Mobilization of Fluids in the Intensive Treatment of Primary and Secondary Lymphedemas.

BACKGROUND: Lymphedema is a clinical condition resulting from the accumulation of macromolecules in the interstitial space with a consequent buildup of fluids. AIM: The objective of this study was to compare the therapeutic response to treatment that mobilizes fluids between primary and secondary lymphedemas. METHOD: Thirty-three patients with severe leg lymphedema who underwent intensive treatment for five consecutive days in 2013 and 2014 at the Clínica Godoy were evaluated in a prospective clinical trial. Diagnosis was based on the patient's history and physical examination. Treatment consisted of eight hours/day of Mechanical Lymphatic Therapy using an electromechanical device (RAGodoy®) that performs plantar flexion and extension associated with 15 minutes of Cervical Lymphatic Therapy, a technique developed by Godoy and Godoy that involves stimulation in the cervical region and a grosgrain compression stocking alternated with elastic bandages. The unpaired t-test and Fisher's exact test were used for statistical analysis with an alpha error of 5% (p value < 0.05) being considering acceptable. Secondary lymphedema was more prevalent in women (Fisher exact test p value < 0.01). RESULTS: The age of patients with secondary lymphedema was greater than those with primary lymphedema (unpaired t-test: p value < 0.03). The mean volume losses were 64.62% and 48.35% for the patients with secondary and primary lymphedema, respectively (p value < 0.03). CONCLUSION: Women are more prevalent and older in the secondary lymphedema group. Volumetric reductions below the knee are faster with intensive treatment for secondary rather than for primary lymphedema.

Prevalence of COVID-19 Among 8000 Patients at a Hospitalized and Mortality in Old Age.

BACKGROUND: COVID-19 created a general challenge to healthcare systems throughout the world and was an important cause of mortality. AIM: The aim of the present study was to report the general evolution of patients with COVID-19 at a teaching hospital and analyze differences by age group and sex considering mortality rates in the years 2020 and 2021 among patients older than 60 years of age. METHODS: A cross-sectional study was conducted with patients hospitalized with a diagnosis of COVID-19 confirmed by RT-PCR at the São Jose do Rio Preto university hospital between March 2020 and March 2022. The patients were male and female patients, of varying ages belonging to the region of Sao Jose do Rio Preto, were accommodated in the wards or intensive care units (ICUs). Overall mortality was analyzed for the hospital as well as in the ICUs and wards. This analysis was performed separately in two years considering age group, sex, and main comorbidities in patients older than 60 years of age. RESULTS: A total of 8032 patients with COVID-19 were hospitalized between March 2020 and March 2022: 2866 patients with 658 deaths (22.92%) in 2020; 4324 patients with 1168 deaths (27.01%) in 2021; and 842 patients with 205 deaths (24.35 %) in 2022 up to the month of March. More than half (53.60%) of the patients were hospitalized in the ICUs and 46.39% were hospitalized in the wards. Differences in the mortality rate were found for the different age groups in the comparison of the years, with more deaths occurring among individuals up to 90 years of age in the second year (p <0.05). Men were affected more and had a higher mortality rate (p <0.0001). The main comorbidities were cardiovascular disease (70.93%), diabetes (37.76%), and obesity (23.68%). CONCLUSION: The mortality rate of older people hospitalized with COVID-19 was higher than the average, it was higher in 2021 compared to 2020 and increased with age. Cardiovascular disease, diabetes, and obesity were the main comorbidities.

Prevalence of Pulmonary Embolism in COVID-19 at Quaternary Hospital Running Head: Pulmonary Embolism in COVID-19.

Background: Patients with COVID-19 are at greater risk of pulmonary embolism. Objective: The aim of the present study was to evaluate the monthly prevalence of pulmonary embolism diagnosed by angiotomography and mortality between March 2020 and May 2021 in more than 6000 patients hospitalized with COVID-19 at a single institution. Methods: A clinical trial was conducted with evaluated medical records the patients hospitalized at the institution who developed pulmonary embolism determined by angiotomography. Monthly and overall mortality rates between March 2020 and May 2021 in this population were evaluated. Results: A total of 6040 patients were hospitalized in this period, 203 of whom (3.36%) had an angiotomographic diagnosis of pulmonary embolism and 119 of these patients (58.62%) died. The largest number of patients with pulmonary embolism occurred in the periods from July to September 2020 and March to May 2021. No significant difference was found between mortality and the two peaks of the pandemic (p = 0.9, Fisher's exact test). Conclusion: Pulmonary embolism is associated a higher mortality rate among patients with COVID-19. Therefore, one of the strategies is an emphasis on the prevention of thrombotic and embolic events.

