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Dionyssiou D, Nguyen D, Topalis A, Deptula P, Paukshto M, Zaitseva T, Demiri E, Cheva A, Rockson S. Treatment of Rat Lymphedema by Propeller Lymphatic Tissue Flap Combined with Nanofibrillar Collagen Scaffolds. J Reconstr Microsurg 2024; 40:145-155. [PMID: 37142251 DOI: 10.1055/a-2086-0269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND The aim of our study was to evaluate a new propeller vascularized lymphatic tissue flap (pVLNT) combined with aligned nanofibrillar collagen scaffolds (CS) (BioBridge) in reducing lymphedema in the rat lymphedema model. METHODS Unilateral left hindlimb lymphedema was created in 15 female Sprague-Dawley rats following inguinal and popliteal lymph nodes (LN) resection and radiation. An inguinal pVLNT was elevated from the contralateral groin and transferred through a skin tunnel to the affected groin. Four collagen threads were attached to the flap and inserted in the hindlimb at the subcutaneous level in a fan shape. The three study groups consisted of group A (control), group B (pVLNT), and group C (pVLNT + CS). Volumetric analysis of both hindlimbs was performed using micro-computed tomography imaging before the surgery (at initial time point) and then at 1 and 4 months, postoperatively, and the relative volume difference (excess volume) was measured for each animal. Lymphatic drainage was assessed by indocyanine green (ICG) fluoroscopy for number and morphology of new collectors and the time required for ICG to move from injection point to the midline. RESULTS Four months after the induction of lymphedema, an increased relative volume difference remained in group A (5.32 ± 4.74%), while there was a significant relative volume reduction in group B (-13.39 ± 8.55%) and an even greater reduction in group C (-14.56 ± 5.04%). ICG fluoroscopy proved the functional restoration of lymphatic vessels and viability of pVLNT in both B and C groups. Notably, only group C demonstrated statistically significant improvements in lymphatic pattern/morphology and in the number of lymphatic collectors as compared with the control group A. CONCLUSION The pedicle lymphatic tissue flap combined with SC is an effective procedure for the treatment of lymphedema in rats. It can be easily translated into treatment of humans' lower and upper limb lymphedema and further clinical studies are warranted.
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Affiliation(s)
- Dimitrios Dionyssiou
- Department of Plastic Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dung Nguyen
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
| | - Anastasios Topalis
- Department of Plastic Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Peter Deptula
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
| | | | | | - Efterpi Demiri
- Department of Plastic Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Angeliki Cheva
- Laboratory of Pathology, Medical School, Aristotle University, Thessaloniki, Greece
| | - Stanley Rockson
- Center for Lymphatic and Venous Disorders, Stanford University School of Medicine, Stanford, California
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2
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McLeod MT, Broome K, Von Deest KA. Quantifying graduation of layered below-the-knee compression garment combinations using a model-based assessment. J Vasc Surg Venous Lymphat Disord 2023; 11:183-191. [PMID: 35987491 DOI: 10.1016/j.jvsv.2022.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/20/2021] [Accepted: 02/05/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE Often people with lymphedema and vascular conditions will be prescribed layered compression garments to assist them in donning their garments and improve treatment compliance. However, little evidence of the interface pressures produced by these layered garments is available. In the present study, we explored the pressures produced by layering high and low class below-the-knee compression garment combinations and quantified the graduation of these combinations to understand the effect that layer order might have on the interface pressure. METHODS The present study used a mechanical test design to measure the interface pressure at four sites (B, smallest ankle dimension; B1, circumference at Achilles tendon and gastrocnemius muscle junction; C, widest calf dimension; and D, below the knee) for 30 combinations of low and high class compression garments using a PicoPress (Microlab Elettronica, Ponte San Nicolò, Italy). RESULTS The results demonstrated a pattern consistent with graduation for sites B1 to D for 100% of the garment combinations. However, the graduation was reversed for sites B to B1 for 100% of the garment combinations, possibly due to limitations regarding the shape of the model limb. The results indicated no significant differences in the interface pressure when the higher class garment was applied as the bottom layer vs the top layer. A strong correlation (R > 0.95; P < .001) was between the actual pressures produced by the combinations of the garments and the expected pressure determined by summing the pressures of the individual garments. CONCLUSIONS Graduation was observed from site B1 to site D, indicating that double layering of these garment combinations maintained guideline adherence. Layering the garments produced pressures that were, in general, cumulative of the pressure from each garment alone, with some variance. Because of the uncertainty of the B site results in the present study, the clinical implications in relation to the primary aim are limited. The findings from the secondary aim suggest that clinically, garment wearers can don their layered garments in any order and achieve the same interface pressure results.
