Efficacy of proprioceptive neuromuscular facilitation in improving shoulder biomechanical parameters, functionality, and pain after axillary lymph node dissection for breast cancer: A randomized controlled study.

PURPOSE: Axillary lymph node dissection and radiotherapy have been associated with pain, physical symptoms, and decreased functional abilities in the upper extremity. This study aimed to evaluate the potential effects of the proprioceptive neuromuscular facilitation (PNF) technique on muscle strength, pain and functionality in this patient group in comparison with progressive resistance training (PRT). METHODS: The study was conducted with a randomized clinical trial design. Sixty-six women were included in the study and randomly divided into three groups: the PNF group (n = 22), the PRT group (n = 22), and the control group (n = 22). The participants were evaluated at the baseline and after eight weeks of treatment. Outcome measures were determined as pain (the Visual Analog Scale), upper extremity strength (isokinetic dynamometer), functionality (the Disabilities of the Arm, Shoulder and Hand questionnaire), and perception of change (the Global Rating of Change Scale). TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05288036. RESULTS: The results showed statistically significant changes in both treatment groups in terms of shoulder flexors/extensors, abductor/adductors, internal/external rotators strength/power/endurance measurement, pain, and functionality (p < 0.05). Concerning functionality and perception of change, the PNF group had a statistically significantly higher improvement compared to the remaining two groups (p < 0.05). CONCLUSION: PNF is an effective technique in increasing upper extremity muscle strength, reducing pain during rest and activity, and improving functionality in patients receiving breast cancer treatment.

Significant Asymmetry of the Bilateral Upper Extremities of a Skeleton Excavated from the Mashiki-Azamabaru Site, Okinawa Island, Japan.

The human skeleton of a young adult male with marked asymmetry of the bilateral upper extremities was excavated from the Mashiki-Azamabaru site (3000-2000 BCE) on the main island of Okinawa in the southwestern archipelago of Japan. The skeleton was buried alone in a corner of the cemetery. In this study, morphological and radiographic observations were made on this skeleton, and the pathogenesis of the bone growth disorder observed in the left upper limb was discussed. The maximum diameter of the midshaft of the humerus was 13.8 mm on the left and 21.2 mm on the right. The long bones comprising the left upper extremity lost the structure of the muscle attachments except for the deltoid tubercle of the humerus. The bone morphology of the right upper extremity and the bilateral lower extremities was maintained and was close to the mean value of females from the Ohtomo site in northwestern Kyushu, Japan, during the Yayoi period. It is assumed that the anomalous bone morphology confined to the left upper extremity was secondary to the prolonged loss of function of the muscles attached to left extremity bones. In this case, birth palsy, brachial plexus injury in childhood, and acute grey matter myelitis were diagnosed. It was suggested that this person had survived into young adulthood with severe paralysis of the left upper extremity due to injury or disease at an early age.

Short-term Effect and Acceptability of Manual Lymphatic Drainage for Paediatric Limb Lymphoedema: A Prospective Study.

Paediatric lymphoedema (LE) is a rare condition, for which there is little data available regarding treatments. The aim of this study was to assess the short-term effect and acceptability of a 30-min session of manual lymphatic drainage (MLD) in children with well-documented LE of the lower limbs. Fifteen children were included (8 males; median age 11 years). Comparison of the sum of circumference values for the whole limb before and after MLD revealed a slight, but significant, reduction (from a median of 289.8 to 285.5 cm, p = 0.024), but the limb volumes did not decrease significantly (from a median of 4,870.3 to 4,772.3 ml, p = 0.394). Dermal thickness, measured by high-resolution ultrasound, decreased from 1.44 to 1.40 mm (p < 0.001). All children reported improvement in well-being, and found MLD useful. In conclusion, MLD is well accepted by children, but has poor impact on LE swelling. However, it decreases cutaneous oedema by mobilizing the lymph fluid.

A Study Using Visual Art Methods to Explore the Perceptions and Barriers of Self-Management in Children and Adolescents with Lymphedema.