Aortic Thrombosis Associated with Three Types of COVID-19 Vaccine.

Aortic thrombosis has been studied little in patients with COVID-19 and an association has recently been reported with the vaccine for this disease. The aim of the present study is to report five cases of aortic thrombosis at our institution within a three-month period associated with the COVID-19 vaccine. Five cases of aortic thrombosis were evaluated-three women and two men aged 29, 49, 51, 60, and 79 years. Four thrombi involved the thoracic aortic and one involved the abdominal aorta, with embolisms found in the kidneys, spleen, liver, upper limbs, and lower limbs. Embolectomy was performed on the limbs, and anticoagulant therapy was performed for the abdominal arteries. The patients recovered well and anticoagulant therapy was maintained. Aortic thrombosis is uncommon but was associated with the AstraZeneca vaccine in this case series.

Association of ApoE genetic polymorphisms with proximal deep venous thrombosis.

The aim of the current study was to evaluate a possible association between apolipoprotein E (ApoE) genetic polymorphisms and deep venous thrombosis. A case-control study of ApoE genetic polymorphisms was carried out in 60 male and female patients with deep venous thrombosis and 60 male and female controls. The ages of the patients ranged between 23 and 90 years old (mean ± standard deviation: 58 ± 16.56 years) and the ages of the control group, varied between 21 and 56 years old (mean ± SD: 33 ± 10.93 years). Genetic polymorphisms were analyzed in respect to the prevalence of alleles (APOE*2, APOE*3 and APOE*4) and genotypes (APOE*2/2, APOE*2/3, APOE*2/4, APOE*3/3, APOE*3/4 and APOE*4/4). The ε2 allele was more common in patients who had suffered thrombotic events (P = 0.0034). Additionally, there was a significant difference on comparing the distribution of alleles in female patients and female controls (P = 0.027). These results demonstrate an association between the ApoE ε2 allele and deep venous thrombotic events in women. This association opens the possibility of a new line of research to better understand these thrombotic events.

Synergic effect of compression therapy and controlled active exercises using a facilitating device in the treatment of arm lymphedema.

TRIAL DESIGN: A randomized controlled trial was performed to evaluate the effect of the combination of compression therapy with active exercising using a facilitating apparatus on arm lymphedema. METHOD: Twenty women with a mean age of 63.3 years were evaluated; all had lymphedema resulting from breast cancer treatment. The inclusion criterion was a difference of 200 mL in size between arms. The apparatus used, called 'pulley system', is a vertical iron wheel fixed on a support at a distance of 10 cm from the patient's body. Participants were submitted to two series of active exercises using this facilitating device, one series using a compression sleeve and the other without. Each series consisted of four 12-minute sessions of exercises separated by 3-minute rest intervals. Volumetry was performed before and after each series of exercises. The paired t-test was utilized for statistical analysis (p-value < 0.05). RESULTS: A significant mean reduction (p-value < 0.007) and non-significant mean increase (p-value < 0.2) in volumes were observed during exercising with and without compression, respectively. CONCLUSION: Controlled active exercising utilizing a facilitating apparatus while wearing a compression sleeve reduces the size of lymphedematous arms.

Monotherapy for the Treatment of Lymphedema in Children: A Review.

The Godoy Method of cervical lymphatic therapy is the first treatment option as monotherapy for children which facilitates achieving normalization or near normalization of the affected limb as well as the maintenance of the results, which could assist millions of children throughout the world.

Diabetes as an Isolated Cause of Minor Lower Limb Amputations.

