Lymphedema duration as a predictive factor of efficacy of complete decongestive therapy.

Lymphedema is a common condition with global impact and a multitude of complications, however, only a few professionals specialize in its management. A retrospective analysis of 105 subjects with unilateral lymphedema upper or lower limb was performed to investigate whether the duration of lymphedema constitutes an important factor associated with the efficacy of complete decongestive therapy (CDT). Subjects were classified into two groups according to the duration of lymphedema, prior to CDT: group A (≤1 year) and group B (>1 year). Both groups were treated daily according to the same CDT protocol for four weeks. The CDT efficacy was determined based on the percent reduction of excess volume (PREV) measurements. Lymphedema was significantly reduced in both groups of subjects, but significantly more in group A (p<0.001). In subjects with upper limb lymphedema, median value of PREV was 80.8% (interquartile range, 79.1-105.0%) in group A and 62.0% (interquartile range, 56.7-66.5%) in group B (p<0.001). In subjects with lower limb lymphedema PREV was 80.7% (interquartile range, 74.9-85.2%) and 64.5% (interquartile range, 56.0-68.1%) for groups A and B, respectively (p<0.001). Duration of lymphedema was found to be a strong predictive factor that may significantly impact CDT efficacy. Therapeutic effects were increased in subjects who were detected and treated earlier for lymphedema.

Tinzaparin Safety in Patients With Cancer and Renal Impairment: A Systematic Review.

Low-molecular-weight heparins are approved for primary and secondary venous thromboembolism prevention. Tinzaparin is the low-molecular-weight heparin with the highest average molecular weight. The purpose of this systematic review is to provide an update regarding the safety profile of tinzaparin, prescribed either as a prophylactic or as a therapeutic regimen for venous thromboembolism in special populations, including cancer patients and patients with renal impairment. We identified prospective studies up to August 2020 reporting safety outcomes for cancer patients and patients with renal impairment on tinzaparin regimens. In patients with cancer major bleeding rates fluctuated between 0.8% and 7%. Patients on tinzaparin exhibited significantly lower rates of clinically relevant nonmajor bleeding events in comparison with those on vitamin K antagonists. Bioaccumulation of tinzaparin was not correlated with age, body weight or creatinine clearance. Periodic administration of either prophylactic or therapeutic doses of tinzaparin did not result in bioaccumulation, even in patients with severe renal impairment and creatinine clearance < 20 ml/min. Major bleeding rates for non-cancer patients with renal impairment on prophylactic tinzaparin regimens were 0%. Non-cancer patients with renal impairment on therapeutic tinzaparin regimens exhibited major bleeding in 0 to 3.4% of cases; major bleeding rates were higher for cancer patients with renal impairment on therapeutic tinzaparin regimens (4.3 to 10%). Tinzaparin can be used without dose adjustment in patients with severe renal impairment and creatinine clearance > 20 ml/min. Tinzaparin represents a safe choice for special populations at increased risk for thrombosis and bleeding.

Physiotherapeutic rehabilitation of lymphedema: state-of-the-art.

Lymphatic diseases, especially lymphedema, represent a serious problem in the health community. We investigated strategies and methods for physiotherapeutic rehabilitation of lymphedema by carrying out a comprehensive search of the Medline and Embase databases from 1990 to 2016 to identify relevant published studies, articles, and reviews. Approaches for conservative management of lymphedema include the following: manual lymphatic drainage, lymphedema rehabilitation exercises, compression therapy, skin care, pneumatic compression, elevation of the extremities, thermal therapy, complete decongestive physiotherapy (CDT), taping, and aqua lymphatic therapy. Treatment of lymphedema with CDT, which is a combination of four methods (manual lymphatic drainage, lymphedema rehabilitation exercises, compression therapy, skin care), can achieve a 45-70% reduction in lymphedema volume. Prerequisites for successful physiotherapy are the availability of physicians, nurses and therapists who are specifically trained, educated, and experienced in each method. CDT is the most effective treatment as it reduces the symptoms of lymphedema and improves patients' functionality, mobility, and quality of life. Although other therapeutic techniques have demonstrated positive results, these surveys are limited and more studies are needed to confirm findings.

Prevalence, risk and aggravating factors of chronic venous disease: an epidemiological survey of the general population of Greece.

