[Soft tissue infections]. / Wekedeleninfecties.

Soft tissue infections are common, but can be difficult to diagnose and manage. In this article, the classification of soft tissue infections is discussed, as well as the diagnostic possibilities and treatment options. Furthermore, the management of recurrent infections and necrotizing soft tissue infections are discussed. The added value of compression therapy is reviewed in more detail.

A care substitution service in the Netherlands: impact on referral, cost, and patient satisfaction.

BACKGROUND: In care substitution services, medical specialists offer brief consultations to provide general practitioners (GPs) with advice on diagnosis, treatment, or hospital referral. When GPs serve as gatekeepers to secondary care, these regional services could reduce pressures on healthcare systems. The aim is to determine the impact of implementing a care substitution service for dermatology, orthopaedics, and cardiology on the hospital referral rate, health care costs, and patient satisfaction. METHODS: A before-after study was used to evaluate hospital referral rates and health care costs during a follow-up period of 1 year. The study population comprised patients with eligible International Classification of Primary Care codes for referral to the care substitution service (only dermatology, orthopaedic, cardiology indications), as pre-defined by GPs and medical specialists. We compared referral rates before and after implementation by χ2 tests and evaluated patient preference by qualitative analysis. RESULTS: In total, 4,930 patients were included, 2,408 before and 2,522 after implementation. The care substitution service decreased hospital referrals during the follow-up period from 15 to 11%. The referral rate decreased most for dermatology (from 15 to 9%), resulting in a cost reduction of €10.59 per patient, while the other two specialisms experienced smaller reductions in referral rates. Patients reported being satisfied, mainly because of the null cost, improved organisation, improved care, and positive experience of the consultation. CONCLUSIONS: The care substitution service showed promise for specialisms that require fewer hospital facilities, as exemplified by dermatology.

Consensus recommendations on lymphedema in Phelan-McDermid syndrome.

Phelan-McDermid syndrome (PMS) is a neurodevelopmental disorder caused by deletions 22q13.3 or pathogenic variants in the SHANK3 gene. Lymphedema can be a clinical feature in 10-25% of individuals with PMS due to a deletion 22q13.3, but is not observed in those with a SHANK3 variant. This paper forms a part of the European consensus guideline for PMS and focuses on what is known regarding lymphedema in PMS in order to present clinical recommendations. The mechanism causing lymphedema in PMS is unknown. Lymphedema can be suggested by pitting oedema of the extremities or, in later stages, non-pitting swelling. It can occur already at a young age and be progressive if untreated, impacting daily functioning. Lymphedema can be treated using existing general multidisciplinary management guidelines, taking the functioning of the individual with PMS into account. Furthermore, well-known risk factors for the development of lymphedema as lack of physical activities and weight gain/obesity should be addressed. Diagnosis and treatment are best performed in a multidisciplinary centre of expertise.

Early Referral for Breast-Cancer-Related Lymphedema: Do We Follow the Evidence? A Two-Year Prospective Multicenter Cohort Study.

The early detection of breast-cancer-related lymphedema and referral for therapy has the potential to reduce lymphedema-related morbidity. Although research shows the benefits, a gap is observed between evidence and daily practice. We aimed to determine whether the early detection of lymphedema and referral for treatment is adequate following the current guidelines. Women with primary breast cancer treated with breast-conserving therapy or ablative treatment were included. Demographic-, general health-, tumor-, and treatment-related data were recorded. Bilateral arm volume measurements were performed preoperatively and 3, 6, 12, and 24 months post-surgery. A 5% or greater Relative Volume Change was considered the cutoff point for lymphedema and as an indication for therapy referral. After 24 months post-surgery, the main outcomes show that among the patients with early signs of lymphedema, based on a Relative Volume Change ≥5%, a nonreferral for therapy was noted in 83%. Additionally, we observed a significant improvement of the mean Relative Volume Change at 24 months within this group, which might implicate that nonreferral was an adequate choice and that watchful waiting is appropriate when lymphedema is detected within the first year post-surgery.

[Diagnosis and treatment of primary and secondary lymphedema]. / Diagnostiek en behandeling van primair en secundair lymfoedeem.