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Affiliation(s)
- Maddison Taylor McLeod
- School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Kieran Broome
- School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, QLD, Australia; Good to Better Pty Ltd, Imbil, QLD, Australia; Bond University, Robina, QLD, Australia.
| | - Kerri-Anne Von Deest
- School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, QLD, Australia
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3
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Nemes A, Kormányos Á, Domsik P, Kalapos A, Kemény L, Szolnoky G. The effects of lower body compression on left ventricular rotational mechanics in lymphoedema (from the MAGYAR-Path Study). ESC Heart Fail 2021; 8:4328-4333. [PMID: 34288554 PMCID: PMC8497360 DOI: 10.1002/ehf2.13487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/01/2021] [Accepted: 06/07/2021] [Indexed: 11/25/2022] Open
Abstract
Aims Lower body half compression of bilateral secondary leg lymphoedema (LE) without relevant cardiac insufficiency gives rise to whether external leg compression may influence left ventricular (LV) function. Patients with LE were subjected to baseline two‐dimensional transthoracic echocardiography (2DTTE) for general assessment then three‐dimensional speckle‐tracking echocardiography (3DSTE) before and 1 h after lower body half external compression for LV torsion analysis. Methods and results Baseline 2DTTE was performed in the cohort of 25 LE patients, and the results were compared with those of age‐ and gender‐matched 52 healthy controls (mean age: 47.8 ± 12.8 vs. 40.7 ± 14.0 years, 24 women/1 man vs. 49 women/3 men, respectively). 3DSTE was conducted for the assessment of LV rotational mechanics where apical (AR), and basal rotations (BR) were measured before and 1 h after the use of compression class 2 (ccl 2) flat‐knitted medical compression pantyhoses (pressure range: 23–32 mmHg). 2DTTE showed significantly larger LV end‐diastolic volume and ejection fraction among LE patients compared with control subjects (108.3 ± 20.1 vs. 98.5 ± 21.7 mL, 69.8 ± 4.8 vs. 65.5 ± 4.3%, respectively) and notably smaller LV end‐systolic diameter and posterior wall thickness (28.9 ± 3.5 vs. 31.2 ± 3.4 mm, 8.1 ± 1.0 vs. 9.0 ± 1.7 mm, respectively). The results of 20 patients with LE were considered in 3DSTE examinations due to the drop‐out of five probands with technical failures. The data of four LE patients showing significant LV rotational abnormalities were managed separately, and the rotational parameters of the remaining sixteen patients did not differ significantly from those of matched controls except significant reduction of LV BR following the application of medical compression stockings (MCS) (−2.70 ± 1.26 degrees after 1 h use of pantyhose in patient group vs. −4.28 ± 2.18 degrees of the control group; P < 0.05). Conclusions The application of compression pantyhoses moderately but significantly decreased LV BR without a remarkable impact on twisting mechanism in LE patients in the absence of LV rotational abnormalities.
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Affiliation(s)
- Attila Nemes
- Department of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Árpád Kormányos
- Department of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Péter Domsik
- Department of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Anita Kalapos
- Department of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Lajos Kemény
- Department of Dermatology and Allergology, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - Győző Szolnoky
- Department of Dermatology and Allergology, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
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Koc M, Wald M, Varaliová Z, Ondrůjová B, Čížková T, Brychta M, Kračmerová J, Beranová L, Pala J, Šrámková V, Šiklová M, Gojda J, Rossmeislová L. Lymphedema alters lipolytic, lipogenic, immune and angiogenic properties of adipose tissue: a hypothesis-generating study in breast cancer survivors. Sci Rep 2021; 11:8171. [PMID: 33854130 PMCID: PMC8046998 DOI: 10.1038/s41598-021-87494-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 03/30/2021] [Indexed: 12/26/2022] Open
Abstract
Later stages of secondary lymphedema are associated with the massive deposition of adipose tissue (AT). The factors driving lymphedema-associated AT (LAT) expansion in humans remain rather elusive. We hypothesized that LAT expansion could be based on alterations of metabolic, adipogenic, immune and/or angiogenic qualities of AT. AT samples were acquired from upper limbs of 11 women with unilateral breast cancer-related lymphedema and 11 healthy women without lymphedema. Additional control group of 11 female breast cancer survivors without lymphedema was used to assess systemic effects of lymphedema. AT was analysed for adipocyte size, lipolysis, angiogenesis, secretion of cytokines, immune and stem cell content and mRNA gene expression. Further, adipose precursors were isolated and tested for their proliferative and adipogenic capacity. The effect of undrained LAT- derived fluid on adipogenesis was also examined. Lymphedema did not have apparent systemic effect on metabolism and cytokine levels, but it was linked with higher lymphocyte numbers and altered levels of several miRNAs in blood. LAT showed higher basal lipolysis, (lymph)angiogenic capacity and secretion of inflammatory cytokines when compared to healthy AT. LAT contained more activated CD4+ T lymphocytes than healthy AT. mRNA levels of (lymph)angiogenic markers were deregulated in LAT and correlated with markers of lipolysis. In vitro, adipose cells derived from LAT did not differ in their proliferative, adipogenic, lipogenic and lipolytic potential from cells derived from healthy AT. Nevertheless, exposition of preadipocytes to LAT-derived fluid improved their adipogenic conversion when compared with the effect of serum. This study presents results of first complex analysis of LAT from upper limb of breast cancer survivors. Identified LAT alterations indicate a possible link between (lymph)angiogenesis and lipolysis. In addition, our in vitro results imply that AT expansion in lymphedema could be driven partially by exposition of adipose precursors to undrained LAT-derived fluid.