INTRODUCTION: Chronic venous disease (CVD) is a common disease all over the world, mainly in Western Europe and the USA. AIM: To evaluate the prevalence of CVD in the Greek general population and the characteristics of CVD. MATERIALS AND METHODS: The study sample included 1500 individuals, 15-64 years of age, who were citizens of Athens, Thessaloniki, or one of five Greek cities with more than 10,000 in the population. The sample was selected by a stratified, multistage, random sampling procedure based on the Greek Census 2001. Questionnaires were completed for each individual by personal interview. RESULTS: From 1500 individuals, 224 (14.9%) had symptoms and/or signs of CVD, 9.6% were men and 20.1% were women. The highest percentage of presenting CVD symptoms was among 45-54-year-olds (23.4%) and 55-64-year-olds (27%). The symptoms that were mostly mentioned among sufferers were 58% achy legs, 37.4% swollen legs and 25.3% heavy legs, whereas the frequent signs were broken capillaries - telangiectasia (19.2%) and varicose veins (14.8%). About 62.9% with CVD had an obese body mass index (BMI > 25). The prevalence of CVD in patients with prolonged standing hours at work (4+ hours) was 20.8%. The symptoms of CVD were worse during the summer period only in 26.8% of the patients whereas in 50.8% during all the year. Regarding quality of life, more than 40% of the patients had either health or cosmetic problems. Sufferers mentioned that they took first advice from physicians (28%), or from friends and relatives (27%) or from pharmacists (26%). CONCLUSION: This is a real whole-population study of Greece - a Mediterranean country that provides important and remarkable data on the epidemiology of CVD and highlights that we need improvement of relations within the triangle constituted by physicians, patients and disease.

Analgesic efficacy of an ibuprofen-releasing foam dressing compared with local best practice for painful exuding wounds.

OBJECTIVE: To examine if wound aetiology has an effect on the pain-relieving properties of an ibuprofen-releasing foam dressing, which was previously shown to reduce pain in wounds of various aetiologies, compared with local best practice (LBP). METHOD: This was a secondary analysis of data from a multicentre, randomised, parallel group trial of patients with painful exuding wounds of various aetiologies. Wound aetiology was determined at enrolment. Of 853 patients enrolled into the trial, 688 belonged to a wound aetiology subgroup that included >25 patients and were included in the analysis reported here. Patients were randomised to a dressing containing 112.5mg of ibuprofen (ibuprofen foam) or to LBP for 5 days. Patients recorded pain relief and pain intensity daily. The main endpoint was the proportion of patients who, from day 1 to day 5, reported a summed pain relief score >50% of the total maximum pain relief score (TOTPARD5>50%) and the corresponding number needed to treat (NNT) for each wound aetiology subgroup. Further analyses included the proportion of patients who, on a daily basis, reported pain relief >50% of the maximum daily pain relief, the proportion of patients who, on day 5, experienced a reduction in pain intensity of >50% of the maximum score (PIDD5>50%), and if PIDD5>50% was related to baseline pain intensity. RESULTS: Patients were categorised by the following five wound types: arterial, venous, and mixed arterial-venous leg ulcers, vasculitis and traumatic ulcers. The ibuprofen foam dressing was associated with significantly greater pain relief than LBP in all different wound aetiology subgroups, whether chronic or traumatic (acute). Overall, TOTPARD5>50% was 55% in the ibuprofen foam group and 24% in the LBP group (p<0.0001; NNT, 3.2). The pain intensity evaluations revealed similar results in favour of ibuprofen foam compared with LBP. No correlation was observed between PIDD5>50 and initial pain intensity. CONCLUSION: In this study, the ibuprofen foam dressing was shown to consistently relieve wound pain in exuding wounds of various aetiologies, irrespective of basal pain intensity. The data suggest that local pain relief by an ibuprofen foam dressing is possible in the most common, painful, exuding, chronic and acute/traumatic wounds and so is a safer alternative to systemic pain treatment.

Effect of collagen powder on lymphorrhea after modified radical mastectomy. A randomized controlled trial.

AIM: Postoperative lymphorrhea is a major complication of axillary lymphadenectomy. The aim of our study was to evaluate the impact of type I collagen in postoperative lymphorrhea in mastectomy patients. METHODS: Eighty patients that underwent modified radical mastectomy for breast cancer were randomized in two groups. In group A (collagen group, n = 42) collagen type I (Cellerate RX powder) was applied in the axillary cavity after lymphadenectomy while in group B (control group, n = 38) lymphadenectomy was performed in the standard fashion without the use of a sealant. Suction drains remained in place until the daily amount of lymphatic drainage fell under 30 ml. The total amount and the duration of drainage, as well as the morbidity and severity of arm pain were compared in the two groups. RESULTS: There was a non significant trend towards lower overall drainage in the collagen group. The duration of drainage and postoperative pain were similar in the two groups, as was morbidity. Subgroup analysis of patients according to the number of lymph nodes excised, revealed significantly less lymphorrhea in terms of volume and duration in patients who had more than ten lymph nodes excised. CONCLUSION: Collagen type I (Cellerate RX powder) appears to attenuate postoperative lymphorrhea in patients undergoing axillary lymphadenectomy especially when > 10 lymph nodes are removed.