Chronic edema is caused by lymphatic impairment due to either overload of interstitial fluid or anatomic/functional lymphatic failure in any part of the body. Lymphatics play a crucial role in interstitial homeostasis, immune surveillance and fat absorption in the gut. Lymphedema is a clinical sign with swelling and not a diagnosis. In the latter stages inflammatory processes lead to fat formation and fibrosis. Untreated lymphedema has an increased risk for erysipelas, physical dysfunction and tends to worsen. Obesity and reduced physical activity are the main influenceable risk factors after oncological treatments in patients with impaired lymphatics. Prior to a multidisciplinary treatment program, a proper diagnosis with health profile is made. Treatment exists of two phases: an initial treatment phase and a maintenance phase in which the focus is on compression, self-management, exercise, minimizing risk factors and creating a healthy lifestyle. Clinimetrics are important for monitoring in both phases.

Improvement of Limb Volumes After Bariatric Surgery in Nine End-Stage Primary, Secondary, and Obesity-Induced Lymphedema Patients: A Multiple Case Report.

Background: Lymphedema (LE) is a chronic condition of swelling due to lymphatic impairment and is characterized by edema and fibro-adipose tissue deposition. LE may be caused by an anomalous development of the lymphatic system, known as primary LE, or may develop secondary to traumatic, infectious, or other external events. Knowledge is increasing about the plural and bidirectional relationship between LE and obesity. The rate of obesity is increasing worldwide, and bariatric surgery offers the most effective and durable treatment, as this surgery exhibits positive effects on many obesity-related diseases. We explored whether bariatric surgery could improve leg volumes in morbidly obese LE patients. Methods and Results: Between 2013 and 2019, 829 patients were hospitalized in our Center of Expertise for Lymphovascular Medicine for intensive treatment of their LE. Nine patients with end-stage primary, secondary, or obesity-induced LE underwent a bariatric procedure related to their morbid obesity. Data concerning age, gender, medical diagnosis, LE stage, type of bariatric treatment, body weight, body mass index (BMI), and limb volumes were retrospectively collected from the patient files. At the individual patient level, body weight, BMI, leg volumes, and their percent reduction between presurgery and postsurgery were calculated. At the group level, paired sample t-tests were conducted to compare the mean body weight, BMI, and volumes of both legs between postsurgery and presurgery. The data demonstrate a significant decrease in body weight, BMI, and leg volumes in morbidly obese end-stage primary, secondary, and obesity-induced LE patients following bariatric surgery. Conclusions: Our multiple case study indicates that bariatric surgery provides a good indication for concomitant treatment of morbid obesity and LE.

The ICC Compression Questionnaire: A Comprehensive Tool to Evaluate Compression Materials or Devices Applied in Subjects with Lymphedema or Chronic Venous Disease.

Background: Compression therapy is an important part of the treatment of patients with lymphedema or chronic venous disease. However, there is no validated questionnaire evaluating the effect of compression and its acceptance by the patient. Therefore, the aims of this study were to construct a questionnaire evaluating the effect of compression and its acceptance by the patient, that is, the Dutch ICC Compression Questionnaire (ICC-CQ), to investigate its reliability and validity, and to translate it into English. Methods and Results: Eleven experts in applying compression and 51 Dutch patients with experience of using compression were involved in the construction process. One part of the ICC-CQ has to be completed by the patient and evaluates seven domains. The other part has to be completed by the health care provider and comprises three domains. Reliability and validity of the final version was investigated in a new group of 79 Dutch-speaking patients with lymphedema or chronic venous disease, wearing compression garments (N = 52) or bandages (N = 27). Except for one domain, the Intraclass Correlation Coefficients for test-rest/interrater reliability ranged from 0.55 to 0.93. Cronbach's alpha for internal consistency ranged from 0.71 to 0.97. Eighty-nine percent of the patients fully understood the questionnaire indicating good face validity, and 87% found it complete indicating good content validity. Construct validity was considered good since 10 out of 11 hypotheses were accepted. Conclusion: The ICC-CQ is the first reliable and valid questionnaire evaluating different kinds of compression and the experience by patients with lymphedema or chronic venous disease.

