Comments on: Comparison of fluid and body composition measures in women with lipoedema, lymphoedema, and control participants.

Recently, we read with interest the article 'Comparison of fluid and body composition measures in women with lipoedema, lymphoedema, and control participants' by Stellmaker R, Thompson B, Mackie H, Koelmeyer L. Clin Obes. 2024:e12658, is very important study, but some considerations are necessary.

Cross-Over Study Evaluating Photobiomodulation in Pain Control in the Lower Limb.

Introduction Photobiomodulation is an emerging treatment modality in dermatology, with increasing use in doctors' offices. Photobiomodulation is the use of various light sources in the red light (620-700 nm) and near-infrared (700-1440 nm) spectrums as a form of light therapy. Objective The objective of the present study was to evaluate the use of photobiomodulation to improve pain in patients who take analgesics daily for chronic non-arterial leg ulcers. Method A cohort trial was performed with 20 patients to evaluate the improvement in pain, patient tolerance to treatment, and evolution of chronic, difficult-to-heal leg ulcers treated with low-frequency laser. Data were entered into a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA, US). Statistical analysis used the Stats Direct 3 program with significance being set at an alpha error of 5% (p-value <0.05). Results An improvement in pain immediately after the first session was experienced by 18/20 patients; these patients remained pain-free for at least four days. One patient had suffered much pain during the entire day; a biopsy with culture and antibiogram was performed with the pain improving after treating an infection with appropriate antibiotics. However, one other case reported no improvement in the pain. Conclusion Photobiomodulation is an optional adjuvant therapy to improve pain in the treatment of chronic, difficult-to-heal leg ulcers.

Mesenteric Infarction With Cerebral Thrombotic Relapses and Pulmonary Embolism Two and Four Months After COVID-19.

The aim of the present study was to report different sites of thrombotic events during and after coronavirus disease 2019 (COVID-19) in a 49-year-old patient who had acute mesenteric infarction in acute phase, stroke 2 months after and pulmonary thromboembolism 4 months after infection by COVID-19. The obese, previously healthy patient experienced myalgia and headache with subfebrile peaks and was tested positive for COVID-19 with a fast polymerase chain reaction (PCR) assay. Ten days after the onset of symptoms, the patient was submitted to exploratory laparotomy, which revealed 20 cm of small intestine loop with signs of suffering and thickening of the wall approximately 120 cm from the ileocecal valve. Two months after the event, angiotomography was performed, revealing effacement of the sulci in the right parietal region and hypersignal of the right middle cerebral artery with stop in M1. Two months later (4 months after the mesenteric infarction), chest angiotomography revealed signs of acute pulmonary thromboembolism, with no typical image of pulmonary infarction. Despite all these complications in the postoperative period, the patient survived.

Lymphedema and Elephantiasis of the Lower Limbs: Normalization or Nearly Normalization.

Lymphedema is a clinical condition resulting from a failure in the drainage of the lymphatic system and the consequent formation of edema and is a chronic progressive condition; its development is an active dynamic process. Physiotherapy techniques are the most widely used method for such cases. However, novel concepts and treatment techniques have emerged in recent years. Godoy & Godoy have developed novel therapy concepts proposing the normalization or near normalization of all clinical stages of lymphedema, including elephantiasis.The Godoy & Godoy method has undergone continual evolution, with the improvement of established and the emergence of novel concepts making contributions to the understanding of the causes and treatment of lymphedema. These researchers developed a novel concept of manual lymphatic drainage based on linear movements, cervical lymphatic therapy, a novel concept in mechanical lymphatic drainage, and hand-crafted stockings made with grosgrain material. Therefore, the aim of the present study is to report the new concepts of treatment for lymphedema and the maintenance of such results by the Godoy & Godoy technique in all stages. The Godoy & Godoy method enables the normalization or near normalization of lymphedema in all clinical stages, including elephantiasis.

Hallermann-Streiff Syndrome and Lower Limb Lymphedema with Nasal Obstruction.