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Affiliation(s)
- Michal Koc
- Department of Pathophysiology, Centre for Research On Nutrition, Metabolism and Diabetes, Third Faculty of Medicine, Charles University, Ruská 87, 100 00, Prague 10, Czech Republic
| | - Martin Wald
- Department of Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague 5, Czech Republic
| | - Zuzana Varaliová
- Department of Pathophysiology, Centre for Research On Nutrition, Metabolism and Diabetes, Third Faculty of Medicine, Charles University, Ruská 87, 100 00, Prague 10, Czech Republic
| | - Barbora Ondrůjová
- Department of Pathophysiology, Centre for Research On Nutrition, Metabolism and Diabetes, Third Faculty of Medicine, Charles University, Ruská 87, 100 00, Prague 10, Czech Republic
| | - Terezie Čížková
- Department of Pathophysiology, Centre for Research On Nutrition, Metabolism and Diabetes, Third Faculty of Medicine, Charles University, Ruská 87, 100 00, Prague 10, Czech Republic
| | - Milan Brychta
- Department of Radiotherapy and Oncology, Kralovske Vinohrady University Hospital, Prague 10, Czech Republic
| | - Jana Kračmerová
- Department of Pathophysiology, Centre for Research On Nutrition, Metabolism and Diabetes, Third Faculty of Medicine, Charles University, Ruská 87, 100 00, Prague 10, Czech Republic
| | - Lenka Beranová
- Department of Pathophysiology, Centre for Research On Nutrition, Metabolism and Diabetes, Third Faculty of Medicine, Charles University, Ruská 87, 100 00, Prague 10, Czech Republic
| | - Jan Pala
- Department of Pathophysiology, Centre for Research On Nutrition, Metabolism and Diabetes, Third Faculty of Medicine, Charles University, Ruská 87, 100 00, Prague 10, Czech Republic
| | - Veronika Šrámková
- Department of Pathophysiology, Centre for Research On Nutrition, Metabolism and Diabetes, Third Faculty of Medicine, Charles University, Ruská 87, 100 00, Prague 10, Czech Republic.,Franco-Czech Laboratory for Clinical Research on Obesity, Third Faculty of Medicine, Prague 10, Czech Republic
| | - Michaela Šiklová
- Department of Pathophysiology, Centre for Research On Nutrition, Metabolism and Diabetes, Third Faculty of Medicine, Charles University, Ruská 87, 100 00, Prague 10, Czech Republic.,Franco-Czech Laboratory for Clinical Research on Obesity, Third Faculty of Medicine, Prague 10, Czech Republic
| | - Jan Gojda
- Franco-Czech Laboratory for Clinical Research on Obesity, Third Faculty of Medicine, Prague 10, Czech Republic.,Second Internal Medicine Department, Kralovske Vinohrady University Hospital, Prague 10, Czech Republic
| | - Lenka Rossmeislová
- Department of Pathophysiology, Centre for Research On Nutrition, Metabolism and Diabetes, Third Faculty of Medicine, Charles University, Ruská 87, 100 00, Prague 10, Czech Republic. .,Franco-Czech Laboratory for Clinical Research on Obesity, Third Faculty of Medicine, Prague 10, Czech Republic.
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5
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Hassani C, Tran K, Palmer SL, Patel KM. Vascularized Lymph Node Transfer: A Primer for the Radiologist. Radiographics 2020; 40:1073-1089. [PMID: 32412827 DOI: 10.1148/rg.2020190118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Lymphedema, the accumulation of lymphatic fluid in the tissues, is a chronic disease and a major cause of long-term morbidity and disability. Lymphedema is usually a secondary condition, often caused by prior oncologic therapy, such as surgery for cancers, radiation therapy, and chemotherapy. Treatment for lymphedema has traditionally been conservative and limited, but new surgical and microsurgical procedures have arisen in recent years. Vascularized lymph node transfer (VLNT) is one of the most promising new microsurgeries. VLNT involves the transfer of functional lymph nodes (LNs) from a healthy donor site to an area of the body with damaged or diseased lymphatic drainage. The goal of the transplant is to restore physiologic LN drainage and improve lymphedema. Donor LNs are commonly found in the groin, axilla, neck, omentum, or submental region. Imaging can be used for preoperative planning to identify donor sites with the richest number of LNs. This can help identify those patients who may be candidates for VLNT and can help identify the best anatomic site for surgical harvest in those candidates. Imaging can be performed with US, CT, or MRI. VLNT preoperative imaging often requires acquisition techniques and reconstruction parameters that differ from those used in routine diagnostic imaging. Furthermore, to properly identify target LNs, the radiologist must be aware of surgical anatomic landmarks. Online supplemental material is available for this article. ©RSNA, 2020.