Primary lymphoedema.

Lymphoedema is the swelling of one or several parts of the body owing to lymph accumulation in the extracellular space. It is often chronic, worsens if untreated, predisposes to infections and causes an important reduction in quality of life. Primary lymphoedema (PLE) is thought to result from abnormal development and/or functioning of the lymphatic system, can present in isolation or as part of a syndrome, and can be present at birth or develop later in life. Mutations in numerous genes involved in the initial formation of lymphatic vessels (including valves) as well as in the growth and expansion of the lymphatic system and associated pathways have been identified in syndromic and non-syndromic forms of PLE. Thus, the current hypothesis is that most cases of PLE have a genetic origin, although a causative mutation is identified in only about one-third of affected individuals. Diagnosis relies on clinical presentation, imaging of the structure and functionality of the lymphatics, and in genetic analyses. Management aims at reducing or preventing swelling by compression therapy (with manual drainage, exercise and compressive garments) and, in carefully selected cases, by various surgical techniques. Individuals with PLE often have a reduced quality of life owing to the psychosocial and lifelong management burden associated with their chronic condition. Improved understanding of the underlying genetic origins of PLE will translate into more accurate diagnosis and prognosis and personalized treatment.

Effect of Nonelastic Compression With an Adjustable Wrap After Total Knee Arthroplasty.

Swelling is a common phenomenon after total knee arthroplasty, with potential for negative impact on the rehabilitation process and final outcome. The aim of this study was to investigate the effectiveness of a new compression protocol with a self-adjustable, nonelastic compression wrap for the knee region. This study was conducted as a prospective comparative study. Total leg volume and the circumference of the knee at three levels were compared between groups. The results of our study suggest that the application of the new compression protocol has no effect on swelling in the acute postoperative phase (0-2 days) but reduces swelling at Day 14 within the subacute phase. The observed positive effect of the compression protocol could be of clinical importance in the subacute phase as well as for a subgroup of patients suffering from aberrant quadriceps weakness concomitant with knee swelling.

Shaving Technique and Compression Therapy for Elephantiasis Nostras Verrucosa (Lymphostatic Verrucosis) of Forefeet and Toes in End-Stage Primary Lymphedema: A 5 Year Follow-Up Study in 28 Patients and a Review of the Literature.

BACKGROUND: Longstanding lymphedema can lead, especially when there is recurrence of erysipelas, to irreversible elephantiasis nostras verrucosa (ENV). This predisposes to new episodes of erysipelas, leading to further damage of the lymphatics and deterioration of the lymphedema as a whole. We report the results of 28 patients with primary lymphedema and surgical removal ENV of the forefoot and toes treated between 2006 and 2014. METHOD: Retrospective descriptive 5 year follow-up study of 28 patients with various diagnosis of primary lymphedema. Wound healing time, number of erysipelas, body mass index (BMI), recurrence of EVN and types of compression were documented during follow-up. RESULTS: After preoperative multidisciplinary work up, operation of the toes with shaving and excision was performed within a conservative treatment program. During the follow up, the number of erysipelas attacks decreased dramatically (mean 17.6 vs. 0.6). Before treatment, no toecaps were used; and in follow up, it was a part of treatment. Recurrence of ENV was not observed. Compared to the literature with often BMI > 35, the mean BMI in our group was 30.0 (overweight). In 12 patients, we concurrently performed circumferential suction-assisted lipectomy for end-stage lymphedema of the leg. CONCLUSION: Although lymphedema patients are treated with garments during the maintenance phase, compression of the toes is often too challenging. Surgical removal of the verrucosis of toes is an effective therapeutic modality as part of an integrated lymphedema treatment program to restore the shape of the toes and enable the wearing of toecaps. This technique can also be effective for ENV of origins other than primary lymphedema. Although ENV is a generally accepted term, it can have undesirable connotations. We suggest using a more inclusive name such as lymphostatic verrucosis, because long-lasting lymphatic impairment is involved in all ENV and the term verrucosis is above discussion.

The Dutch lymphedema guidelines based on the International Classification of Functioning, Disability, and Health and the chronic care model.