Background: Hallermann-Streiff syndrome (HSS) is a rare congenital abnormality involving multiple craniofacial malformations, such as micrognathia, prominent frontal and nasal bones, vision defects, and dental anomalies, which can result in obstructive sleep apnea syndrome. The aim of the present study was to report a case of nasal obstruction in an individual with Hallermann-Streiff syndrome who had never breathed through the nose during treatment for lower limb lymphedema involving cervical lymphatic therapy. Case Report. An 18-year-old female adolescent with a diagnosis of HSS was sent from the genetics service of a teaching school for the treatment of lower limb lymphedema. At around 11 years of age, the patient began to present edema in the left leg, accompanied by broadening of the face and neck. The patient reported having obstructed nostrils and breathing through the mouth her entire life. On the second day of treatment, the patient reported being able to breathe through one of the nostrils, this had never occurred before. Based on this finding, the decision was made to include linear facial lymphatic drainage using the Godoy method, which led to the complete resolution of the nasal obstruction in the first 15 minutes of treatment. Nasal obstruction in children with Hallermann-Streiff syndrome may be caused by lymphedema. Conclusion: A specific lymphatic drainage technique, such as cervical lymphatic therapy and facial linear lymphatic therapy, can resolve the obstruction and maintain the nostrils unblocked for months.

Mortality and Deep Vein Thrombosis in the Gamma Variant of Covid 19 and Lung Injury.

Purpose: The SARS-CoV-2 disease predisposes infected individuals to thrombosis, the underlying mechanisms of which are not fully understood. The balance between pro-coagulant factors and natural coagulation inhibitors in critically ill patients with Covid-19 is fundamental to the prevention and treatment of complications. The aim of the present study was to investigate the pulmonary injury patterns in Covid-19 having higher mortality in the presence of deep vein thrombosis in comparison to patients without venous thrombosis and determine the Gamma variant. Methods: A retrospective study was conducted involving the evaluation of 200 medical records of patients with Covid-19 and a clinical suspicion of deep vein thrombosis (DVT) at the intensive care unit of a public hospital. The sample was divided into two groups of patients were formed - those positive and those negative for DVT. Statistical analysis involved the use of Fisher's exact test, the paired t-test and chi-square test. Results: Patients with DVT had more severe lung injuries (greater than 70%) compared to those without DVT (p = 0.003). Lesions affecting 50% to 70% of the lung area occurred in little more half of the group with DVT and just under half in the group without DVT (p = 0.5). Pulmonary lesions affecting less than 50% of the lung occurred more in patients without DVT (p = 0.0001). The Gamma variant increased prevalence of the both DVT and mortality (p=0.0001). Conclusion: Deep vein thrombosis is an aggravating factor of mortality in patients with SARS-CoV-2, and the Gamma variant is an aggravating factor of both thrombotic events and mortality.

Reduction of Arm Lymphedema Using Manual Lymphatic Therapy (Godoy Method).

BACKGROUND: The manual lymphatic drainage (MLD) technique used during the early stages following surgical treatment of breast cancer can help prevent the progression of clinical lymphedema. OBJECTIVE: The objective of this study was to evaluate the effectiveness of manual lymphatic therapy (MLT) (Godoy method) in reducing the development of lymphedema immediately after breast cancer treatment. METHOD: A randomized, blind, crossover, clinical trial was conducted involving 66 women with breast cancer-related lymphedema (BCRL), who underwent one hour of manual physical therapy and one hour of the control procedure. To evaluate the volume before and after the application of the MLT technique, volumetry, a water displacement technique was used. For statistical analysis, the paired t-test with 5% alpha error by Stats Direct 3(StatsDirect Ltd, Wirral, UK) was used. RESULTS: A significant reduction in the volume of the limb was found in all patients (p-value = 0.0001, paired t-test). CONCLUSION: MLT is effective in reducing lymphedema after breast cancer treatment.

Case Report: Godoy & Godoy method of cervical lymphatic therapy - indirect evaluation of the effect of the duration of stimulation on ocular edema.

The aim of the present study is to report the indirect evaluation of cervical stimulation considering the effect of the duration of the stimulus on the control of intraocular pressure in a patient with bilateral glaucoma with important ocular edema.  A 47-year-old woman reported the onset of pain and bilateral tearing in the eyes at 35 years of age and was diagnosed with glaucoma. The patient began clinical treatment, but intraocular pressure remained 35 to 40 mmHg even with the use of four eye medications in the form of drops. The patient reported that her vision was always blurred despite the use of the eyedrops. The patient was submitted to the Godoy & Godoy method of cervical lymphatic therapy to reduce the edema. The ophthalmologist measured her intraocular pressure every two and three days. We found that the pressure was maintained below 20 mmHg when lymphatic therapy was performed every two days, but intraocular pressure increased and the vision became blurred when therapy was performed every three days. The Godoy & Godoy method of cervical lymphatic therapy constitutes a novel lymphatic system stimulation strategy that maintains its effect on intraocular pressure for approximately 48 hours, as demonstrated through an indirect evaluation.