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Affiliation(s)
- Cameron Hassani
- From the Departments of Radiology (C.H., K.T., S.L.P.) and Plastic and Reconstructive Surgery (K.M.P.), Keck Hospital of the University of Southern California, 1500 San Pablo St, Los Angeles, CA 90033
| | - Khoa Tran
- From the Departments of Radiology (C.H., K.T., S.L.P.) and Plastic and Reconstructive Surgery (K.M.P.), Keck Hospital of the University of Southern California, 1500 San Pablo St, Los Angeles, CA 90033
| | - Suzanne L Palmer
- From the Departments of Radiology (C.H., K.T., S.L.P.) and Plastic and Reconstructive Surgery (K.M.P.), Keck Hospital of the University of Southern California, 1500 San Pablo St, Los Angeles, CA 90033
| | - Ketan M Patel
- From the Departments of Radiology (C.H., K.T., S.L.P.) and Plastic and Reconstructive Surgery (K.M.P.), Keck Hospital of the University of Southern California, 1500 San Pablo St, Los Angeles, CA 90033
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6
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Rosian K, Stanak M. Efficacy and safety assessment of lymphovenous anastomosis in patients with primary and secondary lymphoedema: A systematic review of prospective evidence. Microsurgery 2019; 39:763-772. [PMID: 31571265 PMCID: PMC6899961 DOI: 10.1002/micr.30514] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 08/06/2019] [Accepted: 08/30/2019] [Indexed: 11/29/2022]
Abstract
Introduction Lymphoedema is a chronic, debilitating condition caused by an affected lymphatic system. Supermicrosurgical techniques like lymphovenous anastomosis (LVA) have gained popularity because of its minimal invasiveness, better aesthetic outcome, and lower costs in comparison to physical medicine. This systematic review aims to evaluate the clinical effectiveness and safety of LVA in comparison to conservative or other surgical treatments for primary or secondary lymphoedema patients. Materials and Methods A systematic literature search was performed in four databases in December 2017. We applied a methodological framework based on the HTA Core Model®. According to the grading of recommendations, assessment, development, and evaluation (GRADE) scheme, we synthesized the data on each selected outcome category. The studies were systematically assessed for risk of bias (RoB) using the Risk of Bias Assessment tool for Non‐randomized controlled studies (RoBANS) and the Institute of Health Economics (IHE) Risk of Bias checklist for case series. Results A total of 629 citations were identified and five studies were assessed eligible for final inclusion (one non‐randomized controlled trial and four prospective single‐arm studies). Across the studies, 217 patients were enrolled. All studies showed a moderate to high RoB. The strength of evidence for the effectiveness and safety of LVA is “very low.” Due to the methodological shortcomings of the available evidence, no conclusions can be made about the effectiveness of the procedure. Conclusion LVA might be a safe technique for patients with primary and secondary lymphoedema—particularly because no serious complications were reported. Furthermore, LVA may have a role in the prevention of lymphoedema.
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Affiliation(s)
- Katharina Rosian
- Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria
| | - Michal Stanak
- Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria.,Faculty of Philosophy and Education, University of Vienna, Vienna, Austria
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Dissemond J, Jockenhöfer F, Miller A, Kurzhals G, Noori S, Reich-Schupke S, Schlaeger M, Schubert E, Stücker M, Weberschock T, Jungkunz HW. S1 Guidelines - Dermatoses associated with dermal lymphostasis. J Dtsch Dermatol Ges 2018; 16:512-523. [DOI: 10.1111/ddg.13496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Joachim Dissemond
- Department of Dermatology; Venereology and Allergology; Essen University Medical Center; Essen Germany
| | - Finja Jockenhöfer
- Department of Dermatology; Venereology and Allergology; Essen University Medical Center; Essen Germany
| | - Anya Miller
- “The Skin Experts” - Dermatology; Venereology; Allergology; and Phlebology Practice; Berlin Germany
| | - Günter Kurzhals
- Drs. Kurzhals - Dermatology; Venereology; and Phlebology Practice; Wangen/Allgäu Germany
| | - Shahrouz Noori
- Dr. Noori - Dermatology and Venereology Practice; Vienna Austria
| | - Stefanie Reich-Schupke
- Department of Dermatology; Venereology and Allergology; Center for Venous Diseases of the Departments of Dermatology and Vascular Surgery; Ruhr University; Bochum Germany
| | - Martin Schlaeger
- Dr. Schlaeger - Dermatology; Venereology; and Allergology Practice; Oldenburg Germany
| | - Erich Schubert
- Former Department of Dermatology; Allergology; Phlebology; and Lymphology; Sanaderm Hospital; Bad Mergentheim Germany
| | - Markus Stücker
- Department of Dermatology; Venereology and Allergology; Center for Venous Diseases of the Departments of Dermatology and Vascular Surgery; Ruhr University; Bochum Germany
| | - Tobias Weberschock
- Working Group Evidence-based Medicine Frankfurt; Institute of General Medicine; Johann Wolfgang Goethe University; Frankfurt Germany
- Department of Dermatology; Venereology and Allergology; University Medical Center of the Johann Wolfgang Goethe University; Frankfurt Germany
| | - Hans Wilfried Jungkunz
- Former Department of Dermatology; Allergology; Phlebology; and Lymphology; Sanaderm Hospital; Bad Mergentheim Germany
- Dr. Jungkunz; Dermatology; Venereology; Phlebology; Allergology; and Proctology Practice; Friedberg/Hessen Germany