Background: The aims of this study were to explore, using visual art methodology, how children and adolescents perceive their lymphedema and conceptualize the barriers and enablers in self-management and to explore the role of an educational camp in promoting self-efficacy. Methods: Participants (speaking English, French, and Italian) were recruited during an educational camp for children with lymphedema. Children and adolescents used different methodologies to depict living and self-managing their condition. Younger children (aged 5-12 years) drew pictures, and all children and adolescents (aged 5-18 years) were given cameras and asked to take photographs that depicted their experience of learning self-management of their condition during the camp. Rose's critical visual methodology framework was used for analysis. Results: Analysis of the data produced five categories: Normal versus altered childhood, living with lymphedema; perceptions of lymphedema and self-care in younger children; adolescents' perception of living and managing lymphedema; learning self-efficacy; and insights into cultural differences in self-care. Conclusions: The study has shown that self-management is complex. Children and adolescents face many daily challenges and frustrations in managing their condition in addition to the normal challenges of development and growth that impact on: home life, time with friends, school activities, and relationships. Children expressed a deep longing for cure and a recognition that their lives were altered by having the condition that led to limitations in sport and wearing fashionable clothes and shoes. The importance of relationships with professionals was critical as was the experience of meeting and learning with other children through the camp experience. Attempts to simplify self-management techniques would appear to be a key priority as would a greater understanding of the self-beliefs young people have of their ability to influence and control their condition and its impact on their life.

A Study to Explore the Professional Conceptualization and Challenges of Self-Management in Children and Adolescents with Lymphedema.

Background: The aim of this study was to explore the professional experience of caring for children and adolescents with lymphedema and to explore the way in which they understand and implement self-management strategies and the influence of their own self-efficacy beliefs on this process. Methods and Results: Participants were recruited during an educational camp for children with lymphedema. Three individual semistructured focus groups were undertaken in English, French, and Italian with simultaneous translation. Data were analyzed using interpretative phenomenological analysis (IPA). Analysis of the data produced three superordinate themes: professional concepts of self-management, professional practice, and redefining the cornerstone of lymphedema care. An additional seven subthemes were as follows: readiness to self-management, professional perspectives on self-management, defining success and treatment failure, emotional burden, traditional views on complex decongestive therapy, new ways to practice, and sole practitioner versus multidisciplinary teams. Conclusions: The purpose of the study was to explore the challenges professionals face when introducing self-management to children and adolescents with lymphedema and their parents and to explore their own sense of self-efficacy in approaching this. The research allowed in-depth discussion about the ways they conceptualize self-management and faced professional challenges. The research highlighted the need to define what is considered an acceptable outcome within a complex and uncertain condition and the self-management strategies that are needed to support this.

A Study to Explore the Parental Impact and Challenges of Self-Management in Children and Adolescents Suffering with Lymphedema.

Background: Limited research has shown the impact lymphedema has on children and families. The aim of this study was to explore the parental experience of caring for a child or adolescent with lymphedema and the daily challenges of self-management and self-efficacy. Methods and Results: Participants were recruited during an educational camp for children with lymphedema (N = 26). Three individual semistructured focus groups were undertaken in English, French, and Italian with simultaneous translation. Data were analyzed using interpretative phenomenological analysis. Analysis identified four superordinate themes; the journey, treatment management, independence, and psychosocial impact. Ten subthemes were identified: bandaging/compression, professional support, holistic care, fear, self-efficacy, acceptance, friendship, guilt, distress, and hope. Conclusions: Parental self-management of children with lymphedema is complex and invades many aspects of life. Lack of professional agreement over what constitutes self-management leads to parental confusion and anxiety. Self-management is demanding, and parents are ambivalent to its effectiveness, but choose to persevere through fear of their child's condition deteriorating. Self-efficacy is evident in complex problem solving, despite parents believing that they are not adequately prepared for this.

Cost-Effectiveness of Osteoporosis Interventions to Improve Quality of Care After Upper Extremity Fracture: Results From a Randomized Trial (C-STOP Trial).