Mechanical Lymphatic Drainage (RAGodoy®): Literature Review.

Lymphatic drainage is the main form of therapy for lymphedema, as it affects the pathophysiology of this clinical condition. The two main objectives of lymphatic drainage are the formation and drainage of lymph. In recent years, Godoy & Godoy developed a novel concept of mechanical lymphatic drainage involving a device denominated RAGodoy®, which performs passive exercises of the lower and upper limbs as a form of lymphatic drainage. The aim of the present study was to address the concept of this therapy as well as perform a literature review on its forms of use and the results obtained. All studies analyzed show that this technique used as monotherapy enables the treatment of lymphedema, but superior results are achieved when combined with compression mechanisms.

Mortality of Patients Infected by COVID-19 with and without Deep-Vein Thrombosis.

BACKGROUND: Current evidence points to a state of hypercoagulability (consequence of hyperinflammation) as an important pathogenic mechanism that contributes to the increase in mortality in cases of COVID-19. The aim of the present study was to investigate the influence of deep-vein thrombosis on mortality patient's infected with SARS-CoV-2. METHOD: A clinical trial was conducted involving 200 consecutive patients with COVID-19-100 patients who were positive for deep-vein thrombosis (venous Doppler ultrasound) and 100 who were negative for deep-vein thrombosis at a public hospital. RESULTS: The mortality rate was 67% in the group positive for DVT and 31% in the group negative for DVT. CONCLUSION: Deep-vein thrombosis is associated with an increase in mortality in patients with COVID-19 and failures can occur with conventional prophylaxis for deep-vein thrombosis.

Intensive Treatment for Upper Limb Lymphedema.

Introduction Breast cancer-related lymphedema (BCRL) is a complication of treatment for breast cancer. The aim of the present study is to report a form of intensive treatment for BCRL. Method A crossover study was conducted involving the evaluation of the change in the volume of the upper limbs of 45 women with BCRL who underwent the intensive Godoy Method® (eight hours/day for five days). Volumetric analyses were performed before and after treatment and differences were analyzed using the paired t-test. Reductions in volume were found in all patients. Results The average reduction was 45.38%. The reduction was between 15% and 20% in 6.67% of the women (n = 3); 20% to 30% in 13.33% (n = 6); 30% to 40% in 20% (n = 9); 40% to 50% in 40% (n = 18); and more than 50% in 20% of the women (n = 9). Conclusion The intensive form of treatment for lymphedema is highly effective in a short period of time, with a 40% to 50% reduction in volume in five days, but requires specialized centers adapted to this form of therapy. This is an option for reference centers in the treatment of lymphedema and the formation of human resources.

Exercising and Compression Mechanism in the Treatment of Lymphedema.

AIM: The aim of this study was to evaluate the effect of adjustments to a compression stocking on reductions in leg volume during walking in patients with lymphedema. METHOD: Fourteen women and three men suffering from leg lymphedema with ages between 21 and 68 years old (mean 45.68 years) were randomly enrolled in this study. Evaluations were made by volumetry before and after each session of controlled walking. Patients were subjected to three one-hour sessions of walking slowly on the flat ground monitored by a professional. For the first session, the patients used a well-adjusted cotton-polyester compression stocking, for the second they used a badly adjusted compression stocking made of the same fabric, and for the third, no compression garment was used. The Kruskal-Wallis test was used for statistical analysis. RESULTS: On comparing the volume before and after walking for one hour with the well-adjusted cotton-polyester compression stocking, there was a mean reduction of 46.2 mL ± 66.95 mL (p-value < 0.02) in the volume of the lymphedema. In the one-hour session of walking without any compression, the volume of the leg increased by 74.4 mL ± 99.75 mL (p-value < 0.007). On walking with the compression stocking badly adjusted, there was a mean increase in the volume of 31.6 mL ± 46.9 mL (p-value < 0.14). CONCLUSION: Walking is a type of muscle activity that can be transformed into a type of daily exercise when you are guided by how it is going to be performed. The exercise, in this study specifically, walking, with a strict control of speed and time of realization using a compression mechanism is well adjusted to the volume of the limb and surely effective in reducing edema.