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8
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Dissemond J, Jockenhöfer F, Miller A, Kurzhals G, Noori S, Reich-Schupke S, Schlaeger M, Schubert E, Stücker M, Weberschock T, Jungkunz HW. S1-Leitlinie - Dermatosen bei dermaler Lymphostase. J Dtsch Dermatol Ges 2018; 16:512-524. [DOI: 10.1111/ddg.13496_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Joachim Dissemond
- Klinik und Poliklinik für Dermatologie; Venerologie und Allergologie; Universitätsklinikum Essen
| | - Finja Jockenhöfer
- Klinik und Poliklinik für Dermatologie; Venerologie und Allergologie; Universitätsklinikum Essen
| | - Anya Miller
- Praxis Die Hautexperten; Dermatologie; Venerologie; Allergologie; Phlebologie; Berlin
| | - Günter Kurzhals
- Praxis Dres. Kurzhals; Dermatologie; Venerologie; Phlebologie; Wangen/Allgäu
| | | | - Stefanie Reich-Schupke
- Klinik für Dermatologie; Venerologie und Allergologie; Venenzentrum der Dermatologischen und Gefäßchirurgischen Kliniken; Ruhr-Universität Bochum
| | - Martin Schlaeger
- Praxis Dr. Schlaeger; Dermatologie; Venerologie; Allergologie; Oldenburg
| | - Erich Schubert
- ehemalige Klinik Sanaderm für Dermatologie; Allergologie; Phlebologie; Lymphologie; Bad Mergentheim
| | - Markus Stücker
- Klinik für Dermatologie; Venerologie und Allergologie; Venenzentrum der Dermatologischen und Gefäßchirurgischen Kliniken; Ruhr-Universität Bochum
| | - Tobias Weberschock
- Arbeitsgruppe EbM Frankfurt; Institut für Allgemeinmedizin; Johann Wolfgang-Goethe-Universität; Frankfurt/Main
- Klinik für Dermatologie; Venerologie und Allergologie; Universitätsklinikum der Johann Wolfgang-Goethe-Universität; Frankfurt/Main
| | - Hans Wilfried Jungkunz
- ehemalige Klinik Sanaderm für Dermatologie; Allergologie; Phlebologie; Lymphologie; Bad Mergentheim
- Praxis Dr. Jungkunz; Dermatologie; Venerologie; Phlebologie; Allergologie; Proktologie; Friedberg/Hessen
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9
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Pappalardo M, Patel K, Cheng MH. Vascularized lymph node transfer for treatment of extremity lymphedema: An overview of current controversies regarding donor sites, recipient sites and outcomes. J Surg Oncol 2018; 117:1420-1431. [PMID: 29572824 DOI: 10.1002/jso.25034] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 02/05/2018] [Indexed: 12/11/2022]
Abstract
As lymphatic microsurgery has become more common, vascularized lymph node transfer ascended to the forefront in many centers for the surgical management of advanced stages of lymphedema showing substantial clinical improvement. However, no consensus has been reached among experts regarding many details of the procedures, including patient selection criteria, type of treatment, donor, and recipient sites and postoperative evaluation of the outcome. Here, we will review these issues and provide the current results of this procedure.
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Affiliation(s)
- Marco Pappalardo
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan.,Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Ketan Patel
- Department of Plastic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
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10
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Fischer AS, Rizk C, Sutton L, Krishnan B, Orengo I, Cohen DN. Stewart-Treves syndrome in a spinal cord injury patient with MYC amplification. JAAD Case Rep 2017; 3:515-518. [PMID: 29264380 PMCID: PMC5729014 DOI: 10.1016/j.jdcr.2017.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Andrew S Fischer
- Department of Dermatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Christopher Rizk
- Department of Dermatology, Baylor College of Medicine, Houston, Texas
| | - Leigh Sutton
- Department of Dermatology, Baylor College of Medicine, Houston, Texas
| | | | - Ida Orengo
- Department of Dermatology, Baylor College of Medicine, Houston, Texas
| | - Daniel N Cohen
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas.,Michael E. DeBakey VA Medical Center, Houston, Texas
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11
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Cucchi F, Rossmeislova L, Simonsen L, Jensen MR, Bülow J. A vicious circle in chronic lymphoedema pathophysiology? An adipocentric view. Obes Rev 2017; 18:1159-1169. [PMID: 28660651 DOI: 10.1111/obr.12565] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/07/2017] [Accepted: 04/25/2017] [Indexed: 12/11/2022]
Abstract
Chronic lymphoedema is a disease caused by a congenital or acquired damage to the lymphatic system and characterized by complex chains of pathophysiologic events such as lymphatic fluid stasis, chronic inflammation, lymphatic vessels impairment, adipose tissue deposition and fibrosis. These events seem to maintain and reinforce themselves through a positive feedback loop: regardless of the initial cause of lymphatic stasis, the dysfunctional adipose tissue and its secretion products can worsen lymphatic vessels' function, aggravating lymph leakage and stagnation, which can promote further adipose tissue deposition and fibrosis, similar to what may happen in obesity. In addition to the current knowledge about the tight and ancestral interrelation between immunity system and metabolism, there is evidence for similarities between obesity-related and lymphatic damage-induced lymphoedema. Together, these observations indicate strong reciprocal relationship between lymphatics and adipose tissue and suggest a possible key role of the adipocyte in the pathophysiology of chronic lymphoedema's vicious circle.