Lymphedema is a chronic and progressive condition due to an imbalance between lymphatic filtration and transport capacity. A relative overload of fluid is caused by lymphatic impairment (afterload impairment); an absolute overload is caused by increased filtration (preload raised). Lymphedema can result in considerable disability and loss of quality of life. The Dutch Society of Dermatology organized a task force to create guidelines using the International Classification of Functioning, Disability, and Health. As lymphedema is a chronic condition, a new approach was chosen according to the chronic care model. In the development of the guidelines, the following topics of lymphedema care were proposed: (1) lymphedema detection; (2) clinimetric instruments; and (3) rational treatment modalities. A systematic review of the literature published up to June 2013 was conducted. Statements were based on scientific evidence and experience. The guidelines propose recommendations based on an interdisciplinary approach to lymphedema using a continuum of care from prevention to initial treatment phase, maintenance phase, and follow-up. An integrated treatment program can be conservative or surgical. A therapeutic program depends on stage and origin of lymphedema; International Classification of Functioning, Disability, and Health-based limitations; needs of the patient; ability to perform self-management; and ability to reduce patient-related risk factors, such as overweight and lack of exercise.

First Dutch guidelines on lipedema using the international classification of functioning, disability and health.

Introduction Lipedema is a chronic, progressive condition that can result in considerable disability. In 2011, the Dutch Society of Dermatology and Venereology organized a task force to create guidelines on lipedema, using the International Classification of Functioning, Disability and Health of the World Health Organization. Guideline development Clinical questions on significant issues in lipedema care were proposed, involving (1) making the diagnosis of lipedema; (2) clinimetric measurements for early detection and adequate follow-up; and (3) treatment. A systematic review of literature published up to June 2013 was conducted. Based on available evidence and experience of the task force, answers were formed and recommendations were stated. The guidelines define criteria to make a medical diagnosis of lipedema, a minimum data set of (repeated) clinical measurements that should be used to ensure early detection and an individually outlined follow-up plan, pillars on which conservative treatment should be based and recommendations on surgical treatment options. Conclusions Little consistent information concerning either diagnostics or therapy can be found in the literature. It is likely that lipedema is frequently misdiagnosed or wrongly diagnosed as only an aesthetic problem and therefore under- or mis-treated. Treatment is divided into conservative and chirurgic treatment. The only available technique to correct the abnormal adipose tissue is surgery. Recommendations To ensure early detection and an individually outlined follow-up, the committee advises the use of a minimum data set of (repeated) measurements of waist circumference, circumference of involved limbs, body mass index and scoring of the level of daily practice and psychosocial distress. Promotion of a healthy lifestyle with individually adjusted weight control measures, graded activity training programs, edema reduction, and other supportive measures are pillars of conservative therapy. Tumescent liposuction is the treatment of choice for patients with a suitable health profile and/or inadequate response to conservative and supportive measures.

Functioning in lymphedema from the patients' perspective using the International Classification of Functioning, Disability and health (ICF) as a reference.

PURPOSE: To identify and quantify meaningful concepts in lymphedema from the patients' perspectives using the International Classification of Functioning, Disability and Health (ICF). METHODS: Six focus group interviews in five different centers were organized, audiotaped, transcribed verbatim and analyzed. RESULTS: A total of 2681 relevant ICF linkings were performed with the focus group data, resulting in 130 different second-level categories. Of these 130 second-level categories, 41 (31.5%) categories were categorized as Body Functions, 20 (15.5%) as Body Structures, 41 (31.5%) as Activities and Participation, and 28 (21.5%) as Environmental Factors. Overall, the most important issues according to the patients were the use of hosiery and bandages, support and relationships, and the shape of structures related to movement. CONCLUSION: Based on their experiences with lymphedema, patients reported activity limitations and participation restrictions combined with impaired body functioning. Anatomical changes (Body Structures) were also often mentioned as a problem in daily life. Environmental factors may act as a barrier or facilitator for patient functioning. The ICF provides a valuable reference to identify concepts in statements from lymphedema patients. The results of this research will be used in the development of ICF Core Sets for lymphedema.