Stimulation of Synthesis and Lysis of Extracellular Matrix Proteins in Fibrosis Associated with Lymphedema.

Background: Fibrotic diseases pose a problem for overall health due to their chronic, progressive nature; the lack of a cure; and the fact that such conditions are largely refractory to current medical and surgical treatment practices. Objective: The aim of the present study was to report the physiological stimulation of synthesis and lysis of extracellular matrix proteins during the treatment of primary lymphedema. Material and Methods: A clinical trial was conducted involving the analysis of changes in type I and III collagen fibers and elastic fibers as well as the thickness of the epidermis and dermis in 10 histological fields. Samples were taken from the skin before and after intensive treatment using the Godoy Method® and adapted to the treatment of fibrosis in a patient with a clinical diagnosis of lower limb lymphedema. Slides were stained with orcein, hematoxylin and eosin, picrosirius red, and Gomori's reticulin stains. Weibel's multipoint method was used for the morphometric evaluation. The data were compared using the t-test with a 95% confidence interval. Results: Significant changes were detected in all aspects of interest (thickness of the epidermis and dermis, type I and III collagen fibers, and elastic fibers). Conclusion: The present findings demonstrate the physiological stimulation of synthesis and lysis of the main components of an extracellular matrix, such as type I and III collagen fibers and elastic fibers, as well as a reduction in the thickness of the epidermis and dermis in cases of fibrosis through adequate stimulation of the lymphatic system.

Lipedema and the Evolution to Lymphedema With the Progression of Obesity.

AIM: The aim of the present study was to evaluate the prevalence of subclinical and clinical systemic lymphedema in patients with lipedema and different body mass index (BMI) values. METHOD: A cross-sectional study was conducted to determine the prevalence of subclinical systemic lymphedema and clinical lymphedema of the lower limbs detected by bioimpedance (InBody S10 device, Seoul, Korea) in 258 women with clinically diagnosed lipedema. The patients were divided into three groups based on BMI: Group I - BMI below 30 kg/m2; Group II - BMI between 30 and 40 kg/m2; and Group III - BMI 40 to 50 kg/m2. RESULTS:  Fisher's exact test revealed a statistically significant difference between Group I and both Groups II and III (p = 0.0001) regarding the occurrence of lower limb lymphedema. CONCLUSION: Patients with lipedema can develop edema even when their weight is within the standards of normality. However, obesity is an aggravating factor, as the prevalence of lipedema increases progressively with the increase in weight.

Intensive Treatment of Lower-Limb Lymphedema and Variations in Volume Before and After: A Follow-Up.

Background and objective Lymphedema is a clinical condition resulting from a failure in the drainage of the lymphatic system and the consequent formation of edema. The aim of the present study was to report the results of five days of intensive treatment for lymphedema and the maintenance of such results at the first follow-up evaluation. Method A clinical trial was conducted involving 409 patients with primary or secondary unilateral, lower-limb lymphedema who underwent intensive treatment with the Godoy method. The treatment consisted of eight hours per day of mechanical lymphatic drainage, 15 minutes per day of cervical stimulation, and compression mechanics involving the use of laced grosgrain (non-elastic) stockings alternated with bandages. Volumetric evaluations were performed at baseline, after five days of intensive treatment, and at the first follow-up evaluation performed one to three months after intensive treatment. Results The mean volume was 2,083.43 ml at baseline and 937.55 ml after five days of intensive treatment, corresponding to a 55% reduction. The mean was 800.83 ml at the follow-up evaluation, corresponding to a reduction of 137 ml [17.12 non-significant difference (p = 0.1)]. Conclusion The intensive treatment of lymphedema leads to considerable reductions in edema within a short period of time, facilitating the continuity of treatment and demonstrating the credibility of the method.

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.

Lipolymphedema Associated with Idiopathic Cyclic Edema: A Therapeutic Approach.