Objectives: Amputation is a devastating but preventable complication of diabetes and peripheral arterial disease. The aim of the present study was to investigate whether diabetes mellitus is an important isolated cause of toe amputation. Methods: A cross-sectional study was conducted involving the records of 108 patients with minor lower limb amputations and 80 with major lower limb amputations. Association between diabetes/chronic arterial insufficiency and level of amputation was tested. Statistical analysis was performed using Fisher's exact test. Results: The prevalence of diabetes was 87.5% among patients submitted to minor amputations and 52.5% among those submitted to major amputations with or without chronic arterial disease. This difference was statistically significant (p<0.0001, Fisher's exact test). A total of 44.44% of the patients submitted to minor amputations had diabetes alone (no chronic arterial insufficiency), whereas only 14.81% of the patients submitted to major amputations did not have chronic arterial insufficiency. Thus, diabetes was significantly associated with minor lower limb amputations (p<0.0004, Fisher's exact test). Conclusion: Based on the present findings, patients with diabetes are at greater risk of toe amputation compared to those with chronic arterial disease.

SARS-CoV-2 gamma variant and chronic arterial insufficiency due to late arterial thrombosis.

The current evidence suggests a state of hypercoagulability as one of the sequelae of hyperinflammation. Thus, it is an important pathogenic mechanism that contributes to increase the mortality caused by COVID-19. The aim of the present study is to report chronic arterial insufficiency after post-thrombosis in the same arteries 32 days later, as a sequel after severe acute respiratory syndrome coronavirus 2 P.1. After the 2nd day of discharge, she had a lot of pain in her left and limiting leg and was referred to the vascular service. The patient was evaluated by vascular surgery who underwent a clinical diagnosis of Rutherford II.A arterial thrombosis and underwent arteriography of the limb that revealed thrombosis of the anterior, posterior, and fibular arteries in the middle third and the plantar arch was not contrasted. She underwent emergency embolectomy with selective isolation of the tibial arteries, but with success after the procedure only for the posterior tibial artery. Anticoagulation was maintained and 100 mg aspirin was associated.

Evaluation of the prevalence of concomitant idiopathic cyclic edema and cellulite.

The aim of this study was to evaluate the prevalence of concomitant idiopathic cyclic edema with Grade II and III cellulite. All patients treated for Grade II and III cellulite were evaluated for idiopathic cyclic edema in a retrospective, quantitative and cross-sectional study. The study was carried out at the Godoy Clinic in the period from 2006 to 2010. All patients with body mass indexes > 25, Grade I cellulite and other causes of edema were excluded. The diagnosis of idiopathic cyclic edema was based on a clinical history and fluid retention throughout the day, in particular difficulty in removing rings on waking in the morning which improves later in the day. All patients with cyclic edema were treated with 75 mg aminaphtone three times daily. Statistical analysis considered the frequency of edema. Of the 82 women evaluated with ages between 18 and 58 years old (mean of 34.9 years) 41 (50.0%) were diagnosed with idiopathic cyclic edema. Idiopathic cyclic edema is an aggravating factor for cellulite and is frequently associated with the more advanced stages of the disease. Its control is essential in the treatment of cellulite.

Treatment for chest pain intercurrence after breast cancer surgery using Godoy's intermittent skin therapy.

OBJECTIVE: Chest pain and swelling are routinely reported in women after breast cancer treatment and are often not valued by health professionals. In general, these patients suffer and without many effective solutions. The aim of the present study was to report the results of a novel technique for the treatment of chest pain related to breast cancer treatment. METHODS: A clinical trial was conducted involving 25 women with chest pain resulting from the treatment of breast cancer and submitted to treatment for lymphedema at the Godoy School in 2018. Godoy's intermittent dermal therapy was performed on the participants 2-4 h/day for 2 days until the occurrence of a significant improvement or complete resolution of pain (measured using the visual analog pain scale). RESULTS: All patients reported a significant reduction in pain in the first ½ h of treatment (P < 0.0001, Wilcoxon signed-rank test). Six of the 25 patients (24%) reported the absence of pain after treatment on the 1st day and all (100%) reported the absence of pain at the end of treatment on the 2nd day. CONCLUSION: Chronic chest pain in patients having been submitted to treatment for breast cancer can be significantly reduced with Godoy's intermittent skin therapy, achieving standards of normality or near normality within only a few sessions.