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Affiliation(s)
- F Cucchi
- Department of Clinical Physiology and Nuclear Medicine, Bispebjerg and Frederiksberg Hospitals, Copenhagen, Denmark
| | - L Rossmeislova
- Department for the Study of Obesity and Diabetes, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - L Simonsen
- Department of Clinical Physiology and Nuclear Medicine, Bispebjerg and Frederiksberg Hospitals, Copenhagen, Denmark
| | - M R Jensen
- Department of Clinical Physiology and Nuclear Medicine, Bispebjerg and Frederiksberg Hospitals, Copenhagen, Denmark
| | - J Bülow
- Department of Clinical Physiology and Nuclear Medicine, Bispebjerg and Frederiksberg Hospitals, Copenhagen, Denmark.,Department of Biomedical Sciences, Copenhagen University, Denmark
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McLaughlin SA, DeSnyder SM, Klimberg S, Alatriste M, Boccardo F, Smith ML, Staley AC, Thiruchelvam PTR, Hutchison NA, Mendez J, MacNeill F, Vicini F, Rockson SG, Feldman SM. Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema, Recommendations from an Expert Panel: Part 2: Preventive and Therapeutic Options. Ann Surg Oncol 2017; 24:2827-2835. [DOI: 10.1245/s10434-017-5964-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Indexed: 12/25/2022]
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Dalal A, Eskin‐Schwartz M, Mimouni D, Ray S, Days W, Hodak E, Leibovici L, Paul M. Interventions for the prevention of recurrent erysipelas and cellulitis. Cochrane Database Syst Rev 2017; 6:CD009758. [PMID: 28631307 PMCID: PMC6481501 DOI: 10.1002/14651858.cd009758.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Erysipelas and cellulitis (hereafter referred to as 'cellulitis') are common bacterial skin infections usually affecting the lower extremities. Despite their burden of morbidity, the evidence for different prevention strategies is unclear. OBJECTIVES To assess the beneficial and adverse effects of antibiotic prophylaxis or other prophylactic interventions for the prevention of recurrent episodes of cellulitis in adults aged over 16. SEARCH METHODS We searched the following databases up to June 2016: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registry databases, and checked reference lists of included studies and reviews for further references to relevant randomised controlled trials (RCTs). We searched two sets of dermatology conference proceedings, and BIOSIS Previews. SELECTION CRITERIA Randomised controlled trials evaluating any therapy for the prevention of recurrent cellulitis. DATA COLLECTION AND ANALYSIS Two authors independently carried out study selection, data extraction, assessment of risks of bias, and analyses. Our primary prespecified outcome was recurrence of cellulitis when on treatment and after treatment. Our secondary outcomes included incidence rate, time to next episode, hospitalisation, quality of life, development of resistance to antibiotics, adverse reactions and mortality. MAIN RESULTS We included six trials, with a total of 573 evaluable participants, who were aged on average between 50 and 70. There were few previous episodes of cellulitis in those recruited to the trials, ranging between one and four episodes per study.Five of the six included trials assessed prevention with antibiotics in participants with cellulitis of the legs, and one assessed selenium in participants with cellulitis of the arms. Among the studies assessing antibiotics, one study evaluated oral erythromycin (n = 32) and four studies assessed penicillin (n = 481). Treatment duration varied from six to 18 months, and two studies continued to follow up participants after discontinuation of prophylaxis, with a follow-up period of up to one and a half to two years. Four studies were single-centre, and two were multicentre; they were conducted in five countries: the UK, Sweden, Tunisia, Israel, and Austria.Based on five trials, antibiotic prophylaxis (at the end of the treatment phase ('on prophylaxis')) decreased the risk of cellulitis recurrence by 69%, compared to no treatment or placebo (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.13 to 0.72; n = 513; P = 0.007), number needed to treat for an additional beneficial outcome (NNTB) six, (95% CI 5 to 15), and we rated the certainty of evidence for this outcome as moderate.Under prophylactic treatment and compared to no treatment or placebo, antibiotic prophylaxis reduced the incidence rate of cellulitis by 56% (RR 0.44, 95% CI 0.22 to 0.89; four studies; n = 473; P value = 0.02; moderate-certainty evidence) and significantly decreased the rate until the next episode of cellulitis (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.78; three studies; n = 437; P = 0.002; moderate-certainty evidence).The protective effects of antibiotic did not last after prophylaxis had been stopped ('post-prophylaxis') for risk of cellulitis recurrence (RR 0.88, 95% CI 0.59 to 1.31; two studies; n = 287; P = 0.52), incidence rate of cellulitis (RR 0.94, 95% CI 0.65 to 1.36; two studies; n = 287; P = 0.74), and rate until next episode of cellulitis (HR 0.78, 95% CI 0.39 to 1.56; two studies; n = 287). Evidence was of low certainty.Effects are relevant mainly for people after at least two episodes of leg cellulitis occurring within a period up to three years.We found no significant