Prospective, randomized, controlled trial comparing the effectiveness of adjustable compression Velcro wraps versus inelastic multicomponent compression bandages in the initial treatment of leg lymphedema.

BACKGROUND: Inelastic multicomponent compression (ICM) bandages applied by specialized medical staff are the standard of care for compression therapy of lymphedema of the extremities. However, new adjustable compression wraps (ACWs), which can be applied by patients themselves and, up to now, have been mainly recommended for the maintenance treatment phase of lymphedema, may be an important step toward the self-management of the initial treatment phase. METHODS: This prospective, randomized, controlled comparative study assessed the effectiveness of an ACW in the treatment of leg lymphedema, compared with the traditional treatment with conventional IMC bandages. Included were 30 hospitalized patients admitted due to moderate to severe unilateral lymphedema (stages 2-3) of the leg. The primary outcome measures in both groups were reduction in volume of the affected leg and interface pressure after 2 and 24 hours. Patients were randomized into two groups of 15 patients: group A received ACW and group B received IMC bandages, both applied by experienced staff. After 2 hours, the staff replaced IMC bandages and the patients applied ACW, as previously instructed. Finally, compression was removed after 24 hours. Classic water displacement volumetry was performed before compression and after 2 hours and after 24 hours of compression. The interface pressure was measured immediately after application of compression, 2 hours after compression, before and after compression renewal, and finally, after 24 hours. Patients in the ACW group were allowed to adjust the wrap themselves when they considered it necessary. RESULTS: The reduction in median volume after 2 hours was 109 mL (interquartile range [IQR], 64-271 mL; -3.1%) in the ACW group and 75 mL (IQR, 41-135; -2.4%) in the IMC group (not significant). After 24 hours, the reduction in median volume was 339 mL (IQR, 231-493 mL; -10.3%) in the ACW group and 190 mL (IQR, 113-296 mL; -5.9%) in the IMC group (P < .05). The interface pressure dropped significantly after 2 and 24 hours in the IMC group (-50% and -6%), but significantly less in the ACW group (-26% and -44%), mainly due to self-readjustment. The median pressures achieved after self-application of ACW (52 mm Hg; IQR, 44-61 mm Hg) were of the same order as those produced by the nurses after the first application of ACW (53 mm Hg; IQR, 39-59 mm Hg), with less variation. CONCLUSIONS: In patients with moderate to severe lymphedema of the legs, ACW achieved a significantly more pronounced reduction in volume after 24 hours than IMC bandages. Patients were able to apply and adjust the device after being instructed in its use and after an initial 2-hour period of wear. Autonomous handling of ACW seemed to improve the clinical outcome and is a promising step toward self-management involving effective compression.

Prospective, randomized, controlled trial comparing a new two-component compression system with inelastic multicomponent compression bandages in the treatment of leg lymphedema.

BACKGROUND: New, less-bulky, short-stretch compression bandages could be a valuable alternative in the management of lymphedema of the leg. OBJECTIVE: To compare the effectiveness of a two-component compression (2CC) system in the treatment of leg lymphedema with that of the traditional treatment with conventional inelastic multicomponent compression bandages (IMC). METHODS: Thirty hospitalized patients with moderate to severe unilateral lymphedema (stage II-III) of the leg were included. Patients were divided in two groups; one (n=15) received a 2CC, and the other (n=15) received IMC. Primary outcome was volume reduction of the affected leg; secondary outcome was loss of interface pressure. RESULTS: Median leg volumes before bandaging were 4,150 mL (2CC) and 4,360 mL (IMC). Median volume reduction after 2 hours was 120 mL (2.9%) with the 2CC system and 80 mL (1.8%) with IMC (p>.05). After 24 hours, volume reduction was 8.4% and 4.4% respectively (p>.05). Interface pressure dropped significantly within 2 hours of bandage application in both groups. CONCLUSION: Our results indicate that the 2CC system forms a suitable alternative to IMC in the conventional treatment of moderate to severe lymphedema.

Compression therapy in breast cancer-related lymphedema: A randomized, controlled comparative study of relation between volume and interface pressure changes.