We assessed the cost-effectiveness of two models of osteoporosis care after upper extremity fragility fracture using a high-intensity Fracture Liaison Service (FLS) Case-Manager intervention versus a low-intensity FLS (ie, Active Control), and both relative to usual care. This analysis used data from a pragmatic patient-level parallel-arm comparative effectiveness trial of 361 community-dwelling participants 50 years or older with upper extremity fractures undertaken at a Canadian academic hospital. We used a decision-analytic Markov model to evaluate the cost-effectiveness of the three treatment alternatives. The perspective was health service payer; the analytical horizon was lifetime; costs and health outcomes were discounted by 3%. Costs were expressed in 2016 Canadian dollars (CAD) and the health effect was measured by quality adjusted life years (QALYs). The average age of enrolled patients was 63 years and 89% were female. Per patient cost of the Case Manager and Active Control interventions were $66CAD and $18CAD, respectively. Compared to the Active Control, the Case Manager saved $333,000, gained seven QALYs, and averted nine additional fractures per 1000 patients. Compared to usual care, the Case Manager saved $564,000, gained 14 QALYs, and incurred 18 fewer fractures per 1000 patients, whereas the Active Control saved $231,000, gained seven QALYs, and incurred nine fewer fractures per 1000 patients. Although both interventions dominated usual care, the Case Manager intervention also dominated the Active Control. In 5000 probabilistic simulations, the probability that the Case Manager intervention was cost-effective was greater than 75% whereas the Active Control intervention was cost-effective in less than 20% of simulations. In summary, although the adoption of either of these approaches into clinical settings should lead to cost savings, reduced fractures, and increased quality-adjusted life for older adults following upper extremity fracture, the Case Manager intervention would be the most likely to be cost-effective. © 2019 American Society for Bone and Mineral Research.

Trauma in the upper limb of an Upper Paleolithic female from Caviglione cave (Liguria, Italy): Etiology and after-effects in bone biomechanical properties.

The impact of injury on the health and activities of human foragers is of great interest for understanding the adaptability of past populations to their environments. For the Gravettian female of Caviglione 1, a violent blow has been suggested as the origin of the left radial fracture, and abnormal body asymmetry has been observed. Access to high resolution CT-scans of the upper limb allows us to address new etiologic considerations and assess the after-effects of trauma on bone biomechanical properties by focusing on cortical and trabecular bones and conducting a comparative analysis of cross-sectional geometric properties in an Upper Paleolithic context. This originally right-dominant female, who became left-handed, was mainly affected by severe bone modifications on the proximal right humerus due to secondary changes following a traumatic event. The left radial fracture is very well consolidated with thick and homogeneous cortical bone. Etiological considerations point to a Galeazzi fracture for the left forearm occurring during a fall. The bone structure and robusticity of the left arm probably prove the lack of strong and enduring dependency of this female on her group for the usual cultural tasks despite the strongly limited function of the right arm.

Melilotus, Rutin and Bromelain in primary and secondary lymphedema.

As reported in the literature, benzopyrones (alpha and gamma) have important effects on the microcirculation through various mechanisms. Coumarins are an alpha-benzopyrone as derivatives of Melilotus Officinalis, while bioflavonoids are a gamma-benzopyrone and include Rutin. Alpha-benzopyrones have two fundamental pharmacological effects: they have pro-lymphokinetic action by activating contractility of lymphangions; and the activation of macrophages to provide a proteolytic effect. Gamma-benzopyrones, such as Rutin, have an important anti-exuding and membrane stabilizing effect. Bromelain is known for its anti-inflammatory effect. The present study enrolled 52 patients with primary and/or secondary lymphedema in clinical stages I or II (according to the ISL classification) with 31 cases involving the lower limbs and 21 cases involving the upper limbs. All subjects were given for six months a natural compound consisting of 100 mg of natural Melilotus, that contains 20 grams of Coumarin, 300 mg of Rutin and 100 mg of Bromelain. The following parameters were studied at zero time (T0), after three months (T1), and after six months of treatment (T2): pitting, Stemmer's sign, measurement of limb circumferences, measurement of superficial tissue thickness in the affected limbs using ultrasound, and blood tests to evaluate hepatic function (ALT, AST, GGT, total and fractional bilirubin). At the end of the treatment (T2), the following results were observed: disappearance of pitting in 72% of the cases; unchanged Stemmer's sign; average decrease in limb circumferences of 4.2 cm; and average reduction of the superficial thickness of 29%. There was no variation in the liver function parameters examined. The combination of natural compounds (Melilotus, Rutin, and Bromelain) has been shown to be a valuable aid in the clinical control of both primary and secondary lymphedema of clinical stages I and II as well as in control of inflammatory phenomena related to chronic stasis. There were no side effects and no alteration of liver function parameters found.