differences in adverse effects or hospitalisation between antibiotic and no treatment or placebo; for adverse effects: RR 0.87, 95% CI 0.58 to 1.30; four studies; n = 469; P = 0.48; for hospitalisation: RR 0.77, 95% CI 0.37 to 1.57; three studies; n = 429; P = 0.47, with certainty of evidence rated low for these outcomes. The existing data did not allow us to fully explore its impact on length of hospital stay.The common adverse reactions were gastrointestinal symptoms, mainly nausea and diarrhoea; rash (severe cutaneous adverse reactions were not reported); and thrush. Three studies reported adverse effects that led to discontinuation of the assigned therapy. In one study (erythromycin), three participants reported abdominal pain and nausea, so their treatment was changed to penicillin. In another study, two participants treated with penicillin withdrew from treatment due to diarrhoea or nausea. In one study, around 10% of participants stopped treatment due to pain at the injection site (the active treatment group was given intramuscular injections of benzathine penicillin).None of the included studies assessed the development of antimicrobial resistance or quality-of-life measures.With regard to the risks of bias, two included studies were at low risk of bias and we judged three others as being at high risk of bias, mainly due to lack of blinding. AUTHORS' CONCLUSIONS In terms of recurrence, incidence, and time to next episode, antibiotic is probably an effective preventive treatment for recurrent cellulitis of the lower limbs in those under prophylactic treatment, compared with placebo or no treatment (moderate-certainty evidence). However, these preventive effects of antibiotics appear to diminish after they are discontinued (low-certainty evidence). Treatment with antibiotic does not trigger any serious adverse events, and those associated are minor, such as nausea and rash (low-certainty evidence). The evidence is limited to people with at least two past episodes of leg cellulitis within a time frame of up to three years, and none of the studies investigated other common interventions such as lymphoedema reduction methods or proper skin care. Larger, high-quality studies are warranted, including long-term follow-up and other prophylactic measures.
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Affiliation(s)
- Adam Dalal
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Marina Eskin‐Schwartz
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Daniel Mimouni
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Sujoy Ray
- St. John's Medical College and HospitalDepartment of PsychiatrySarjapur RoadBangaloreKarnatakaIndia560008
| | - Walford Days
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamUKNG7 2NR
| | - Emmilia Hodak
- Beilinson Hospital, Rabin Medical CenterDepartment of Dermatology39 Jabotinski StreetPetah TikvaIsrael49100
- Tel Aviv UniversityThe Sackler School of MedicineTel AvivIsrael
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine EKaplan StreetPetah TikvaIsrael49100
| | - Mical Paul
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
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Yeung W, Semciw AI. Aquatic Therapy for People with Lymphedema: A Systematic Review and Meta-analysis. Lymphat Res Biol 2017; 16:9-19. [PMID: 28346851 DOI: 10.1089/lrb.2016.0056] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Aquatic therapy has several proposed benefits for people with lymphedema. A systematic review of the evidence for aquatic therapy in lymphedema management has not been conducted. METHOD AND RESULTS Systematic review and meta-analysis were conducted. Five electronic databases were searched to identify randomized controlled trials (RCTs) of people with lymphedema, which compared aquatic therapy with other lymphedema interventions. Qualitative analysis was undertaken where quantitative analysis was not possible. Study quality was assessed using physiotherapy evidence database (PEDro) scores. The strength of evidence was evaluated using the Grades of Recommendations Assessment, Development and Evaluation (GRADE) approach. Four RCTs of moderate quality (average PEDro score 6.5/10) were included in the review. Two studies provided results for inclusion in meta-analysis. There was moderate-level evidence of no significant short-term differences in lymphedema status (as measured by lymphedema relative volume) between patients who completed aqua lymphatic therapy (ALT) compared to land-based standard care (standardized mean difference [SMD]: 0.14; 95% confidence interval [CI]: -0.37 to 0.64, I2 = 0%, p = 0.59); and low-quality evidence of no significant difference between ALT and standard care for improving upper limb (UL) physical function (SMD -0.27, 95% CI: -0.78 to 0.23, I2 = 0%, p = 0.29). No adverse events reported. CONCLUSIONS Current evidence indicates no significant benefit of ALT over standard land-based care for improving lymphedema status or physical function in people with UL lymphedema. Patient preference should guide the choice of care to facilitate adherence. Further research is required to strengthen the evidence from four studies in people with UL lymphedema, and to establish the efficacy of this intervention in people with lower limb lymphedema. Review registration: PROSPERO (CRD42015019900).
