dʼadultes féminins ont été prélevés pour études macroscopiques, microscopiques etimmunohistochimiques des nerfs pelviens. Les coupes ont été colorées puis immunomarquées pour détecter les fibres nerveuses (PS-100), somatiques(PMP22), autonomes adrénergiques (TH), cholinergiques (VAChT), sensitives(CGRP) et les fibres pro-érectiles (nNOS). Les lames ont été numérisées et reconstruites en 3D.Résultats : Les fibres nerveuses du SNA, richement interconnectées,véhiculent de façon mixte lʼinflux sympathique et parasympathique.Celles issues du plexus hypogastrique inférieur contrôlant les fonctions sexuelles sont regroupées avec le pédicule vaginal long et forment la bandelette neuro-vasculaire (BNV) sur la face antérolatérale du rectum à « 2et 10h ». Cette BNV est en avant de lʼexpansion postérolatérale du septum recto vaginal (SRV) qui la protège et qui est lʼéquivalent chez lʼhomme du fascia de Denonvilliers. Cette BNV concentre lʼensemble des fibres nerveusespro-érectiles destinées au périnée. Une lésion tronculaire de cette bandelette pourrait conduire à un trouble de lʼérection clitoridienne et de la lubrification vulvaire car, à ce niveau, les efférences sympathiques et parasympathiques coexistent.Conclusion: Un modèle anatomo-physiologique et pédagogiquedʼinnervation pelvipérinéale féminine a été développé. Ces travaux offrent des perspectives dʼétudes cliniques afin de mieux évaluer les dysfonctions sexuelles postopératoires. / Introduction: The nerve supply of the autonomic nervous system (ANS) to the pelvis is located above the levator ani muscle, and the somatic nerve supply to the pelvis is situated below levator ani. Sympathetic innervation assures secretory functions and parasympathetic innervation allows erection. The rectum is anatomically closely associated with these nerves. Protectomy with total excision of the mesorectum for cancer is associated with sexual sequellae due to iatrogenic damage to the pelvic nerves.Objectives: To study the physiology and topographic and structural anatomy of the innervation of the pelvis.Materials and methods: Five fœtal pelvises and ten adult female pelvises were collected for macroscopic, microscopic, and immunohistochemical studies of pelvic nerves. Sections were stained and then immunostained to reveal nerve fibres (PS-100), somatic nerves (PMP22), adrenergic autonomic nerves (TH), cholinergic autonomic nerves (VAChT), sensory nerves (CGRP) and pro-erectile nerves (nNOS). Sections were numbered and reconstructed in 3D.Results: ANS nerve fibres, densely interconnected, carry a combination of sympathetic and parasympathetic fibres.Nerve fibres controlling sexual function from the inferior hypogastric plexus are clustered along the vaginal pedicle and form the neurovascular bundle (NVB) on the anterolateral face of the rectum between “2 and 10 o’clock”. This NVB is in front of the expansion of the rectovaginal septum (RVS) which protects it. In males, the equivalent structure is the rectoprostratic fascia. This NVB contains all of the pro-erectile nerves supplying the perineum. A truncal lesion to this bundle could result in erectile dysfunction of the clitoris as well as difficulties in vulvar lubrication because sympathetic and parasympathetic efferent fibres are both present at this site.Conclusion: An educational anatomical and physiological model of the innervation of the female pelvis and perineum has been developed. This work offers perspectives for clinical studies to facilitate better evaluation of cases of post-operative sexual dysfunction.