Terapia física complexa no tratamento do linfedema maligno / Complex physiotherapy in the tratament of malignant lymphedema

O linfedema de membro superior é uma complicação frequente após tratamento do câncer de mama. Quando há recidiva do tumor ou crescimento tumoral desconhecido que gera infiltração ou compressão da rede linfática, pode ocorrer o desenvolvimento do linfedema maligno. O objetivo terapêutico para o linfedema maligno é estabilizar a doença e mantê-la assintomática. A fisioterapia pode auxiliar no tratamento por meio da técnica denominada "terapia física complexa". O presente estudo aborda o caso de uma paciente de 61 anos pós-tratamento de câncer de mama diagnosticada com linfedema maligno no membro superior esquerdo. A equipe de fisioterapia utilizou a terapia física complexa para redução e controle do linfedema no membro superior afetado e obteve valores expressivos na diminuição do volume em relação à avaliação inicial e ao final do tratamento, ainda, não houve retrocesso a valores iniciais após período de 3 meses de seguimento. (AU)

Upper limb lymphedema is a frequent complication following breast cancer treatment. When there is tumor relapse, or unknown tumor growth that leads to lymph nodes compression or infiltration, the development of malignant lymphedema can take place. The therapeutic goal for malignant lymphedema is to stabilize the disease, and keep it asymptomatic. Physical therapy can help in the treatment through the technique called "complex physical therapy". The present study deals with the case of a 61-year-old patient after treatment of breast cancer diagnosed with malignant lymphedema in the left upper limb. The physiotherapy team used complex physical therapy to reduce and control the upper limb lymphoedema, and obtained significant values in volume reduction at the end of treatment compared to baseline, and no reversal to initial values after a 3-month follow up was observed. (AU)

Tratamiento de la enfermedad de Hailey-Hailey generalizada con fototerapia UVB de banda estrecha / Narrowband UV-B Phototherapy in the Treatment of Generalized Hailey-Hailey Disease

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Complex Decongestive Therapy Enhances Upper Limb Functions in Patients with Breast Cancer-Related Lymphedema.

BACKGROUND: We aimed to evaluate the effects of complex decongestive therapy (CDT) on upper extremity functions, the severity of pain, and quality of life. We also searched the impact of the sociodemographic and clinical characteristics on the improvement in upper extremity functions. METHODS: A total of 37 women with breast cancer-related lymphedema (BCRL) [age, 53.6 ± 11.2 (28-72)] were included in this study. All patients underwent CDT-phase 1 program, including meticulous skin care, manual lymphatic drainage, remedial exercises, and compression bandages. Arm volume was calculated by a formula for truncated cone using circumferential measurements. A baseline questionnaire, including sociodemographic and clinical properties, was used for each patient. Short Form-36 (SF-36), Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and Visual Analog Scale (VAS) for pain and heaviness were used as clinical assessment scales. RESULTS: The mean of the posttreatment volume of the affected limb was lower compared to pretreatment volume (2741.81 ± 696.85 and 2990.67 ± 745.49, respectively), and the mean percentage change in edema volume was 38.1% ± 26.5%. We observed a statistically significant reduction in pain and heaviness VAS scores and improvement of shoulder mobility among upper extremities with lymphedema (p < 0.001) after CDT. The mean of posttreatment DASH score was lower compared to pretreatment score (37.19 ± 16.01, 49.81 ± 18.84, respectively, p < 0.001). All subgroups of the SF-36 parameters were increased after the CDT application (p < 0.01). Besides being under 65 years old, having a body mass index above 30 and short duration of lymphedema were found to be related to greater improvement in upper extremity functions. CONCLUSIONS: CDT provides enhancement of upper extremity functions and quality of life in patients with BCRL. The reduction in lymphedema volume, pain, and heaviness and the improvement in shoulder mobility may be the contributed factors.

Successful treatment of chromoblastomycosis of 10-year duration due to Fonsecaea nubica.