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Affiliation(s)
- Wai Yeung
- 1 Department of Physiotherapy, Princess Alexandra Hospital , Brisbane, Australia
| | - Adam I Semciw
- 1 Department of Physiotherapy, Princess Alexandra Hospital , Brisbane, Australia .,2 School of Health and Rehabilitation Sciences, The University of Queensland , Brisbane, Australia .,3 Centre for Functioning and Health Research , Metro South Health, Brisbane, Australia
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Kitayama S, Maegawa J, Matsubara S, Kobayashi S, Mikami T, Hirotomi K, Kagimoto S. Real-Time Direct Evidence of the Superficial Lymphatic Drainage Effect of Intermittent Pneumatic Compression Treatment for Lower Limb Lymphedema. Lymphat Res Biol 2017; 15:77-86. [DOI: 10.1089/lrb.2016.0031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Shinya Kitayama
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Jiro Maegawa
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Shinobu Matsubara
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Shinji Kobayashi
- Department of Plastic and Reconstructive Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Taro Mikami
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Koichi Hirotomi
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Shintaro Kagimoto
- Department of Plastic and Reconstructive Surgery, Yokohama City University School of Medicine, Yokohama, Japan
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Sun D, Yu Z, Chen J, Wang L, Han L, Liu N. The Value of Using a SkinFibroMeter for Diagnosis and Assessment of Secondary Lymphedema and Associated Fibrosis of Lower Limb Skin. Lymphat Res Biol 2017; 15:70-76. [PMID: 28277926 DOI: 10.1089/lrb.2016.0029] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Di Sun
- Lymphology Centre of Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ziyou Yu
- Lymphology Centre of Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiajia Chen
- Lymphology Centre of Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Wang
- Lymphology Centre of Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Linghua Han
- Lymphology Centre of Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ningfei Liu
- Lymphology Centre of Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Tzou CH, Meng S, Ines T, Reissig L, Pichler U, Steinbacher J, Pona I, Roka-Palkovits J, Rath T, Weninger WJ, Cheng MH. Surgical anatomy of the vascularized submental lymph node flap: Anatomic study of correlation of submental artery perforators and quantity of submental lymph node. J Surg Oncol 2016; 115:54-59. [DOI: 10.1002/jso.24336] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 06/12/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Chieh Han Tzou
- Division of Plastic and Reconstructive Surgery; Department of Surgery; Medical University of Vienna; Vienna Austria
| | - Stefan Meng
- Department of Systematic Anatomy; Institute of Anatomy; Center for Anatomy and Cell Biology; Medical University of Vienna; Austria
| | - Tinhofer Ines
- Division of Plastic and Reconstructive Surgery; Department of Surgery; Medical University of Vienna; Vienna Austria
| | - Lukas Reissig
- Department of Systematic Anatomy; Institute of Anatomy; Center for Anatomy and Cell Biology; Medical University of Vienna; Austria
| | - Ursula Pichler
- Division of Plastic and Reconstructive Surgery; Department of Surgery; Medical University of Vienna; Vienna Austria
| | - Johannes Steinbacher
- Division of Plastic and Reconstructive Surgery; Department of Surgery; Medical University of Vienna; Vienna Austria
| | - Igor Pona
- Division of Plastic and Reconstructive Surgery; Department of Surgery; Medical University of Vienna; Vienna Austria
| | - Julia Roka-Palkovits
- Division of Plastic and Reconstructive Surgery; Department of Surgery; Medical University of Vienna; Vienna Austria
| | - Thomas Rath
- Division of Plastic and Reconstructive Surgery; Department of Surgery; Medical University of Vienna; Vienna Austria
| | - Wolfgang J. Weninger
- Department of Systematic Anatomy; Institute of Anatomy; Center for Anatomy and Cell Biology; Medical University of Vienna; Austria
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery; Department of Plastic and Reconstructive Surgery; Center for Tissue Engineering; Chang Gung Memorial Hospital; College of Medicine; Chang Gung University; Taoyuan Taiwan
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Piccolo V, Baroni A, Russo T, Schwartz RA. Ruocco's immunocompromised cutaneous district. Int J Dermatol 2015; 55:135-41. [PMID: 26475059 DOI: 10.1111/ijd.13086] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 12/14/2014] [Accepted: 01/22/2015] [Indexed: 12/18/2022]
Abstract
The concept of 'locus minoris resistentiae' (lmr) is an old but still effective way of thinking in Medicine. In Dermatology, there are many reports of privileged localization of cutaneous diseases on injured skin, which therefore represents a typical condition of lmr. Lately the innovative concept of immunocompromised cutaneous district (ICD) has been introduced to explain why a previously injured cutaneous site may become in time a privileged location for the outbreak of opportunistic infections, tumors, and immune reactions. An ample documentation of multifarious disorders (infectious, neoplastic, immune) appearing in ICDs was delineated by Ruocco et al. in 2009. These cases were grouped according to the clinical settings responsible for the local immune imbalance: regional chronic lymphedema; herpes-infected sites, which feature the well-known Wolf's isotopic response; and otherwise damaged areas, comprising sites of vaccination, ionizing or UV radiation, thermal burns, and traumas. In the following five years, what was a "novel" pathogenic concept has been extended to an enlarging variety of clinical conditions. This paper focuses on ICD and the expanding spectrum of this now established pathogenic concept.
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Affiliation(s)
- Vincenzo Piccolo
- Department of Dermatology and Venereology, Second University of Naples, Naples, Italy
| | - Adone Baroni
- Department of Dermatology and Venereology, Second University of Naples, Naples, Italy
| | - Teresa Russo
- Department of Dermatology and Venereology, Second University of Naples, Naples, Italy
| | - Robert A Schwartz
- Dermatology and Pathology, Rutgers New Jersey Medical School, Newark, NJ, USA
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Blei F. Update December 2014. Lymphat Res Biol 2014. [DOI: 10.1089/lrb.2014.1242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Ruocco V. The immunocompromised district: How the pieces of the puzzle gradually fell into place. Clin Dermatol 2014; 32:549-52. [PMID: 25160094 DOI: 10.1016/j.clindermatol.2014.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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