Thrombosis of the right iliac, femoral, popliteal, and tibial arteries in a post-COVID-19 in adolescent.

BACKGROUND: Viral infection into lung, muscular, and endothelial cells results in inflammatory response, including edema, degeneration, and necrotic alterations. The involvement of the major arteries in adolescent with COVID-19 has been infrequently reported in the literature. The aim of the present study is to report thrombosis of the right iliac, femoral and tibial arteries and stenosis of left iliac artery in an adolescent with COVID-19 and to discuss the pathophysiological hypotheses. CASE PRESENTATION: We report the case of a 17-year-old female patient with COVID-19 infection. She was seen at the physician specialized general medicine in her hometown, was diagnosed with COVID-19 but did not require hospitalization. After 15 days, she had sudden pain in the left leg that has limited her ability to walk more than 10 met, associated with extremity cyanosis and coldness. Angiotomography revealed thrombosis of a portion of the iliac and popliteal arteries. Na emergency embolectomy was successfully performed, followed by full-dose heparinization with unfractionated heparin. CONCLUSION: Arterial thrombosis of large arteries may be associated with chronic inflammatory syndrome secondary to COVID-19 infection and the treatment with a late embolectomy was successful, even in a thrombotic event.

Clinical aspects of congenital primary lymphedema.

PURPOSE: Lymphedema is a specific type of edema with a chronic, progressive nature. The aim of the present study is to report clinical findings related to edema and its location in children with primary lymphedema. METHODS: Sixty-eight children with congenital primary lymphedema were evaluated at the Godoy Clinic in São Jose do Rio Preto, Brazil, between 2014 and 2017. A retrospective, cross-sectional study was conducted involving the analysis of clinical data on the location of edema in 68 children with congenital primary lymphedema. We evaluated the charts of all children with this condition in the period analyzed, recording the affected limbs and conditions associated with lymphedema. RESULTS: Sixty-eight children, 37 girls (54.41%) and 31 boys (45.58%), were evaluated. CONCLUSION: We found that congenital primary lymphedema predominantly affects the lower limbs and is more prevalent in girls than boys.

Effect of systemic arterial pressure on erectile dysfunction in the initial stages of chronic arterial insufficiency.

OBJECTIVE: To report the effect of systemic arterial pressure on erectile dysfunction (ED) in patients in the initial stages of peripheral arterial disease. PATIENTS AND METHODS: All patients with a diagnosis of ED in the urology outpatient clinic of the Medicine School in São José do Rio Preto, Brazil were evaluated in a cross-sectional, quantitative study. The patients were assessed using the International Index of Erectile Function, the ankle-brachial index, and measurement of arterial blood pressure. Binary logistic regression, log-likelihood, Pearson chi-square and likelihood ratio chi-square and Kruskal-Wallis Test were used for statistical analysis with P < 0.05 being considered acceptable. Fifty-two patients (mean age 56.63 years) were enrolled in the study. RESULTS: Differences were detected between the median grades of ED of patients with differing degrees of chronic arterial insufficiency. Hypertensive patients in the initial stages of peripheral arterial disease had less severe grades of ED than normotensive patients. CONCLUSIONS: The progression of ED parallels the development of chronic arterial insufficiency. Systemic arterial hypertension in the initial stages of peripheral arterial disease might protect against ED, but peripheral arterial disease constitutes an aggravating factor for ED, and thus hypertension might exert a paradoxical effect in this stage of the disease.

Hospital infection after major amputations.

The aim of the current study was to evaluate the prevalence of stump infections after major amputations of the lower extremities. Patients rehospitalized in Hospital de Base of the Medicine School in São José do Rio Preto in the period from January 2005 to January 2007 due to stump infection after major amputations of lower extremities were evaluated in a retrospective study. All the patients underwent prophylactic antibiotic therapy at the time of the surgery. The Fisher exact test was utilized for statistical analysis with an alpha error of 5% (p-value < 0.05) being considered acceptable.A total of 231 patients were submitted to major amputations during this period and 17 (7.3%) were rehospitalized due to amputation stump infections of which 5 (29.4%) died within one month. The association between death due to stump infection and other causes of death during rehospitalizations was not significant (Fisher exact test: p < 0.1). However, death during rehospitalizations was significantly higher than in the initial hospitalization.