We report a case of chromoblastomycosis due to the presence of large plaque and verrucous hyperplasia lesions on the left upper limb, with elbow abnormal activities, in a 56-year-old male. The diagnosis of chromoblastomycosis was based on gross and microscopic morphologies, histopathological examination and clinical manifestation. Molecular tools were applied to identifying the causative agent Fonsecaea nubica, which is rarely reported to be associated with chromoblastomycosis. The patient was initially treated orally with terbinafine (250 mg/day) and itraconazole (200 mg/day), subsequently patient received thermotherapy (45-50°C, 3 h/day) for 1 month. The patient was successfully cured. A literature review was performed to assess general features, treatment and outcome of chromoblastomycosis due to F.  nubica. All the 5 reviewed patients were male, over 30 years old and their lesions occurred after traumatic inoculation.

Prevalence and Patterns of Injury Sustained During Military Hand-to-Hand Combat Training (Krav-Maga).

BACKGROUND: Krav-Maga (KM) is a unique Israeli hand-to-hand combat system, designed to teach soldiers self-defense in true-to-life situations. With the increase in military Israel Defense Force (IDF) units participating in KM training in recent years, the number of injuries incurred in KM has also increased. The purpose of our report is to describe the prevalence and pattern of these injuries. METHODS: Instances of KM injury were taken from IDF patients' computerized clinical records over a 1-year period. Data pertaining to the type, location, and severity of the injury, as well as data relating to soldier's gender and age were collected from the charts. "Moderate" injury was defined as injury necessitating absence from military activity for more than 1 week; "major" injury was defined as injury necessitating surgical intervention. FINDINGS: During the year 2014, 916 soldiers complaining of 946 traumatic injuries sustained during KM training were evaluated in IDF clinics. The vast majority of injuries (95%) occurred in male soldiers, and most injured soldiers (92%) were between the ages of 18 and 22. The upper limbs were the most frequently injured body parts, with the fingers, hands, and wrists being the most involved regions (31%) followed by the shoulder (16%). Injury severity was mild in most cases. However, 64 soldiers (6.7%) were moderately injured and major injuries necessitating surgical treatment occurred in 33 cases (3.5%). DISCUSSION: KM involves both striking and grappling elements, and we assume that injuries result from both fighting forms. With striking styles, such as boxing and kickboxing, hand and wrist are the prevalent injury locations; with grappling styles such as wrestling, strain and sprain injuries of large joints are most prevalent. Head and neck injuries, a major concern in martial arts sports, were not identified as significant problems in KM. To minimize participant injury, preventative measures should focus on improving protective equipment, especially of the hand, as well as warm up and training technique modifications, and shoulder strengthening exercises.

Sarcomas en la extremidad superior: revisión del Servicio de Cirugía Plástica - Comité de Sarcomas de Partes Blandas del Hospital Dr Negrin / Upper extremity sarcomas. Review from Plastic Surgerym Department - Soft-Tissue Sarcoma Committee at Dr. Negrin Hospital