OBJECTIVE: Short stretch bandages are very effective in the initial management of arm lymphedema. However, no studies to date have measured the pressure required to achieve specific amounts of volume reduction. The purpose of this study was to determine whether there is a difference between low and high-pressure bandaging in terms of therapeutically intended volume reduction of the compressed arm. METHODS: Experimental, randomized and comparative study with two study-groups consisting of high and low initial interface pressure bandages. Thirty-six hospitalized patients in Nij Smellinghe hospital suffering from moderate to severe unilateral breast cancer-related lymphedema not responsive to outpatient treatment were included. Bilateral arm volume was measured by inverse water volumetry before, after two hours and after 24 hours of bandaging. The amount of edema was calculated by subtracting the volume of the diseased arm from that of the contralateral side. Sub-bandage pressure was measured after bandage application and two hours later. Bandages were then re-applied and the pressure was measured again. Twenty-four hours later, the pressure measurement was repeated and bandages were removed for final volumetry. Patients were randomized into two groups: group A received low pressure bandages (20-30 mm Hg) and group B received high pressure bandages (44-58 mm Hg). The main outcome measures were reduction of arm volume and edema volume in the affected arm in both study groups. Secondary outcome parameters were changes in sub-bandage pressure and patient comfort. RESULTS: Median arm volume reduction after two and 24 hours was 104.5 mL (95% confidence interval [CI], 51.2-184.2) (-2.5%) (P < .0001) and 217 mL (95% CI, 143.9-280.2) (-5.2%) (P < .01) for group A and 56.5 mL (95% CI, -2.7-123.1) (n.s.) and 167.5 mL (95% CI, 105.2-316.1) (-4.2%) (P < .01) for group B, respectively. There was no statistically significant difference between the volume changes in group A and group B. After 24 hours, edema decreased by median percentage of 9.2% in group A and 4.8% in group B (n.s.). Bandages in group A were better tolerated. The sub-bandage pressure drop in the first two hours was between 41% and 48% in both treatment groups at both measuring sites. After 24 hours, the pressure drop was between 55% and 63%. No proximal swelling above the bandage was observed. CONCLUSIONS: Inelastic, multi-layer, multi-component compression bandages with lower pressure (20-30 mm Hg) are better tolerated and achieve the same amount of arm volume reduction as bandages applied with higher pressure (44-58 mm Hg) in the first 24 hours.

Lymphedema-distichiasis syndrome: a distinct type of primary lymphedema caused by mutations in the FOXC2 gene.

Lymphedema-distichiasis syndrome (LD, OMIM 153400) is an autosomal dominant disorder with variable expression. It is caused by mutations in the FOXC2-gene, which codes for a forkhead transcription factor involved in the development of the lymphatic and vascular system. LD is characterized by late childhood or pubertal onset lymphedema of the limbs and distichiasis (double row of eyelashes). While the latter is the most common expression of LD, venous insufficiency occurs in half of the patients. Other associations have been reported, including congenital heart disease, ptosis, cleft lip/palate and spinal extradural cysts. Here we describe a family with classical lymphedema-distichiasis syndrome caused by a duplication in the FOXC2-gene.

Controlled, comparative study of relation between volume changes and interface pressure under short-stretch bandages in leg lymphedema patients.

BACKGROUND: Pressure loss under short-stretch bandages (SSBs) is a well-known phenomenon and is thought to be related to bandage relaxation and poor quality of application. AIM: The aim was to demonstrate that therapeutically intended volume reduction of the compressed leg is the most important cause for the loss of bandage pressure. DESIGN: This was an experimental, controlled comparative study. METHODS: In 20 patients suffering from lymphedema of the lower extremities and in 9 healthy persons, lower leg volume was measured by water displacement. After application of a pressure measurement device (Kikuhime) at the B1 region, SSBs were applied on one leg according to a standard protocol. Volume and pressure measurements were performed at 0, 2, and 24 hours in supine as well as standing positions. RESULTS: A significant reduction of leg volume is already achieved 2 hours after bandage application, both in lymphedema patients and in normal controls. A further volume decrease of the lymphedematous legs is observed in the following 24 hours after application of a new bandage (-290 mL). The volume reduction is associated with a significant loss of bandage pressure from initial values over 60 mmHg by 37 and 48% in controls and lymphedema patients, respectively. CONCLUSIONS: Inelastic, multilayer, multicomponent compression bandages lead to an immediate reduction of leg volume, both in lymphedematous and in normal legs. This therapeutically intended volume reduction seems to be the main reason for the fast decrease of the subbandage pressure. This study was supported by Lohmann & Rauscher, Ltd. Germany.