Emmanuil Kondoleon: pioneer in surgical treatment for lymphedema.

Our era is characterized by the rapid improvements in treatment in all areas of medicine. But we should not forget those pioneers who, with their medical actions and inspiration, changed the course of their era and left their mark on medical history. One of those is the Greek surgeon Emmanuil Kondoleon (1879-1940). His brilliant scientific personality, numerous teaching activities, and his notable publications made him a distinguished Professor of Surgical Pathology. At the beginning of the 20th century, when very little was known about lymphedema and especially its treatment, Emmanuil Kondoleon arrived on the scene with his own original technique that led the surgical treatment of lymphedema for more than 50 years. Made famous as Kondoleon's procedure, his technique included wide excision of the fascia and concomitant partial excision of the hypertrophic tissue. Such important personalities as Kondoleon set great examples in medical history and inspire future young generations of physicians.

Interstitial magnetic resonance lymphography: the clinical effectiveness of a new method.

The aim of this study is to evaluate effectiveness of interstitial magnetic resonance lymphography as an examination for the depiction of the lymphatic system in humans by comparison with direct x-ray lymphography. We studied 14 subjects (two volunteers and 12 patients with clinical suspicion of lymphedema of the lower extremities). We first administered subcutaneous gadobutrol between the toes and performed MR lymphography. After seven days, we injected lipiodol into the lymph vessels of 8 patients and performed x-ray direct lymphography to compare findings of two methods. We identified the normal lymphatic system (lymph vessels and inguinal lymph nodes) of volunteers. In seven subjects, we were able to image an abnormal lymphatic system with decreased number of lymph vessels, lymphoceles, and ectatic lymph vessels. In three subjects we identified both an abnormal lymphatic and venous system and in two patients only the venous system. In all cases x-ray direct lymphography confirmed the findings of the MR lymphography. No side effects were observed from either contrast agent. We expect that in the future, interstitial MR lymphography will be improved and evolve into a valuable diagnostic tool for the evaluation of lymphatic diseases particularly those who present with primarily lymphedema in the lower limbs or second, in regions other than extremities.

Interstitial magnetic resonance lymphography: is it a new method for the diagnosis of lymphedema?

AIM: The aim of this study was to evaluate the method of interstitial magnetic resonance lymphography (MRL) as an examination for the depiction of the lymphatic system in humans in comparison with the method of direct X-ray lymphography. METHODS: We studied 6 persons, 2 volunteers and 4 patients with clinical suspicion of lymphedema in lower extremities. We administered subcutaneous gadobutrol for the MRL with a volume of 5 mL composed of 4.5 mL of Gadobutrol mixed with 0.5 mL of lidocaine hydrochloride and after 7 days lipiodol in the lymph vessel for the X-ray direct lymphography (in 3 patients) in order to compare the findings of the two METHODS: We then followed up all individuals for 7 days for any possible side effect of the contrast agents. RESULTS: Using MRL, we depicted the lymphatic system (lymph vessels and inguinal lymph nodes) of volunteers in 60 min. Moreover, in patients we depicted several abnormalities of the lymphatic system including decreased number of lymph vessels, lymphocele and ectatic lymph vessels. X-ray direct lymphography confirmed the findings of the MRL in all cases. No side effects were observed. CONCLUSION: In our pilot study, Gadobutrol seems to be a good contrast agent for the painless depiction of the lymphatic system in humans through interstitial MRL. More extensive studies are needed in order to establish the efficacy and the dosage of Gadobutrol.

Interstitial magnetic resonance lymphography with gadobutrol in rabbits and an initial experience in humans.

The purpose of this study was first to evaluate gadobutrol as a contrast agent for interstitial Magnetic Resonance Lymphography (MRL) in rabbits, and second, to extend the study to humans, if the initial results were satisfactory. In our experiment, gadobutrol was injected into twelve white New Zealand rabbits. In nine animals, 0.5 ml of gadobutrol was subcutaneously administered through each foot pad of the hindlegs while in the remaining three animals the agent was given in each foot of the forelegs. In four of the nine rabbits, slight local massage was applied at the site of administration. Subsequently, we proceeded to administer 5 ml (4.5 ml gadobutrol mixed with 0.5 ml hydrochloride lidocaine) into the limbs of two healthy humans. We achieved imaging of four lymph node groups (popliteal, inguinal, iliac and paraortic) in the hind-legs of the nine-rabbit group, whereas, in the forelegs of the remaining three rabbits, three lymph node groups (axillary, parasternal, mediastinal) were depicted. The flow of the contrast agent was significantly faster in the rabbits that received local massage (P<0.02). In humans, normal lymph vessels, as well as inguinal lymph nodes, were depicted in the legs. No side-effects were observed either in the rabbits or humans.