Introducción y Objetivo. Los sarcomas de la extremidad superior suponen un bajo porcentaje dentro de los sarcomas en general. Las características anatómicas de las extremidades superiores representan un reto quirúrgico a la hora de conjugar la radicalidad con la preservación funcional de la extremidad. Por el contrario, la raíz de la extremidad ya presenta otras características anatómicas y dimensiones, permitiendo extirpaciones más amplias y siendo además asiento favorito de sarcomas de bajo grado. Con estas premisas, es de suponer que el pronóstico global de esta localización sea más favorable que el del resto de la extremidad. El objetivo del presente estudio es confirmar dicha hipótesis en base a nuestra propia experiencia. Material y Método. De los 131 sarcomas intervenidos en nuestro Servicio durante los últimos 10 años, recogemos 29 casos de sarcomas en extremidad superior, que dividimos en 2 grupos según su asiento: los que afectan a la cintura escapular (hombro, escápula y clavícula), con 12 casos; y los de asiento en la extremidad propiamente dicha (axila, brazo, antebrazo y mano) con 17 casos. Analizamos una serie de variables en ambos grupos: sexo, edad, localización, tipo histológico, grado de diferenciación, presentación, tipo de extirpación, tratamiento quirúrgico, terapias complementarias, estado local, estado general y seguimiento. Resultados. Los sarcomas de la cintura escapular fueron, en nuestro grupo de estudio, de menor grado que los de la extremidad propiamente dicha. Se presentaron en su mayoría como casos primarios. Estos sarcomas son susceptibles de tratamientos más radicales y como consecuencia, los márgenes obtenidos fueron mejores que los del otro grupo. Ninguno de los 12 pacientes con sarcoma en cintura escapular presentó enfermedad local o general. Los sarcomas de la extremidad superior propiamente dicha fueron de predomino femenino, de más alto grado y se presentaron como recidivas o persistencias en más de la mitad de los casos. Las posibilidades quirúrgicas locorregionales son menores. Se practicaron 3 amputaciones y 1 desarticulación. Se emplearon colgajos libres en 5 pacientes, 2 de ellos con componente óseo. El 47% de los pacientes recibió alguna forma de radioterapia y 2 pacientes recibieron quimioterapia. Contabilizamos 4 pacientes fallecidos, lo que supone un 24% del total de los casos de nuestro grupo. Conclusiones. Las características en nuestra serie de sarcomas de la raíz de la extremidad y de la extremidad propiamente dicha son distintas. En la primera las presentaciones primarias fueron más frecuentes, los grados de desdiferenciación más bajos y las extirpaciones más amplias, lo que se traduce en menor enfermedad local, general y mortalidad. Por el contrario, las presentaciones iniciales de los sarcomas de la extremidad (brazo, antebrazo y mano) fueron con frecuencia tras resecciones no planeadas, lo que se traduce en persistencias o recurrencias. Además, el grado de desdiferenciación de los sarcomas en esta zona es más alto y las extirpaciones que se consiguen no son tan amplias, por lo que los resultados en cuanto a enfermedad local, general o muerte por la enfermedad son peores (AU)

Background and Objective. Upper extremity sarcomas represent just a small percentage of all sarcomas. The anatomic characteristics of upper extremity challenge the goal of combining radicality and limb functional preservation. On the other hand, the limb root presents other features regarding dimensions and anatomy thus allowing wider resections. Moreover it is a common place for low grade sarcomas. With such premises it can be considered that the prognosis of sarcomas of this location is more favorable than those of the rest of the extremity. The aim of this study is to confirm this hypothesis, based on our own experience. Methods. During the last 10 years 131 sarcomas were operated in our Unit, 29 of them affecting the upper extremity were recruited. They were further subdivided into 2 groups according to their location: shoulder girdle (shoulder, scapula and clavicle) with 12 cases, and those arising at the limb itself (axilla, arm, forearm and hand) with 17 cases. Several variables were analyzed in both groups: gender, age, location, hystologic type, differentiation grade, presentation, extirpation regarding margins, surgical treatment, complementary therapies, local status, general status and follow - up. Results. Sarcomas of the shoulder girdle own lower grade than those of the extremity itself. They present mostly as primary cases.Wide resections were feasible and therefore the obtained margins were better than those of the other group. None of the 12 patients of this group has had neither local or general disease. Sarcomas of the extremity itself appeared more in women, with higher grades and they are seen firstly at our institution after inadequate surgical margins or as recurrences in more than half of the cases. Locoregional flap options are scarce. Three amputations and 1 shoulder disarticulation were done in this group. Five free flaps, 2 of them with osseous component, were used. Forty-seven patients received some kind of radiotherapy and 2 more patients received chemotherapy. Four deads were recorded among this group representing 24% of all cases. Conclusions. In our series the characteristics of sarcoma to the shoulder girdle and those of the extremity itself were different. In the former primary presentations as new cases are more frequent, dedifferentiation grades were lower and resections wider resulting in lower rates of local recurrences, general disease or mortality. On the other hand, sarcomas to the extremity appear mainly after unplanned resections as recurrences or inadequate margins excisions. Dedifferentiation grades here are higher and resections are not as wide as in the other group. Worse results regarding local disease, general disease or mortality were here recorded (AU)

T4 Syndrome: A Scoping Review of the Literature.