Bakgrund. Att få en allvarlig bristning i samband med förlossning kan ge kvinnor smärta, lidande, och låg livskvalitet under lång tid. Syfte. Syftet med förbättringsarbetet har varit att förbättra eftervården genom att införa strukturerad uppföljning, öka kvalitén i bedömning och diagnostik, förbättra informationen till patienten och utveckla former för patientdelaktighet i förbättringsarbetet. Syftet med studien har varit att ur ett verksamhetsperspektiv beskriva erfarenheterna av patientdelaktigheten i förbättringsarbetet. Metod. Förbättringsarbetet har designats med hjälp av Förbättringstrappan och utgått från ett patientprocessorienterat perspektiv. Metod för studien var kvalitativ i form av en fallstudie. Resultat. Genom förbättringsarbetet följs kvinnorna upp via bristningsregistret, uppföljningsbesök med 3D- ultraljud görs på en specialinrättad mottagning. Vidare får kvinnorna individuell fysioterapeutinformation innan hemgång, en vårdkedja har införts och former för patientdelaktighet har utformats och använts. Dessa är frågeformulär, intervjuer, workshops och patientföreträdare i förbättringsnätverket. Resultatet från studien visar att formerna för patientdelaktighet ger skilda förutsättningar för delaktigheten. Resultatet visar på betydelsen av organisatoriska förutsättningar, värdet av patientdelaktighet, utmaningar vid införande och vilket reellt inflytande som patientdelaktigheten haft under processen och för resultaten av förbättringsarbetet. Slutsatser. Patientdelaktighet skapar värde i flera dimensioner. Patientdelaktighet behöver designas, anpassas till kontexten och förbättringsarbetets mål och dess syfte behöver vara tydligt uttryckt. / Background. Perineal tears during childbirth can lead to after-delivery complications that leads to great suffering and low quality of life for a long time. Purpose. The purpose has been to improve after-delivery care by systematic follow-up, increasing the quality of diagnostics and management of these women, improving the information for the patient and developing new ways of improving including patients in the improvement work. The purpose of the study has been to study the effect of patient participation in the improvement work. Method. "The improvement ramp" and patient process-oriented perspective has been used to design the improvement work. The method of the study was qualitative in the form of a case study. Results. Follow-up using 3D-ultrasound is introduced. A care chain has been introduced and ways of patient participation have been designed and used. These are questionnaires, interviews, workshops and patient representatives in the improvement network. The results of the study show that the ways of patient participation provide different conditions for participation. The result shows the importance of organizational conditions, the value of patient participation, challenges in the introduction and the real influence that patient participation has had during the process and on the results of the improvement work. Conclusions. Patient-participation in QI creates values in several dimensions. Patient-participation needs to be carefully designed in compliance with context, goals and purpose.

Orientador: Maria Salete de Angelis Nascimento / Banca: Sérgio Serrano / Banca: José HumbertoTavares Fregnani / Resumo: O aumento considerável de pessoas no mundo acometidas por câncer, associado ao prolongamento da vida, em decorrência das avançadas tecnologias utilizadas no tratamento, reforça a importância de se utilizar a qualidade de vida como uma medida importante dos tratamentos realizados. Para os pacientes com câncer de reto, com tumores muito próximos aos esfíncteres anais ou envolvendo essas estruturas, a amputação abdominoperineal do reto continua sendo o principal tratamento. Como alternativa à colostomia abdominal para pacientes selecionados, a colostomia perineal, segundo a técnica de Alcino Lázaro, tem sido empregada com resultados satisfatórios. No entanto, esses pacientes terão que realizar a auto irrigação para o resto da vida, garantindo a continência intestinal. Assim, o objetivo deste estudo foi avaliar as complicações cirúrgicas e a qualidade de vida dos pacientes submetidos à amputação abdominoperineal do reto com colostomia abdominal, ou com colostomia perineal que se auto irrigam, seguindo um novo método de irrigação e avaliar a eficácia desse novo método. Foi realizado um estudo transversal, após aprovação do Comitê de Ética em Pesquisa do Hospital do Câncer de Barretos, entre junho de 2009 a novembro de 2009. A qualidade de vida foi avaliada utilizando dois questionários desenvolvidos pela European Organization for Research and Treatment of Câncer (EORTC), sendo um específico para câncer (EORTC QLQ-C30) e outro específico para câncer de reto (EORTC QLQ-CR38). Um total de 38 pacientes foram incluídos, sendo 21 com colostomia perineal e 17 com colostomia abdominal. Em relação às características sócio demográficas, clínicas e terapêuticas, os grupos foram semelhantes no que diz respeito à idade, sexo, cor, estado civil, escolaridade, renda, ocupação, estádio clínico,... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The considerable increase of people in the world suffer from cancer, associated with prolongation of the life in result of the advanced technologies used in the treatment, reinforces the importance of using quality of life as an important measure of the carried through treatments. For patients with rectal cancer, with tumors very close to the anal sphincter or involving these structures, amputation abdominoperineal of the rectum continues being the main treatment. As an alternative to abdominal colostomy for selected patients, a perineal colostomy, using the technique of Alcino Lázaro, has been used with satisfactory results. However, these patients will have to perform self-irrigation for the rest of your life, guaranteed bowel continence. The aim of this study to evaluate the surgical complications and the quality of life of patients who underwent the abdominoperineal amputation of the rectum and either had an abdominal colostomy or a perineal colostomy and self-irrigation through a new method of irrigation and evaluate the effectiveness of this new method. After official approval from the Ethics Committee in Research of the Cancer Hospital of Barretos, Brazil, a cross-sectional study with prospective data collection of 38 patients was carried out from June 2009 to November 2009. The quality of life was evaluated through two questionnaires developed by the European Organization for Research and Treatment of Cancer (EORTC): one was specific for cancer (EORTC QLQ-C30) and the other one was specific for rectal cancer (EORTC QLQ-CR38). A total of 38 patients were included, 21 with perineal colostomy and 17 with abdominal colostomy. Regarding socio-demographic, clinical and therapeutic characteristics, the groups were similar in age, gender, race, marital status, education, income, occupation, clinical... (Complete abstract click electronic access below) / Mestre