Idiopathic cyclic edema is a type of generalized edema that mainly affects women. Diagnosis is made by the patient's clinical history and an evaluation of the accumulation of weight during the day. The objective of this study is to report the clinical control of lymphedema associated with idiopathic cyclic edema using calcium dobesilate. A 55-year-old female patient reported generalized edema for years in that she woke up in the morning with her legs swollen and the edema worsened during the day. The physical examination revealed generalized edema. After four days of treatment with calcium dobesilate, the patient returned to the Clínica Godoy, Brazil, with less edema and reductions in body weight and the amount of extracellular and intracellular fluid. With further treatment, there was a total reduction of the edema. It is concluded that calcium dobesilate helps to control lymphedema secondary to idiopathic cyclic edema.

Maintenance of the Results of Stage II Lower Limb Lymphedema Treatment after Normalization of Leg Size.

OBJECTIVE: The aim of this study was to identify strategies to transfer responsibility of the maintenance of the results of lymphedema treatment to the patient. METHODS: Maintenance of the reduction of edema was evaluated in a prospective clinical trial in patients with Stage II leg lymphedema. Twenty-one lymphedematous lower limbs were evaluated in Clínica Godoy in 2014 and 2016. The evaluation was done by volumetry at baseline and weekly thereafter for volume control. Patients wore Venosan® cotton 20/30 and 30/40 mmHg elastic compression stockings followed by a custom-made inelastic stocking made of grosgrain fabric. The Friedman test for multiple comparisons and Conover post hoc test were used for statistical analysis with an alpha error of 5%. RESULTS: On comparing leg volume changes using the different types of stockings, the 20/30 mmHg elastic compression stockings failed in the first week to maintain the volume reductions but the 30/40 mmHg compression stockings did not allow significant increases in volume (p value > 0.05). During one week, the grosgrain stocking reduced leg volumes to baseline values (p value = 0.24). CONCLUSION: Higher compression of elastic stockings is better than lower compression but the inelastic grosgrain stocking is even better than both to maintain the results.

Prevalence of Idiopathic Cyclic Edema in Women with Lower Limb Lymphedema.

Cyclic edema is a clinical condition in women that leads to fluid retention in the orthostatic position. The aim of the present study was to evaluate the prevalence of idiopathic cyclic edema in women with lower limb lymphedema. The prevalence of idiopathic cyclic edema was evaluated in a retrospective study of 100 consecutive female patients submitted to leg lymphedema treatment at the Clínica Godoy. The diagnosis of lymphedema was clinical, based on patient history and a physical examination. Patients with clinical stage II lymphedema were included in the study with those in stages I and III being excluded. The diagnosis of idiopathic cyclic edema was based on the patient's history and fluid retention of more than one kilogram between 7:00 a.m. and 5:00 p.m. Clinical signs of this disease include difficulty removing rings in the morning that becomes easier during the course of the day, waking up with a swollen face, and abdominal discomfort during the day. After diagnosing cyclic edema, a therapeutic test was performed using aminaphtone or calcium dobesilate with which fluid retention was reduced to less than 300 g during the same period. The patients were instructed to drink liquids only when they were thirsty.

Evolution of Skin during Rehabilitation for Elephantiasis Using Intensive Treatment.

The objective of this study is to describe the evolution of the skin during rehabilitation for elephantiasis using intensive treatment. We report on the case of a 55-year-old patient with a seven-year history of leg edema. The patient reported that it began with repeated outbreaks of erysipelas over several years. One leg evolved with significant edema leading to an inability to ambulate and for about one month the patient said that he could not get out of bed. Moreover the patient was obese weighing 130 kilos and with a BMI of 39. Intensive treatment was performed over three weeks resulting in a significant reduction in limb volume. The treatment consisted of Mechanical Lymphatic Therapy (RAGodoy), Cervical Lymphatic Stimulation (Godoy & Godoy technique), and a custom-made inelastic stocking of a grosgrain textile. What caught the attention during therapy were the open wounds resulting from fragmentation of the plaque as the edema reduced; the plaque was about 0.5 cm thick. As the treatment evolved the plaque disappeared and the wounds healed. The limb size decreased by more than 80% in three weeks after which the patient began to be treated in an outpatient setting with ambulation using a grosgrain stocking.