Godoy & Godoy technique in the treatment of lymphedema for under-privileged populations.

The aim of this paper is to report new options in the treatment of lymphedema for under-privileged populations. Several articles and books have been published reporting recent advances and contributions. A new technique of manual lymph drainage, mechanisms of compression, development of active and passive exercising apparatuses and the adaptation of myolymphokinetic activities have been developed for the treatment of lymphedema. This novel approach can be adapted for the treatment of lymphedema in mass.

Effect of walking on pressure variations that occur at the interface between elastic stockings and the skin.

The aim of this work was to dynamically study pressure variations exerted by elastic compression stockings during walking. While study participants walked, the pressure variations at the interface between elastic stockings and the skin were measured dynamically. Three healthy individuals wearing 10/20 and 20/30 elastic compression stockings manufactured by Sigvaris((R)) (Jundiai, São Paulo-Brazil) were requested to walk along a course for ten times at a constant speed. For every event, an apparatus specifically developed for the study and programmed to take readings at half-second intervals was used to measure the pressure exerted by the elastic stockings. The pressure exerted by the 10/20 stockings varied between 5 and 32 mmHg and for the 20/30 stockings it varied from 10 to 52 mmHg. Elastic stockings with larger pressures generate larger pressure variations during muscle activity (P-value < 0.001). In conclusion, muscle movements during walking cause the pressure exerted by elastic stockings on the leg to vary; thus, the pressure is not constant but has peaks and troughs according to the type of muscle movement and the gradient of the stockings.

Aminaphtone in the control of Schamberg's disease.

The aim of this case report is to describe control of Schamberg's disease using aminaphtone. We report on the case of a 28-year-old patient who presented with multiple purpuric lesions of the lower extremities which had appeared spontaneously. A biopsy of the skin was performed that showed a perivascular T-cell lymphocytic infiltrate centered on the small superficial blood vessels of the skin and so a diagnosis of Schamberg's disease was reached. The patient was prescribed corticoids and the lesions disappeared however on suspension of the medication the lesions re-emerged within three to seven days. This treatment was unsuccessfully continued for more than one year. Thus another therapeutic option was attempted: 75 mg of aminaphtone was prescribed twice daily for one month and the purpuric lesions disappeared within about one week. One year after suspending the medication no relapse of the purpura was observed.

Systemic subclinical lymphedema due to obesity as the cause of clinical lymphedema: A new concept.

On evaluating patients with lymphedema, the authors found that obesity is associated with generalized edema of all extremities and the trunk with increased intracellular and extracellular fluids, thus suggesting a new concept of lymphedema that the authors have termed systemic subclinical lymphedema. Animal studies show that obesity and its progression lead to changes in the lymphatic system and microcirculation with alterations in lymphatic motility, inflammatory processes, capillary permeability and immune response. Systemic subclinical lymphedema is diagnosed when above normal fluid levels are detected in all the extremities and the trunk with the progression of obesity; this can lead to the appearance of clinical lymphedema of the extremities.

Elephantiasis and Directed Occupational Rehabilitation.

The aim of the present study was to demonstrate the cure of elephantiasis over a ten-year follow-up period and novel discoveries with directed occupational rehabilitation. A 66-year-old female patient with a history of bilateral lower limb lymphedema reported the aggravation of the condition over the years, reaching stage III (elephantiasis). The physical examination confirmed elephantiasis. The circumference of the left lower limb was 106 cm. Her body weight was 106 kilograms, height was 160 cm, and the body mass index (BMI) was 41.6 kg/m2. The patient was submitted to intensive treatment for three weeks, which led to a 21-kg reduction in weight and 66 cm reduction in leg circumference. Ten years after treatment, the patient has maintained the results with the compression stockings. Elephantiasis can be cured, although lymphedema cannot. The cure of elephantiasis depends on maintaining the treatment of lymphedema after normalization or near normalization. Directed occupational therapy stimulates the search for new activities and a life closer to normality.