OBJECTIVE: The purpose of this scoping review was to identify any available evidence regarding T4 syndrome. METHODS: Databases were searched from inception through October 2015 and included PubMed, CINAHL, PEDro, Google Scholar, Osteomed-DR; Index to Chiropractic Literature, PROSPERO, and Chiroaccess. All studies with information about T4 syndrome that were published in a peer-reviewed journal or textbook were included. The information was organized in the format of the International Classification of Functioning, Disability, and Health. Studies were ranked using Sackett's levels of evidence. RESULTS: Eight articles met the inclusion criteria. Studied areas included theoretical pathophysiology and symptom etiology, diagnosis, symptoms, treatment, and outcomes of T4 syndrome. The methodological quality of included studies was low. CONCLUSION: T4 syndrome is a diagnosis of exclusion that appears to be rare. It has been treated conservatively in the literature using mobilization and exercise. There is no high-quality evidence published about T4 syndrome, and we caution clinicians when considering it as a primary means to determine patient care.

[Comprehensive physical antiedematous therapy in treatment of patients with lymphedema]. / Kompleksnaya fizicheskaya protivootechnaya terapiya v lechenii patsientov s limfedemoi.

Presented in the article is retrospective analysis of the results of treatment of patients with lymphedema. We treated a total of 33 patients with primary (n=6) and secondary (n=27) lymphedema. Stage II lymphedema was diagnosed in 18 (54.5%) patients, stage III lymphedema in 15 (45.5%) patients. The 33 patients had a total of 44 affected limbs (9 hands and 35 legs). All patients were subjected to comprehensive physical antiedematous therapy including: manual lymph drainage massage, formation of compression bandage, selection of individual class 3 plain stitch compression knitwear, special complex of therapeutic exercises, care of the skin of the affected limb. A positive effect was achieved in all cases. In patients with upper limb lesions the volume of the extremity decreased averagely by 1'235.0±283.7 cm3 (22.6% of the baseline volume, p<0.005), in patients with lower limb lesions it decreased by 2'712.0±350.3 cm3 (22.1% of the initial volume, p<0.005). The carried out therapeutic course resulted in improvement of quality of life at the expense of decrease of the deformity and improvement of the function of the limb, increase of the scope of movements in the joints, regression of trophic alterations, widening of possibilities of wearing footgear and clothes. A conclusion was made that comprehensive antiedematous physical therapy is an effective method of treatment of patients with limb lymphedema, making it possible to attain regression of trophic disorders and to improve patients' quality of life.

A New Method for Treatment of Lymphedema of Limbs: Standardized Manual Massage with a New Device Linforoll in Conservative and Surgical Therapy Protocols.

OBJECTIVES: Edema fluid in lymphedematous limbs should be evacuated to sites where it can be absorbed. It should be moved either to the hypogastrium or arm/scapular regions along tissue channels or implanted silicon channels or through lymphovenous anastomoses. For that purpose, the manual lymphatic drainage of limb is an effective method. Standardization of manual massage applied force and timing becomes necessary. AIM: A device with known pressing area and continuously showing the applied force while moving it toward the root of the limb is needed. Moreover, force could be adjusted to the stiffness of the massaged tissues that varies at different levels of the limb. Results from such a device would be repeatable and reproducible by others. METHODS: In this study we present data on tissue fluid hydromechanics obtained from 20 patients with obstructive limb lymphedema during massage with a massaging roller called Linforoll. Linforoll is composed of a hand piece with roller and pressure sensor connected wireless to the computer displaying the pressure curve of the applied force. Electron microscopy studies for checking eventual tissue changes were done. RESULTS AND CONCLUSIONS: Linforoll provides the possibilities of: 1) regulating the applied force according to the hydromechanic conditions of the massaged tissues; 2) standardization of massage repeatable in the same patient; 3) decrease of limb volume; 4) evident increase in tissue elasticity; 5) application as a driving force for fluid flow along the surgically implanted tubing and vessels running to the lymphovenous shunts.

[Conservative treatment of tendinopathies of upper limbs in occupational health: a literature review]. / Trattamenti conservative nelle tendinopatie agli arti superiori in ambito occupazioinale: revision narrative.