Validation of the inverse water volumetry method: A new gold standard for arm volume measurements.

BACKGROUND: No consensus exists with respect to a commonly accepted and standardized method for measuring arm volumes in patients with lymphedema. Knowing the exact volume in (potential) lymphedemic arms and comparing this volume with healthy arms is important to detect the first signs of lymphedema and to study the effects of treatment. METHODS: A new apparatus, based upon the principle of measuring shortness of water, was developed to measure arm volumes. This measuring-method, inverse water volumetry, was prospectively validated in patients, suffering from lymphedema after complete or partial mastectomy for primary breast cancer. Healthy and lymphedemic arm were measured 3 times: twice by nurse A (A1 and A2) and once by nurse B (B). Subsequently, these differences in volumes were compared with differences in volumes obtained by the Herpertz method, which is based upon circumferential measurement. RESULTS: In every patient at every occasion volume of the lymphedemic arm was bigger than the corresponding volume of the control arm. Mean volumes of healthy arms were 3958(A1), 3966(A2) and 3961(B) ml respectively. Mean volumes of lymphedemic arms were 4721(A1), 4752(A2) and 4773(B) ml respectively, volume B being significantly different from volume A1. Volume difference of edemic arms minus control arms was not significant between measurements (A1 vs. A2 and A1 vs. B, respectively), while this difference was significant (A1 vs. B) using the Herpertz method. CONCLUSION: Inverse water volumetry is an easy measuring device with a high inter- and intra-observer agreement. The small but significant volume increase of lymphedemic arms in time compared to the constant volumes of control arms is as well indicative for the accuracy of the method as for the volume of lymphedemic arms to increase when no therapeutic garment is carried.

Twice weekly fluticasone propionate added to emollient maintenance treatment to reduce risk of relapse in atopic dermatitis: randomised, double blind, parallel group study.

OBJECTIVE: To explore the efficacy and safety of fluticasone propionate, cream and ointment, applied twice weekly in addition to maintenance treatment with emollients, in reducing the risk of relapse of chronic recurrent atopic dermatitis. DESIGN: Randomised, double blind, parallel group study of 20 weeks' duration. SETTING: Dermatology outpatient clinics (6 countries, 39 centres). PARTICIPANTS: Adult (aged 12-65) patients with moderate to severe atopic dermatitis who were experiencing a flare. METHODS: Participants applied fluticasone propionate (0.05% cream or 0.005% ointment; once or twice daily) regularly for four weeks to stabilise their condition. The patients whose disease was brought under control then continued into a 16 week maintenance phase, applying emollient on a daily basis with a bath oil as needed and either the same formulation of fluticasone propionate or its placebo base (emollient alone) twice weekly to the areas that were usually affected. MAIN OUTCOME MEASURE: Time to relapse of atopic dermatitis during maintenance phase. RESULTS: 376 patients entered the stabilisation phase, and 295 continued into the maintenance phase. After 16 weeks in the maintenance phase, the disease remained under control in 133 patients (87 using fluticasone propionate twice weekly, 46 using emollient alone), 135 (40 fluticasone propionate, 95 emollient) had experienced a relapse, and 27 had discontinued. Median time to relapse was six weeks for emollient alone compared with more than 16 weeks for additional fluticasone propionate. Patients who applied fluticasone propionate cream twice weekly were 5.8 times less likely (95% confidence interval 3.1 to 10.8, P < 0.001) and patients using fluticasone propionate ointment 1.9 times less likely (1.2 to 3.2, P=0.010) to have a relapse than patients applying emollient alone. The groups showed no differences in adverse events. CONCLUSION: After atopic dermatitis had been stabilised the addition of fluticasone propionate twice weekly to maintenance treatment with emollients significantly reduced the risk of relapse.