BACKGROUND: In the last few years, the incidence of upper limbs tendon injuries has seen a dramatic increase among workers. Conservative treatment is the first choice to relieve symptoms, allowing a safe return to work. However, the scientific evidence of its  efficacy is widely debated. OBJECTIVE AND METHODS: Research and literature review on the efficacy of conservative treatment of upper limbs tendon injuries in occupational settings. RESULTS: A total of 271 references were found on Medline and Embase up to May 2015. 116 papers were excluded, 155 articles were included and the full text read. CONCLUSIONS: After a timely diagnosis, a prompt start of the rehabilitation programme and a limitation of complete rest are useful to relieve pain, increase functionality and reduce work absenteeism in the long term. Conservative treatment combinations, such as manual therapy, specific exercises focused on increasing flexibility and muscle strength and specific-gesture training, achieves more significant results than a single isolated treatments. Currently, there is no strong scientific evidence to support prolotherapy and Platelet-Rich Plasma (PRP). However, current promising results will encourage further studies. Awareness among both employers and employees about prevention and risk factors should be enhanced.

Two cases of sporotrichosis of the right upper extremity in right-handed patients with diabetes mellitus / Dos casos de esporotricosis de la extremidad superior derecha en pacientes diestros con diabetes mellitus

Background. Sporothrix species have proved to show high degrees of endemicity. Sporothrix globosa is the only pathogenic Sporothrix species that has till date been reported from China, where it is endemic in the northeastern provinces. Aims. We report two cases of lymphocutaneous sporotrichosis with diabetes mellitus as underlying disease in patients from the non-endemic area of China. Methods. A 59-year-old farmer and a 60-year-old gardener were admitted in February and June 2014, respectively. Both patients were right-handed men and presented with progressive plaques and nodules, which they had for several years, involving the right upper extremity. Skin biopsy from the granuloma was taken and cultured on Sabouraud medium, and molecular identification based on the calmodulin region was performed. Antifungal susceptibility testing was also performed with the microdilution method. Results. Biopsy of the lesions showed the presence of infectious granuloma. The fungal cultures were identified as Sporothrix globosa by conventional methods, and confirmed by molecular identification. A subsequent course of oral antifungal therapy with low dosage of itraconazole was well tolerated and resolved the infection. Conclusions. Identification of fungal species and antifungal susceptibility testing are mandatory for epidemiological and therapeutic reasons. Early diagnosis of sporotrichosis is essential to prevent those sequelae when the disease progresses and provides highly effective methods for treating this emerging disease. Avoiding the exposure to plant material potentially contaminated with fungal spores should be recommended, especially in immunocompromised patients (AU)

Antecedentes. Las especies de Sporothrix han demostrado un alto nivel de endemicidad. Sporothrix globosa es la única especie patógena descrita hasta la fecha en China, donde es endémica en las provincias del nordeste. Objetivos. Se describen dos casos de esporotricosis linfocutánea con diabetes mellitus como enfermedad de base, en pacientes procedentes de un área no endémica de China. Métodos. Un campesino de 59 años y un jardinero de 60 años de edad fueron atendidos en febrero y junio de 2014, respectivamente. Ambos eran varones, diestros y se presentaron con placas y nódulos de varios años de evolución, que afectaban a la zona superior del brazo derecho. Se tomaron biopsias de los granulomas de la piel, que fueron cultivados en medio de Sabouraud, y se realizó una identificación molecular basada en la región de la calmodulina. Se evaluó la sensibilidad a los antifúngicos mediante el método de microdilución. Resultados. La biopsia de las lesiones mostró la presencia de un granuloma infeccioso. Los hongos aislados en los cultivos fueron identificados como Sporothrix globosa por métodos convencionales, y confirmados mediante identificación molecular. La subsecuente administración de terapia antifúngica oral con bajas dosis de itraconazol fue bien tolerada y resolvió la infección. Conclusiones. La identificación de las especies fúngicas y el análisis de la sensibilidad a los antifúngicos son necesarios por razones epidemiológicas y terapéuticas. El diagnóstico temprano de la esporotricosis es esencial para prevenir las secuelas que genera el progreso de la enfermedad y para ofrecer métodos altamente efectivos para el tratamiento de esta enfermedad emergente. Debe recomendarse evitar la exposición a material vegetal potencialmente contaminado con esporas fúngicas, especialmente en pacientes inmunocomprometidos (AU)